Every finding on record at Premier at the Springs

Based on observations, interviews, record review, and facility policy review, the facility failed to accurately develop and implement a baseline Care Plan for one (Resident #1) of one resident reviewed for baseline care planning. Specifically, the facility failed to include minimum healthcare information such as, administration of an anticoagulant and the resident being at risk for falls, necessary to ensure the facility staff provided continuity of care, staff communication, resident safety, and prevention of adverse events for Resident #1. The findings included: Review of Resident #1's Medical Diagnoses Report revealed Resident #1 had diagnoses that included a history of respiratory failure with hypoxia (low oxygen levels), atrial fibrillation (irregular heart rhythm), unspecified fall subsequent encounter (frequent falls), spinal stenosis lumbar region with neurogenic claudication (the lower spinal canal is narrowed, compressing nerves and causing weakness/numbness/pain in the legs), and other abnormalities of gait and mobility. Review of Resident #1's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS revealed Resident #1 required partial to moderate assistance for chair/bed to chair transfers, and substantial to moderate assistance for toileting hygiene, to shower/bathe self, lower body dressing and putting on/taking off footwear. The MDS also revealed Resident #1 had a diagnosis of falls. Review of Resident #1's Care Plan initiated on [DATE], revealed the care plan did not indicate Resident #1 was on an anticoagulant and did not include interventions for facility staff to provide resident safety or monitor for fall risk while taking an anticoagulant. Review of facility document titled, Fall Risk Assessment Criteria, dated [DATE], revealed a score of 12, which indicated the resident should be considered high risk for potential falls and a prevention protocol should be initiated and care planned. The Fall Risk Assessment also revealed Resident #1 had a history of falls with an occurrence of 1-2 in the past 3 months. The Fall Risk Assessment Criteria also revealed Resident #1 had a balance problem while standing/walking, decreased muscular coordination/jerking movements, and required the use of assistive devices. Review of Resident #1's Order Summary dated [DATE], revealed Resident #1 was ordered an anticoagulant that was to be taken two times a day related to atrial fibrillation. Review of the facility's Medication Administration Record (MAR) dated [DATE], revealed Resident #1 was administered an anticoagulant that started on [DATE], twice a day through the morning dose on [DATE]. Review of a Skilled Charting Assessment narrative note dated [DATE] at 2:16 PM, revealed Resident #1 was newly admitted , used a wheelchair for mobility, was weak in extremities, and needed assistance of one staff for the bathroom. Review of a Hospital Referral dated [DATE], revealed that Resident #1 had gone to the hospital post fall with weakness and numbness to right lower extremity (RLE) and increasing pain status post-surgery. Resident #1 had a right iliofemoral thromboendoarterectomy with stent explant, thrombectomy with fasciotomies (removal of a blood clot from the femoral artery) on [DATE].The Hospital Referral listed Resident #1's treatment plan as discharge to skilled therapy. Review of Resident #1's Progress Notes dated [DATE], revealed staff were called to Resident #1's room. Upon entering, Resident #1 was lying on the floor on the left side with blood under the head from a laceration. Resident did not respond verbally. The resident responded to painful stimuli, had shallow and slow respirations. Facility staff called 911. Emergency Medical Services (EMS) transferred the resident to the ambulance where the resident expired. Resident #1 was listed as Do Not Resuscitate (DNR). EMS brought the resident back into the facility and family was notified. During an interview on [DATE] at 6:21 PM, a family member of Resident #1 stated the resident walked with their back bent over due to spine surgery. The family member stated the resident did not like to have people help them and wanted to do things themselves. The family member asked the facility staff about a fall mat and the use of bed alarm. The family member stated the staff had informed them, they don't use bed alarms here. The family member stated the resident was admitted at the facility on [DATE], passed away on [DATE] and was to be discharged from skilled therapy on [DATE]. During an interview on [DATE] at 4:18 PM, Certified Nursing Assistant (CNA) #1 stated, I know how to take care of a resident by looking at their care plan in the kiosk. If there is something that is not on the care plan, I don't know how to take care of that resident. If a resident is a fall risk and it is not on the care plan, I don't know to be more cautious of that resident. During an interview on [DATE] at 4:30 PM, CNA #2 stated, to take care of a resident, you have to look at their care plan. Each resident is different. If there is something that is not on the care plan, we do not know they need it to be done, unless we are told verbally. If a resident is a fall risk, we don't know they need the interventions for falls [without it being on the care plan]. During an interview on [DATE] at 4:40 PM, Licensed Practical Nurse (LPN) #3 stated she always refers to care plans to know how to care for a resident. I always observe the residents to see how they are doing but, if it is not on the care plan, I really wouldn't know what exactly was needed for that specific resident. During an interview on [DATE] at 12:07 PM, LPN #4 stated she knew how to take care of a resident by referring to their care plan and talking with the resident and family. I believe if a fall risk assessment is done and they have had falls; it is put on the care plan at that time. LPN #4 stated, No one knows what to do for a resident if the care plan is not right. During an interview on [DATE] at 12:54 PM, Director of Nursing (DON) #2 stated he remembered Resident #1 being admitted to the facility and knew the resident had falls prior to being admitted . He indicated that is why the resident came was for skilled therapy from falls and was known for jumping up and trying to go. The DON #2 stated they had startup meetings every morning Monday through Friday where things were discussed. He stated there were multiple people that should have caught that the care plan for Resident #1 was not accurately filled out. The DON #2 stated we have to manually enter falls on the care plan after the MDS admission is filled out. But the admission nurse should have placed the anticoagulant and at risk for falls on the baseline care plan. During an interview on [DATE] at 1:48 PM, the Long-Term Care (LTC) MDS Coordinator stated, when a resident was admitted , a baseline care plan was done by the admission assessment nurse. She stated, if a resident is admitted late in the afternoon on a Friday, we will review the information on Monday morning but a baseline care plan with the basics is done upon admission, and it is posted immediately. She stated the following should be included in the basic care plan: pain, activities of daily living (ADLS), falls, skin conditions, isolations, code status and discharge plan. The LTC MDS Coordinator stated, If a resident was admitted with a history of falls and it is not put on the basic care plan (indicating the baseline care plan), it placed the resident at a higher risk of falls and injury. During an interview on [DATE] 2:13 PM, The Skilled Therapy (ST) MDS Coordinator stated, all care plan items are manually put in the care plan. The nurse's admission assessment does trigger over to the basic care plan starting day one. He stated the admission nurse performed a fall risk assessment and she should have put it on the basic care plan if there was a history of falls. The ST MDS Coordinator stated if falls were not included on the basic care plan, it could increase risk of additional falls. He stated, if the admission nurse did not include it on the basic care plan and did not tell the facility staff, the facility staff would not know the resident was at risk for falls. During an interview on [DATE] at 2:27 PM, DON #1 stated that if a resident had a history of falls prior to being admitted to the facility, it should be reflected on the MDS and it had to manually be entered on the care plan. The DON #1 stated if a resident was at risk for falls, interventions were automatically implemented such as bed in lowest position, non-skid socks, fall mat, and all the standard interventions. She stated, if it was not included on the baseline care plan, the staff would not know. During an interview on [DATE] at 2:45 PM, the Administrator stated that if a resident was admitted to the facility with a history of falls, it should have been on the baseline care plan. He stated if the nursing admission assessment indicated a resident had a history of falls 1-2 in the past 2-3 months prior to admission, it should be added to the care plan. He also stated, that is how the care plan is built, by the assessments. The Administrator indicated staff would not know a resident was at risk of falls if it was not on the baseline care plan. He stated, but it will for sure be added from now on.Review of a facility policy titled Care Plans-Baseline, revised in [DATE], revealed the baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: initial goals based on admission orders and discussion with the resident/representative; physician orders; therapy services; and social services.

Based on facility document review, interviews, facility policy review, it was determined that the facility failed to conduct a thorough facility assessment for the staffing required for day/evening/weekend coverage of resident needs and failed to formulate a plan for staff recruitment and retention to meet the needs of the residents when completing their facility assessment. The findings include: A review of the Facility Assessment, dated 07/07/2025, revealed the following: “The Facility Assessment Team” was identified as the Administrator, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, and Medical Director. The average census used was 132 and the assessment indicated that prior to the admission of any resident, the Director of Nursing and nursing department staff along with the IDT [interdisciplinary team] team assessed physical and psychosocial needs of the residents. “Facility Staffing” identified the managers and “Additional Staff: Licensed Registered Nurses, Licensed Practical Nurses, State Tested Nursing Assistants, Resident Assistants, Diet Tech & Dieticians, Housekeeping staff, Laundry staff, Dietary staff, Business office staff, Therapy is provided under contractual agreement including licensed physical therapists, occupational therapists, and speech therapists, Volunteers.” The Facility Assessment also indicated that staffing assignments were based on staff, resident, and family input and the facility was “committed to consistent assignment, based on censes and acuity.” No staffing decisions were outlined for the facility based on the resident populations assessed needs to ensure sufficient and appropriate staffing were available on all day/evening/night/weekend, shifts, to care for the residents. There was no section to address the development and maintenance of recruitment and retention of the direct care staff. No direct care staff or resident/resident representatives were listed as part of the facility assessment team showing input or involvement in the self-assessment process. During an interview on 08/12/2025 at 12:06 PM, Assistant Director of Nursing (ADON) #1 stated, she did the nursing schedules, and they had been done the same for the length of her employment. She stated there was a minimal staffing formula on the Office of Long-Term Care state website to meet minimal staffing requirements. She stated Human Resources decided how many people were there each day and she went by what the corporation told her. ADON #1 revealed she did not reference the facility’s assessment as a guideline for scheduling staff. During an interview on 08/13/2025 at 10:25 AM, the Director of Nursing (DON) stated, the facility assessment was just to check things like fire alarms, ensure everything was in place like air conditioning, and everything was up and running properly. The DON stated the Administrator was responsible for the facility assessment. During an interview on 08/13/2025 at 12:21 PM, the Administrator stated the facility staffing was based on census. The facility assessment was his responsibility and was a large document which covered vendors, emergency supplies, and contracts for needs or improvements. He stated staffing had a federal minimal requirement of about 3.5 hours per resident per day, but he did not have the document in front of him. The Administrator did not reference the facility’s assessment when identifying the facility’s need for sufficient and appropriate staff each shift to meet the needs of the residents. A review of a facility policy titled, Facility Assessment, with a revision date of October 2018, indicated a facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. The facility assessment includes a detailed review of the resident population. This part of the assessment includes factors that affect the overall acuity of the residents, such as the number and percentage of residents with: Need for assistance with ADLs; Mobility impairments; incontinence (bowel and bladder); Cognitive or behavioral impairments; and Conditions or diseases that require specialized care (e.g., dialysis, ventilators, wound care). The facility assessment includes a detailed review of the resources available to meet the needs of the resident population. This includes the following: equipment and supplies (medical and non-medical), contractors or agreements with third parties to provide services, equipment, and supplies to the facility during normal operations and in the event of an emergency; Services currently provided, including: Skilled or specialized care (e.g., memory care). All personnel, including Regular employees (full and part time) and contracted staff (full and part time). A breakdown of the training, licensure, education, skill level and measures of competency for all personnel.

Based on observation, record review, interview and facility policy review, the facility failed to ensure a glucometer was cleansed according to the manufacturer's guidelines for two of two glucometers observed being used to perform blood sugar checks; and failed to ensure wound care was performed using proper infection control measures for one (Resident #126) of one resident observed during wound care. The findings include: Resident #126 wound care Review of the admission Record for Resident #126 indicated they were admitted to the facility on [DATE] with diagnoses which included acquired surgical amputation of toes of left foot, type 2 diabetes mellitus, peripheral vascular disease (a condition where the blood vessels in the arms, legs, and other extremities become narrowed or blocked), anxiety disorder, and absence of the right leg above the knee. A review of Resident #126’s admission Minimum Data Set with an Assessment Reference Date of 07/14/2025, revealed a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact and had no symptoms of delirium or behaviors. Resident #126’s MDS also revealed the resident had impairment to both lower extremities, was dependent on staff for bathing dressing, and was independent with locomotion in a wheelchair. A review of Resident #126’s Physician Orders dated 07/15/2025, indicated the treatment to be performed to the left foot including how to clean and apply the wound vacuum on Monday Wednesday and Friday and as needed it if was dislodged or soiled. A review of Resident #126’s Care Plan, with a revision date of 07/18/2025, indicated the resident had a Surgical Wound to foot and to monitor and document any drainage, pain, swelling, or signs of infection and notify the physician if present and to provide treatment as ordered. During an observation on 08/10/2025 at 11:21 AM, this surveyor observed Resident #126 pushing themselves down the 300 and 500-hall in a wheelchair. Resident #126 had their left foot on the wheelchair footrest, a wound vacuum was hanging on the back of the resident’s wheelchair with tubing connecting it to the dressing on the left foot, the dressing was covered with a blue surgical shoe cover. This surveyor detected a faint noxious odor coming from Resident #126 as they wheeled by. During an observation on 08/11/2025 at 3:36 PM, this surveyor observed Licensed Practical Nurse (LPN) #14/Treatment Nurse, perform wound care with wound vacuum change to Resident #126’s left foot. LPN #14 went into the resident’s room, removed personal items from the over bed table, sanitized their hands, before taking supplies from the treatment cart and laying them directly on Resident #126’s over-bed table, without placing a barrier down or sanitizing the table first. Resident #126 transferred themselves to their bed where LPN #14 placed a pillow under the residents ankle to elevate their left foot. When LPN #14 removed the old dressing this. surveyor observed the wound to have copious amount of pink tinged purulent drainage and a noxious odor. A moderate amount of this purulent drainage dropped onto the resident’s blanket on the bed, as there was no barrier under their foot. Wearing the same gloves she used to remove the old dressing, LPN #14 then picked up a cup with gauze saturated in wound cleanser from the over bed table, took out a 4x4 inch gauze pad and wiped around the outer edge of the foot wound, folded the used gauze and wiped the inside of the wound then discarded the gauze. LPN #14 then took another gauze pad with wound cleanser from the cup and wiped the inside of the wound, folded it and wiped the inside of the wound again then discarded the gauze. After sanitizing and donning a clean pair of gloves LPN #14 picked up the wound preparation spray and sprayed the outer area of the foot around wound. LPN #14 then opened a pack of would vacuum supplies and used the scissors she had previously laid on the un-sanitized over bed table to cut the foam to fit into the wound bed. She then packed Resident #126’s wound and applied the transparent dressing, took the same scissors and cut a small hole in the dressing and attached the would vacuum. LPN #14 replaced Resident #126’s personal items back on the over bed table, picked up the skin prep spray and scissors in ungloved hands and sat them on top of the treatment cart. When questioned, LPN #14 confirmed she should have cleaned the wound by wiping from the inside out and only used the gauze pad one time and not reused it. When asked about the skin prep spray and scissors being placed on top of the treatment cart, LPN #14 verbalized she was going to sanitize them. During an interview on 08/14/20/2025 at 10:40 AM, the Director of Nursing (DON) confirmed he expected wound treatments to be done in a clean professional manner, according to physician orders. A review of the facility’s policy for Wound Care indicated to use a disposable cloth to establish a clean field on top of the over bed table, place a disposable cloth under the wound to prevent soiling the bed linen or other body sites. The policy when on to say to preform hand hygiene and don gloves, remove the wound dressing and discard along with used gloves. Preform hand hygiene again and don gloves and gown. The policy indicated, wear sterile gloves when physically touching the wound, after treatment to wipe reusable items with alcohol prior to returning them to the treatment cart. Glucometer observation During an observation on 08/13/2025 from 12:26 PM to 12:42 PM, this surveyor observed LPN #13 perform fingerstick blood sugars on several residents, rotating between two different glucometers, and failing to perform proper sanitizing between each resident, After each fingerstick, LPN #13 would take the glucometer back to the medication cart and place it on top of the medication cart. After the second fingerstick check, LPN #13 took out an alcohol pad and wiped down the glucometers and laid them both back on top of the medication cart. During an interview on 08/13/2025 at 12:46 PM, LPN #13 confirmed she cleaned the glucometers with an alcohol pad. She revealed she used to clean the glucometers with a commercial disinfectant wipe, but when she asked about it a few weeks prior, she was told to use an alcohol wipe by upper management, but could not remember who it was. During an interview with the Director of Nursing on 08/14/2025 at 10:40 AM, he indicated germicidal wipes were used to clean the glucometers between residents and he was unaware of the nurse using an alcohol wipe to clean. A review of the manufacture guidelines for cleaning and disinfecting the glucometer used by facility indicated two options: use a registered disinfectant detergent or germicide or use a solution of household bleach and water.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure personal care was provided for two (Resident #106 and Resident #126) of two residents reviewed for activities of daily living. The findings include: Resident #126 Review of Resident #126’s admission Record indicated Resident #126 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following surgical amputation [of toes of left foot], type 2 diabetes mellitus with diabetic nerve pain, absence of left toes, disorder in which narrowed blood vessels reduce blood flow to the legs and feet, anxiety disorder and absence of right leg above the knee. Review of Resident #126’s admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/14/2025, indicated a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #126 was cognitively intact. The MDS also indicated Resident #126 had no behavior or rejection of care and required moderate assistance with personal hygiene. Review of Resident #126’s Care Plan with a revision date of 08/04/2025, indicated the resident would improve their current level of function in self-care and be clean and well-groomed daily. The Care Plan also indicated Resident #126 was able to perform personal hygiene with partial assistance. On 08/10/2025 at 12:06 PM, Resident #126 told this surveyor they had been asking for a shave since being admitted to the facility but had only been shaved in the barber shop one time and had to pay 10 dollars. The resident went on to relate, prior to admission to the facility, they always kept themself clean shaven and did not like having facial hair. Resident #126 was observed on 08/11/2025, 08/12/2025, and 08/13/2025 to continue to have a thick growth of facial hair approximately 1.5 inches long. During an interview on 08/13/2025 at 11:15 AM, Certified Nursing Assistant (CNA) #12 confirmed the facility had razors and shaving cream. CNA #12 stated CNAs were responsible for assisting residents with personal grooming, including shaving, and stated she would assist Resident #126 to shave that day. During a second interview on 08/14/2025 at 9:16 AM, CNA #12 again confirmed that CNAs were responsible for assisting residents with personal hygiene and stated, “residents should be able to get a shave if they want.” CNA #12 went on to state when she asked Resident #126 on 08/13/2025 about getting a shave, the resident stated they were going to smoke and would be back. CNA #12 then stated Resident #126 had thick coarse facial hair and one razor would not shave them. When questioned if more than one razor could be used to shave them, CNA #12 confirmed more than one could be used. On 08/14/2025 at 10:45 AM Resident #126 was observed in their bathroom with two CNAs and was receiving a shave. When the Director of Nursing (DON) asked the resident if they had been requesting a shave from the staff. Resident #126 confirmed that they had asked several times since admission but did not remember the name of who they had asked. During an interview on 08/14/2025 at 10:00 AM, the DON confirmed it was the CNA’s responsibility to assist residents with personal hygiene, but anyone could assist with this as long as they had the proper training. The DON stated, “residents who want to be shaved should absolutely be assisted with this.” Resident #106 A review of a Face Sheet, indicated the facility admitted Resident #106 with diagnoses that included paralysis and muscle weakness affecting one side of the body following a stroke, pain, heart disease characterized by buildup of plaque in the arteries, atrial fibrillation, chronic kidney disease, and chronic viral hepatitis. The quarterly MDS, with an ARD of 07/03/2025, revealed Resident #106 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired. A review of Resident #106’s Care Plan, dated on 07/03/2025, revealed the resident had an activities of daily living self-care deficit. The Care Plan also included interventions that included to check and trim nails as necessary. A review of Physician’s Orders revealed Resident #106 had orders to see a podiatrist as needed. A review of an activity of daily living “Nail Task,” revealed Resident #106’s nails had been checked on 07/13/2025 at 9:02 AM, 07/20/2025 at 12:59 PM, 07/27/2025 at 8:47 AM, 08/03/2025 at 10:34 AM, and 08/10/2025 at 9:35 AM. During an observation on 08/10/2025 at 12:09 PM, Resident #106’s feet were uncovered while resident was lying in bed and all toenails were noticeably long, curled, discolored, and jagged. During an interview on 08/10/2025 at 12:09 PM, Resident #106 confirmed that the long toenails were bothersome and had been reported to the nurse several times. Resident #106 could not remember the dates nails were reported. During an interview on 08/12/2025 at 2:09 PM, CNA #3 confirmed that CNAs could clip fingernails and toenails unless they had a medical condition, such as diabetes and nails were to be checked on shower days. CNA #3 stated nails were to be reported to the nurse if a resident was diabetic and needed to be trimmed. CNA #3 confirmed staff were in-serviced on activities of daily living often but did not remember the last in service. During an interview on 08/12/2025 at 2:09 PM, CNA #4 confirmed that CNAs were to check nails on shower days and clip them if needed unless the resident was a diabetic or had been told otherwise. Specifically, if the resident had long or curled toenails. CNA #4 stated that toenails that required professional attention were reported to the nurse. During an interview on 08/12/2025 at 2:14 PM, CNA #5 stated CNAs were in-serviced on nail care and activities of daily living annually and as needed. CNA #5 stated CNAs were allowed to clip toenails of residents that were not diabetic. During an interview on 08/13/2025 at 8:52 AM, Licensed Practical Nurse (LPN) #8, stated CNAs clipped toenails unless a resident was a diabetic. Then they reported to the nurse that the resident’s toenails needed clipped. The nurse clipped the toenails of diabetic residents unless they were thick or curled, then the Social Service Director (SSD) was notified that the resident needed a podiatrist appointment. During an interview on 08/13/2025 at 8:54 AM, LPN #9 stated CNAs perform body audits while showering the residents and would report to the nurse if nails needed clipped. During an interview on 08/13/2025 at 9:00 AM, Medication Assistant- Certified #10 confirmed that CNAs were supposed to check toenails in the shower and clip them unless the resident was a diabetic. If the resident was diabetic, the CNAs reported to the nurse that the resident needed their toenails trimmed. During an interview on 08/13/2025 at 9:38 AM, Assistant Director of Nursing (ADON) #2 stated the treatment nurse normally trimmed diabetic resident’s toenails unless a podiatry appointment was needed. The Social Service Director was notified if a resident needed a podiatrist appointment and the resident’s name was placed on a list for when the podiatrist came to the facility. During an interview on 08/13/2025 at 11:33 AM, CNA #6 confirmed that Resident #106’s toenails were long and needed to be trimmed. CNA #6 stated CNAs were supposed to report long toenails to the nurse. During an interview on 08/13/2025 at 11:40 AM, ADON #1 stated the shower team would clip the toenails or report them to the treatment nurse. ADON #1 was asked to examine Resident #106’s toenails. ADON #1 confirmed that Resident #106’s toenails needed to be clipped by a podiatrist, who comes to the facility once a month. A podiatry list was kept by the Social Services Director (SSD). The SSD provided the current podiatry list and Resident #106 was not listed. During an interview on 08/13/2025 at 12:24 PM, the DON stated CNAs in the facility were allowed to cut resident’s toenails as long as they were not really long or curled and the resident was not a diabetic. The DON stated that a resident having long toenails was at risk for hanging the nail on something causing pain, injury, infections, and fungus. During an interview on 08/14/2025 at 8:43 AM, the Administrator stated all staff were responsible for checking resident’s feet and ensuring they get proper care. A review of a facility policy titled, “Activities of Daily Living,” revised on 03/2018, indicated, “Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.” A review of the facility’s policy titled “Foot Care,” revised March 2025, indicated Residents will be provided with foot care and treatment in accordance with professional standards, of practice, overall foot care will include the care and treatment of medical conditions associated with foot complications (e.g., diabetes, peripheral vascular disease, etc.), residents will be assisted in making transportation appointments to and from specialists (podiatrist, endocrinologist, etc.) as needed. Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes. Residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals'.” A review of professional standards from the Centers for Disease Control (CDC)'s guidelines indicated for infection prevention in podiatry settings emphasize the importance of standard precautions to prevent ingrown toenails, reduce the risk of fungal infections, and minimize the risk of bacterial infections

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure necessary equipment was maintained in a clean and sanitary state for one (Resident #122) of three residents reviewed, specifically not ensuring a resident’s wheelchair was free of dirt and debris. The findings include: During an observation on 08/11/2025 at 3:38 PM, Resident #122 was resting in bed, and their wheelchair was parked to the right of the bed. This surveyor observed that Resident #122’s wheelchair had white and brown flakes and crumbs caked on both sides of the seat cushion and on the front legs that connected the wheels and brakes. During an observation on 08/12/2025 at 8:30 AM, this surveyor observed Resident #122 in the dining room for breakfast and that their wheelchair was still dirty. During a concurrent observation and interview on 08/13/2025 at 11:49 AM, Resident #122 lifted the seat cushion to show Assistant Director of Nursing (ADON) #1 the dirt and debris on the wheelchair. ADON #1 confirmed the wheelchair was dirty and needed to be cleaned. A review of Resident #122’s admission Record indicated the facility admitted the resident on 05/13/2022 with diagnoses which included hypertensive heart disease, vascular dementia, and acute kidney failure. A review of Resident #122’s quarterly Minimum Data Set, with an Assessment Reference Date of 07/13/2025, revealed a Brief Interview for Mental Status score of 04, which indicated the resident had severe cognitive impairment. A review of Resident #122’s Care Plan, dated 07/11/2025, revealed the resident had a self-care performance deficit with limited mobility. Further review of Resident #122’s Care Plan revealed an intervention with an initiation date of 05/16/2024, that directed staff to include independence with supervision for locomotion with a wheelchair. A review of Resident #122’s Activity of Daily Living (ADL) task ADL Locomotion, revealed the resident had supervision in wheelchair checked off twice per day for the past 14 days. During an interview on 08/11/2025 at 3:38 PM, Resident #122 said their wheelchair was dirty and had been dirty for a long time, but was not able to recall the exact timeframe. During an interview on 08/12/2025 at 10:23 AM, the Housekeeper confirmed all staff could clean a wheelchair, but the night shift Certified Nursing Assistants (CNAs) were supposed to check and clean them at night, as part of their job duties. During an interview on 08/12/2025 at 2:08 PM, CNA #3 confirmed night shift CNAs checked and cleaned wheelchairs as necessary. During an interview on 08/12/2025 at 2:37 PM, CNA #4 confirmed that part of the night shift CNAs job duties was to check and clean wheelchairs and other resident equipment. During an interview on 08/12/2025 at 2:39 PM, CNA #5 confirmed the night shift CNAs job duties included checking and cleaning resident equipment, including wheelchairs. During an interview on 08/13/2025 at 8:52 AM, Licensed Practical Nurse #8 stated CNAs were supposed to clean wheelchairs. During an interview on 08/13/2025 at 9:05 AM, Medication Assistant- Certified #10 stated all CNAs could clean a wheelchair, but the overnight staff should check and clean resident equipment. During an interview on 08/13/2025 at 9:31 AM, Assistant Director of Nursing #2 confirmed night shift staff checked wheelchairs and other equipment to ensure everything was kept clean and not broken. ADON #2 stated leaving wheelchairs dirty posed a risk of effecting resident’s dignity, causing unpleasant odors, and affecting the life of the wheelchair. During an interview on 08/13/2025 at 12:33 PM, the Director of Nursing revealed night shift CNAs were supposed to clean wheelchairs to reduce the risk of germs, infection, and attracting pests. During an interview on 08/13/2025 at 1:13 PM, CNA #7 stated it was the responsibility of the night shift CNAs to keep the resident’s equipment clean, including wheelchairs. During an interview on 08/14/2025 at 8:50 AM, the Administrator stated it was everybody’s responsibility to keep the residents wheelchairs clean, but the primary responsibility fell on the night shift CNAs. The Administrator revealed maintenance could help as well. During an interview on 08/13/2025 at 3:12 PM, Nurse Consultant #11 stated the facility did not have any policies or in-services for environment or wheelchair cleaning.

Based on record review, interview, and facility policy review, it was determined that the facility failed to ensure an abuse allegation was reported to law enforcement for one (Resident #108) of five sampled residents. The findings include: The quarterly Minimum Data Set, with an Assessment Reference Date of 07/17/2025, revealed Resident #108 had a Staff Assessment of Mental Status with a score of 3, which indicated the resident had severely impaired (never/rarely makes decisions) cognitive skills for daily decision making. A review of Resident #108’s Care Plan dated 07/13/2025 revealed the resident was receiving hospice services and was at risk for skin integrity issues. The Care Plan included interventions that included to keep nails trimmed, conduct weekly body audits, reposition, and report skin concerns to the nurse. A review of the Medical Diagnosis Report revealed Resident #108 had diagnoses which included damage of brain cells affecting memory and thinking skills, hearing deficit, cognitive communication deficit, and excessive worry, fear, and nervousness. A review of Physician’s Orders revealed Resident #108 received hospice services along with pain and antianxiety medications. On 08/12/2025 at 2:56 PM, during review of the facility’s internal investigation packet which contained an abuse allegation involving Resident #108, that was reported on 07/08/2025 at 11:14 AM, a police report or incident number was not located. On 08/13/2025 at 8:00 AM, the Administrator stated that the police were contacted regarding the incident. A police officer was not sent out and an incident number was not given. The Administrator gave the name of the officer that the incident was reported to. During an interview on 08/13/2025 at 8:50 AM, the police officer named by the Administrator that took the call about the abuse allegation, indicated that the specific day the call regarding the incident reportedly came in was not a scheduled workday. The officer confirmed there was no report from the facility on that specific day. The police officer researched records for the entire month of July 2025 and did not have a report involving Resident #108. During an interview on 08/14/2025 at 8:25 AM, the Director of Nursing (DON) confirmed that when an abuse allegation was received, part of the process was to report the allegation to law enforcement. During an interview on 08/14/2025 at 8:47 AM, the Administrator confirmed that one part of the reporting process of abuse allegations was to report to law enforcement. The facility’s policy and procedure titled, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating” indicated under the headline, Reporting Allegations to Administrator and Authorities that the administrator would immediately report the suspicion to the following persons or agencies, of those options law enforcement officials were to be notified.

Based on observations and interviews it was determined that the facility failed to post the required staffing information. Specifically, the facility failed to post the facility census and actual hours worked by licensed personnel. The findings include: During an observation on 08/12/2025 at 9:36 AM, on a bulletin board by the front entrance time clock, two papers were posted. The first contained the facility name and date with staff assignments. The paper identified the staff name, shift assignment, and the hall they were assigned to. The second paper identified the number of licensed staff broken down by Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA) without names. No census or actual hours worked was posted. During an observation on 08/13/2025 at 9:37 AM, on a bulletin board at the front entrance time clock, two papers were posted. The first contained the facility name and date with staff assignments. The paper identified the staff name, shift assignment, and the hall they were assigned to. The second paper identified the number of licensed staff broken down by RN, LPN, and CNA without names. The census stated 127. No actual hours worked was posted. During an interview on 08/13/2025 at 10:25 AM, the Director of Nursing stated the posted staffing was to show the CNAs where to go each day and that there was a CNA schedule by the time clock. During an interview on 08/13/2025 at 11:07 AM, the Administrator stated the posted staffing was to show the number of employees and where they were stationed.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 1 (Resident #3) of 1 sampled resident, reviewed for care plan accuracy. The Findings are: Review of Resident #3's Admission Record, with an admitted [DATE], revealed diagnoses of sudden (acute) decrease in breathing (respiratory failure) with low oxygen (hypoxia) and sleep apnea. Review of Resident #3's Order Summary Report, dated November 1, 2024, indicated change oxygen tubing each week, every night shift, every Wednesday, oxygen two (2) liters per minute (LPM) through nasal cannula (NC) as needed for shortness of breath each day. Review of Resident #3's Care Plan with a date of October 21, 2024, did not note the resident received oxygen as needed. Review of Resident #3's Discharge, return anticipated, Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/2024, indicated in Section O0110, Special Treatments, procedures and programs that Resident #3 was receiving oxygen while a resident in the facility . During an interview with the Minimum Data Set Coordinator (MDS) #1, on 12/03/2024 at 2:43 PM, he confirmed he was familiar with Resident #3 and there was a physician's order for oxygen at two (2) LPM as needed. He also confirmed the MDS with an ARD of 11/07/2024 indicated Resident #3 received oxygen while a resident in the facility and should be care planned for oxygen but was not. During an interview with the Director of Nursing (DON), on 12/03/2024 at 3:08 PM, he confirmed he was somewhat familiar with Resident #3 and that there was a physician's order for oxygen at 2 LPM as needed. He also confirmed that the MDS with an ARD of 11/07/2024 indicated Resident #3 received oxygen while a resident in the facility and should be care planned for oxygen but was not. Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2024, noted Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Also, Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/ her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; e. reflects currently recognized standards of practice for problem areas and conditions.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #1) sampled resident whose MDS was reviewed. The findings are: Review of the Admission Record revealed the facility admitted Resident #1 with a diagnosis of Moderate Protein-Calorie Malnutrition. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was independent for their daily decision making. Section J, subsection J1400 was marked no and section O0110, subsection K1 Hospice was marked yes . Review of Resident #1's Care Plan initiated 09/24/2024 revealed the resident elected hospice services with Baptist Hospice. During an interview on 12/03/2024 at 3:00PM, MDS Coordinator #2 stated that she marked No on section J1400 of the 09/25/2024 significant change MDS. During review of the RAI manual, with MDS Coordinator #2, she stated the definition of Hospice Services, r. Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the documentation is in the medical record. MDS Coordinator #2 then verified that section J1400 on 09/25/2024 should have been marked yes, verifying resident prognosis with a condition or chronic disease that may result in a life expectancy of less than 6 months.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and storage area were covered or sealed to maintain freshness and prevent potential cross contamination of food and beverages; expired food items were promptly removed/discarded by the expiration or use by dates; kitchen vents cleaned; provide a sanitary environment for food preparation; floors, kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, debris, rust, and dirt; 3 of 3 ice machines were maintained in a clean and sanitary condition to prevent food and beverage contamination; and staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for contaminating food items. This failed practice had the potential to affect 108 residents who received food from the 1 of 1 kitchen. The findings are: 1. During a tour of the kitchen with the Dietary Supervisor, the following observations were made in the kitchen. a. On [DATE] at 08:37 AM, the ice machine panel and area where the ice forms before dispensing into the ice collect had a wet sage residue. The surveyor asked the Dietary Supervisor to wipe out the wet sage colored substances found on the panel and the area where ice forms. She wiped them off with tissue paper, and wet black substances easily transferred onto the tissue paper. The surveyor asked the Dietary Supervisor who uses ice from the ice machine and how often the ice machine has been cleaned. She stated, We clean it weekly and wipe it down daily. We use it to fill beverages served to the residents at mealtimes. That's the ice the Certified Nursing Assistant uses to fill the resident's room with water pitchers. 2. On [DATE] at 08:43 AM, the following opened food items stored on the shelf in refrigerator were not covered or sealed. a. A box of Parmesan Cheese. b. A box of sausage patties. c. A box of chicken. 3. On [DATE] 08:45 AM, the following opened food items stored in the freezer were not covered or sealed. a. A box of cobbler crust dough sheets with sheets that were discolored and had freezer burn. The surveyor asked Dietary Employee (DE) to describe the appearance of the dough sheets. She stated, They have freezer burn and I will throw them away. b. A box of dinner dough stuck together frozen with ice cycles. Dietary Supervisor stated, They look like they were refrozen. c. A box of egg rolls. d. A box of broccoli. e. A container of leftover spaghetti with a store date of [DATE]. f. A container of leftover mixed vegetables with a store date of [DATE]. 4. On [DATE] 09:08 AM, the temperature of the upright refrigerator was 51.8 degrees Fahrenheit. The surveyor asked the Dietary Supervisor to check the internal temperature on the carton of the shake and honey milk in a glass on a shelf in the upright refrigerator. She did and stated, House shake was 48 degrees Fahrenheit. The manufacturer's specification on the carton documented, Store frozen. Thaw under refrigeration at 40 or below. A glass of honey thickener milk was 47 degrees Fahrenheit. The surveyor asked the Dietary Supervisor how long the refrigerator had been out. She stated, It has not been long. I think it was disconnected when they were mopping. 5. On [DATE] at 09:40 AM. the following observations were made in the dish washing machine room and the kitchen area. a. The wall paint in the dish room, in the kitchen area was peeling, exposing the cement. b. The air ventilation panels were peeling exposing the metals underneath them. c. The ceiling tile had black/sage stains on it. d. The ceiling tile by the 3-compartment sink had a loose mesh, exposing the concert and cement. The air vents between the 2- compartment sink, the stove, and around the deep fryer had peeling paint exposing the metal underneath them. The paints were also hanging down from panels. e. The edges of the light fixture above the 3-compartment sink had rust stains. f. The light fixture above the upright refrigerator had an accumulation of dirt and lint. g. Above the 2-compartment sink there was settled dirt and lint. 6. On [DATE] at 09:53 AM, one unopened box of vanilla med pass 2.0 was on a shelf in the refrigerator in the pantry (Nourishment) room on 300- hall. The med pass had a manufacturer's best by date of [DATE]. 7. On [DATE] at 09:54 AM, the top panel and the left interior panel of the ice machine in the pantry (Nourishment) room on the 300-hall had wet sage colored residue on them. Dietary Supervisor was asked by the surveyor to wipe residues inside the ice machine. She did, and the sage colored substances easily transferred to the tissue napkins. She was asked, How often do you clean the ice machine and who uses ice from the machine? She stated, The maintenance man cleans it once a month. That's the ice the Certified Nursing Assistant uses to fill the resident's rooms with water pitchers. 8. On [DATE] at 09:59 AM, 7 unopened boxes of vanilla med pass 2.0 were on a shelf in the refrigerator in the medication room on 300- hall. The med pass 2.0 had a manufacturer's best by date of [DATE]. The Nurse stated, We don't have anyone on med pass 2.0. 9. On [DATE] at 10:09 AM, one unopened box of vanilla med pass 2.0 2-cal was on a shelf in the medication room on 200-hall. The med pass had a manufacturer's best by date of [DATE]. 10. On [DATE] 10:15 AM, the left interior panel of the ice machine in the pantry (Nourishment) room on the 200-hall had wet sage residue on them. Dietary Supervisor was asked by the surveyor to wipe residues inside the ice machine. She did so, and the sage colored substances easily transferred to the tissue napkins. She was asked, How often do you clean the ice machine and who uses ice from the machine? She stated, The maintenance man cleans it once a month. That's the ice the Certified nursing assistant uses to fill the resident's rooms with water pitchers. 11. On [DATE] at 10:31 AM, DE #1 turned on the food preparation sink faucet and washed the blender bowl and the blade with hot water. She then turned off the sink faucet with her bare hands, contaminating them. DE #1 did not sanitize the blender bowl or the blade before attaching the blade to the base of the blender to be used pureeing food items to be served residents on pureed diets for lunch. The surveyor asked DE#1 if she should sanitize the blender bowl and the blade before using them. DE #1 stated, Yes, I should have sanitized them. 12. On [DATE] at 10:45 AM, DE #1 placed a pan of pureed cream of corn in the oven. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who required pureed diets. 13. On [DATE] at 10:48 AM, DE #2 touched her blouse. Without washing her hands, she picked up clean bowls to be used in portioning dessert to be served to the residents for lunch the meal and placed them on the counter with her fingers inside the bowls. 14. On [DATE] at 11:05 AM. the floor in the storage room had sage-colored stains on it. The base board was loose, exposing the cement. The air vent in the storage room was covered with lint and rust. 15. On [DATE] at 1:15 AM, Dietary Employee (DE) #1 had mittens on her hands. As DE # was transferring cooked meat into a pan, the mitten on her hand was touching the meat. 16 On [DATE] at 11:29 AM, Dietary Employee (DE) #2 removed a container of peanut butter and a container of jelly from the refrigerator and placed them on the counter. She then removed gloves from the glove box and placed them on her hands contaminating the gloves. She untied a bag of bread that was on the counter. Without removing gloves and washing her hands, she removed slices from the bag, and placed them on the trays, spreading peanut butter and jelly on them. Then topped each slice of bread with another slice of bread and made peanut butter and jelly sandwiches to be served to the residents who requested it with their lunch meal. 17. A facility policy titled Quick Resources Hand Washing documented when to wash your hands, wash your hands as often as possible. It is important to wash your hands. Before starting to work with food, utensils, or equipment. Before putting on gloves and as often as needed during food preparation and when changing tasks.

Based on observations, interviews and record review, the facility failed to ensure that privacy and dignity was maintained for 2 (Resident #9 #13) sampled residents. The findings are: 1. According to list of diagnosis in the electronic records Resident 9 had a diagnosis of history of urinary tract infection, Overactive bladder, Retention of urine, and Acute cystitis. a. According to Significant Change Minimum Data Set (MDS) with the Assessment Reference Date of 4/15/24 Resident 9 scored 07 (indicates severely impaired cognition) on the Brief Interview of Mental Status (BIMS), and that the Resident had an indwelling catheter, and always incontinent of bowel. b. A Care Plan, with a revision date of 05/01/2023, documented that Resident 9 was at risk for impaired Skin Integrity related to (r/t) decreased mobility and incontinence. c. On 05/05/24 at 02:28 PM, the Surveyor observed Certified Nursing Assistant (CNA) #8 and #7 at the bedside of Resident #9 with the blanket pulled back, incontinence brief detached, and privacy curtain not pulled exposing the Resident to her roommate and anyone that entered the resident's room. d. On 05/05/24 at 02:45 PM, CNA #7 acknowledged the privacy curtain should have been pulled prior to pulling back the covers and detaching the Resident's incontinence brief. 2. Resident #13 had a diagnosis of Paraplegia and Quadriplegia. a. According to Quarterly Minimum Data Set with the Assessment Referenced Date of 04/11/24 Resident 13 scored 15 (13-15 indicating cognitive intact) on the Brief Interview of Mental Status. b. A Care Plan for Resident #13, with the revision 04/24/24, documented that the resident had Activities of Daily Living (ADL) self-care performance deficit and impaired mobility related to (r/t) Quadriplegia and contractures. c. On 05/07/24 at 10:15 AM, the Surveyor observed CNA #9 and #10 pushing Resident #13 on the shower bed down the hall to the shower wearing a hospital gown with nothing covering his person. d. On 05/07/24 at 10:20 AM, CNA #9 voiced that she was aware that the resident should have been covered prior to transport but, the decision was not made by her to transport the resident uncovered. e. On 05/07/24 at 10:30 AM, CNA #10 confirmed that she was aware the resident should have been covered prior to transport. CNA #10 voiced there was not a blanket available in the Resident's room and there was no time to get a clean sheet from the linen closet because she was trying to catch up. f. On 05/08/24 at 09:30 AM, the Director of Nursing (DON) voiced that the door should be closed, privacy curtain pulled, and blinds closed prior to providing care to a resident, and a resident should be covered with a sheet when transported via shower bed to protect the resident's privacy and dignity. g. On 05/08/24 at 10:54 AM, the Surveyor was provided a policy titled Resident Rights that documented Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: to privacy and confidentiality.

Based on record review and interviews the facility failed to accurately assess the comprehensive assessment for 2 (Resident #52, #90) sampled residents. The findings are: 1. Resident 52 had a diagnosis of bi-polar, depression, and anxiety disorder. a. A Significant Change Minimum Data Set with the Assessment Referenced Date of 08/24/23 documented that Resident #52 scored 03 (indicating severe cognitive impairment) on the Brief Interview of Mental Status (BIMS), and Resident was not currently considered by the state level II Pre-Admission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. b. A Care Plan for Resident #52, with the revision date of 06/19/2023, documented Resident had mood problem related to (r/t) bipolar disorder. c. On 05/08/24 at 08:15 AM, the Minimum Data Set (MDS) Coordinator was not aware that Resident 52 was considered by the state as PASSAR level II. MDS Coordinator voiced that the electronic records did not reflect that information. 2. Resident #90 had a diagnosis of depression, old Myocardial Infarction, Chronic Obstructive Pulmonary Disease (COPD). a. According to a Smoking Safety Screen, with the effective Date 11/27/2023, documented Resident #90 smoked 2-5 cigarettes per day. b. A Care Plan for Resident #90, with the revision date 04/30/2024, showed Resident had Chronic Obstructive Pulmonary Disease (COPD) and was a smoker at risk for shortness of breath (SOB). c. A Significant Change Minimum Data Set with the Assessment Reference Date of 10/18/23 documented Resident was not a smoker. d. On 05/08/24 at 08:15 AM, the Minimum Data Set Coordinator confirmed Resident #90 was a smoker, it was not coded on the comprehensive Assessment the Resident was a smoker, and the smoking should have been documented on the Significant Change Minimum Data Set (MDS). e. On 05/08/24 at 09:30 AM, the Director of Nursing (DON) confirmed the comprehensive assessment did not reflect Resident #52 was considered by the state as PASSAR level II and Resident #90 was a smoker which was incorrect. f. On 05/08/24 at 3:00 PM, the facility had not provided the Surveyor with a MDS coding policy, or the section of the Resident Assessment Instrument manual used to code.

Based on observation, record review and interview, the facility failed to ensure an effective pest control program was maintained to keep the facility free of pests. The findings are: On 05/07/2410:50 AM, the following observations were made in the kitchen areas during the noon meal preparation and meal serving. a. There were 2 flies at the edges of a cart by the food preparation sink that contained clean scoops. b. One fly was on the wall leading to the dishwashing machine. c. Two flies were on the wall by the plate warmer. d. Two flies were flying around the food preparation area. On 05/07/24 11: 26 AM, there were 4 flies on the corners of a clean dish rack where clean scoops were kept. There was a fly on top of a box of iodized salt. On 05/07/24 11:53 AM, there were 3 flies on the window by the food preparation counter. One was on the menu, one on top of the microwave and one on the right side of the 2-door refrigerator. The surveyor asked the Dietary Supervisor to count the flies that were not moving. She did so and stated, I counted 10 flies, excluding the ones flying. 05/08/24 10:21 AM, the surveyor asked the Dietary Supervisor how long have you been having problems with flies? She stated, It just started, because it started to warm up. Usually, a lot of flies are outside the back door. A Pest Elimination Service provided by the Dietary Supervisor on 05/ 08/2024 at 09:29 AM with following results. a. Service Provided 02/22/204 at 05:32 AM documented, The monthly pest control service and inspection was performed today. All exterior bait stations were dated, and bait was replaced where needed. Found roach activity in the kitchen coming from the wall behind the salad defiled. Flies were not reported. Target Pests . Service provided on 02/26/2024 at 12:01 PM documented, Inspected and treated for roaches. Target: Pest. Flies were not reported. b. Pest Elimination Monthly Fly Service provided on 03/21/2024 at 10:52 AM documented, The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated, and bait was replaced where needed. Treated and replaced all glue boards in the kitchen. Where roach found. Target: Pest. Flies was not reported. C. Pest Elimination Monthly Fly Service Provided 04/22/2024 at 10:30 AM Service Provided. Pest Elimination Monthly Fly Service documented, The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated, and bait was replaced where needed. Treated and replaced all glue boards in areas with roach findings. Target: Pest. Flies were not reported.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 27 residents who had mechanical soft diets. 7 residents received pureed diet from 1 of 1 kitchen. The findings are: 1. The menu for lunch documented the residents on mechanical soft diets and pureed diets were to receive 3/4 cup of pork chili Verde. 2. On 05/07/24 at 11:31 AM, Dietary Employee (DE) #1 used a 6-ounce spoon to place 8 servings of boiled seasoned pork cubes into a blender, ground and poured into a pan. 3. On 05/07/24 at 12:10 PM, the following observations were made on the steam table. a. A 4- Ounce spoon was (1/2) cup was in a pan of ground meat. b. A #8 scoop was in a pan of pureed pork chili Verde. c. On 05/08/24 at 10:57 AM, the surveyor asked the Dietary Supervisor if they ran out of mechanical soft meat when serving lunch meal. She stated, Yes, we did. I did extra 4 more servings. d. On 05/08/24 at 11:00 AM, the surveyor asked DE #1 how many servings of pork chili Verde she prepared for the residents on mechanical soft diets on 05/07/2024. DE #1 stated, I did 7 servings. e. On 05/08/24 12:25 PM, the surveyor asked Dietary Employee #3 what size spoon she used to serve mechanical soft pork chili Verde and how many servings she gave to each resident at the lunch meal on 05/07/2024. DE #3 stated, I don't remember. I gave one serving to each resident. 2. On 05/08/24, the menu for the lunch meal documented that residents who received mechanical soft diets were to receive 4 ounces of blackened chicken breast. a. On 05/06/24 at 12:25 PM, DE #3 was serving a single portion of mechanical soft blackened chicken breast to the residents who received mechanical soft diets. The surveyor immediately asked DE #3 what size spoon she used to serve the mechanical soft chicken and how many servings she gave to each resident. DE #3 stated, I used a 2-ounce spoon, and I gave one serving to each resident.

Based on interview and record review, the facility failed to ensure a dose reduction was implemented for 1 (Resident #82) of 5 (Resident #10, #30, #37, 79, and #82) sampled residents reviewed for unnecessary medication administration. The findings are: A review of a Physician Order, indicated Resident #82 had a diagnosis of Major Depressive Disorder. A Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 5/28/24 documented the Resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMs). A review of a care plan initiated 9/26/22 documented, .Administer antidepressant medications as ordered by physicians . A review of Pharmacy Medication Regimen Review, dated 3/14/24 documented, .Please consider a gradual dose reduction or tapering the dose of this medication in an effort to determine optimal dose or if it may be unnecessary for this resident . It revealed Resident #82 original start date for Sertraline 125 milligrams was on 6/15/2023. The physician recommended reducing the Sertraline to 100 milligrams daily effective 3/14/24. The Director of Nurse (DON) signed the recommendation. A review of the May 2024 Physician Orders, revealed Resident #82 had an order for Sertraline HCI 125 milligrams at hour of sleep. A review of the April 2024 Medication Administration Record, revealed Resident #82 received 125 mg of Sertraline April 1, 2024, through April 30, 2024. A review of the May 2024 Medication Administration Record, revealed Resident #82 received 125 mg of Sertraline May 1, 2024, through May 07, 2024. On 5/08/24 at 1:41 PM, Licensed Practical Nurse (LPN) #4 was asked, How much Sertraline does Resident #82 receive? She looked in the computer at the orders then she stated, 125 milligrams at bedtime. The surveyor asked, Who's responsible for putting the orders in the system when the physician reduces a medication? She stated, The Director of Nurse (DON), or the Assistant Director of Nurse (ADON) put it in the system. On 5/08/24 at 1:44 PM, the DON was asked, Who's responsible for putting the orders in the system when the physician reduces medication? She stated, Myself or the ADON. The surveyor asked Can you tell me how much Sertraline Resident #82 receives? The DON looked in the computer and stated, She gets 125 milligrams at bedtime. The surveyor asked, Can you tell me why the doctor's orders to reduce the Sertraline to 100 milligrams was not implemented? The DON, I don't know why it wasn't changed. I signed the order.

Based on observation, interview and record review, the facility failed to ensure bed rails were not used for 1 Resident #104 of 2 (Resident #90 and Resident #104) sampled residents reviewed for accidents without a side rail assessment to prevent the potential for accidents. The findings are: Resident #104 had a diagnosis of Pressure Ulcer Sacral Region Stage 4. The Medicare-5 Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 4/08/24 did not indicate that Resident #104 used side rails. A review of a side rail assessment dated [DATE], indicated Resident #104 did not use bed rails. On 5/05/24 at 11:45 AM, Resident #104 indicated he needed to be repositioned in bed. His bed rails were up x 2. On 5/05/24 at 11:48 AM, Certified Nurse Aide (CNA) #11 was asked, How long has Resident #104 used side rails? She stated, He's had them since he's been here. On 5/06/24 at 8:54 AM, Resident #104 was in bed. His side rails were up x 2. On 5/07/24 at 3:14 PM, Resident #104 was in bed. His side rails were up x 2. On 5/08/24 11:03 AM, the Assistant Director of Nurse (ADON) was asked, Did Resident #104 have side rails? She stated, That I can't remember. She was asked, If a resident has side rails should the resident have a side rail assessment? The ADON stated, yes. On 5/08/24 at 12:12 PM the DON confirmed Resident #104 used side rails. On 5/08/24 at 12:58 PM the administrator provided a policy titled, Bed Safety. It documented, .If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative .

Based on observation and interview the facility failed to provide a clean oxygen tubing to 1 Resident #97 of 2 (Resident #32 and #97) sampled residents on oxygen therapy, and the facility failed to ensure oxygen tubing was placed in a storage bag for 1 Resident #32 of 2 (Resident #32, and Resident #97) sampled residents on oxygen. The findings are: 1. On 5/05/2024 at 9:02 AM, surveyor entered Resident #32's room to find oxygen tubing lying on the floor. a. On 5/07/2024 at 8:54 AM, surveyor asked Certified Nursing Assistant (CNA) #1 what should a staff person do when a resident's oxygen tubing is found lying in the floor? CNA #1 said go get the nurse. b. On 5/08/2024 at 10:40 AM, surveyor asked Director of Nursing (DON) what should a staff person do when they find oxygen tubing lying on the floor? DON said the tubing would need to be immediately replaced. c. Oxygen administration policy and services were provided by DON. 2. Resident #97 had diagnosis of Moderate Persistent Asthma. The 5-Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 5/03/24 documented the resident scored 00 (00-07 indicates severe impairment) on a Brief Interview for Mental Status (BIMs). The May 2024 physician order documented, .Oxygen 2.5 liters per minutes by nasal cannula as needed . On 5/05/24 at 12:04 PM, Resident #97's oxygen machine was on. The oxygen was not attached to the resident. The tubing was on top of the oxygen machine and was not in a storage bag. On 5/05/24 at 12:30 PM, Resident #97's oxygen machine was on. The oxygen was not attached to the resident. The tubing was on top of the oxygen machine and was not in a storage bag. On 5/05/24 at 12:48 PM Registered Nurse (RN) #1 confirmed Resident #97 gets out of bed with assistance from staff, and staff removes the Resident's oxygen. She was asked, How should Resident #97's oxygen tubing be stored when not in use? RN#1 stated, It should be in a storage bag. On 5/08/24 12:16 PM the DON was asked, If oxygen tubing is not in use where should it be stored? She stated, Usually they're hanging on the concentrators in bags.

Based on observation and interview, the facility failed to ensure hydration was available at all times for 1(Resident #69) of 2 (Resident #69 and Resident #214) sampled residents reviewed for hydration. The findings are: A review of the Physician Order indicated Resident #69 had a diagnosis of constipation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/24 revealed Resident #69 had a Brief Interview of Mental Status (BIMS) of 15 (13-15 indicates cognitively intact). A review of Resident #69's care plan initiated on 10/02/21 documented, .Encourage and assist with fluid intake to promote hydration . On 5/05/24 at 11:58 AM Resident #69 asked the surveyor to get some water. The surveyor asked, How long have you been out of water? Resident stated, I haven't had any all day. The surveyor asked, How often are you out of water? Resident stated, Mostly on weekends. On 5/05/24 at 12:30 PM, Resident #69 doesn't have any water available. On 5/05/24 at 1:40 PM Certified Nurse Aide #11 was asked, Can you tell me why Resident #69 doesn't have any water available? She stated, I haven't had a chance to pass water today. I usually pass it twice a day, but I've been busy. On 5/08/24 at 2:30 PM the Director of Nurse (DON) was asked, Should residents have water available at all times? She stated, Yes.

Based on observations, interviews and record review, the facility failed to ensure 1 Resident #104 of 3 (Resident #54, #91, and #104) sampled residents reviewed for Activities of Daily Living (AD)s nails were clean and that they received a shave. The findings are: Resident #104 had diagnosis of Pressure Ulcer Sacral Region Stage 4. The Medicare-5 Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 4/08/24 documented resident scored 04 (00-07 indicates severe impairment) on a Brief Interview for Mental Status (BIMs) and required substantial/maximal assistance with bathing. A review of a facility policy titled, Shaving the Resident, dated 05/08/2024, indicated, The purpose of this procedure is to promote cleanliness and to provide skin care. A review of a facility policy titled, Fingernails/Toenails, Care of, dated 05/08/2024, indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . A care initiated 3/08/24 documented, .Check nail length and trim and clean as necessary . On 5/05/24 at 11:45 AM, Resident #104's nails had a black substance underneath. His beard was approximately 2 inches long. He was asked, When was the last time you received a shave. He stated, They haven't shaved me since I've been here. I would like to have a shave. He was asked, How often do the staff clean your nails? He stated, They don't. On 5/06/24 at 9:49 AM Resident #104's nails had a black substance underneath, and his beard was approximately 2 inches long. On 5/06/24 at 2:49 PM Resident #104's nails had a black substance underneath, and his beard was approximately 2 inches long. On 5/06/24 at 2:55 PM Certified Nurse Aid (CNA) #11 was asked, How often does Resident #104 get a shave, and get his nails cleaned? She stated, He is supposed to get a shower tomorrow. She was asked, Can you tell me how Resident #104 nails, and beard look? CNA #11 walked in Resident #104's room, looked at his nails, then she stated, Yes they do need to be cleaned, and he needs a shave. 05/08/24 12:15 PM, the DON was asked, How often should he have been shaved and his nails cleaned? She stated, According to his task list Tuesday, Thursdays and Saturdays.

49981 Based on observation, interview, and record review the facility failed to ensure a call light was within reach for 4 (Resident #19, #32, #45, and #82) of 5 (Resident #32, #45, #82, #17, and #19) sampled residents reviewed for call lights. The findings are: On 5/05/2024 at 9:30 AM, during initial rounds, surveyor observed Resident #19 did not have a call light within reach. On 5/05/2024 at 1:26 PM, surveyor observed Resident #32 did not have a call light within reach. The call light was on the floor near the foot of the bed. On 5/06/2024 at 8:33 AM, surveyor observed Resident #19 did not have a call light within reached. On 5/08/2024 at 8:08 AM, surveyor asked CNA #2 what is important to do before exiting the resident's room. CNA said to make sure the residents have their call light. On 5/08/2024 at 8:30 AM, surveyor asked CNA #3 what is one of the last things a person needs to do before leaving a resident's room. CNA said to make sure residents have their call light. On 5/08/2024 at 8:34 AM, surveyor asked CNA #4 what is one of the most important things to do when exiting a resident's room. CNA said to make sure the residents have their call light. On 5/08/2024 at 10:40 AM, surveyor asked Director of Nursing (DON) what is one of the last things staff should do before leaving out of a resident's room. DON said to make sure the residents have their call lights. Resident #45 had a diagnosis of repeated falls, irritant contact dermatitis due to fecal, urinary or dual incontinence, and Candidiasis of skin and nail. According to Quarterly Minimum Data Set with the Assessment Reference Date of 02/29/24 documented that Resident #45 scored 04 (0-7 indicates severe cognitive impairment) on the Brief Interview of Mental Status and, that Resident 45 was always incontinent of bowel and bladder. A Care Plan for Resident #45, with a revision date of 10/03/23, documented the Resident was at risk for impaired skin Integrity related to (r/t) immobility/incontinence and that incontinence care/ peri care should be provided as needed. On 05/05/24 at 09:45 AM, the surveyor observed Resident #45 lying in bed awake with the call light lying on the floor near the middle of the room next to the recliner. On 05/05/24 at 12:08 PM, the surveyor observed Resident #45 lying in bed awake with the call light lying on the floor near the middle of the room next to the recliner. On 05/05/24 at 01:23 PM, the surveyor observed Resident #45 lying in bed awake with the call light lying on the floor near the middle of the room next to the recliner. On 05/05/24 at 2:45 PM, the surveyor observed Resident #45 lying in bed awake with call light on the floor near the middle of the room next to the recliner. On 05/08/24 at 02:45 PM, the surveyor observed Certified Nursing Assistant (CNA) #7 pick the call light off the floor and give it to Resident #45. On 05/06/24 at 03:35 PM, the Surveyor observed Resident #45 lying in bed awake with a call light wrapped around wheel at the foot of the bed and lying tucked in the blanket under the Resident's foot. On 05/05/24 at 02:45 PM, CNA voiced that Resident #45 uses the call light when she needs assistance, and the call light was on the floor out of reach of the Resident. On 05/05/24 at 02:45 PM, the Registered Nurse (IP) voiced that Resident #45 may be able to reach call light, but it would be hard. On 05/08/24 at 09:30 AM, the Director of Nursing (DON) voiced it is important for the Resident to have a call light within reach, so the Resident can call for help. The DON confirmed that if the call light is not within reach it puts the Resident at risk for falls, dehydration, and/or skin breakdown. A review of a Physician Order, indicated resident #82 had a diagnosis of Major Depressive Disorder. A Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 5/28/24 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMs). A care plan initiated on 9/26/22 documented, .Encourage the resident to use call light or ask for assistance as needed . On 5/05/24 at 10:12 AM Resident #82 call light was observed on the floor. Resident # 82 stated, They don't answer the call lights. I have to wait a long time before anyone comes. She was asked, Do you know how to use the call light? She stated, Yes I know how to use it. On 5/5/24 at 10:33 AM Resident #82 cellphone was ringing. She stated, Can you get me my phone? Licensed Practical Nurse (LPN) #5 walked in resident #82 room. LPN #5 confirmed that Resident #82 call light was on the floor, and it should be always within reach. On 5/5/24 at 10:40 AM Resident #82 was asked if she could turn her call light on. She hit the call light button, and it came on. On 5/08/24 at 12:19 PM the Director of Nurse (DON) was asked, Should the call light be within reach at all times? She stated, Yes ma'am.

Complaint # (AR 693) was substantiated, all, or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure as-needed (PRN) pain medication was administered prior to a painful wound treatment in accordance with the plan of care and failed to ensure the licensed nurse stopped the wound treatment and evaluated the need for additional pain medication when the resident exhibited signs / symptoms of severe pain, to control the resident's pain to the extent possible and assist the resident in achieving her highest practicable level of well-being for 1 (Resident #8) of 1 case mix resident who experienced severe pain during wound care. This failed practice resulted in actual harm to Resident #8, who cried, moaned and grimaced throughout treatment to wounds to the lower extremity. The facility also failed to ensure a resident who experienced dental pain due to an abscess was re-evaluated by the Physician or dentist when the resident continued to require pain medication one month after treatment for [REDACTED].#1) of 1 case mix resident who had dental pain. These failed practices had the potential to affect 1 resident who had pain during wound care and 1 resident who had dental pain, according to lists received from the Director of Nursing (DON) on 7/12/18. The findings are: 1. Resident #8 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 6/23/18 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), was totally dependent on 2 people for personal hygiene, required extensive assistance of 2 plus people for bed mobility, had frequent pain with a pain scale of 6 (pain scale 0-10), had 1 unstageable pressure ulcer with eschar, and other open lesion to the foot. a. The Care Plan dated 3/29/18 documented, I have an arterial / ischemic ulcer of the right ankle r/t (related to) vascular insufficiency . (Resident #8) will have ischemic leg pain maintained at a tolerable level . [MEDICATION NAME] as ordered. Observe for side effects and effectiveness . [MEDICATION NAME] administered per schedule and as needed. Administer prior to dressing changes . Avoid mechanical trauma . b. The (MONTH) (YEAR) Physician order [REDACTED]. Cover with non-adhesive foam and secure with Kerlix every day shift, Mon (Monday), Wed (Wednesday), and Fri (Friday). Right heel clean with Dakin's 0.25% apply Hydrogel dressing cover with ABD (abdominal) pad, secure with Kerlix every 8 hours as needed for dressing soiled or dislodged, every shift Mon, Wed, and Fri. Right lateral ankle, clean with Dakin's 0.25% apply Hydrogel dressing cover with ABD pad, secure with kerlix every Mon Wed and Fri. c. The Weekly Wound Note dated 7/9/18 15:58 (3:58 p.m.) documented, Right Heel. 100% moist Eschar. The wound type, Pressure Ulcer. Stage Unstageable due to Slough/Eschar. Onset Date, 5/14/18. Size of wound Length 7 cm x Width 5 cm x 0 Depth. Type of Exudate Serosanguinous, Exudate amount Small. Wound Bed, Eschar. New change in treatment, Dakin's, Hydrogel, ABD Pad, 3x (times)/wk (week) and PRN (as needed).8.0 cm in length x 5.0 in width cm x 0.0 cm in depth with Eschar, black and brown. The weekly Wound Note dated 7/9/18 at 16:02 (4:02 p.m.) and signed by the Treatment Nurse documented, Right ankle (outer) Lateral ankle 80% loose adhered slough 40% granulation. Bone present in wound bed, increased pain if joint articulated. What type of wound: Non-Pressure. Size of the wound: length 11 cm (centimeter) x (by) Width 8.0 cm x 0.0 cm in depth, with Eschar, black brown . Exudates: Serosanguinous Exudate, Moderate, Odor: Moderate, Wound bed: Slough . Type of pain resident is having related to the wound: Severe. Response to treatment: Deteriorated . d. On 7/11/18 at 11:40 a.m., Licensed Practical Nurse (LPN) #1 performed wound care to the arterial ulcer on the resident's right outer ankle and the pressure ulcers to both heels. The resident was lying on her back, and Certified Nursing Assistant (CNA) #1 was holding the resident's hands, standing on the right side of the bed. Throughout the treatments, the resident was moaning, crying, 'No, No' and grimacing. There was a large amount of dark drainage on the soiled dressings that were removed from the wounds. The wound on the left heel measured approximately 8.0 cm in length x 5.0 in width (unable to determine depth), with loose eschar that was black / brown. The wound to the right lateral ankle measured 11 cm x 8 cm (unable to determine depth). The LPN cleansed the right heel and the resident continued crying, 'No, No', with facial grimacing and tears in her eyes throughout the treatment. The LPN did not stop the treatment or attempt any intervention to alleviate the pain, but continued on with the wound care. e. As of 7/12/18 at 11:00 a.m. the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. f. On 7/12/18 at 1:13 p.m., LPN #1 was asked, What type of wounds does the resident have? The LPN stated the resident was a hospice resident and had an arterial ulcer on the right outer ankle and the right heel and, The heel is probably pressure, but I don't want to tell you wrong. The LPN was asked if the resident had pain. The LPN stated, Yes, she has a lot of pain. The LPN was asked if the resident was having pain during the wound treatment on 7/11/18. The LPN stated, Yes. The LPN was asked, Was the resident moaning, saying 'No,' crying, and did the resident have tears in her eyes? The LPN stated, Yes. The LPN was asked, What are you supposed to do when a resident is having pain during a treatment? The LPN stated I try to be as gentle as I can. I don't know if I can stop. The LPN was asked, If the resident continued to say 'No', continued to have facial grimacing, and the resident was crying, what should you have done? The LPN stated, I don't know if I could have stopped. The LPN was asked if she had read the resident's Care Plan. The LPN stated, I honestly don't know. We started the new computer system in December. I haven't read all of it. She was asked, Is the resident supposed to be pre-medicated before treatments? The LPN stated, The [MEDICATION NAME] had been discontinued. The LPN was asked, If you knew the resident had pain during the wound treatment, and when you changed the dressing on the right outer ankle and right heel, and the resident was saying, 'No', moaning and crying, should the wound care have been stopped? She stated, The Treatment Nurse told me on Monday (7/9/18) that the pain medication was not holding her. I called Hospice on Monday regarding the pain. The Hospice Nurse came out and wrote new orders. She was asked, Did you call Hospice yesterday, when the resident was crying and moaning during wound care? The LPN stated, I'm trying to think; no, I talked to the Hospice Nurse today. The LPN was asked, Did you tell the Hospice Nurse that the resident was having pain during the treatment? The LPN stated, No, I told her that the resident cried out during the night. No, I don't believe that I told her about the pain during the treatment. g. On 7/12/18 at 2:20 p.m., the Treatment Nurse was asked, Does the resident have pain during the wound care? The Treatment Nurse stated, On Monday, when I went to wrap the right foot, I manipulated the ankle; it was severe pain. She was asked, If, a resident is crying and moaning during a dressing change, what should the nurse do? The Treatment Nurse stated, The treatment should be stopped. I was not aware that the pain medication prior to the treatment had been discontinued. The arterial ulcer on the right lateral ankle - the bone is exposed - a Doppler was done and she had been scheduled for amputation. She came back (from hospital) on hospice, because she wasn't a good surgical candidate. When she was having pain, she would say, 'I don't want to die.' 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/9/18 documented the resident scored 2 (0-7 indicates severely impaired) on a BIMS, received scheduled and prn pain medication and had pain medication 6 of the last 7 days. a. A Physician order [REDACTED]. Give 400 mg orally every 8 hours as needed for tooth pain, start date 6/9/18 . [MEDICATION NAME] tablet 5-325mg ([MEDICATION NAME]-[MEDICATION NAME]). Give 1 tablet by mouth every 4 hours as needed for dental pain . b. The Progress Notes dated 6/11/18 at 16:40 (4:40 p.m.) documented, Resident returned from Dental appointment.Daughter notified 1835 (6:35 p.m.) and acknowledges understanding. c. The Progress Notes dated 6/12/18 at 8:27 a.m. and signed by Physician #1 documented, Patient (Pt) seen today for management of their chronic disease. Pt was lying in bed during our visit. Since last visit she was seen by a dentist about dental pain. She was seen prior to her dental appt (appointment) and was given [MEDICATION NAME] 500 mg (milligram) po (by mouth) q (every) 12 h (hours) x (times) 7 days and after seeing the Dentist was given [MEDICATION NAME] 300 mg po QID (four times daily) for a dental abscess. She reports discomfort and pain due to the dental abscess. She says the pain keeps her from sleeping well and keeps her from having very much of an appetite. Pt is stable. Nursing reports no new complaints . Assessment / Plan 1. Dental Abscess, continue [MEDICATION NAME] 300 mg po QID until bottle empty and D/C (Discontinue) [MEDICATION NAME] 500 mg. Continue [MEDICATION NAME] 5-325 1 tab (tablet) q 4 hrs. Schedule [MEDICATION NAME] 10 mg BID (two times daily) x 3 days for added pain control. 2. Weight Loss, continue nutrition plan of Med Pass 60 cc (centimeter) TID (three times daily). Reassess after dental abscess has healed as this could be a barrier to eating. d. The Progress Notes for (MONTH) (YEAR) documented the resident continued to have dental pain and received [MEDICATION NAME] 5-325 a total of 42 times during the month of (MONTH) (YEAR) for complaints of dental pain, as follows: 6/10/18 at 10:44 a.m. and 11:43 a.m. 6/11/18 at 10:27 a.m., 12:06 p.m., 7:32 p.m. and 10:35 p.m. 6/12/18 at 7:29 a.m., 12:02 p.m., 5:44 p.m., and 9:24 p.m. 6/13/18 at 9:05 a.m., 12:43 p.m., 2:24 p.m., and 6:15 p.m. 6/14/18 at 8:31 a.m., 1:30 p.m., and 8:20 p.m. 6/15/18 at 8:07 a.m. and 5:41 p.m. 6/16/18 at 8:20 p.m. 6/17/18 at 5:34 p.m. 6/18/18 at 9:16 a.m., 4:30 p.m. and 8:49 p.m. 6/19/18 at 9:29 a.m. 6/20/18 at 1:03 p.m. and 7:48 p.m. 6/21/18 at 9:11 a.m., 1:29 p.m., 5:30 p.m., and 9:45 p.m., 6/22/18 at 9:14 a.m., 1:29 p.m., and 10:58 p.m. 6/23/18 at 6:12 p.m. 6/24/18 at 5:31 p.m. 6/25/18 at 6:39 a.m. and 1:03 p.m., 6/26/18 at 9:05 a.m., 1:18 p.m., and 4:21 p.m. 6/27/18 at 9:21 a.m. and 1:09 p.m. 6/28/18 at 1:16 p.m. 6/30/18 at 4:03 p.m. The Progress Notes for (MONTH) (YEAR) documented the resident received [MEDICATION NAME] 5-325 mg a total of 10 times between 7/1/18 and 7/12/18, as follows: 7/1/18 at 4:31 p.m. 7/4/18 at 10:25 a.m. 7/5/18 at 12:01 p.m. 7/6/18 at 8:44 a.m. and 1:24 p.m. 7/7/18 at 4:09 p.m. 7/9/18 at 9:31 a.m. 7/10/18 at 8:10 p.m. 7/11/18 at 9:12 a.m. 7/12/18 at 8:47 a.m. e. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. From (MONTH) 12, (YEAR) to (MONTH) 12, (YEAR), there was no documentation in the progress notes of any nursing assessment of the resident's mouth to determine if the abscess was improving. There was no documentation in the Progress Notes for (MONTH) and (MONTH) (YEAR) to indicate the physician was consulted when the resident continued to complain of dental pain one month after the treatment for [REDACTED]. f. On 7/12/18 at 2:20 p.m., Licensed Practical Nurse (LPN) #1 was asked if she had administered pain medication to Resident #1. The LPN stated, Yes. The LPN was asked if she consulted the physician when the resident continued to experience dental pain after a month. She stated she did not. The LPN was asked if the physician should have been consulted when the resident continued to complain of dental pain for 1 month and stated, Yes. g. On 7/12/18 at 2:30 p.m., the Assistant Director of Nursing (ADON) for the 300 Hall was asked if she was aware the resident had been medicated for dental pain for the past 30 days and that there was no documentation the physician had been notified and she stated No. The ADON was asked if the physician should have been consulted regarding the resident's continued complaints of dental pain and stated, Yes. h. On 7/12/18 at 5:25 p.m., the Social Service Director (SSD) was asked about Resident #1's dental issues and stated he had spoken to Resident #1's daughter on several occasions regarding making an appointment with a dentist. The SSD was asked if the staff had notified him that the resident was continuing to have dental pain and continued to receive [MEDICATION NAME] 5-325 mg for the pain. The SSD stated he was not aware of the continued dental pain. i. On 7/25/18 at 5:25 p.m. the Director of Nursing (DON) was informed of the resident's ongoing complaints of dental pain and continued administration of [MEDICATION NAME] and was asked if this should have been addressed with the physician. The DON stated the resident's daughter had been contacted and was to have made an appointment with a dentist. The DON was again asked if the physician should have been consulted and stated, Yes.

Complaint # (AR 69) was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to provide adequate supervision to ensure 2 staff persons were utilized as per the resident's care plan during the use of a mechanical lift; to ensure staff competency with mechanical lifts were routinely monitored; and to ensure staff reported any suspicions of failure to use a mechanical lift appropriately to prevent potential injuries for 1 (Resident #1) of 5 (Residents #1, #3, #4, #5 and #6) case mix residents who required the use of a mechanical lift for transfers. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who sustained a head laceration and fractured leg after a fall from a mechanical with only 1 staff person operating the lift and had the potential to affect 20 residents who required 2 person transfer with the use of a mechanical lift according to a list provided by the Director of Nursing (DON) on 2/3/16 at 11:21 a.m. The facility removed the Immediate Jeopardy on 1/20/16 prior to survey entrance date, however, the underlying deficient practices were not corrected. The Director of Nursing (DON) was informed of the Immediate Jeopardy on 2/4/16 at 11:18 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/15 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status and totally dependent on two people for transfers. a. The Care Plan dated 12/10/15 documented in the Problem section, I need total assistance with my activities of daily living. The Approach section documented, I require the use of a mechanical lift and 2 staff for all transfers; please be safe and transfer me correctly. b. A Nurse's Note dated 1/20/16 at 6:59 a.m. and written by Licensed Practical Nurse (LPN) #1 documented, This nurse was summoned to (Resident) room 300. Upon entering the room I observed a res (resident) on the floor bleeding from her head and res was moaning aloud. I assessed her body. As I turned her to her back, the res yelled out with a cry and grabbed her rt (right) pant in the thigh area. VS (Vital signs) (blood pressure) 194/146, P (pulse) 86, RR (respirations) 20 . 1) A Resident Incident Report dated 1/20/16 at 5:15 a.m. documented, CNA (Certified Nursing Assistant - CNA #2) was transferring this res using mechanical lift when the pad slipped from under this resident and the res fell to floor. Back of res head was bleeding from an open area in the center area of the back of her head. She also grimaced and yelled out grabbing her rt thigh area. 2) A DMS (Division of Medical Services)-7734, Incident and Accident Next Day reporting Form, dated 1/21/16 documented, 1/20/16 - At approximately 6:15 a.m., while an aide was transferring the resident to her wheelchair using the mechanical lift, the resident fell out of the lift sling. The care plan for the resident and facility protocol for lift use each called for a two person assist with the lift. The aide was transferring alone. The resident was sent to the hospital for evaluation. The aide performing the transfer was suspended pending investigation . 3) A DMS-762, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, dated 1/28/16 documented, At approximately 5:15 a.m. on 1/20/16, an aide was transferring the resident from her bed to her wheelchair using a mechanical lift. During the transfer the aide states that the resident's right leg fell out of the sling. When it did the aide let go of the handle to keep the head of the person being transferred up. This caused the head to fall down giving the resident a laceration on the head . The resident's care plan indicates that the resident is a two person assist . In conclusion the aide has been terminated for not following facility protocol for transfer, lift operation and for not following care plan. c. A Hospital Emergency Department Note dated 1/20/16 documented, Patient seen on arrival with resident. Patient arrived by EMS (emergency medical services) from nursing home where she reportedly fell from a lift during a transfer. The patient has dementia . Patient moaning through exam. Patient found to have a laceration to the occipital region . Impression: Subdural hematoma . fall from a bed lift 4-5 feet, she has a laceration . RLE (right lower extremity) was entrapped in lift during the fall . Impression: New oblique comminuted fracture involving the right femur adjacent to the tip of the dynamic hip screw . A Hospital Discharge Summary dated 1/22/16 documented, (Resident #1) is a 96 yo (year old) . admitted [DATE] from her NH (nursing home) after a fall with subsequent R (right) femur fracture and SDH (subdural hematoma). Family has elected against intervention regarding SDH or fracture and is pursuing comfort care measures . Hospice. d. On 2/3/16 at 6:50 a.m., CNA #1 was asked what happened with Resident #1 the morning of 1/20/16. She stated, I saw the nurse running down there. I went down to assist with vital signs. (Resident #1) was on the floor, bleeding. (CNA #2) had blood all over her. I did the vital signs, gave them to the nurse. I don't know if (CNA #2) tried to catch her or what. She was already in the floor when I got there. Then the nurse got ready to send her to the hospital. CNA #1 was asked if she knew why CNA #2 did the transfer by herself. She stated, She had a habit of doing it by herself. She did everything by herself. She wouldn't ask for help and if we offered, she would refuse. CNA #1 was asked if she had ever reported this to administration. She stated, You know? That never crossed my mind. We have told (CNA #2) 'get those people dressed and we will help you get them up.' Her words were 'I got it.' That's what she would say. She wasn't a team player. CNA #1 was asked how she thought the resident fell that morning. She stated, I don't know how she came out. If she's hooked up right and she's positioned correctly, there ain't no way she could come out. CNA #1 was asked if the Hospice CNAs in the facility had been trained on how to use the mechanical lift. She stated, Yes. That's another thing. They came in that morning. She could have gotten them to help. e. On 2/3/16 at 8:08 a.m., LPN #1 was asked what happened the morning of 1/20/16. She stated, There were four CNAs on the hall. CNA #2 was at the front. Sometime around 5 (a.m.), (CNA #2) came running down to the Nurse's station yelling 'call the paramedics! She fell !' I ran down there and I saw (Resident #1) on the floor bleeding from her head and moaning. I told (CNA #1) to get vitals. I rolled her over and when I did that, she yelled. I went and called the doctor and got an order for [REDACTED]. When the paramedics got here, they rolled her and she yelled out so bad. When she got to the hospital, I got a call from a doctor who said her leg was broke and that he was going to admit her to ICU (intensive care unit). LPN #1 was asked at what point did she know how the resident fell . She stated, When I was waiting for the ambulance, that's when I asked (CNA #2) how she fell . She told me and I said to her that's why you got to have two people. People here have been fired because they don't get help. The rule is you dress your people in bed then you get help. She said she knew that. LPN #1 was asked if CNA #2 routinely did mechanical lift transfers by herself. She stated, No. I asked her that morning why she did that by herself. She said I don't know. LPN #1 was asked if she did routine monitoring of the night shift CNA's on their ability to use the mechanical lift. She stated, I often am the second person, the spotter, on using the lift with the CNAs. But as far as having a schedule and documenting it, no. f. On 2/3/16 at 12:30 p.m., CNA #2 was asked what happened the morning of 1/20/16. She stated, I hooked everything up and the leg part of the sling just fell off. It came undone. When I went to catch her leg, she went back and her head hit the leg of the lift. Even though her head hit that, her leg was hung up in the sling. The CNA was asked if she was aware that she was supposed to have another person in the room with her to assist with the lift. She stated, Yes, I was aware. The CNA was asked why she did the transfer by herself. She stated, There's only so many people on the night shift and everybody else was busy getting their residents up. It's hard on night shift. CNA #2 was asked if she stopped to think that an accident might happen if she did the transfer by herself. She stated, I know accidents can happen, but it can happen with two people too. The CNA was asked if she normally did mechanical lift transfers by herself. She stated, No. That was the first time. CNA #2 was asked how long she had been on night shift. She stated, Probably about two months. I've been in long term care a little over eleven years. The CNA was asked if anyone such as the night shift nurse or DON had watched her use the mechanical lift recently or routinely to see if she was using it correctly. She stated, No. g. On 2/4/16 at 11:41 a.m., CNA #3 was asked what happened the morning of 1/20/16. He stated, The CNA down there, she was late coming to work. I saw her a couple of times during the shift, but she was late doing her stuff. The nurse told me I was supposed to be her spotter. I went down there and she said she wasn't ready. I went back in a little bit and she said she didn't need any help. I heard the next day that the lady got real bad hurt. CNA #3 was asked if CNA #2 routinely did mechanical lift transfers without assistance. He stated, I don't know that. But all the residents on that end of the hall are lifts and she never asked for help. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/25/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status and required extensive assistance of 2 staff for transfers. a. The Care Plan dated 1/29/16 documented in the Problem section, I need extensive assistance with my activities of daily living. The Approach section documented, I transfer with Marissa Lift and two person assist. b. On 2/3/16 at 11:40 a.m., the resident was asked if she was transferred with a mechanical lift. She stated, Yes. A Hoyer lift. The resident was asked if there was always two staff using the lift during her transfer, or if there was sometimes only one. She smiled and stated, Well . I guess I need to be honest. They sometimes do it by themselves, but for the most part they use two. At this time, the resident's roommate stated, Sometimes it's not worth having to wait for the second person because it takes forever. Resident #6 was asked how recent someone transferred her using a lift by themselves. She stated, Oh . I don't know. She was asked if it had happened in the past week. She stated, Yes. She was asked if it happened on every shift. She stated, I would have to say it's mostly day shift. 3. On 2/4/16 at 10:09 a.m., the DON was asked if the facility had a system in place to routinely monitor staff on their ability to use a mechanical lift prior to the incident on 1/20/16. She stated, No. We had a big skills blitz back in August 2015. That's when we did the training for everyone. We did IV's (intravenous), lifts, everything. We made staff get in the lift to see how it felt. The CNAs loved it. They got to ask questions. They got to feel what the residents were feeling. We have done a lot of in-services since then, but as far as lifts . I don't think we have covered lifts since then. The DON was asked if she was aware Resident #6 had stated staff had transferred her by themselves with the lift in the past week. She stated no. She was asked if she was aware another CNA knew CNA #2 had routinely transferred residents with a lift by herself, but had not reported this to administration. She stated no. 4. The facility removed the Immediate Jeopardy on 1/20/16 and the scope/severity was reduced to a G on 1/20/16 when the facility initiated the following interventions: a. 1/20/16 - CNA #2 was suspended immediately after incident. b. 1/20/16 - Investigation was started on incident. c. 1/20/16 - All lifts and lift pads were inspected per Manufacturer's Guidelines by Maintenance to ensure equipment was in proper working order. d. 1/20/16 - Staffing was reviewed from that shift to assure proper staffing was in place. e. 1/20/16 - Discussed incident with Quality Assurance (QA) Committee. QA monitoring started immediately. f. 1/20/16 - Nurses were trained on lifts and transfers so they could properly observe correct technique and protocol. g. 1/20/16 - In-serviced staff on Abuse/Neglect, and reporting. h. 1/20/16 and 1/21/16 - Staff in-serviced with return demonstration for use of mechanical lifts. Staff did not work until they were signed off for proper use and technique according to Manufacturer's Guidelines. i. 1/20/16 - Started monitoring lift use every shift with 3 residents each shift and have continued monitoring. j. 1/20/16 and 1/21/16 - All residents who use lifts and slings were reviewed for proper sizing. k. 1/28/16 - CNA #2 was terminated.

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure Resident #1 received and the facility provided the necessary care and services to attain or maintain the highest practicable well-being. The facility failed to ensure staff responded to an emergent change in condition for 1 (Resident #1) of 1 case mix resident who repeatedly complained of choking during the evening meal as evidenced by facility failure to ensure the resident was thoroughly assessed for choking, to attempt the [MEDICATION NAME] maneuver or other emergency action when the resident repeatedly stated she was choking, and to attempt to obtain vital signs when resident became unconscious. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who expired after a choking incident in the dining room, and had the potential to cause more than minimal harm for 10 residents who were at risk of choking due to swallowing problems. The Administrator was informed of the Immediate Jeopardy on [DATE] at 2:00 p.m. The findings are: 1. The facility's policy and procedure titled "Change in Resident's Condition/Notification", provided by the Director of Nursing (DON) on [DATE], documented, "Anytime there is a change of condition, the nurse must complete the following: Do a complete assessment. Vital signs (to include pulse ox), assess lung sounds, check neuro (neurological) function, check cardiovascular function. Perform any emergency treatment necessary (must be an immediate response, don't hesitate, have other staff member call for help). Stop bleeding, apply oxygen (may apply O2 at 2 LPM (liters per minute) without MD order per nurse practice act). Support any broken areas with towels or other materials. Notify the doctor. Notify family, administration and any other parties of interest. Note: Never leave the resident without a licensed nurse in case of emergency change of condition." 2. Resident #1 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident scored 2 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status and needed set-up assistance for meals and supervision for eating. a. A Nurse's Note dated [DATE] at 9:22 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "CNA (Certified Nursing Assistant) told this nurse that resident said she was choking. Resident was at table. I asked what's wrong, resident was whispering. I was unable to understand what she was saying. The resident coughed. She didn't appear to be choking. Resident sounded gurgley. The resident's mouth was open, did not see food in her mouth. Resident took her bottom dentures out her mouth. This nurse went to main dining room to get nurse working resident hall. Informed her of above. I came back to nurses' station. CNA stated resident didn't look good. Resident appeared pale, trying to get air. Pushed her to her room. Her nurse arrived, I went to get chart to check code status." On [DATE] at 11:35 a.m., the surveyor asked LPN #1about the incident involving Resident #1 on [DATE]. She stated, "(CNA #2) told me the resident said she was choking. She didn't appear to be choking because she was speaking words. I couldn't understand her. I was like, ok, she's coughing and whispering so she's not choking on food. She did sound a little gurgley. She didn't appear to be in any distress. So I went to her nurse and told her what I had observed. She said she had been a little gurgley... I didn't think above and beyond that because I wasn't sure what had been going on with her." The surveyor asked LPN #1 what type of assessment of the resident she did when the CNA first reported to her that the resident was choking. She stated, "The resident took out her teeth, she was coughing, I looked in her mouth..." The LPN was asked if she did a lung assessment. She stated, "I did not. That's when I went to get her nurse. When I came back, the resident was still at the table. The CNA said she said she was still choking." The surveyor asked LPN #1 how much time went by from the time she left to go get the resident's nurse and the time she came back to the fine dining area. She stated, "Just a matter of minutes. Then just a few minutes later the CNA said she needed help. The resident was pale and I had her pushed to her room." The surveyor asked the LPN what the resident was doing as she was pushed to her room. She stated, "I don't recall anything. She was breathing. I remember her taking a few deep breaths like she was gasping for air. Her nurse came and I went to get the chart. They were about to lay her down when I left the room." The surveyor asked LPN #1 who took the resident's vital signs. She stated, "I'm not sure. When I walked back to the room, the nurse said she's gone." The surveyor asked the LPN if anyone attempted the [MEDICATION NAME] maneuver. She stated, "No." The surveyor asked why and the LPN stated, "I didn't because she was coughing and speaking." The surveyor asked the LPN why (the [MEDICATION NAME] maneuver) was not attempted when the resident stopped speaking and became unconscious. The LPN did not verbally respond, but shook her head. The surveyor asked LPN #1if she thought it was appropriate to initially leave the resident after the resident said she was choking. She stated, "Right, right... I thought about that after the fact. I should've sent the CNA..." b. A Nurse's Note dated [DATE] at 10:25 p.m. and signed by LPN #2 documented, "...This nurse was assigned to work in dining room for supper. The other nurse came to dining room and told this nurse about 1810 (6:10 p.m.) that CNA had reported to her that resident was choking. She assessed resident and she was talking, took her teeth out and had no sign of choking but did sound a little gurgley. This nurse told the other nurse she had been gurgley and this nurse would check as soon as I got out of dining room. Then maybe 3 minutes later, this nurse was paged STAT (immediately) about 1813 (6:13 p.m.). This nurse went to room where resident was. She was very pale sitting up in her wheelchair having labored breathing and then all of a sudden turned a blue/grey color and stopped breathing. A finger sweep was done on resident when this nurse entered the room with no foreign objects noted. Resident was gasping. This nurse had staff help to lay (the resident) down as other nurse checked the chart. She took one deep gasp and was absent of all vitals at this time which was 1615 (4:15 p.m.). Supervisor called, MD (Medical Doctor) called...Coroner called, daughter called to make aware. Spoke to DON (Director of Nursing)..." 1) On [DATE] at 1:25 p.m., the surveyor asked CNA #2 about the incident on [DATE] involving Resident #1. She stated, "I was assigned to the fine dining room on 300 hall. I was passing trays when (Resident #1) reached out and touched me. I turned around and said, 'Yes ma'am?' She put her hands to her throat and whispered, 'I'm choking'. I told the nurse (LPN #1) she said she was choking." The surveyor asked CNA #2 what the nurse did. She stated, "She came over and assessed her. She coughed a little but, didn't cough anything up. The nurse said, 'She's able to talk and cough. She's ok'. Then she went and told the other nurse. (Resident #1) was still saying, 'I'm choking'." The surveyor asked the CNA what the resident had eaten. She stated, "There was a pimento cheese sandwich and some vegetables and a dessert but, I don't know if she had eaten it..." The surveyor asked what happened next. The CNA stated, "When (LPN #1) came back, she said (LPN #2) said she'd check her when she came back. I did tell her again at that time that the resident said she was still choking. (LPN #1) said, 'She's ok' and went and sat down. Even after she sat down, I told her one more time the resident said she was still choking but, she didn't come back over there." The surveyor asked CNA #2 if she believed the resident when she said she was choking. She stated, "If she tells you she's choking, then something's wrong... So I went on about my job. Then I turned around and she was laid back in her chair just as pale... I yelled for (LPN #1) and we got to her at about the same time. We took her to her room. When (LPN #2) came in, she looked at her and said, 'Oh, my God, she's dead..." The surveyor asked CNA who took the resident's vital signs. She stated, "No one did. She just looked at her and said she's dead." The CNA was asked if anyone attempted the [MEDICATION NAME] (maneuver). She stated, "No. I've since been in-serviced and told she was not choking." 2) On [DATE] at 12:26 p.m., the surveyor asked LPN #2 about the incident on [DATE] involving Resident #1. She stated, "I was assigned to the main dining room... it was close to 6:00 p.m. The other nurse came over and said that one of my residents was choking but, she took her teeth out and was talking, and she checked her mouth. She also said she was gurgling. Well, (Resident #1) had been kind of gurgling. The nurse just came walking in like it was no big deal, so I didn't think anything about it. Then maybe 3 minutes later - it could've been longer - you know how time gets away, they paged me STAT. I went into her room, she was gray. She was having periods of apnea. As we laid her down, she took this big gasp and that was it. Her mouth was open and I didn't observe anything in her mouth at all." The surveyor asked the LPN why she did not go and assess the resident when LPN #1 first came and told her the resident was choking. She stated, "If there had been an emergency, she wouldn't have come walking in there like she did. If it was me, I would have never left the resident. It doesn't matter what hall I'm on, I would have never left her." The surveyor asked the LPN if the [MEDICATION NAME] maneuver was attempted. She stated, "No." The surveyor asked why and she stated, "I don't know." The surveyor asked the LPN who took the resident's blood pressure. She stated, "I think (CNA #2) did." The surveyor asked if anyone did a lung assessment. She stated, "I did not." The surveyor asked who felt or listened for the resident's pulse. She stated, "I don't know that anybody checked her pulse." The surveyor asked LPN #2 if she told the coroner that the resident had complained of choking prior to her death. She stated, "No, I didn't even think about it." c. The Pulaski County Chief Deputy coroner report, issued to the facility on [DATE], documented, "To Whom It May Concern, In accordance with Act 499 of 1999, please be advised this office has completed the investigation into the death of the above captioned decedent (Resident #1). It is the determination of this office that the death is of natural causes and no further investigation is warranted at this time." On [DATE] at 12:14 p.m., the surveyor asked the Chief Deputy Coroner of Pulaski County about the normal protocol for determining if a nursing home resident died of natural causes. He stated, "If a death is reported, we get information from the nursing home on the phone, like patient history, ask about any injuries, falls, etc. (etcetera),... The LPN told me the resident had fallen last week. Based on what we were told, we didn't feel the need to go out and take pictures or anything." The surveyor asked the Deputy Coroner if he was informed that the resident possibly choked. He stated, "No. There was nothing mentioned about possible choking." The surveyor asked if that information would have changed anything about his investigation. He stated, "Had we known, we would've come out and at least taken some pictures and maybe looked at it from a different angle. It would depend on what the investigator found out." d. On [DATE] at 10:46 a.m., the surveyor asked LPN #3, who worked ,[DATE] (7:00 a.m. - 3:00 p.m.) shift on [DATE], about Resident #1. She stated, "She was able to feed herself but, had a poor appetite. Occasionally, we could get her to eat a grilled cheese. The day she passed, that was the most food she had eaten in a couple of weeks (referring to lunch). She had chronic headaches. She would always ask for pain medicine. She could talk but, she couldn't hear at all. I wrote her notes. She could talk to you about current events if you just took the time. She would tell me if she felt bad or if she was hurting. She would tell me on Mondays, 'Oh I'm so glad you're back.' She would talk about current events, like ball games. She'd say, 'Oh you should've seen the game!' If she was constipated, I'd give her medicine and then the next day she would tell me, 'I had a good one.' She could tell you a lot." The surveyor asked LPN #3 if the resident normally made gurgling noises. She stated, "No. Not unless she had a URI (Upper Respiratory Infection)." The surveyor asked if the resident had symptoms of a URI the day she passed. The LPN stated, "No." The surveyor asked if the resident told her she was choking, would she believe her. She stated, "Yes, I sure would." The surveyor asked the LPN if it was normal for the resident to whisper. She stated, "No, but she does talk soft." e. On [DATE] at 11:12 a.m., the surveyor asked CNA #1 about the incident on [DATE] involving Resident #1. She stated, "I had just got finished feeding. I was leaving the main dining room with a resident and stopped by the nurses' station. (CNA #2) was calling for a nurse. (LPN #1) got up from the nurse's station and then they wheeled her to her room." The surveyor asked the CNA why the resident was wheeled to her room. She stated, "Because she acted like she was choking. Then (LPN #1) said to call (LPN #2) STAT, so I did. Then I went to the room, put gloves on and did a finger sweep. At that time (LPN #2) came up with a pulse ox (pulse oximeter) - it got nothing." The surveyor asked CNA #1 who took the resident's vital signs. She stated, "To my knowledge, nobody." The surveyor asked if anyone took a stethoscope and listened to the resident's lungs or heart. She stated, "I did not see that. I just heard (LPN #2) say 'she's gone'. Then me and (CNA #2) put her to bed and cleaned her up." f. On [DATE] at 10:00 a.m., the Director of Nursing (DON) provided a copy of an inservice for facility LPNs that was conducted on [DATE] regarding the incident that occurred on [DATE] involving Resident #1. The inservice sheet documented, "When a resident has expired, no post mortem care will be performed until both the physician and the coroner have released the body. Do not remove foley catheters, feeding tubes, O2 (oxygen) tubing, clothing, eye glasses, etc until the body has been released. Do not alter or change the position of the body until the body has been released. Upon release of the body, the nurse will remove any IV (intravenous) access, foley catheter, disconnect feeding tubes, etc. Then the resident's body may be cleaned and positioned respectably. Do not touch the body until it has been released. In the event of death, notify the physician and document the date and time of notification as well as the time 2 nurses declared an absence of vital signs. Notify the coroner and the family. The coroner may ask for information such as events leading to death, presence of wounds, medical history, etc. So be prepared to answer any questions. The family will confirm the mortuary of choice. When the coroner releases the body, the doctor will give an order to release the body as well. You must write an order to release the body. The mortuary will be notified after the order to release the body has been received. The mortuary representative will sign the attached form at the time the body is picked up." The inservice did not address responding to a resident or assessing a resident at the time of an emergent change in condition. g. On [DATE] at 2:00 p.m., the DON provided an in-service sheet (not dated) that documented, "Emergency management: In emergencies, always stay calm. Respiratory problems: get sat O2 (blood oxygen saturation), add O2. Get vitals. Get resident away from other residents when you can. Call 911 for medical emergency." Only 8 nurses had signed the signature sheet. According to a list of current employees provided by the Administrator on [DATE] at 2:29 p.m., the facility employed 33 nurses. 3. The immediate jeopardy was removed and the scope and severity lowered to "G" when the facility implemented the following Plan of Removal: "1) Suspension of two LPNs at 1500 (3:00 p.m.) [DATE] pending further investigation related to allegation of delay in treatment, identification, assessment and timely response to a change in a resident's condition per the CEO (Chief Executive Officer). 2) Inservice/retraining on change of condition notification, timely treatment and nursing assessment are being completed with all staff that are currently in the facility with verbalization of understanding and all other staff that are not currently in the facility will be inserviced and retrained and will not be allowed to begin their assigned shift until they have been inserviced and retrained by DON and or designee. Inservice and retraining started [DATE] at 1500 per the Director of Nursing to be completed immediately and staff that are currently working will not be allowed to end shift until inservice and retraining is completed. 3) DON and or designee will monitor ongoing for proper assessment and change of condition notifications and timely treatment during morning start up to include nursing notes and 24 hour reports. All negative findings will be reported to the CEO which will provide information to the QA (Quality Assurance) committee for review and recommendation with all negative findings being addressed immediately per the Director of Nursing. 4) 109 residents have the potential to be affected by the identified practice and all full MDSs completed in the last 30 days were reviewed for change of conditions [DATE] at 1400 (2:00 p.m.) without negative finding per the MDS Coordinator and DON."