Every finding on record at Pruitthealth - Fairburn

Based on staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to develop and implement a plan of care that accurately reflected physician ordered interventions for one of four residents (R) R17. The deficient practice had the potential for R17 to not receive treatment according to her care needs. Findings included:A review of the facility's policy titled, Care Plans revised of 10/21/2025, revealed the comprehensive person-centered care plan would be developed to include measurable goals and timeframes to meet a residents' medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment.A review of R17's clinical record revealed R17 was admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure and chronic kidney disease stage 3B.A review of R17's admission Minimum Data Set (MDS) assessment, dated 08/04/2026, Section V (Care Assessment Area [CAA] Summary), revealed the assessment triggered nutritional status, and dehydration/fluid maintenance.Review of the physician orders dated 07/30/2026 specified R17 was to be weighed daily for 30 days, with an effective date of 07/31/2026 and should not exceed more than 2000 millimeters (ML) per day. The order specified 360 ml fluid should be allocated for each meal from dietary consisting of 360 ml breakfast, 360 ml lunch, and 360 ml dinner, and 460 ml nursing allocation during the day shift and 460 ml nursing allocation during the night shift, for a maximum total of 2000 ml in 24 hours. The order also specified that the day shift allocation included 240 ml from a glucerna shake.Review of R17's care plan dated 07/31/2026 identified an approach to weigh and monitor results on admission weekly x 4, that did not reflect the physician order which specified daily weights for 30 days. Additionally, the care plan did not specify R17 required a 2000 ml fluid restriction.During an interview on 08/10/2026 at 8:43 AM, the Director of Health Services (DHS) stated the care plan interventions should include fluid restrictions and daily weights and should be triggered for the CNA point of care, so they are aware of R17's needs on their task list. Interview on 08/10/2026 at 12:49 PM with the (MDS) Coordinator Licensed Practical Nurse (LPN) PP stated the weight order noted on the care plan should have been written for weights to be done as ordered and not as written for a specified time such as once-a-week x 4 weeks. Interview on 08/10/2026 at 11:04 AM with the Regional Nurse Consultant (RNC) revealed that R17's physician orders should match the care plan. Cross Reference 684

Based on observations, staff interviews, record review and review of the facility's policy titled Administration via Central Infusion Access Device, the facility failed to expel air from a normal saline syringe prior to flushing a peripherally inserted central catheter (PICC) line for one of one resident (R) R9 with a PICC line. This deficient practice had the potential to cause air embolism (air bubbles in a blood vessel that block the flow of blood) to R9.Findings include: Review of the facility's policy titled Administration via Central Infusion Access Device revised 12/11/2015 documented Page four of six, Intermittent:12; Remove normal saline syringe from kit, flush and remove AIR. After Medication Has Infused: 19; Remove normal saline syringe from kit flush. Remove AIR.Review of the electronic medical records (EMR) documented R9 was admitted to the facility on [DATE] with diagnosis included but not limited to sepsis.Review of the 5-day Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 15 which indicated R9 had intact cognition, Section I (Active Diagnosis) R9 had Septicemia and Section N (Medications) R9 received antibiotics.Review of care plan dated 07/30/2026 documented included but not limited to R9 receives antibiotic medication related to (R/T) Bacteremia (blood infection) with intervention to administer antibiotic as ordered. Review of Physician's Orders dated 07/31/2026 documented included but not limited to Zosyn in dextrose (iso-osm) (piperacillin-tazobactam-dextrs) piggyback; 4.5 gram/100 milliliters (mL); amount (amt): 1; intravenous (IV), Special Instructions: Zosyn 4.5 grams (G) IV intravenous every eight hours (Q8hrs) x 12 days, 06:00 AM, 02:00 PM, 10:00 PM.Observation on 08/09/2026 at 2:22 PM during PICC line observation with Licensed Practical Nurse (LPN) MM revealed she did not expel the air from the normal saline syringe and was about to connect the syringe to the PICC line port to flush the tubing, prior to infusing the antibiotics. The surveyor stopped LPN MM, and she proceeded to expel the air from the syringe. Unit Manager (UM) CC was present during the observation.Record review of the requested LPN MM's PICC line competency checklist revealed the facility's competency checklist for PICC line titled Comprehensive Skills Competency Checklist for PICC Flushing & Locking. was completed on 08/09 2026, which was the day of the PICC line observation during the survey. Interview on 08/09/2026 at 2:50 PM with LPN MM revealed she confirmed and verified that she did not expel the air from the normal saline syringe and was about to connect the syringe to the PICC line port to flush the tubing when the surveyor stopped her. She stated that prior to infusing the antibiotics, the PICC line was to be flushed and the air in the normal saline syringe needed to be expelled from the syringe before the syringe was connected to the PICC line tubing. She stated the normal saline syringes contain air before they were opened and she needed to always expel the air before flushing the tubing. During the interview, LPN MM opened a new normal saline syringe and confirmed that the syringe had approximately one ml of air. She attempted to expel the air from the syringe three times by holding the syringe slanted horizontally. LPN MM stated that a negative outcome when she did not remove the air from the syringe would be air would go into R9's bloodstream and cause an embolism. Interview on 08/09/2026 at 2:55 PM with UM CC revealed she stated LPN MM did not expel the air from the normal saline syringe and was about to connect the syringe to the PICC line port to flush the PICC line, prior to infusing the antibiotics. She confirmed the surveyor stopped LPN MM just as she was about to connect the syringe to the PICC line and that was when LPN MM expelled the air from the syringe. UM CC stated that a negative outcome when air is not expelled from the normal saline syringe would be R9 could get an air embolism.Interview on 08/10/2026 at 11:24 AM with the Director of Health Services (DHS) revealed she stated her expectations were for the nurses to expel air from normal saline syringes prior to flushing the intravenous tubing. She stated the process included holding up the syringe to get rid of the air bubble, then the nurse could thump the syringe with the fingers, then push the normal saline up to the tip until one drop of normal saline came out. The nurse could also look to see if the air bubble was out of the syringe. The DHS stated it was not ok to flush IV tubing without first getting rid of the air in the syringe. She further stated that if the air bubble was not removed from the syringe, and the air was pushed into the IV tubing, the resident could get an air embolism.

Based on observations, interviews, record review, and review of the facility policies titled, Weight Monitoring Program and Fluid Restrictions, the facility failed to ensure one of four residents (R) R17 received treatment and care in accordance with the physicians' orders. Specifically, the facility failed to ensure physician ordered daily weights were obtained and failed to implement and monitor a physician-ordered fluid restriction for R17.Findings included:Review of the facility policy titled Weight Monitoring Program revised 06/02/2023, stated that each resident is to be weighed once a month unless otherwise ordered by the physician.Review of the facility policy titled, Fluid Restrictions revised 03/24/2016 stated that physician ordered fluid restrictions would be ordered and implemented with fluid allotments specified between the Dietary and Nursing Departments. The policy specified, No water pitchers will be at the bedside of the resident that is on a fluid restriction.Record review for R17 revealed resident was admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure and chronic kidney disease stage 3B.Review of the physician orders dated 07/30/2026 specified R17 was to be weighed daily for 30 days, with an effective date of 7/31/2026. Continued review revealed R17 was to have no more than 2000 millimeters (ml) per day. The order specified 360 ml fluid should be allocated for each meal from Dietary consisting of 360 ml breakfast, 360 ml lunch, and 360 ml dinner, and 460 ml nursing allocation during the day shift and 460 ml nursing allocation during the night shift, for a maximum total of 2000 ml in 24 hours. The order also specified that the day shift allocation included 240 ml from a glucerna shake.Review of R17's meal tickets did not identify the physician ordered fluid restriction. Review of R17's care plan revealed an intervention to obtain and monitor weights on admission and weekly for four weeks instead of daily for 30 days as ordered by the physician. Review of R17's weight documentation from 07/31/2026 through 08/09/2026 revealed R17 was not weighed 7 of 10 days. Resident weights were obtained on 08/01/2026, 08/05/2026 and 08/07/2026, there were no weights documented for the dates of 07/31/2026, 08/02/2026, 08/03/2026, 08/04/2026, 08/06/2026, 08/08/2026 or 08/09/2026.Observation on 08/08/2026 at 11:10 AM and 08/09/2026 at 7:30 AM R17 revealed R17 had multiple cups of fluid and a pitcher filled with fresh ice water sitting on the bedside table.Observation on 08/09/2026 8:39 AM review of R17's breakfast ticket showed CCHO/NAS mechanical diet. There was no reference to any fluid restriction. R17 was observed with a 240 ml mug of coffee, a 240 ml cup of water, a 240 ml cup of orange juice, and a 236 ml carton of milk, for a total of approximately 956 ml of fluid provided with the breakfast meal. Additionally, there was approximately 700 ml's of water in the bedside pitcher.Observation on 08/09/2026 at12:37 PM R17's lunch tray included; two 240 ml cups of fluid, a 236 ml carton of milk, and a cup with approximately 2.5 ounces of water. A 1000 ml water pitcher was also present, with approximately 600 ml remaining with ice and water. The meal ticket did not identify a fluid restriction.Interview on 08/10/2026 at 8:05 AM, with the restorative Certified Nursing Assistant (CNA) revealed that R17 was to be weighed only once weekly. Interview on 08/10/2026 at 8:43 AM, with the Director of Health Services (DHS) revealed that physician orders should be followed as written. The DHS verified the physician order that required R17 to be weighed daily for 30 days and verified that the only weights documented were dated 08/01/2026, 08/05/2026, and 08/07/2026. The DHS stated R17 should have been weighed daily, and the weights were to be recorded in the electronic health record. Interview on 08/10/2026 at 12:49 PM with the Minimum Data Set (MDS) coordinator Licensed Practical Nurse (LPN) PP revealed the weight order noted on the care plan should have been written for weights to be done as ordered and not as written for a specified time such as once-a-week x 4 weeks.Interview on 08/10/2026 at 8:43 AM, with the DHS verified the physician order for R17's fluid restriction and confirmed there was 1670 ml of fluid present on R17's breakfast tray including a water picture. The DHS stated nursing and CNAs should be aware of which residents have fluid restrictions and should monitor their fluid intake. The DHS further stated the care plan interventions should include fluid restrictions, and it should be triggered for the CNA point of care task list so the CNAs would be aware of the restriction. The DHS stated R17 required fluid restrictions and daily weights due to chronic diastolic congestive heart failure and CKD stage 3B. Interview on 08/10/2026 at 9:43 AM with the kitchen manager provided R17's meal ticket and stated dietary staff were not aware R17 had a fluid restriction.Interview on 08/10/2026 at 10:55 AM, with the Unit Manager revealed that orders related to residents' dietary needs should be entered as a diet order so any restrictions would carry over to the dietary meal ticket. Interview on 08/10/2026 at 11:04 AM, with the Regional Nurse consultant (RNC) revealed physician orders should match the care plan and daily weights, and fluid intake will be documented by the nurse in the electronic medical record.

Based on observations and staff interviews, the facility failed to ensure food items were properly dated, labeled, and stored; failed to ensure an ice machine was free from a black spotted substance; and failed to perform proper hand hygiene while handling food to prevent contamination. The deficient practice had the potential to affect 68 of 68 residents that received an oral diet. Findings include: During the initial walk-through observation and interview on [DATE] at 9:00 am with the Dietary Manager (DM) revealed the seasonings were not dated, items such as lemon juice and imitation vanilla extract were not properly stored, the sugar bin was not labeled or dated, and two flour bins had expired dates. Continued with the interview, the DM confirmed the black spotted substance inside the ice machine bin and stated it should be cleaned out once a week. She confirmed the seasonings items on the racks did not have the used by dates or expiration dates, confirmed the items that require refrigeration were not properly stored, and confirmed the sugar and flour bin labels were expired and needed to be cleaned out every two weeks. During an observation on [DATE] at 11:03 am at with Dietary Aide OO revealed while preparing puree food with gloves on, she touched seasonings items from the rack, went back to handling food, turned on the sink and rinsed her right hand with the glove on underneath the running water, and continued with handling and preparation of the food. During an interview on [DATE] at 11:10 am with Dietary Aide OO stated she didn't know she was supposed to change her gloves and said she put her glove underneath the water and asked was she supposed to change gloves in that moment. During an interview on [DATE] at 11:50 am with the DM revealed there was zero tolerance for cross contamination and we need to make sure we are doing things right and education would be provided. During an interview on [DATE] at 11:57 am with the Administrator stated all staff were expected to follow guidelines and proper procedures.

Based on observations, staff interviews, record review and review of the facility policy titled, Intravenous (IV) Antibiotic Therapy, the facility failed to provide care that met professional standards for one of two residents (R) (R124) receiving intravenous (IV) antibiotics therapy. The deficient practice has the potential to place R124 at risk for lack of healing of infection, clotting of IV line, and sepsis. Findings include: Review of facility policy titled Intravenous Antibiotic Therapy reviewed 7/2/2024 revealed under Procedure: .10. Policy and procedures for the specific infusion access device will be followed unless specific physician orders are present.14. At the end of each antibiotic dose, the nurse will place a new sterile cap/cover over the end of the tubing to maintain sterility then flush the infusion access device per protocol. Review of the care plan dated 5/19/2025 reflected that R124 will be free from signs and symptoms of sepsis and bacteremia through next review date. Review of Physician orders revealed that R124 was to receive five milliliters (ml) of 0.9% (percent) normal saline (NS) in a 10 ml syringe every shift. R124 had an order for ceftriaxone two grams daily through peripherally inserted central catheter (PICC). Review of the electronic medical record (EMR) revealed the Medication Administration Record (MAR) revealed that R124 should receive 5 ml of 0.9% NS in a 10 ml syringe every shift through PICC. An observation of R124 on 5/20/2025 at 12:56 pm revealed that her PICC line was not clamped but had an antiseptic cap in place. During an observation and interview on 5/21/2025 at 2:06 pm, Registered Nurse (RN) CC administer ceftriaxone to R124. She mixed medication, labeled medication, and applied gown, gloves and a face mask. After cleaning the access site, RN CC flushed PICC line with 10 ml of 0.9% NS in a 10 ml syringe. She did not draw back blood to confirm patency (line inserted correctly), then connected the IV antibiotic to the PICC line. RN CC confirmed that she flushed the access with 10 ml of NS and not the ordered 5 ml. An observation of R124 on 5/22/2025 at 9:14 am that the PICC line did not have an antiseptic cap, but the line was clamped. An interview on 5/22/2025 at 2:09 pm with interim Infection Preventionist (IP) (RN) NN revealed that the facility has protocols for the management of PICC lines in the computer. She stated PICC lines were to have an antiseptic cap at the end of the luer-lock (connection at the end of IV tubing). The nurse should draw blood back before administering medication to confirm patency, RN NN revealed that flushing would be before and after each antibiotic. The nurse would disinfect the luer-lock with alcohol and then apply a new antiseptic cap. She stated that dressing changes were weekly, usually every Monday. Registered nurses completed dressing changes, but Licensed Practical Nurses (LPN) can hang medications with monitoring by an RN. An interview on 05/22/2025 at 2:24 pm with the Director of Nursing (DON) revealed an RN would flush and assess the PICC every shift. PICC care was an order set in the computer. RNs received training at hire and as needed through in-services and computer training.

Based on observations, staff interviews, and review of the facility's policies, How to Puree Food and Puree Vegetable Blend - 4 ounces (oz), the facility failed to follow a recipe and use measurement devices when preparing puree food for three of seven residents receiving a puree diet. The deficient practice had the potential to result in inconsistent texture modification, nutritional imbalance, and increased risk of aspiration. Findings include: Review of the undated facility's policy titled How to Puree Food documented under the section Preparation Steps: 1. depending on the resident's dietary restrictions follow the proper recipe and . 5. if required, for hot foods as a small amount of hot liquid, such as gravy, sauce, or cooking liquid, to be cooked with hot food. For cold food, cold liquid such as milk or fruit juice - Do not add water. Under section Common Mistakes: .3. not following recipes. Under section Simple Solutions: .3. follow proper recipe for restrictions. Review of the undated facility policy titled Puree Vegetable blend - 4oz documented under Procedures: 1. Drain the vegetable blend, measure according to the recipe and place in the food processor. 2. Process the vegetable blend by pulsing until the consistency of applesauce. 3. Reheat the puree vegetable to 165 degrees fahrenheit (F) for a minimum of 15 seconds. 4. Hold at a minimum temperature of 140-degree F for higher or per center policy. 5. Serve a 1/2 cup or 4 oz (ounce) using 8 scoops. Under the section Note: .2. For pureed: measure desired number of servings into food processor. Blend until smooth. Add broth or gravy if the product needs thinning. Add commercial thickener if product needs thickening. During an observation on 5/21/2025 at 11:03 am with Dietary Aide OO revealed there was no recipe in sight during the puree process. Dietary Aide OO had mixed vegetables steaming on the stove and removed the food item and poured the liquid out. She continued to grab vegetable seasoning and traditional seasoning salt from the racks and sprinkled it onto the mixed vegetables. From there, she scooped out vegetables into a container, filled a container with water and proceeded to blend the mixed vegetables and added water as needed. During an interview on 5/21/2025 at 11:27 am with Dietary Aide PP revealed everyone had the same diet and they do not have a specific mixed vegetables recipe for puree. She continued to state she followed the guidelines and that was the recipe for all puree and if she needed to keep the nutritive value, she would add extra meat or vegetables. During an interview on 5/21/2025 at 11:50 am with the Dietary Manager (DM) confirmed the guideline was not the recipe and she expected the staff to follow the recipes.

Based on resident, family and staff interviews, and record review, the facility failed to provide written notification to the resident and the resident representative (RP) with an explanation of why the move to a new room was required for one of 36 samples resident (R) (R275). Findings include: Review of the electronic medical record (EMR) revealed R275 was admitted to the with a diagnosis of but not limited to acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity (blood clot in deep vein). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 5/20/2025 at 10:52 am with R275 revealed she was originally in room [ROOM NUMBER] which was a private room, was sent out to the emergency department (ED), and when she returned to the facility, she was in a semi-private room. During a telephone interview on 5/22/2025 at 12:42 pm with the family member of R275 revealed her mother was sent out to the ED and was gone for approximately eight hours and when she returned to the facility the staff informed her of the room change. During an interview on 5/21/2025 at 1:55 pm with the Admission Director (AD) revealed R275 came into a facility in a private room because they did not have a semi-private room available. She stated when she left and went to the hospital, they had an admission who needed a private room, and the bed was not being held for R275, because they only held beds for Medicaid residents and not all insurances. During an interview on 5/21/2025 at 4:52 pm with Licensed Practical Nurse (LPN) PP stated while R275 was at the hospital she was told by the AD to move R275 out of room [ROOM NUMBER] because she was not paying for a private room. She continued to state the family member of R275 came back into the facility and that was when they informed her she was no longer in room [ROOM NUMBER] and had been switched to room [ROOM NUMBER]. During an interview on 5/21/2025 at 5:03 pm with the AD revealed she sent an email to the Housekeeping Manager to inform them to deep clean R275's room. She stated she would confirm information with the nursing department before making a decision, but she was under the impression based on the resident not wanting to be here and the private room being a courtesy, she decided to switch her room. When R275's family member arrived, that was when they informed her of the room change. During an interview on 5/21/2025 at 5:22 pm with the Administrator revealed these decisions were an interdisciplinary (IDT) approach and the family needed to be notified.

Based on observations, record review, and staff interviews, the facility failed to ensure the safe and sanitary storage of dentures for one of 36 sampled residents (R) (R224). Specifically, dentures were not stored in a labeled denture cup and the upper denture was found on an unclean surface rather than in a designated labeled container. The deficient practice had the potential to cause contamination, misplacement or damage of R224's denture. Findings include: The facility's dental policy was not available from the facility upon request. Review of the facility's document titled Clinical Procedure: Denture Care dated 2024 documented: Procedure Cleaning the Dentures: . If the dentures are not being worn immediately, place them in a clean denture cup filled with water or a denture-soaking solution to keep them moist. Review of the facility's Electronic Medical Record (EMR) revealed R224 was admitted with diagnoses including but not limited to Alzheimer's disease with late onset and dementia. Review of the Admission Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognition) a Brief Interview of Mental Status (BIMS) score of 3, which indicated resident had severely impaired cognition, Section GG (Functional Abilities) R224 requires set-up for oral hygiene and supervision for personal hygiene. Review of a care plan dated 4/22/2025 documented to include but not limited to cognitive loss / dementia, R224 has intermittent confusion, memory loss related to diagnosis of dementia. Observation on 5/20/2025 at 10:29 am revealed one upper denture on the surface of the bedside table in front of R224. Observation on 5/20/2025 at 11:00 am revealed one upper denture on the surface of the bedside table in front of R224. Observation and interview on 5/20/2025 11:10 am revealed one upper denture on the surface of the bedside table in front of R224. Licensed Practical Nurse (LPN) AA confirmed and validated there was one upper denture on the surface of the bedside table in front of R224. She told R224 to put it back in her mouth. LPN AA stated the dentures should not be on the surface of the bedside table, they should be in a denture cup because R224 could have bacteria build up in her mouth and get an infection. Interview on 5/21/2025 at 4:59 pm with the Director of Health Services (DHS) revealed her expectations were for the staff to make sure the dentures were placed in a denture cup when not in use near bedside and accessible to the resident. She stated a negative outcome would be damage to the dentures and when the dentures were lying around on the bedside table, they were not clean and it would be an infection control issue because bacteria can be transferred to the resident and this could make the resident sick and have infection. Interview on 5/22/2025 at 9:47 am with Certified Nursing Assistant (CNA) BB dentures were to be kept in a denture cup with a denture tablet when the residents were not using them. She further stated the dentures were to be cleaned before they were placed back into the resident's mouth. She stated dentures were not to be on the surface of a bedside table because the resident could get germs and the dentures could get lost or broken. Interview on 5/22/2025 at 9:55 am with the Assistant Director of Health Services (ADHS) revealed she stated her expectations were for dentures to be cleaned, mouth care provided, and when not in use, dentures should be placed in a denture cup with denture cleaner. She stated dentures should not ne on a bedside table because they could be lost, broken, and contaminated if not in a denture cup/container. The ADHS further stated the resident could develop mouth sores, have bad mouth odors and could get ill.

Based on observation, record review, staff interviews, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to ensure that all medications were taken and not left unattended on the bedside table for one of 36 sampled residents (R) (R224). The deficient practice had the potential to increase the residents risk of adverse health outcomes related to incorrect medication dosage. Findings include: Review of the facility's policy titled Medication Administration: General Guidelines reviewed 7/22/2024 documented under Policy Statement: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Review of the facility's electronic Medical Records (EMR) revealed R224 was admitted with diagnoses including but not limited to vitamin D deficiency, Alzheimer's disease with late onset, and dementia. Review of the admission Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 3, which indicated R224 had severe cognitive impairment. Review of care plan dated 4/22/2025 included but not limited to Cognitive Loss / Dementia. R224 has confusion, memory loss related to diagnosis of dementia. Review of the Physician's Orders dated 4/21/2025 included but not limited to: Cholecalciferol (vitamin D3) 25 microgram (mcg) (1,000 unit) tablet, 2 tablets once a day. Observation on 5/20/2025 at 10:29 am revealed one white tablet in a cup of water on the bedside table in front of R224. Observation on 5/20/2025 at 11:00 am revealed one white tablet in a cup of water on the bedside table in front of R224. Observation and interview on 5/20/2025 11:10 am revealed Licensed Practical Nurse (LPN) AA confirmed there was one white tablet in a cup of water on the bedside table in front of R224. She stated it should not be there because if a resident did not get the full dose of the medication, it could affect the resident negatively. Review of the Nurses' Progress Notes dated 5/20/2025 revealed LPN AA documented Resident had spit her Vitamin D3 into her cup of water, that was found later and then replaced, left Msg [message] with [NAME] NP (Nurse Practitioner) . Interview on 5/21/2025 at 4:59 pm with the Director of Health Services (DHS) revealed her expectations were that nurses should ensure residents swallow the medications before they leave the resident's rooms. She stated the nurses should stay with the residents to ensure all medications were taken. She stated a negative outcome would be the resident could receive an incorrect dose if the medication was not taken. The DHS further stated if the resident took the medication in the water close to the time of the next dose, the resident could get too much of the medication which would lead to overdose and cause harm to the resident. Interview on 5/22/2025 at 9:55 am with the Assistant Director of Health Services (ADHS) revealed her expectations were that no pill should be left at the residents' bedside. She stated the nurses should ensure all pills were swallowed by the resident because the nurse may not know which pill was not swallowed. The ADHS further stated the resident may not get the full dose of the medication and get sick.

Based on observations, record review, resident and staff interviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to have a physician's order for oxygen (O2) administration and failed to provide the correct O2 liter flow per physician's order for two of 15 residents (R) (R64 and R5) receiving oxygen therapy. The defieicent practice had the potential for R64 and R5 to have respiratory issues with O2 set at the incorrect level. Findings include: Review of the facility's electronic medical record (EMR) revealed R64 was with a diagnosis including but not limited to wheezing. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 14, which indicated resident had intact cognition. Section O (Special Treatments) revealed R64 receives Respiratory Treatments- Oxygen therapy, Section I (Active Diagnosis) revealed diagnoses of asthma, chronic obstructive pulmonary disease (COPD). Review of a care plan dated 3/9/2025 documented but not limited to R64 has abnormal vital signs (low O2 saturation). Goal: R64 will have no signs and symptoms of abnormal vital signs through the next review date, transfer to hospital for evaluation. Review of the Physician's Orders revealed no evidence of physician's order for O2 administration. Observation and interview on 5/20/2025 at 10:53 am revealed R64 in bed in her room. She had 4 liters per minute (LPM) O2 therapy in progress via nasal cannula (NC). R64 stated she received O2 therapy for shortness of breath (SOB), and she had been receiving O2 every day for months. She stated the nurses have put on the NC and turned on the O2 flow on the O2 concentrator every day for months. Observation on 5/20/2025 at 11:42 am revealed R64 in bed in her room. O2 therapy at 4 LPM in progress via NC. Review of a Hospital Discharge Summary dated 3/13/2025, page 3, Discharge Instructions, documented Use 2 liter oxygen via nasal canula continuously. Interview on 5/21/2025 at 5:46 PM revealed the Assistant Director of Health Services (ADHS) confirmed and verified R64 was receiving O2 therapy and there was no physician's order. She stated R64 was receiving O2 therapy before her hospitalization on [DATE] and continued to receive O2 after her readmission to the facility on [DATE]. The ADHS stated if there were no order for R64 to receive O2 therapy a negative outcome would be that the resident would receive the wrong amount of O2 or the resident may receive O2 continuously when they should be receiving it intermittently or if the resident was ordered to receive O2 intermittently, the resident could receive it continuously because there was no order to follow. She stated that if the resident received the wrong dose of O2 or did not receive O2 at all when they should, they could become ill or have a bad outcome and be affected negatively. She stated that the nurse who admitted the resident was responsible for putting in orders and should transcribe the orders from the hospital to the facility orders. She stated that the nurse who admitted the residents was responsible for calling the doctor or the nurse practitioner and informing them that the resident was admitted and there were orders to be made. She stated that if the nurse who admitted R64 did not put the orders in their system and the clinical team was responsible for double checking and confirming the orders. She stated the clinical team included the Director of Health Services (DHS) and herself and they were responsible for double checking the orders and ensured the orders were entered in the EMR for each admitted resident. She confirmed that the orders were not put in and she did not check to ensure it was transcribed from the hospital discharge summary to the facility's EMR. Interview on 5/21/2025 at 5:56 pm with the DHS revealed she confirmed and validated R64 was receiving O2 therapy. She stated she was a member of the clinical team and confirmed she was responsible for double checking that the orders were transcribed from the hospital discharge summary to the facility's EMR, and she did not. The DHS confirmed R64 had been without a doctor's order since 3/13/2025 after she was readmitted to the facility. She confirmed that the discharge orders from the hospital on 3/13/2025 stated that the resident was to be maintained on 2 LPM of O2 via NC continuously. The DHS stated that since R64 was receiving O2 therapy without a doctor's order, a negative outcome would be the R64 could get a reduced amount of O2 or too much O2 if there was no physician's order to follow or the resident could receive O2 intermittently or continuously which could be the opposite of the physician's order. She stated this would be detrimental to R64. Interview on 5/22/2025 at 1:40 pm with Registered Nurse (RN) CC revealed she stated R64 was receiving O2 therapy and there needed to be an order for the O2 administration. She stated the nurses needed to check that there was a physician's order for the liter flow of O2 before administering the O2. She stated the nurse should check the physician's order if it was to be given as needed or continuously before the O2 can be given. She stated the nurse was to put the order in the EMR and the MAR (medication administration record) so that the nurse could sign that it was administered. She stated if there was no order, the nurse should not administer the O2. She stated R64 could get the wrong amount of O2 and they could also get it on and off instead of continuously and this could cause R64 to have worsening of her medical condition. 52527 2. Review of the EMR revealed R5 was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), unspecified; acute and chronic respiratory failure with hypoxia; pleural effusion; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; cerebral infarction, unspecified; other seizure; upper respiratory infection; 2019-nCoV acute respiratory disease; shortness of breath; wheezing; cough. Review of the annual MDS dated [DATE] revealed a BIMS score of 14, which indicates R5 was cognitively intact. Section GG, functional status, revealed R5 required two-person physical assistance for functional mobility, including changing positions in bed, transfers, and ambulation. Section O, special treatments, R5 was receiving oxygen therapy. Review of R5 care plan dated 3/28/2024 identified a problem related to oxygen use secondary to COPD and respiratory failure. Goals included but not limited to maintaining optimal breathing and oxygen level within the constraints of terminal diagnosis. Review of the Physician's Orders for R5 included but was not limited to: Order for oxygen at three liters per minute (LPM) via nasal cannula continuously for diagnosis of COPD with frequency of every shift (days and evenings). Observation and interview with R5 on 5/20/2025 at 11:46 am revealed that he reported being prescribed 3 LPM of O2. However, upon closer examination of the O2 concentrator, the flow meter was observed to be set at 4 LPM, which was inconsistent with the resident's report. Observation with R5 on 5/21/2025 at 4:30 pm revealed the O2 flow between 2 and 3 LPM but not aligned with the 3 LPM marker. Observation with R5 on 5/22/2025 at 8:44 am revealed the O2 flow continued to be set at between 2 and 3 LPM but not aligned with the 3 LPM marker. Review of the MAR confirmed a physician order for 3 LPM of O2. Review of staff education records for the past year revealed no documented training or in-service on O2 administration or O2 concentrator use. Interview on 5/22/2025 at 9:01 am with Licensed Practical Nurse (LPN) AA in R5's room while observing the O2 concentrator together, revealed she acknowledged the O2 was incorrectly set and that she failed to verify the flow meter at eye level, as she typically did not bend down to set the flow or check the reading. Interview on 5/22/2025 at 2:11 pm with the DHS confirmed that registered nurses (RNs) and licensed practical nurses (LPNs) receive training on O2 concentrator use through online modules but was unable to confirm when the last return demonstration or O2 competencies were conducted. The DON acknowledged that incorrect O2 administration was considered a medication error and requires documentation, as well as notification of the physician and resident family. She also described that staff were expected to verify O2 settings at eye level, and this expectation was included in their training.

Based on observations, record review, staff interviews, and review of the facility's policy titled, Controlled Substances for Healthcare Center, the facility failed to ensure that controlled substances were documented immediately after administration for three of 36 sampled residents (R) (R32), (R17) and (R275), in accordance with accepted standards of nursing practice. This deficient practice had the potential to cause medication errors, including overdoses. Findings include: Review of the facility's policy titled Controlled Substances for Healthcare Center reviewed 4/1/2025 documented: Records: 1. The pharmacy will provide a Controlled Drug Record forms (proof of use sheet). This record shall be accurately maintained and shall include: o Name of patient/resident. o Name of the prescriber. o Prescription number Name, strength and dosage form of medication. o Date and time of administration. o Signature of the person administering the medication (after the medication is actually administered). Review of physician's orders for R17 dated 3/13/2025 documented included but not limited to: hydrocodone-acetaminophen tablet; 5-325 mg, 1 tablet two times a day for moderate- severe pain scale 4-6. Twice A Day 9:00 am, 5:00 pm. Review of physician's orders for R32 dated 7/30/2024 documented included but not limited to: pregabalin 100 mg; 1 capsule; oral three times a day 9:00 am, 1:00 pm, 5:00 pm. Review of physician's orders for R275 dated 5/12/2025 documented included but not limited to: pregabalin 50 mg1 capsule three times a day 9:00 am, 5:00 pm, 10:00 pm. Observation on 5/21/2025 at 12:54 pm during a medication cart review, Registered Nurse (RN) CC stated in the presence of the Director of Nursing (DON) that she did not sign the narcotics proof-of-use record for narcotic medications she had already administered earlier that morning. Review of the facility's narcotic book revealed the following omissions were confirmed: pregabalin 100 milligram (mg) capsule was administered to R32 at 11:00 am, hydrocodone/APAP 5-325mg tablet was administered to R17 at 9:00 am and Alprazolam 0.25mg tablet was administered to R275 at 11:00 am. Interview on 5/21/2025 at 12:55 pm with RN CC revealed she confirmed she did not sign the narcotics proof-of-use record for narcotic medications she had already administered earlier that morning. She stated she should have signed the narcotics book immediately after administration because this could cause the resident to get a double dose of the medication and get an overdose which could lead to adverse reactions. Interview on 5/21/2025 at 4:59 pm with the Director of Health Services (DHS) revealed she stated her expectations were that nurses must sign the narcotic book immediately after giving the medication. She explained that failure to do so could result in another nurse unknowingly administering a second dose, which could be detrimental and lead to serious harm or overdose for the resident. Interview on 5/22/2025 at 9:55 am with the Assistant Director of Health Services (ADHS) revealed her expectation was that the narcotic book should be signed as soon as the medication was administered. If not, staff could forget to sign it, or another nurse could come afterwards and give the narcotic again. She stated this would be a duplicate dose given to the resident and this could cause a bad outcome for the resident.

Based on observations, interviews, and record reviews, and review of the facility policies titled, Infection Prevention and Control Plan and Infection Prevention Control and Surveillance, the facility failed to ensure appropriate infection control practices were implemented by staff to prevent the spread of infection for one of 36 sampled residents (R) (R40). Specifically, staff failed to perform hand hygiene when entering and exiting rooms on contact precautions, and properly clean and disinfect reusable medical equipment. The deficient practices had the potential to contribute to the transmission of communicable diseases and place residents at risk for infection. Findings include: Review of the policy titled Infection Prevention and Control Plan, revised 6/21/2024, revealed the purpose of the infection prevention and control program is to decrease morbidity and mortality attributable to infections in residents; prevent and control outbreaks of infection in residents; prevent acquisition of infection by staff members; maintain resident functional status; and maintain an optimal social environment for residents. Review of facility policy titled Infection Prevention Control and Surveillance revised 11/23/2024 revealed that the Infection Preventionist (IP) provides education on standard based precautions and conducts surveillance on all residents. 1. Observation made on 5/20/2025 at 1:34 pm, it was revealed that the signage for a resident room was incorrect; the resident had a diagnosis of conjunctivitis, which required Standard Precautions, not Enteric Contact Precautions. Observation made on 5/22/2025 at 9:20 am, Licensed Practical Nurse (LPN) CC exited a resident room, under Contact Precautions, with a blood pressure machine and covered it with a clear plastic bag without disinfecting it, then left the equipment in the hallway before continuing medication administration. Interview with LPN CC on 5/22/2025 at 09:38 AM revealed she did not clean and disinfect the blood pressure machine, despite disinfection wipes being available on the cart. She acknowledged knowing the machine should have been disinfected but failed to do so. LPN CC also reported being unaware of the purpose of the clear plastic bag placed over the equipment, stating that staff had been instructed to cover the equipment with a bag, but no explanation was provided regarding its intended use. 52545 2. Review of the most recent significant change in status Minimal Data Set (MDS) assessment dated [DATE] revealed that R40 has a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Section I, Active Diagnoses, revealed diagnoses of but not all-inclusive cerebral vascular disease (CVD), chronic kidney disease (CKD), dysphagia, and sacral pressure ulcer. Section GG, Functional Goals and Abilities, revealed that R40 was totally dependent on staff for activities of daily living. Review of a care plan dated 4/24/2025 revealed that R40 was to be monitored for pressure ulcers/injuries. R40 was to be monitored for signs of infection to the sacral wound. Review of Physician orders revealed that R40's dressing to be changed daily. R40 had an order for offloading (getting weight off wound). R40 had an order for magnetic resonance imaging (MRI). Review of the EMR revealed that R40 had a pressure ulcer to the sacrum since February 2025 by a wound care provider. Documentation dated 5/17/2025 that wound care provider worked R40 up for suspicion for osteomyelitis. Observation and interview on 5/21/2025 at 9:01 am revealed Registered Nurse (RN) FF performed wound care on for R40. RN FF was observed wearing a mask and gloves. RN FF placed the treatment cart outside of the resident's room. She cleaned the bedside table with a disinfectant wipe, then covered the table with trash bags. RN FF opened sterile gauze with ungloved hands. She cut some tape. She opened sterile water and poured into a cup of gauze. She then poured Dakin's (wound treatment) into a cup of gauze as well. RN FF removed the dressing by peeling back the dressing slowly. Then R40 experienced pain. RN FF stopped the dressing change to obtain pain medication. After the procedure was aborted, RN FF stated, What is enhanced barrier precaution (EBP)? She admitted that she was wearing gloves and mask and did not wear a gown. She admitted that the wound had some drainage. Upon returning to the room to continue dressing change observation, the resident was under enhanced barrier precautions. An interview on 5/21/2025 at 11:13 am with interim Infection Perfectionist (IP) RN NN and training IP MM revealed that staff received hand hygiene and enhanced barrier precautions training on hire (competency), quarterly, weekly, and as needed. Staff received enhanced barrier and transmission precautions checkoffs were quarterly and during a period of outbreak.

Based on resident, resident representative, and staff interviews, record review, and review of the facility's arbitration agreement, the facility failed to inform three of three sampled residents (Resident (R) 64, R30 and R9) and/or their resident representatives reviewed for arbitration agreements that signed arbitration agreements, that the provisions of this agreement shall remain in effect after any other agreements between the parties have been terminated, and this agreement shall survive the death of a patient. Findings Include: Review of a blank copy of the facility's Arbitration Agreement, provided by the facility, indicated, . Scope of Agreement. Any and all disputes between the Patient and the Center shall be submitted to binding arbitration, except claims that may be brought in the applicable State small claims court. This includes any disputes arising out of or in any way relating to the enforceability of this Agreement, the Admission Agreement, or any of the Patient's stays at the Center, whether existing or arising in the future, whether for statutory, compensatory or punitive damages, and irrespective of the legal theories upon which the claim is asserted. This Agreement shall not apply to involuntary discharge from the Center, which shall be resolved through the administrative appeals procedure. This Agreement shall not limit the Patient's right to file a grievance with the Center, the long-term care ombudsman, or any state or federal agency. If any provision of this Agreement is determined by a court of competent jurisdiction to be invalid or unenforceable, in whole or in part, the remaining provisions shall nevertheless be binding and valid and enforceable. The provisions of this Agreement shall remain in effect after any other agreements between the parties have been terminated. This Agreement shall survive the death of patient. 1. Review of R64's Admission Packet, located under the Resident Documents tab of the electronic medical record (EMR) revealed R64 was admitted on [DATE], and the Arbitration Agreement was signed between R64's resident representative and the facility representative, Former Admission Coordinator (FAC), on 6/26/2023. 2. Review of R30's Admission Packet, located under the Resident Documents tab of the EMR revealed R30 was admitted on [DATE], and the Arbitration Agreement had a notation that indicated the resident refused to the Arbitration Agreement on 5/26/2023. Review of R30's quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 8/27/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. 3. Review of R9's Admission Packet, located under the Resident Documents tab of the EMR revealed R9 was admitted on [DATE], and the Arbitration Agreement was signed between R9's and the FAC, on 6/27/2023. R9's quarterly MDS assessment completed on 7/28/2023 indicated the resident has a BIMS score of nine out of 15, indicating R50 was moderately cognitively impaired. During an interview on 10/05/2023 at 9:42 AM the Regional Admission Director (RAD), revealed, The signing of the Arbitration Agreement is stating that both parties are waving their right to a jury trial and will meet with each other to come to a common ground. It is not a forced document; they don't have to sign, and they can rescind the document in 30 days. When asked specifically about, This includes any disputes arising out of or in any way relating to the enforceability of this Agreement, the Admission Agreement, or any of the Patient's stays at the Center, whether existing or arising in the future, whether for statutory, compensatory or punitive damages, and irrespective of the legal theories upon which the claim is asserted. The provisions of this Agreement shall remain in effect after any other agreements between the parties have been terminated. This Agreement shall survive the death of patient. The RAD was unable to provide any type of answer and said this was something they would have to look into. During an interview on 10/05/2023 at 10:13 AM with the FAC, revealed that they were the person that explained the Arbitration Agreement to the residents and resident representatives. When asked to explain the statement, This includes any disputes arising out of or in any way relating to the enforceability of this Agreement, the Admission Agreement, or any of the Patient's stays at the Center, whether existing or arising in the future, whether for statutory, compensatory or punitive damages, and irrespective of the legal theories upon which the claim is asserted. The provisions of this Agreement shall remain in effect after any other agreements between the parties have been terminated. This Agreement shall survive the death of patient. The FAC revealed that was something that would have been passed onto the RAD and that they were not familiar with that statement. During an interview on 10/05/2023 at 10:37 AM the resident representative of R64 revealed no one explained or talked with them about the Arbitration Agreement. The representative stated the packet was emailed to me and I was told I needed to sign the packet and send it back to them. I have signed Arbitrations before but this part about, shall survive the death of the patient is very different. During an interview on 10/05/2023 at 10:49 AM, it was revealed that R9 signed the Arbitration Agreement themselves. R9 indicated not being aware of the Arbitration Agreement. During an interview on 10/05/2023 at 11:07 AM revealed R30 refused to sign the Arbitration Agreement. R30 revealed not signing the agreement because they could not explain what was being signed.

Based on resident and staff interviews, record review, and review of the facility policy titled, Grievance: Healthcare Center, the facility failed to act to resolve resident council grievances regarding the facility failing to serve food that was palatable and hot at meals for 13 of 18 sampled residents (Resident (R)12, R21, R64, R41, R32, R33, R7, R30, R9, R55, R3, R11 and R20) who attended the monthly Resident Council meetings. Findings Include: Review of the facility policy titled, Grievance: Healthcare Center, revision date 11/21/2022, specified, The Administrator of each healthcare center serves as its grievance official and is responsible for the following: overseeing the grievance process; receiving and tracking grievances through to the conclusion; leading necessary investigations; maintaining confidentiality of all information associated with grievances (for example, the identity of the patient for those grievances submitted anonymously); issuing written grievance decisions to the person who filed the grievance (if known); and coordinating with state and federal agencies as necessary in light of specific allegations. A grievance includes, but is not limited to, complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient's facility stay. Review of the monthly Resident Council Meeting Minutes for 9/11/2023, 8/10/2023, 7/13/2023, 6/28/2023, (No meeting minutes were provided March 2023-May 2023), 2/13/2023, and 1/26/2023 revealed in every meeting there were concerns voiced about the meals. Concerns were the food being cold, the same meals week after week, and no flavor to the meals. A group interview meeting was conducted on 10/03/2023 at 3:00 PM with 13 residents whom the facility identified as reliable historians, cognitively intact and attended monthly Resident Council meetings. The residents confirmed they have monthly meetings, and the Activities Director (AD) normally takes the meeting minutes. The President of the Resident Council (R21) indicated taking meeting minutes notes as well. The residents revealed the food did not taste good and was not hot when served at mealtimes. The residents indicated this was an ongoing issue. The residents revealed the trays were covered with plastic wrap, so when the food was initially hot and then cooled off, it made the food sweat, so if you would get food that was soggy. Residents that attended the resident council meeting made the following statements: On 10/02/2023 at 1:53 PM, R12 stated, The food is trash; it is cold, tasteless. On 10/02/2023 at 10:57 AM R17 stated, The food is terrible and never hot, always at room temperature. The resident stated the food tasted like nothing and that he was on a renal (kidney) diet. The resident stated, Whatever they cook, that's what you get. On 10/03/2023 at 1:50 PM, R7 stated that, The food is just not good. On 10/03/2023 at 2:21 PM, R37 stated that residents complained the food tasted bad. Interview on 10/04/2023 at 3:30 PM with the AD revealed there are a lot of complaints in the meeting about food. The information was passed on to the Administrator, to be made aware of the issues. Residents do complain about the temperature of the food as well as the variety. Interview on 10/05/2023 at 1:27 PM with the Administrator revealed residents have complained about the different specific food issues, like the grilled cheese sandwiches being sweaty in the plastic and meals being cold. With trays having to be covered in plastic wrap, we have been trying to implement all hands-on deck to get residents trays to them faster. Cross refer to F804.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to ensure that two of five residents (Residents(R)27 and R55) observed during medication administration, received their medications within either the hour before or the hour after the physician ordered administration time. The deficient practice could result in a resident not maintaining a therapeutic level of the prescribed medications. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines, dated 5/31/2023, revealed, Medications are administered as prescribed, in accordance with good nursing principles, and practices .medications are administered in accordance with written orders of the attending physician .Medications are administered within 60 minutes before or after scheduled time .Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the healthcare center. Review of the undated Medication Pass document provided by the facility, in the survey book, revealed the facility's medication pass times listed as 9am, 1pm, 5pm, 9pm. 1. During medication administration observation conducted on 10/04/2023 at 10:21 AM, RN2 administered R55's fluticasone propion-salmeterol inhaler (treatment for chronic obstructive pulmonary disease) scheduled for 9:00AM. Additionally, RN2 was observed administering R56's following medications at 10:27AM, that were scheduled for 9:00AM: Eliquis (blood thinner), folic acid, MiraLAX (laxative), senekot (laxative), dorzol/timol (glaucoma) given at 10:29 AM, and carboxymethylcellulose sodium (eye lubricant) at 10:32 AM. The resident refused both laxatives. During an interview conducted on 10/04/2023 at 10:35 AM with Unit Manager (UM)1, who had been present during the observation as a resource for RN1, confirmed the medications for R55 and R56 were administered late. UM1 added that medications are considered late if not within the one hour before and after ordered time. 2. During medication administration observation conducted on 10/04/2023 at 10:57 AM, Licensed Practical Nurse (LPN)1 was observed administering R27's following medications scheduled for 9:00 AM: Decub-O-Vit [multi-vit-folic acid-zinc-vit c], Lisinopril [blood pressure], polyvinyl alcohol-povidon (eye lubricant), and Liquid Protein supplement (wound healing). LPN1 confirmed during the medication administration observation that the medications were being given late. During an interview conducted on 10/04/23 at 11:14 AM with the Clinical Nurse Consultant (CNC)1, CNC1 stated the nurses are supposed to administer the medications as ordered. When Medication Administration Record (MAR) audits were requested, CNC1 provided copies and stated the actual administration times don't show up on the MARs, only if the medication is omitted. During an interview conducted on 10/04/23 at 11:28 AM with the Director of Nursing (DON), the DON stated she expects staff to follow the administration policy, ensuring medications are administered within the one hour before/after the ordered times.

Based on observations, staff interviews, and review of the facility policy titled, Meal Delivery, the facility failed to serve food that was palatable and hot to 4 of 18 sampled residents (Resident (R)12, R7, R17, and R37) interviewed for food palatability. Findings include: Review of the facility policy titled, Meal Delivery, revised 4/11/2016 on section for Hall l Meal Service number one and two stated: 1. All foods leaving the kitchen to be served to residents/patients in their rooms will be covered. 2. Hot items will be served with insulated domes/bases and lids to maintain the heat or served with another system designed to maintain temperature during transportation . Hot food will be delivered and held at or above 135 degrees Fahrenheit. Observation of meal service on Hall 2 on 10/02/2023 at 11:45 AM revealed meals served from plastic covered tray cart. All meals served were covered only with plastic wrap with no temperature control. During an interview on 10/02/2023 at 3:45 PM the Dietary Manager revealed that for several months the enclosed food carts have not been used because of broken wheels and broken doors. The Dietary Manager also stated that the plastic covered carts would not accommodate domed food plates (The two-piece domed, double walled, and insulated product that is used to encompass a serving plate (top and bottom) to retain heat and cold foods served to residents.). On 10/03/2023 at 11:00 AM a request was made to provide any work orders and/or ordered parts for repair of food carts to accommodate domed lids on meals served. Interview on 10/03/23 at 11:30 AM, the Dietary Manager stated that the invoices for the ordered parts were unavailable in the computer and that she was not sure if the parts were ever ordered. No work orders for repairing the food carts were provided. During an interview on 10/03/2023 at 11:50 AM with the Administrator, she said that she thought the previous administrator may have ordered the parts, but she could not find a record of orders or invoices. The previous administrator has not worked in the facility since November of 2022. The Administrator also said, we were told that the open carts would be acceptable. She stated she was not aware that the carts being used would not accommodate the domed lids. On 10/03/2023 at 12:16 PM a test tray from last hall cart was served in the conference room by the Dietary Manager. The food tray contained a plate with a domed lid and was barely warm when the domed lid was removed. The appearance of the food was appetizing, but the flavor was very bland. The cauliflower texture looked to be mushy and overcooked. The mashed sweet potatoes were very bland with little flavor. The fried chicken was well cooked with little seasoning. Observation of the tray line on 10/04/2023 at 11:50 AM revealed the following temperatures: Hamburger Meat patties-165.70 Degrees Fahrenheit (F) Alternate sliced turkey-155.50 F Pureed meat-200.1 F Puree starch-164.9 F Chopped meat-183.9 F. On 10/04/2023 at 12:48 PM a test tray from the last cart on Hall 1 served to surveyors revealed the food temperature was barely warm. The Dietary Manager was asked to check the temperatures of the served trays. The hamburger was served at 97 F. The alternate food choice was sliced turkey and was served at 98 F. The Dietary Manager tasted the food on the test tray. The Dietary Manager stated that she thought the food tasted okay since they do not add seasoning because of the varied physician ordered diets with no salt.

Based on observations, staff interviews, and review of the facility policy titled, Infection Prevention-Hand Hygiene, the facility failed to ensure that hand hygiene was performed during medication administration for two of five residents (Residents(R)55 and R56) observed during the medication administration task. The deficient practice had the potential to spread infection. Findings include: Review of the facility's policy titled, Infection Prevention-Hand Hygiene, dated 8/15/2023, revealed, .indications requiring hand wash or hand rub 1. Before and after contact with the resident, 2. Before donning gloves, including sterile gloves .7. Immediately after removal of personal protective equipment (e.g., gloves, gowns, facemasks). During medication administration observations along with Unit Manager (UM)1, Registered Nurse (RN)2 did not sanitize his hands prior to the preparation of R56's medications on 10/04/2023 at 10:14 AM. RN2 was unable to administer R56's medications and secured the medications. At 10:21 AM, RN2 proceeded to prepare and administer R55's medications. RN2 administered R56's medications without sanitizing his hands prior to donning gloves and doffing gloves, until UM1 told RN2 to make sure he washed his hands. During an interview on 10/04/2023 at 10:35 AM, UM1 confirmed she had also observed RN2 had not performed hand hygiene during the medication administration observation. UM1 confirmed RN2 should have sanitized his hands and that is why she said something to him. During an interview on 10/04/2023 at 11:14 AM Clinical Nurse Consultant (CNC)1 stated it is an expectation that the nurses perform hand hygiene during the medication pass. During an interview on 10/04/2023 at 11:28 AM the Director of Nursing (DON) stated she expects staff to follow hand hygiene during medication administration.

Based on observation, interview, and record review the facility failed to ensure dependent residents were provided Activities of Daily Living (ADL) care for two of seven sampled residents (R) (R#1 and R#2) related to incontinence and dressing. The findings include: A review of Facility Grievances from November 2021-May 2022 revealed several complaints of residents be left soiled for extended periods. A review of the Resident Council Meeting Minutes dated 4/7/22 stated residents complained of having to wait over an hour to be provided ADL care. 1. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R#1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R#1 had a brief interview for mental status (BIMS) score of 12, indicating moderate to severe impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require the extensive assistance of one staff with toileting and dressing. R#1 was assessed to be always incontinent of bladder. The resident was assessed to always be incontinent of bowel. A review of the Care Area Assessment (CAA) summary revealed R#1 triggered urinary incontinence on the MDS assessment requiring further evaluation of urinary continence. A review of the care plan (created 6/8/20) for R#1 revealed incontinence of bowel and bladder was identified as a problem deficit, which placed the resident at risk for skin breakdown. The goal established included R#1 would have toileting and incontinence needs met and not exhibit skin breakdown, [CONDITION(S)], impaired social interaction, lowered self-esteem secondary. Interventions included staff to provide R#1 with incontinence care on rounds and PRN (as needed). During an observation on 5/9/22 at 10:00 a.m. and 1:00 p.m., R#1 was observed lying in bed and was not dressed for the day. During an interview with R#1 and their family member on 5/9/22 at 1:00 p.m. the family member expressed concerns related to R#1 being left in soiled briefs for extended periods of time, the facility being short staffed, and R#1 missing 12 appointments to outpatient therapy due to not being up and dressed in time when the transportation service arrived. The family member further stated that R#1 will call her and ask for her to call the desk for the staff to change his brief. She stated that there are times when she called the facility, and no one answered the phone. She stated that she has notified the Administrator and of her concerns. R#1 stated that this has been his experience. During an observation on 5/9/22 at 3:00 p.m., R#1 was observed still lying in bed and was not dressed for the day. During an observation on 5/10/22 at 11:05 a.m., R#1 was observed lying and was not dressed for the day. 2. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R#2 had a brief interview for mental status (BIMS) score of nine (15), indicating little to no impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require the extensive assistance of one staff with toileting. R#2 was assessed to be always incontinent of bladder. The resident was assessed to always be incontinent of bowel. A review of the care plan (created 1/28/22) for R#2 revealed incontinence of bowel and bladder was identified as a problem deficit, which placed the resident at risk for skin breakdown. The goal established included R#2 would have incontinence and toileting needs met and not develop signs and symptoms of [CONDITION(S)] related to incontinence. Interventions included staff to provide R#2 with incontinence care on rounds and PRN (as needed). During an interview and observation on 5/9/22 at 9:35 a.m. R#2 was observed propped on her side using the right arm to hold her back off the bed. R#2 and her bedding was observed soiled in feces and urine. R#2 stated that she had propping herself up to avoid laying back on the wet and soiled sheets. She said she had been ringing the call bell for over an hour and someone came in and said they would be back, but they never did come back. She stated that this happens frequently. During an interview on 5/10/22 at 9:45 a.m. with a Licensed Practical Nurse, (LPN) AA, she revealed there is never enough staff since the facility stopped using agency in April 2022. She stated normally she works 7:00 a.m.- 3:00 p.m. but is currently working 7:00 a.m.- 11:00 p.m. four days a week due to the staffing shortage. She further revealed the facility needs more Certified Nursing Assistants (CNAs) and that the CNAs typically work with 25 residents for each CNA. She revealed the CNAs are not able to keep up with properly changing soiled residents but that they are doing their best. During an interview on 5/10/22 at 10:30 a.m. with CNA CC, she stated that expectation is to round on residents every two hours, but they are not able to do that. She stated if she is in a resident's room for the extended period to provide care to meet the resident needs, this delays her from rounding and checking on each resident every two hours. During an interview on 5/11/22 at 4:45 p.m. with Anonymous Staff BBB, they revealed that they have witnessed residents remain soiled for an entire shift within the last few months. They work from 8:30 a.m.-4:30 p.m. and revealed being out on the floor most of the days helping when residents are getting up to stand beside to make sure they don't fall. They stated visibly seeing residents soiled for hours and notifies the certified nursing assistant (CNA) and then returns to the resident letting them know staff has been notified. She helps with getting water to residents due to the staffing shortage and things got worse after the facility stopped using agency in April. During an interview on 5/12/22 at 12:30 p.m. with the Administrator, they stated that when residents are reported as left soiled, she files a grievance and addresses each situation on a cases-by-cases basis depending on the grievance and that the expectation is for staff to round on residents every two hours. During an interview on 5/12/22 at 12:50 p.m. with the Director of Nursing (DON) she stated she has been employed with the facility for one week. She stated that her expectation is that there is continence rounding every two hours on all incontinent residents and that she has had to assist with rounds.

Based on observations, record review, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff to provide residents the assistance needed with Activities of Daily Living (ADLs) for two of seven sampled residents (R) (R#1 and R#2). Findings include: 1. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R#1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R#1 had a brief interview for mental status (BIMS) score of 12, indicating moderate to severe impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require the extensive assistance of one staff with toileting and dressing. R#1 was assessed to be always incontinent of bladder. The resident was assessed to always be incontinent of bowel. A review of the Care Area Assessment (CAA) summary revealed R#1 triggered urinary incontinence on the MDS assessment requiring further evaluation of urinary continence. A review of the care plan (created 6/8/20) for R#1 revealed incontinence of bowel and bladder was identified as a problem deficit, which placed the resident at risk for skin breakdown. The goal established included R#1 would have toileting and incontinence needs met and not exhibit skin breakdown, [CONDITION(S)], impaired social interaction, lowered self-esteem secondary. Interventions included staff to provide R#1 with incontinence care on rounds and PRN (as needed). During an observation on 5/9/22 at 10:00 a.m. and 1:00 p.m., R#1 was observed lying in bed and was not dressed for the day. During an interview with R#1 and their family member on 5/9/22 at 1:00 p.m. the family member expressed concerns related to R#1 being left in soiled briefs for extended periods of time, the facility being short staffed, and R#1 missing 12 appointments to outpatient therapy due to not being up and dressed in time when the transportation service arrived. The family member further stated that R#1 will call her and ask for her to call the desk for the staff to change his brief. She stated that there are times when she called the facility, and no one answered the phone. She stated that she has notified the Administrator and of her concerns. R#1 stated that this has been his experience. During an observation on 5/9/22 at 3:00 p.m., R#1 was observed still lying in bed and was not dressed for the day. During an observation on 5/10/22 at 11:05 a.m., R#1 was observed lying and was not dressed for the day. 2. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R#2 had a brief interview for mental status (BIMS) score of nine (15), indicating little to no impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require the extensive assistance of one staff with toileting. R#2 was assessed to be always incontinent of bladder. The resident was assessed to always be incontinent of bowel. A review of the care plan (created 1/28/22) for R#2 revealed incontinence of bowel and bladder was identified as a problem deficit, which placed the resident at risk for skin breakdown. The goal established included R#2 would have incontinence and toileting needs met and not develop signs and symptoms of [CONDITION(S)] related to incontinence. Interventions included staff to provide R#2 with incontinence care on rounds and PRN (as needed). During an interview and observation on 5/9/22 at 9:35 a.m. R#2 was observed propped on her side using the right arm to hold her back off the bed. R#2 and her bedding was observed soiled in feces and urine. R#2 stated that she had propping herself up to avoid laying back on the wet and soiled sheets. She said she had been ringing the call bell for over an hour and someone came in and said they would be back, but they never did come back. She stated that this happens frequently. A review of Facility Grievances from November 2021-May 2022 revealed multiple complaints of lack of care and services related to staffing: On 11/19/21, a resident filed a grievance stating she did not receive care timely. On 12/30/21, a family member filed a grievance stating the resident urinated through her bedding and stated this had happened multiple times. On 3/8/22, a members of the Resident Council complained about not getting showers every day. On 4/6/22, a resident filed a grievance stating he was not receiving timely care regarding not getting changed. On 4/7/22, a members of the Resident Council complained about needing more help in the building, lights not being answered at all or in a timely manner, and staff turning the lights off and never returning to assist. On 4/25/22, a family member filed a grievance stating that the resident was found in urine and feces-soaked sheets up to the resident's shoulders and on both sides of the body. Observation on 5/9/22 during day shift the facility was working with one licensed nurse and two certified nursing assistants in direct patient care. The census was 50. Observation on 5/10/22 during day shift the facility was working with one licensed nurse and two nursing assistants in direct patient care. The census was 50. During an interview on 5/10/22 at 9:45 a.m. with a Licensed Practical Nurse, (LPN) AA, she revealed there is never enough staff since the facility stopped using agency in April 2022. She stated normally she works 7:00 a.m.- 3:00 p.m. but is currently working 7:00 a.m.- 11:00 p.m. four days a week due to the staffing shortage. She further revealed the facility needs more Certified Nursing Assistants (CNAs) and that the CNAs typically work with 25 residents for each CNA. She revealed the CNAs are not able to keep up with properly changing soiled residents but that they are doing their best. During an interview on 5/10/22 at 10:30 a.m. with CNA CC, she stated that expectation is to round on residents every two hours, but they are not able to do that. She stated if she is in a resident's room for the extended period to provide care to meet the resident needs, this delays her from rounding and checking on each resident every two hours. During an interview on 5/11/22 at 4:45 p.m. with Anonymous Staff BBB, they revealed that they have witnessed residents remain soiled for an entire shift within the last few months. They work from 8:30 a.m.-4:30 p.m. and revealed being out on the floor most of the days helping when residents are getting up to stand beside to make sure they don't fall. They stated visibly seeing residents soiled for hours and notifies the certified nursing assistant (CNA) and then returns to the resident letting them know staff has been notified. She helps with getting water to residents due to the staffing shortage and things got worse after the facility stopped using agency in April. During an interview on 5/12/22 at 12:30 p.m. with the Administrator, she stated that she is aware of the staffing shortage and believed that it began around April 2022. During an interview on 5/12/22 at 12:50 p.m. with the Director of Nursing (DON) she stated she has been employed with the facility for one week. She stated that her expectation is that there is continence rounding every two hours on all incontinent residents and that she has had to assist with rounds.

Based on observations, interview, and review of the facility policy, the facility failed to serve food in the kitchen under sanitary conditions. This problem can affect 53 of 60 residents that take food by mouth. Findings include: A tour of the kitchen on 03/08/22 at 10:30 a.m. to 10:55 a.m. revealed the following concerns: The kitchen floor was observed with black tile grout, to be very greasy and dirty with large amounts of food debris and dust. Two, four-foot sections of grout were missing causing large caverns under the tile for food and debris to collect. Two floor mats near the stove were observed with large amounts of dust build up and food debris within the open sections of the floor mat. An uncovered meat slicer on the counter near the stove in the kitchen was observed to have large amounts of dust and food debris on the cutting surface and blade. The kitchen ceiling near the steam table was observed with large white dried splashes in an approximate 10-foot section. The wall near the food puree device was observed with splashes of white, brown, and red substances on the wall directly behind the device. Below the device was a large sugar container with a lid, full of food splashes of white, red, and brown substances. A doorbell device used to notify kitchen staff of an employee entrance to the kitchen was plugged into the wall and covered in dirt, dust, and food debris behind the puree device. Observations of the kitchen refrigerator used for drinks and desserts revealed an approximate three-foot section of white splashes from the bottom of the refrigerator side up on one side. Observations of the white surface at the base of the exit door leading into the dining room revealed large amounts of food splashes in red, white, and brown color all over the surface on the kitchen side of the door. Observations of the stainless-steel wall behind the fryer near the oven revealed food splashes on the wall in an approximate five-foot-wide section. Observations of an orange large two-foot diameter floor fan revealed each side of the fan grill were large amounts of dust build up coupled with grease and dirt on the outside of the fan. The fan is used to blow air through the kitchen area after mopping floors or to keep the air in the room moving and cool. Observations of the walk-in freezer revealed large amounts of paper and plastic build up coupled with food debris on the floor. Package wrappers in paper and plastic and ice cream lids were also found on the floor under the freezer shelves. Review of the facility policy on cleaning procedures for the main kitchen and food service areas titled Cleaning Schedule Policy revised 03/22/16 revealed in a policy statement that the DM will prepare a list of all cleaning tasks and post them in the dietary department. It's the DM's responsibility to develop and enforce the cleaning schedule and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. Cleaning schedules for daily, weekly and monthly lists all cleaning tasks, specifics, frequencies and position responsible for completion of the task. Completed, daily, weekly and monthly cleaning schedules should be kept on file for six months. Interview with the Dietary Manager (DM) on 3/8/22 at 3:30 p.m. revealed each night the kitchen staff swept the floor in the kitchen and wipe down the counters. The DM stated, with COVID-19 we have been short staffed and not always cleaning as needed. Further interview revealed the DM had no cleaning schedule and no documentation of any cleaning in the kitchen in the past or present. In addition, there was no cleaning scheduled posted anywhere in the kitchen at the time of this interview. All findings were confirmed with the DM at the time of this interview. Interview with the Maintenance Director (MD) on 3/8/22 at 3:40 p.m. revealed we have a power wash cleaning process for the floors that occurs every six months coinciding with the kitchen hood inspections. Both the power wash and kitchen hood system maintenance are done at the same time on night shift. He indicated the last power wash was in January 2022. Interview with the Administrator on 3/8/22 at 3:45 p.m. indicated her expectations are that the kitchen be cleaned more often or on a regular basis and not be in its current condition. All findings were verified with the Administrator at the time of this interview.

Based on observation, record review, interviews and policy review, the facility failed to revise the care plan to reflect actual harm to R C who sustained a fracture during transfer and failed to invite Resident (R) R #45 to quarterly care plan meetings . The facility census was 40. Findings include: 1. Review of the facility policy titled Care Plans revised 10/5/2017, revealed it is the policy of the health care center for each patient/resident to have a person centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Care plan review and updates will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by nurses, Case Mix Directors (CMD) DD and HH, or any other interdisciplinary team member so that the care plan will reflect the patient/residents needs at any given moment. Review of the facility policy titled Occurrences revised 5/4/2016, Investigation and follow-up, bullet number four (4) revealed the licensed nurse will be responsible for updating the patient/resident's care plan with appropriate occurrence prevention interventions. Review of the clinical record for R C revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Review of the care plan, onset date of 11/22/17 and updated on 8/6/18, revealed that resident has potential for injury from falls related to resident non ambulatory. Approaches for R C include remind resident to call for assistance with transfers and/or ambulation, maintain proper shoe size with non-skid soles, keep bed in low position, keep call light within reach while in bed, keep pathways clear and free of obstacles, maintain safety with transfers, physical therapy to evaluate as warranted, bed bolsters to define bed parameters, floor mat when in bed. Care plan had problem dated 7/19/18 that resident has refusals of transfers with total lift, but no approaches to care were added for this identified problem. Review of the resident's care plan also revealed that the care plan was not updated to reflect that the resident had a right tibial fracture. Observations or R C on 8/15/18 at 9:08 a.m. and 8/16/18 at 9:38 a.m. revealed soft splint intact to right leg. Interview on 8/16/18 at 7:22 p.m., with Licensed Practical Nurse (LPN) Case Mix Director DD, stated that she interviews the resident/family member, interviews the staff about changes in condition, and also reviews the medical record to find out what to update on the assessment and care plan. She stated that she did the quarterly Minimum Data assessment on 7/24/18. She further stated that any licensed staff can update the care plan. She stated that she does not have an explanation as to why the care plan was not updated until 7/24/18 quarterly assessment. Interview on 6/16/18 at 8:15 p.m., the DHS, stated it was her expectation that care plans be revised and updated as soon as possible. She stated that any nurse could update a residents care plan. She further stated she did not know how it could have been missed when this residents situation was discussed in morning meeting. 2. R#45 was admitted with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate cognitive impairment. During an interview with R#45 on 8/13/18 at 3:25 p.m., he stated he had not been invited yet to a care plan meeting and he had been in the facility for almost a year. R#45 stated he would like to be a part of his plan of care because he wants an update on his condition and would like to see if he can start eating again and receive physical therapy. The resident was not aware that he was being cared for under Hospice Services. Interview on 8/16/18 at 3:24 p.m. with the Case Mix Director (CMD) HH she participates in the resident care plan meetings. She stated the meetings are scheduled in relation to the Quarterly MDS assessments. CMD HH stated both the cognitive residents and family are invited to the meeting. She stated the families are invited through a letter sent to them in the mail and resident's that are their own responsible party or cognitive residents also receive a written letter. CMD HH state the care plan meetings allows the resident an opportunity to express desires, wants, needs and be a part of his/her plan of care. She stated she is in the meeting and goes over the care plan for a resident. She stated if a desire or changes are expressed, they would update the care plan approaches, otherwise the nursing staff update the care plans as they go. CMD HH stated they had a care plan policy but it did not include any reference related to participation in care plan meetings or resident and/or family invitation to care plan meetings. Interview on 8/16/18 at 3:38 p.m. with the Social Service Director (SSD), revealed the CMD's gives her a list of who is going to have a care plan and she sends a written invitation by letter to family and keeps a copy in her personal records and the Social Service section of the chart. The SSD stated she verbally invites the residents and if they want family to come, they will contact them. She will escort the resident to the conference room or hold the meeting in the resident's room, if resident prefers not to come out of his/her room. She stated they always invite the residents to participate unless they are not cognitive, and have the option to decline or attend. The SSD stated she did not have a copy or evidence that R#45 was invited to attend his care plan meetings and further stated they were behind and trying to catch up. The SSD stated did not remember ever having a care plan meeting R#45 or his daughter. The SSD stated had R#45 been invited to his care plan meetings, he would have had the opportunity to express his desires related to his care and understanding/update of his condition. She stated she looked in the computer and there was nothing in the computer to confirm that R#45 had been invited to his care plan meetings. The SSD stated the truth is, nor he or his daughter had not been invited to attend cross refer 689

Based on observation, interviews, policy review and review of the facility documents, the facility failed to ensure a safe and secure environment related to accidents, which resulted in actual harm to resident (R) C who was being transferred from the bed to the geri-chair by one Certified Nursing Assistant (CNA) rather than two as per the care plan which resulted in a nondisplaced tibia fracture. In addition, resident (R) E was attempting to remove the Continuous Passive Motion (CPM is a postoperative treatment method that is designed to aid recovery after joint surgery) without assistance from staff and her left hand got caught in the machine. This resulted in injury to R E left hand. Two of three records were reviewed for incidents. The sample size was 40 residents. Findings Included: 1. Review of the clinical record for R C revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Section G revealed that the resident was assessed for extensive assist by two plus person for bed mobility, locomotion on/off the unit, dressing and toilet use. The resident was assessed as total dependence with transfers. Review of the care plan, onset date of 11/22/17 and updated on 8/6/18, revealed that resident has potential for injury from falls related to resident non ambulatory. Approaches for R C include remind resident to call for assistance with transfers and/or ambulation, maintain proper shoe size with non-skid soles, keep bed in low position, keep call light within reach while in bed, keep pathways clear and free of obstacles, maintain safety with transfers, physical therapy to evaluate as warranted, bed bolsters to define bed parameters, floor mat when in bed. Added to the care plan dated 7/19/18 the resident has refusals of transfers with total lift, but no approaches to care were added for this identified problem. Review of the CNA Care Intervention Record Form revised 1/14/15 revealed under Transfer section revealed resident is a two person assist and mechanical lift with two persons. A notation in the margin of the CNA Care Intervention Record Form dated 7/1/18 stated that patient refuses to use the lift to transfer: non-compliant. A second notation in the margin of the CNA Care Intervention Record Form dated 7/2/18, stated that resident request at times to be lifted manually by one person. Neither of these notations are signed by a staff member, eligible to document on the CNA Care Intervention Record Form. Review of facility incident report dated 7/1/18 at 12:40 p.m., revealed Certified Nursing Assistant (CNA) transferred resident and the residents leg bumped on the geri-chair during the transfer from bed to the gerichair. Resident stated that the CNA did not do it intentional. Twenty four (24) hour follow-up revealed upon investigation it was determined that CNA transferred resident manually from the bed to the gerichair times one (1) assist. CNA stated resident demanded that she transfer her. It is further documented, follow-up revealed that resident refuses care according to prescribed care plan. Also educated to never attempt to transfer a resident without notifying nurse first of refusal. CNA went into room to transfer resident to gerichair with Hoyer lift Resident demanded that she be lifted with the Hoyer and then refused. Resident demanded CNA get her up manually. Review of the facility nurses note dated 7/1/18 at 1:00 p.m., revealed resident alert and oriented. Resident has a small 4 centimeter (cm) bump to right lower extremity with some swelling. Resident given something for pain and offered some ice but refused. Message left for daughter and on call Nurse Practioner (NP). Resident has no new changes in range of motion (ROM). No distress noted. Nurses note dated 7/1/18 at 4:30 p.m., revealed resident up in geri chair in hallway with extensive assisted care monitoring. Slight raised area noted to right lower leg. No open area, no drainage, no complaints (c/o) of pain. Previous shift nurse attempted to call daughter and NP. Call placed at this time for follow-up. Nurses note dated 7/1/18 at 8:30 p.m., revealed no return all from daughter. Call placed with message of right leg. Staff will attempt to follow-up Nurses note dated 7/2/18 at 4:00 p.m., revealed NP in this a.m. with orders for x-rays to right leg due to hematoma to area. Results received with positive (+) tibial fracture noted. NP reviewed with orders to transfer to emergency room (ER) for evaluation and treat. Daughter notified. No concerns voiced at this time. Resident denies pain or discomfort. Transferred by ambulance via stretcher to a (local hospital.) Nurses note dated 7/2/18 at 4:15 p.m. revealed resident in route to hospital per ambulance. Nurses note dated 7/3/18 at 1:30 a.m., revealed patient returned from Emergency Department (ED) with soft cast in place on right lower extremity (RLE) for tibia fracture (fx). Femur fx noted (distal) in Doctors notes. No complaints of pain or discomfort at this time. Made comfortable in bed. New order for [MEDICATION NAME]/APAP liquid. Nurses note dated 7/4/18 at 4:30 a.m., revealed resident dressing to RLE (right lower) is intact. Assessed for circulation no new changes noted. C/O pain as need (PRN) pain meds were given. Family at bedside this shift and was concerned about current condition. Explained to family a follow-up of request of records can be discussed with medical records. Will follow-up with concerns later this day. Patient resting in bed with eyes closed. Will continue to monitor. Review of the Care Activity Details notes from the Nurse Practioner dated 7/2/18 at 9:30 a.m., revealed NP was notified by facility nurse that member had an injury to her right lower leg yesterday (7/1/18) during transfer with staff assistance from the gerichair to the bed. Nurse stated that member hit her right lower leg against a metal part on the gerichair and member now has a large lump where it was hit. Nurse stated the member states the area is tender to touch, no open areas. Nurse stated that she called the on-call service with Pruitt Health [MEDICATION NAME] (PHP) and Primary Care Physician (PCP) but did not receive a return call before she left for the day, and was unsure if the on-coming nurse called the on-call nurse again to follow-up to notify PCP of member's leg injury. Assessed member this morning and right anterior shin swelling noted with a large raised area of localized swelling, tender to palpation, no overlying redness or open sores. Member states tenderness to right anterior and posterior right lower leg. Skin warm and dry. Plan right lower leg pain-right tibia/fibula x-ray ordered (2 views). Apply ice to affected area for ten (10) minutes three times daily (TID) for four (4) days, monitor skin site frequently notify provider if any changes. 2:00 p.m. x-ray results received. Right tibia/fibular x-ray results. Non-displaced [MEDICAL CONDITION] shaft. Pretibial soft tissue welling. No definite fibular fracture. Acute tibial fracture. Conclusion: overall, osseous mineralization is decrease. This could reflect osteopenia or [MEDICAL CONDITION], in the correct clinical context. Facility nurse called for clarification of the report conclusion due to no mention of the fracture in the conclusion, stated she was told they will send it to the radiologist for review. Care Activity Details dated 7/2/18 at 4:25 p.m., activity note revealed member sent to ER for further evaluation of right tibia fracture. Review of Physician's Interim Orders dated 7/2/18 revealed to obtain x-ray of right tibia/fibula (2 views). Apply ice to affected area of right shin for ten (10) minutes three (3) times daily for four (4) days. Notify provider for any changes. Physician's Interim Orders dated 7/2/18 at 2:30 p.m., revealed to send to emergency room (ER) for further evaluation of right lower extremity (RLE) fracture (tibia). Review of the ER records dated 7/2/18 at 1940 (military time) imaging studies were ordered. Radiologists interpretation includes: X-ray femur right two views final results impression: 1. Remote distal femur fracture 2. Acute tibial fracture 3. Soft tissue [MEDICAL CONDITION] about the knee 4. Severe osteopenia. Review of the Orthopedics office note dated 7/26/18, revealed resident was seen in the office on 7/26/18. Recommendations are as follows: She has a non-displaced tibia fracture. My understanding is that the patient does not ambulate, however, she is to be 100% non weight bearing on the right leg. She will need to remain in her splint for eight (8) weeks. The splint will need to be removed every two (2) weeks for skin checks to prevent breakdown of skin and ulceration. I recommend [MEDICATION NAME] 40 milligrams (mg) one (1) every six (6) hours for pain as needed (PRN). I recommend that she return to the office in eight (8) weeks with two (2) views of the right tibia and fibula done at your facility to determine whether or not the splint can be removed permanently. Review of the upcoming appointment is for 9/20/18 at 11:25 a.m. Interview on 8/15/18 at 3:32 p.m., with Director of Health Services (DHS) stated that she heard about residents accident through reading her reports and from staff members. Certified Nursing Assistant (CNA) was transferring resident from bed to gerichair manually by herself because resident refused the use of the lift. Leg was bumped on the gerichair, and that's how she got the fracture (fx). She stated that each resident has a CNA care plan, kept in a book in the chart room. She stated the admission nurse does the initial CNA care plan, but that any of the licensed staff can update or change the care plan as needed. She further stated it is her expectation that staff follow the care plans, and if residents refuse care, they should be educated about the risks of refusal. She further stated that staff should get assistance with transfers. Interview on 8/16/18 at 8:40 a.m., with CNA AA stated she bathed resident and dressed her in the morning hours, around 11:00 a.m. She then went to get the Hoyer lift and re-entered the residents room alone. She further stated that resident said to her I do not like that machine. Just transfer me over. She described the transfer as assisting resident to sit on side of bed. Resident put her arms around staff neck, and staff member placed her arms under residents arms and lifted her from the bed to the chair. She stated that resident could bear weight on her legs, but she is not certain if resident was bearing weight during that particular transfer. She further stated that as she was transferring resident from the bed to the gerichair, her knee hit the right arm rest of her chair. She further stated that she felt like the resident was holding on to her tighter than usual, like maybe she was afraid of falling. She stated that she reported the incident to floor nurse. She stated that resident refuses for staff to use the lift, and because she refuses so often, she doesn't always attempt to use the lift. She further stated that she automatically assumes resident will refuse the lift. She just manually lifts and transfers her. She stated she has transferred her by herself before two to three (2-3) times, and denies any type of injury with those transfers. She further stated that she does it by herself and doesn't ask for help, because she can't find help most of the time. She was asked why she didn't ask the floor nurse to help her and she replied I don't know. CNA continued to state that resident complained to her during rounds that her foot was swelling and that she was in pain. She stated she reported it to the nurse again, and nurse told her that she would look at it. Towards the end of her shift that day, resident had told CNA again that her foot was swelling and that she was in pain. She further stated that she reported to nurse again. Interview on 8/16/18 at 9:12 a.m., with Registered Nurse BB stated that she provided immediate 1:1 education to CNA AA. The agenda of the education was notifying nurse if patient refuses to accept care according to care plan. Do not attempt to transfer patient otherwise for any reasons without notifying the nurse. The date on in-service education Summary Record Form is 7/2/18. She stated that she provided the same in-service training to all staff members, and provided sign-in log dated 7/2/18 with 13 staff members signatures. Phone interview on 8/16/18 at 4:14 p.m., the Medical Director, stated that he was notified of residents accident with injury, but he cannot recall the date or time that he was notified. He further stated that he has not seen resident since her accident. He stated that the resident is being followed by Pruitt Health [MEDICATION NAME] (PHP) and the NP see's the resident monthly and his office sees the resident quarterly. He stated that he attends the Quality Assessment Performance Improvement (QAPI) meeting quarterly and denies that the facility has brought any concerns with staff transferring residents by one person, when care plan indicates two person transfer. Phone interview on 8/16/18 at 5:01 p.m., with Nurse Practioner (NP) CC stated that she saw the resident on 7/2/18, after the injury on 7/1/18. Assessed the area to note a raised area on right lower leg. She ordered for 2 view x-ray of right leg. Report of x-ray was called to her, and she ordered to send resident to hospital for further evaluation. She stated that she is being followed by orthopedics for treatment of [REDACTED]. 2. Record review revealed that R E was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Record review on 8/14/18 the Minimum Data Set (MDS) and the Comprehensive Care Plan not in R E record. Due for completion. An observation on 8/13/18 at 12:53 p.m. of R E was sitting in a chair with her left hand wrapped in ace bandage. Continuous Passive Motion (CPM is a postoperative treatment method that is designed to aid recovery after joint surgery) machine sitting on her bed. An interview was conducted on 8/13/18 at 12:54 p.m. with R E. The resident revealed that she was admitted to the facility status [REDACTED]. The resident revealed this morning she was attempting to take her leg out of the CPM machine and started to remove the straps of the machine from her legs and her left hand got caught in the machine and squeezed her hand. The resident stated she stopped the machine by pushing the red button on the control of the CPM machine and called for help by yelling out for staff and pressing the call bell. Resident E stated a nurse entered her room and unplugged the machine and assisted her in removing her hand from the CPM machine. Resident E revealed she applied the ace bandage to her left hand herself no assistance from the staff. Resident E stated her hand was tender and she had a small tear on the side of her hand. The resident stated she places the machine on and off herself because when she puts her light on and it takes the staff to long to come in and assist her. An observation and interview on 8/15/18 at 10:30 a.m. R E in the physical therapy department. Skin tear noted at left wrist same side of pinky finger. Resident E stated her wrist was tender. Record review of a physician order [REDACTED]. Record review of a physician order [REDACTED]. There was no evidence found in the clinical record to confirm if the physician ordered to resume CPM machine. Record review of the undated medication record revealed: Resume CPM machine order 0-100 flex may use 8 to 6 hours per day no more than 2 hours at a time usage. Documentation under hour of administration FYI. An interview was conducted on 8/15/18 at 12:39 p.m. with Certified Nursing Assistant (CNA) AA regarding R E. CNA AA revealed that when she came to work on 8/13/18 around 7:15 -7:30 a.m. she was taking R E vital signs and notice R E left hand was wrapped in an ace bandage. CNA AA revealed she asked R E what happen to her hand. The resident responded by stating her hand was caught in the CPM machine and she had to push the emergency button to stop the machine. CNA AA stated the resident told her the incident happen around 3 a.m. CNA AA stated she reported the incident to her charge nurse on duty immediately. CNA AA revealed she has never been in-serviced on CPM machine and has never assisted resident in applying the CPM machine but have seen her using the machine. An interview was conducted on 8/15/18 at 12:40 p.m. with Physical Therapy Aide (PTA) II regarding training for the staff and resident using the CPM machine. PTA II revealed that the staff should have been in serviced on the proper use of CPM machine. PTA II also, stated the resident should not be placing the CPM machine on/off that the staff should place her leg in and out of the CPM machine. PTA II stated he spoke with the Clinical Competency Coordinator (CCC) and requested that an in-service date and time to provide education to the staff and he never received a response. PTA II stated he did educated the resident on how to operate the CPM control and how the CPM machine should feel/look when it is on correct/incorrect. An interview was conducted on 8/15/18 1:48 p.m. with the facility's CCC who is responsible for staff in-services. The CCC stated she does not have an in-service on how to apply CPM machine to R E left leg. CCC confirmed that the therapy department did try to set up an in-service time. CCC stated it is not appropriate for the resident to apply the machine because the resident could injury themselves. An interview was conducted on 8/15/18 at 2:51 p.m. with the Director of Health Services (DHS) regarding R E injury. The DHS revealed R E should have not been placed in a position of applying the CPM machine. DHS stated we are here to take care for the patients and assist them with their needs. An interview was conducted on 8/16/18 at 8:47 a.m. with R E regarding the ace bandage she had on her left hand on 8/13/18. Resident E revealed she wrapped her hand in the ace bandage she had been using on her knee. An interview was conducted on 8/16/18 at 8:56 a.m. with CNA KK has been employed for six weeks regarding the CPM machine. CNA KK revealed she is not familiar with the CPM has never assisted R E in/out of the machine. CNA KK stated she has never been in-serviced. An interview was conducted on 8/16/18 at 9:02 a.m. with Licensed Particle Nurse (LPN) LL. LPN LL revealed she was not informed or has any knowledge of R E hand being caught in the CPM machine. An interview was conducted on 8/16/18 at 9:45 a.m. LPN JJ regarding R E hand being stuck in the CPM machine. LPN JJ confirmed she worked on 8/12/18 (11p.m.-7a.m.) stated that R E or the CNA on duty never reported any incidents with the CPM machine. An interview was conducted on 8/16/18 at 9:10 p.m. Interview with the administrator regarding equipment in the facility. Revealed the CPM machine is the only equipment in the facility resident is currently using. The facility failed to educate the staff on the proper use of equipment for a resident. This resulted in an injury to a resident.

Based on observation, resident and staff interviews, and record review, the facility failed to develop a care plan which include person-centered objectives and interventions to address the use of a wearable, external defibrillator for one resident (R#188) out of 29 sampled residents reviewed. The failure resulted in staff not being aware of the medical device; specific instructions as to what to do after the defibrillator (Life Vest) discharges and precautions to avoid accidental shocks. Those failures placed the resident at risk of immediate harm and potential death. Cross reference F328. Findings include: Review of R#188's Admission Minimum Data Set (MDS), dated [DATE], indicated under Section B, items B0700 and B0800 the resident was able to both understand others and make himself understood. Section C, item C0500 specified his Brief Interview Mental Status (BIMS) Summary Score was a 15 out of 15, which indicated he was cognitively intact. Section C, item C1310 indicated the resident had no signs or symptoms of [MEDICAL CONDITION] or acute mental status change. Section D, item D0300 indicated R#188's Total (Mood) Severity Score was 0 which indicated no depression. Section E, items E0100 through E1100 indicated the resident exhibited no signs or symptoms of [MEDICAL CONDITION] or behavioral symptoms (expressions of distress), and no rejection of care or wandering during the assessment's evaluation periods. R#188 was coded as being totally dependent on staff for all Activities of Daily Living (ADLs) which included bathing, dressing and grooming. Life Vest Definition: A Life Vest is a wearable, external defibrillator that is a treatment option for sudden [MEDICAL CONDITION] (SCA) that offers patients advanced protection and monitoring as well as improved quality of life. It is worn outside the body (as opposed to an implantable cardioverter defibrillator (ICD). It continuously monitors the patient's heart with dry, non-adhesive [MEDICATION NAME] to detect life-threatening abnormal heart rhythms. If a life-threatening rhythm is detected, the device alerts the patient prior to delivering a treatment shock, and thus allows a conscious patient to delay the treatment shock. If the patient becomes unconscious, the device releases a Blue gel over the therapy [MEDICATION NAME] and delivers an electric shock to restore normal rhythm. The patient needs to be seen at the Emergency Department, to be evaluated by a cardiologist, following a treatment shock and the vest has to be reloaded with new [MEDICATION NAME], as they only release Blue gel once. A subsequent shock without reloading could result in a failed shock and skin burns. Observation of R#188 on 7/31/17 at 5:45 p.m., revealed him to be asleep in his room. He was observed to have a thick black strap around his neck, to which a black monitor (approximately 5.0 x 6.0 x 1.5 inches) was attached. During a family interview on 7/31/17 at 6:10 p.m., indicated R#188 had a Life Vest on and had been applied during his cardiology appointment on 7/27/17. Record review of R#188's clinical record revealed there was no physicians order for the device; it was not on his care plan (initiated 7/20/17 and updated 7/28/17 and 7/31/17) and nowhere in the Progress Notes was there any mention of the device. Multiple interviews with staff (Cross reference F328) proved at least some were aware of the device and either did not ask what the device was, and/or report the device to the nursing staff. The Administrative Staff (The Director of Nursing, The Administrator and the Nurse Consultant) nor the resident's Attending Physician (who was also the Medical Director), were aware the medical device was in place for five days until notified by the surveyor. By not identifying the medical device (external defibrillator, Life Vest) placed on R#188 and not developing an appropriate plan of care, the facility failed to ensure direct care staff were aware and knowledgeable on how to monitor and care for R#188; which placed him at risk of serious harm and potential death. A Credible Allegation of Compliance was received on 8/3/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated the corrective plans and the immediacy of the deficient practice was removed on 8/3/17. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessment procedures to ensure any equipment a resident received was physician-ordered; all direct care staff were trained in the proper use/oversight of said medical equipment; and a policy/procedure was instituted to address the use (specifically) of an external defibrillator. This oversight process included the analysis of in-service materials and records on 8/3/17. Interviews were conducted with staff on 8/3/17 to ensure they demonstrated knowledge of facility Policies and Procedures governing external defibrillators. The resident's record was reviewed on 8/3/17 to ensure resident care and treatment, including physician orders [REDACTED]. All verification was confirmed by facility staff interviews, documentation and clincal record reviews. Allegation of Compliance Verification as follows: 1. Immediate Action Taken for Residents: 8/2/2017 at 12:00 p.m. 'Zoll Life Vest Company' did an In-Service for all working staff. In-services continue by the 'Clinical Nurse Consultant (CNC) and the Director of Nursing Services (DNS).' No staff will return to work until in serviced on 'Life Vest' and following up on doctors' orders. 'Zoll Life Vest Company' completed assessment of resident R#188 on 8/2/2017. This was verified via interview with the Life Vest Technician on 8/2/17 at approximately 2:30 p.m. Then on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of the training outline as well as a list of direct care staff that had obtained training that day. The NC also confirmed no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. A 100% audit was completed 8/2/17 to assure no other residents had an external defibrillator. All residents will be assessed upon admission to facility for external defibrillator. This was verified and confirmed through the interview with the NC on 8/2/17 at 4:00 p.m., all residents residing in the facility were checked for medical devices including any external defibrillator devices and no other resident was identified having such said device. Care Plan was updated 8/2/17 for R#188 to include Life Vest. This was verified and confirmed on 8/2/17 at 4:00 p.m. by review of the actual care plan for R#188. Activities of Daily Living (ADL) care record was updated on 8/2/17 R#188 to reflect Life Vest. This was verified and confirmed 8/2/17 at 4:00 p.m. by review of the actual ADL Care Record for R#188. Life Vest Information pamphlet in Medication Administration Record [REDACTED]. This was verified and confirmed on 8/2/17 by surveyor ensuring these things were in place on the MAR, ADL care record and R#188's closet door. Facility Clinical Start Up form will be used at 9:00 a.m. meeting to ensure follow up of all Medical Doctor (MD) appointments and all MD orders. This future implementation was verified to be put in place by interviews with the facility administration staff members. No form was made available, as it was a part of the Plan of Correction going forward. 2. Action taken to assure no other residents will be affected in the future: An immediate audit of 100% of resident's charts began on 8/2/17 to ensure all MD follow up orders have been implemented. This was verified and confirmed via interview with the NC on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of training outline as well as a list of direct care staff that had obtained training that day. The NC also stated no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. 8/2/17 In-Service on LifeVest to ensure training was given to all direct care staff. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. In-service staff on proper follow up for all MD appointments. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. 3. Monitoring: R#188 was put on one to one until all staff were in-serviced on LifeVest. This was done prior to the AOC and eduation done by the Life Vest Technician on 8/2/17 at 12:00 p.m. The faciliy made the surveyor aware after the fact. DNS and CNC will audit 10% of MD follow up appointment for one week. Then DHS and/or CNC will complete a random audit of doctor's appointment follow up orders weekly for four weeks. This was part of the going forward Plan of Correction. Facility will continue to monitor our performance improvement plan monthly in QAPI meetings. This was part of the going forward Plan of Correction.

Based on observations, staff, resident and family interviews, and record reviews the facility failed to ensure one resident (R#188) from a total of 29 sample residents received the necessary care and treatment including medical and nursing care services for the use and monitoring of a specialized device; an external defibrillator. The facility Administrative Staff (Director of Nursing, Nurse Consultant, Administrator nor his Attending Physician (whom was also the Medical Director) were unaware of the Life Vest being applied on R#188 which placed him at risk because; an immediate follow up with a cardiologist was required when the Life Vest needed to be reloaded after a treatment shock. A subsequent discharge from the Life Vest could be ineffective, and could result in death, and potentially cause serious skin burns. Staff were being placed at risk for incidental shocks by not having appropriate training and education. R#188 was in immediate danger of injury or death due to the facility's failures. Findings include: Resident (R) #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A normal ejection fraction ranges from 55 - 70%. An EF of 20 indicates heart failure). He was determined to have severe 3 vessel [MEDICAL CONDITION] but was deemed a poor surgical candidate due to [MEDICAL CONDITION] viability and a Life Vest (A Life Vest is a wearable, external defibrillator that is a treatment option for sudden [MEDICAL CONDITION] (SCA) that offers patients advanced protection and monitoring as well as improved quality of life) was placed on 7/17/17, then removed due to a suture preventing appropriate skin contact. It was replaced on 7/27/17 at the cardiologist's office. Review of R#188's Admission Minimum Data Set (MDS), dated [DATE], it indicated under Section B, items B0700 and B0800 that the resident was able to both understand others and make himself understood. Section C, item C0500 specified his Brief Interview Mental Status (BIMS) Summary Score was a 15 out of 15, which indicated he was cognitively intact. Section C, item C1310 indicated the resident had no signs or symptoms of [MEDICAL CONDITION] or acute mental status change. Section D, item D0300 indicated R#188's Total (Mood) Severity Score was 0 which indicated no depression. Section E, items E0100 through E1100 indicated the resident exhibited no signs or symptoms of [MEDICAL CONDITION] or behavioral symptoms (expressions of distress), and no rejection of care or wandering during the assessment's evaluation periods. He was coded as being totally dependent on staff for all Activities of Daily Living (ADLs) which included bathing, dressing and grooming. Life Vest Definition: A Life Vest is a wearable, external defibrillator that is a treatment option for sudden [MEDICAL CONDITION] (SCA) that offers patients advanced protection and monitoring as well as improved quality of life. It is worn outside the body (as opposed to an implantable cardioverter defibrillator (ICD). It continuously monitors the patient's heart with dry, non-adhesive [MEDICATION NAME] to detect life-threatening abnormal heart rhythms. If a life-threatening rhythm is detected, the device alerts the patient prior to delivering a treatment shock, and thus allows a conscious patient to delay the treatment shock. If the patient becomes unconscious, the device releases a Blue gel over the therapy [MEDICATION NAME] and delivers an electric shock to restore normal rhythm. The patient needs to be seen at the emergency department, to be evaluated by a cardiologist. Following a treatment shock the vest would have to be reloaded with new [MEDICATION NAME], as they only release Blue gel once. A subsequent shock without reloading could result in a failed shock and skin burns. On 7/31/17 4:55 p.m., during an attempt to do a resident interview as part of survey process, a large (approximately 5.1 x 6.125 X 1.6 inches) monitor of some sort was observed to be around R#188's neck, with a black strap. Review of R#188's clinical record, revealed no documentation either in Progress Notes, Physician Orders or the Care Plan regarding the device. A subsequent telephone interview on 7/31/17 at 6:10 p.m., with the family of R#188 (as he was initially not available due to sleeping and in therapy) revealed it was a Life Vest monitor. The family member stated R#188 had the device prior to being admitted to the facility, but upon discharge from the hospitalization (6/18/17 - 7/18/17) it was determined the Life Vest could not be applied until the sutures were removed. The family member stated it was reapplied on 7/27/17 while R#188 was at his cardiologist. The family member stated she had discussed the device with the nurse on duty (several phone messages to that nurse went unreturned). The nurse told the family member she had heard of the Life Vest but had no experience with it and had not been trained in its use. Further review of R#188's clinical record, revealed the nurse did not document the device being in place, or completed any type of assessment of R#188 upon his return from the cardiologist. There was no documented evidence the facility tried to follow up by phone with the cardiologist. A record review of the Care Plan for R#188, initiated 7/20/17, with updates noted 7/28/17 and 7/31/17, revealed there was no mention of the resident having a Life Vest in place. There was no documentation in the Progress Notes, by nursing, indicating the presence of the Life Vest. There was no physician's order for the use of [REDACTED] A review of the Bathing records revealed the following bathing assistance was provided to R#188. Out of the six Certified Nursing Assistants (CNA) who documented bathing the resident from 7/27/17 through 8/1/17, four were interviewed regarding observations made after 7/27/17, when the Life Vest was applied. The results were as follows: 1. CNA DD documented bathing care was given on 7/27/17 and was a bed bath, 7/31/17 as a shower, and 8/1/17 as a bed bath. An interview with CNA DD on 8/3/17 at 8:03 a.m., revealed She gave R#188 a bed bath sometime last week and she saw the vest and pack and thought the facility knew about it. She indicated she did not ask questions or report it to the facility. She further indicated she was not told he had a vest on and the charge nurse should advise if there was a change in care for the resident. 2. CNA BB documented bathing care was given on 7/27/17 and was a bed bath, and 7/28/17 as a bed bath. An interview with CNA BB on 8/2/17 at 5:25 p.m., revealed she did not ask what the battery pack was for and she would assume the nurse knew the resident had the vest from resident assessment because it was around his neck. CNA BB indicated she gave him a bed bath and did not report the battery pack to the facility. 3. CNA CC documented bathing care was given on 7/30/17 and was a sponge bath. An interview with CNA CC on 8/2/17 at 5:45 p.m., revealed she did not remember the resident and she had not provided care for him. She indicated she let a new CNA use her number to chart because she did not have a number yet, and that was why she showed up as having given R#188 a bed bath. 4. CNA AA documented bathing care was given on 7/31/17 and was a bed bath. An interview with CNA AA on 8/2/17 at 5:30 p.m., revealed she gave R#188 a bed bath and he had a vest on. She further indicated she did not ask resident about pack and confirmed he had the vest on when she gave him a bath. She continued to indicate she did not ask the nurses about the pack and stated the nurses did not ask or talk to the CNA's regarding the pack. An interview with the Director of Nursing (DON) and the facility Nurse Consultant (NC) on 8/2/17 at 10:30 a.m., revealed neither of them were aware R#188 had the Life Vest on. The NC indicated it was facility protocol for anything unusual (like a change in condition, the appearance of unidentified medical equipment, etc.) was to be immediately documented on a form they used entitled Stop and Watch form (A 2-part form where changes regarding the resident were to be noted then passed on to nursing; or be documented on their 24-hour Report). They further revealed R#188's Life Vest was never reported in Morning Stand Up 9:00 a.m. meeting. Further interview with the DON and the NC revealed they both indicated their surprise that no one had reached out in the five days since R#188 had the vest placed, to follow up with nursing and/or the physician. They continued to indicate both had heard of the Life Vest but had not had specific training regarding its use and/or oversight required for both resident and staff safety. The DON revealed they sent paperwork with all residents when they go to a doctor's appointment (which consisted of a face sheet, current Medication Administration Records (MARs), and blank Progress Notes). The NC indicated it was the facility's expectation the physician's office document any treatments or new orders on the provided Progress Notes. She further revealed they did not receive anything back from the cardiologist visit on 7/27/17 and no one called the cardiologist's office to inquire if there were any changes or new orders. An interview with LPN GG on 8/2/17 at 11:45 a.m., revealed information regarding a conversation with the NC. The NC had stated one nurse on the hall R#188 resided on had been trained in the use and oversight of the Life Vest at a sister facility. The surveyor interviewed LPN GG and she stated she did not have any training in the use or oversight of the Life Vest. When advised of the discrepancy, the NC went to LPN GG, with the surveyor, and suggested she had the training (and named the facility). LPN GG indicated she had never worked at the sister facility and maintained she had never been trained on the Life Vest. On 8/2/17 at approximately 1:30 p.m., the NC indicated after researching the situation with R#188, she determined what had happened was a family member brought the Life Vest in the facility on 7/27/17 after R#188 returned from his doctor and the family had placed the vest on the resident. Further investigation revealed the vest was placed during the 7/27/17 cardiologist visit, for which the facility provided transportation for R#188. On 8/2/17 at 2:00 p.m., revealed the DON previously independently interviewed his staff and provided the surveyor with the following results: Out of six CNAs, eight LPNs and one RN, he documented 11 of 15 staff members did not notice the device at all, and four staff members seen it and did not report it to anyone. He did express his disappointment in the lack of communication. An interview with the Licensed Physical Therapy Assistant (LPTA) on 8/2/17 at 3:45 p.m., revealed the LPTA overseen R#188's therapy program. He indicated he saw the device on 7/28/17 and reported to his supervisor. The LPTA further indicated he assumed the nursing staff were aware of the device. When asked if he was familiar with the Life Vest, as far as the purpose of and what sort of safety/oversight measures might be required, he stated, I am not. The therapists were contracted and not direct employees of the facility. A telephone interview with the Therapy Department Manager (TDM) on 8/3/17 at 9:45 a.m., revealed she confirmed the LPTA did report to her R#188 did have a Life Vest. She also revealed she too assumed if he had the device on, nursing was aware. She further indicated she did not report it to any other staff member or review R#188's clinical record to obtain additional information about the device. When asked if she was familiar with the Life Vest, as far as the purpose of and what sort of safety/oversight measures might be required, she stated she was not. An interview with the Administrator on 8/2/17 at 3:45 p.m., revealed she was unaware R#188 had a Life Vest on and she was not familiar with its use or required safety and oversight. She also stated the facility did not have a policy or procedure in place to address the use of external defibrillators. She further revealed it was the facility protocol for staff to use the Stop and Watch form to document changes in condition, which would include an observation of medical equipment not otherwise noted. They did not have a written policy for the use of the Stop and Watch form. The Zoll Life Vest Technician (LVT) came to the facility on [DATE] at 12:00 p.m., and revealed she had come to the facility to provide training for staff regarding the use and oversight of the Life Vest at the request of the Nurse Consultant (NC). Once advised of the issue regarding the staff being unaware of the Life Vest use, the NC independently arranged for a technician from the medical equipment provider (Zoll) to come out and do a training in-service for all direct care staff. After she provided the training to staff the surveyor met with her. An interview with the LVT on 8/2/17 at 2:30 p.m., revealed she had come to the facility to provide training for staff regarding the use and oversight of the Life Vest at the request of the NC. She further indicated the resident did have a Life Vest on he had used prior to hospitalization (6/18 - 7/18/17). She revealed she was given the assignment to see the resident on 7/22/17 and revealed she was not aware he was in a 'Skilled Nursing Facility (SNF) and thought she was seeing him at home. Due to the suture, still being in place (from chest tube placement while hospitalized ) she was unable to place the Life Vest. The LVT indicated she did not communicate with the facility because the resident was supposed to independent with the Life Vest. The LVT further indicated she went to see R#188 on 7/27/17 at the cardiologist appointment. R#188's family member had possession of the vest (from prior to the admission to the facility use) and brought it to the appointment. The technician revealed she measured the resident and determined the vest was the correct size. She placed it on R#188 and left the office. She further indicated it was meant to be used independently by a patient and R#188 was aware of how to use it. She explained when the monitor (of the Life Vest) detects an abnormal rhythm of the heart it alarms and warns the patient. They have 20 seconds to press two buttons simultaneously to stop the shock. If the patient does not stop it will shock. If the vest was not fitting properly it can generate artifact that will make the monitor think it needs to shock them. If the patient was unconscious the unit will provide the charge. There are conductor pads inside the vest that open and release a Blue gel (that acts as a skin protectant to prevent [MEDICAL CONDITION] the defibrillator and increased conductivity). The LVT revealed patients are directed to go to the emergency department to be evaluated by a cardiologist after the vest provides a charge. Then the emergency department (Life Vest provider) will reload the vest with new [MEDICATION NAME]. She also revealed patients are taught how to change the batteries if needed. R#188 also had an extra vest so one can be cleaned while he still had another one. The only time the patient should remove the vest was while showering or bathing. When the LVT came to facility 8/2/17 to provide the staff education, the family of R#188 wanted her to stop in and see the resident. She advised the family member she could not without an order. The family called and had an order sent by physician. The LVT did go and meet with the resident. She returned to report on the visit. She stated R#188 was quite defensive and rude with her, indicating he was very frustrated with all of the attention he was getting today regarding the Life Vest. Due to the facility, not being aware of when the Life Vest was applied, the LVT indicated we could reach out to the company office and they would provide a Wear Time Histogram (detailed graph showing when R#188 was wearing the Life Vest and it was in proper working order). Once received, it confirmed the vest was placed in the cardiologist's office on 7/27/17 and it remained in use as of 8/1/17. The LVT further confirmed it was still working on 8/1/17 through her visit on 8/2/17 as well. When asked if there could be any potential danger to staff or bystanders regarding the Life Vest if it discharged , the LVT stated, yes, a person could sustain a shock if they touched him while a treatment shock was in progress and the fact the facility staff were unaware R#188 would need to go to the hospital to be re-evaluated and would need the Life Vest reloaded, put R#188 at risk of serious harm or death. On 8/2/17 at 4:00 p.m. revealed the NC had a representative from the Life Vest provider come to the facility and provide an in-service for all direct care staff on duty. The in-service covered the use, the required oversight (which included the expected facility response to ensure follow up at an emergency department) as well as safety precautions to prevent staff being inadvertently shocked by the defibrillator should it discharge. The NC indicated between herself and the DON, training was provided and documentation to confirm all of the direct care staff on duty had received the training in the proper use and oversight of the Life Vest (handouts and written directives and pictures were provided). The NC stated no direct care staff would be allowed to work until they had received the training from either the NC or DON. A telephone interview with the Medical Director, who was also the Attending Physician for R#188, on 8/2/17 at 6:15 p.m., revealed he had been the Medical Director of the facility for approximately three years. When asked if he was familiar with the Life Vest, he indicated he was. He further revealed he was not aware R#188 had a Life Vest. He continued to reveal he was familiar with it and indicated he was surprised the resident had it applied and had been wearing it for five days without any facility staff intervention, including him being notified. The Medical Director also indicated he was not aware of any specific policy or procedures the facility had regarding the use of a Life Vest. Continued interview with the Medical Director revealed, when asked, what would he think the facility policy should address regarding the use of a Life Vest, he stated, In general it should allow for training, specifically any special safety instructions and required follow up that may be needed. When the Medical Director was made aware of the fact several facility staff members were aware R#188 had the Life Vest and had not reported nor documented it, his response was surprise and he stated, That was not what I was told. He indicated the facility staff had told him no one knew R#188 had the Life Vest until it was identified by the surveyor. A Credible Allegation of Compliance was received on 8/3/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated the corrective plans and the immediacy of the deficient practice were removed on 8/3/17. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessment procedures to ensure any equipment a resident received was physician-ordered; all direct care staff were trained in the proper use/oversight of said medical equipment; and a policy/procedure was instituted to address the use (specifically) of an external defibrillator. This oversight process included the analysis of in-service materials and records on 8/3/17. Interviews were conducted with staff on 8/3/17 to ensure they demonstrated knowledge of facility Policies and Procedures governing external defibrillators. The resident's record was reviewed on 8/3/17 to ensure resident care and treatment, including physician orders for external defibrillator therapy, were current and accurate. All verification was confirmed by facility staff interviews, documentation and clincal record reviews. Allegation of Compliance Verification as follows: 1. Immediate Action Taken for Residents: 8/2/2017 at 12:00 p.m. 'Zoll LifeVest Company' did an In-Service for all working staff. In-services continue by the 'Clinical Nurse Consultant (CNC) and the Director of Nursing Services (DNS).' No staff will return to work until in serviced on 'LifeVest' and following up on doctors' orders. 'Zoll LifeVest Company' completed assessment of resident R#188 on 8/2/2017. This was verified via interview with the 'Life Vest Technician' on 8/2/17 at approximately 2:30 p.m. Then on 8/2/17 at 4:00 p.m. the 'Nurse Consultant' provided copies of the training outline as well as a list of direct care staff that had obtained training that day. The NC also confirmed no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. A 100% audit was completed on 8/2/17 to assure no other residents had an external defibrillator. All residents will be assessed upon admission to facility for external defibrillator. This was verified and confirmed through the interview with the NC on 8/2/17 at 4:00 p.m., all residents residing in the facility were checked for medical devices including any external defibrillator devices and no other resident was identified having such said device. Care Plan was updated 8/2/17 for R#188 to include LifeVest. This was verified and confirmed on 8/2/17 at 4:00 p.m. by review of the actual care plan for R#188. Activities of Daily Living (ADL) care record was updated on 8/2/17 R#188 to reflect LifeVest. This was verified and confirmed 8/2/17 at 4:00 p.m. by review of the actual ADL Care Record for R#188. LifeVest Information pamphlet in Medication Administration Record [REDACTED]. This was verified and confirmed on 8/2/17 by surveyor ensuring these things were in place on the MAR, ADL care record and R#188's closet door. Facility Clinical Start Up form will be used at 9:00 a.m. meeting to ensure follow up of all Medical Doctor (MD) appointments and all MD orders. This future implementation was verified to be put in place by interviews with the facility administration staff members. No form was made available, as it was a part of the Plan of Correction going forward. 2. Action taken to assure no other residents will be affected in the future: An immediate audit of 100% of resident's charts began on 8/2/17 to ensure all MD follow up orders have been implemented. This was verified and confirmed via interview with the NC on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of training outline as well as a list of direct care staff that had obtained training that day. The NC also stated no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. 8/2/17 In-Service on 'LifeVest' to ensure training was given to all direct care staff. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. In-service staff on proper follow up for all MD appointments. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. 3. Monitoring: R#188 was put on one to one until all staff were in-serviced on LifeVest. This was done prior to the AOC and education done by the Life Vest Technician on 8/2/17 at 12:00 p.m. The facility made the surveyor aware after the fact. DNS and CNC will audit 10% of MD follow up appointment for one week. Then DHS and/or CNC will complete a random audit of doctor's appointment follow up orders weekly for four weeks. This was part of the going forward Plan of Correction. Facility will continue to monitor our performance improvement plan monthly in QAPI meetings. This was part of the going forward Plan of Correction.

Based on observation, interview, and record review, the facility was not administered in an effective manner, utilizing all its resources, resulting in Immediate Jeopardy creating the likelihood of death or serious harm to one of 29 sampled residents (R#188) residing in the facility. The Administrator did not ensure all residents were protected from potential hazards related to unsafe oversight, or lack of, in regard to the use of an external defibrillator; failure to provide appropriate education to all direct care staff in the use of external defibrillators; and failure to ensure external defibrillator oversight policies were developed, implemented and reviewed in the Quality Assurance (QA) program. The sampled size was 29 residents at the time of the survey and one resident (R#188) currently at risk of immediate injury and potential death. Cross reference F328. This deficient practice resulted in an Immediate Jeopardy to R#188's safety, which began on 7/27/17 when R#188 had the Life Vest applied during a cardiology appointment. The Administrator, the Nurse Consultant (NC) and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/3/17 at 9:35 a.m. The Immediate Jeopardy was considered abated as of 2:35 p.m., on 8/3/17, as they had submitted an acceptable plan to remove the IJ related to F328. Findings include: 1. Observations, staff interviews, and record review revealed the facility was not in substantial compliance during the recertification survey of 7/31/17 - 8/4/17. Refer to the following deficiencies for specific details of the noncompliance: a. Comprehensive Care Plans: 483.21 F279 - Failure to develop a care plan to indicate the use of an external defibrillator for R#188. b. Treatment /Care for Special Needs: 483.25 F328 - Failure to ensure R#188 received appropriate external defibrillator care and monitoring from staff caring for R#188 and ensure proper oversight and training was provided to direct care staff that would interact with the Life Vest. c. Administration: 483.70 F490 - Failure to ensure the facility was administered in an effective manner related to the use and care of an external defibrillator for R#188 by failing to ensure the Medical Director was aware of the requirement for developing and implementing policies and procedures for the use of an external defibrillator; ensure all residents had been assessed to determine whether or not they returned from outside appointments with any new medical devices, and to ensure they received documentation of physician's visits, as to new orders and status from the visit; ensure staff were aware of reporting protocol for changes in condition (including new medical devices put in place); and ensure there was a written policy to address the expected use of the Stop and Watch form. F501 - Failure to assist the facility in the development and implementation of a policy and procedure related to the use and care of an external defibrillator. d. Quality Assurance & Performance Improvement: 483.75 F520 - Failure to ensure a Quality Assurance (QA) for external defibrillator use was developed and implemented. Life Vest Definition: A Life Vest is a wearable, external defibrillator that is a treatment option for sudden [MEDICAL CONDITION] (SCA) that offers patients advanced protection and monitoring as well as improved quality of life. It is worn outside the body (as opposed to an implantable cardioverter defibrillator (ICD). It continuously monitors the patient's heart with dry, non-adhesive [MEDICATION NAME] to detect life-threatening abnormal heart rhythms. If a life-threatening rhythm is detected, the device alerts the patient prior to delivering a treatment shock, and thus allows a conscious patient to delay the treatment shock. If the patient becomes unconscious, the device releases a Blue gel over the therapy [MEDICATION NAME] and delivers an electric shock to restore normal rhythm. The patient needs to be seen at the Emergency Department, to be evaluated by a cardiologist, following a treatment shock and the vest has to be reloaded with new [MEDICATION NAME], as they only release Blue gel once. A subsequent shock without reloading could result in a failed shock and skin burns. An interview with the Administrator on 8/2/17 at 3:45 p.m., revealed she was unaware R#188 had a Life Vest on and she was not familiar with its use or required safety and oversight. She also stated the facility did not have a policy or procedure in place to address the use of external defibrillators. She further revealed it was the facility protocol for staff to use the Stop and Watch form to document changes in condition, which would include an observation of medical equipment not otherwise noted. They did not have a written policy for the use of the Stop and Watch form. A Credible Allegation of Compliance was received on 8/3/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated the corrective plans and the immediacy of the deficient practice was removed on 8/3/17. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessment procedures to ensure any equipment a resident received was physician-ordered; all direct care staff were trained in the proper use/oversight of said medical equipment; and a policy/procedure was instituted to address the use (specifically) of an external defibrillator. This oversight process included the analysis of in-service materials and records on 8/3/17. Interviews were conducted with staff on 8/3/17 to ensure they demonstrated knowledge of facility Policies and Procedures governing external defibrillators. The resident's record was reviewed on 8/3/17 to ensure resident care and treatment, including physician orders [REDACTED]. All verification was confirmed by facility staff interviews, documentation and clincal record reviews. Allegation of Compliance Verification as follows: 1. Immediate Action Taken for Residents: 8/2/2017 at 12:00 p.m. 'Zoll LifeVest Company' did an In-Service for all working staff. In-services continue by the 'Clinical Nurse Consultant (CNC) and the Director of Nursing Services (DNS).' No staff will return to work until in serviced on 'LifeVest' and following up on doctors' orders. 'Zoll LifeVest Company' completed assessment of resident R#188 on 8/2/2017. This was verified via interview with the Life Vest Technician on 8/2/17 at approximately 2:30 p.m. Then on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of the training outline as well as a list of direct care staff that had obtained training that day. The NC also confirmed no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. A 100% audit was completed 8/2/17 to assure no other residents had an external defibrillator. All residents will be assessed upon admission to facility for external defibrillator. This was verified and confirmed through the interview with the NC on 8/2/17 at 4:00 p.m., all residents residing in the facility were checked for medical devices including any external defibrillator devices and no other resident was identified having such said device. Care Plan was updated 8/2/17 for R#188 to include Life Vest. This was verified and confirmed on 8/2/17 at 4:00 p.m. by review of the actual care plan for R#188. Activities of Daily Living (ADL) care record was updated on 8/2/17 R#188 to reflect Life Vest. This was verified and confirmed 8/2/17 at 4:00 p.m. by review of the actual ADL Care Record for R#188. Life Vest Information pamphlet in Medication Administration Record [REDACTED]. This was verified and confirmed on 8/2/17 by surveyor ensuring these things were in place on the MAR, ADL care record and R#188's closet door. Facility Clinical Start Up form will be used at 9:00 a.m. meeting to ensure follow up of all Medical Doctor (MD) appointments and all MD orders. This future implementation was verified to be put in place by interviews with the facility administration staff members. No form was made available, as it was a part of the Plan of Correction going forward. 2. Action taken to assure no other residents will be affected in the future: An immediate audit of 100% of resident's charts began on 8/2/17 to ensure all MD follow up orders have been implemented. This was verified and confirmed via interview with the NC on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of training outline as well as a list of direct care staff that had obtained training that day. The NC also stated no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. 8/2/17 In-Service on LifeVest to ensure training was given to all direct care staff. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. In-service staff on proper follow up for all MD appointments. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. 3. Monitoring: R#188 was put on one to one until all staff were in-serviced on LifeVest. This was done prior to the AOC and eduation done by the Life Vest Technician on 8/2/17 at 12:00 p.m. The faciliy made the surveyor aware after the fact. DNS and CNC will audit 10% of MD follow up appointment for one week. Then DHS and/or CNC will complete a random audit of doctor's appointment follow up orders weekly for four weeks. This was part of the going forward Plan of Correction. Facility will continue to monitor our performance improvement plan monthly in QAPI meetings. This was part of the going forward Plan of Correction.

Based on observation, staff interview and record review the facility failed to ensure the Medical Director coordinated medical care in the facility including provision of clinical guidance and oversite for the implementation of resident care policies related to sampled resident (R#188). Specifically, the Medical Director failed to help develop, implement and evaluate resident care policies and procedures for the use of a wearable, external defibrillator. The sample size was 29 residents. Cross reference F328. Findings include: Resident (R) #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A normal ejection fraction ranges from 55% - 70%. An EF of 20 indicates heart failure). He was determined to have severe 3 vessel [MEDICAL CONDITION] but was deemed a poor surgical candidate due to [MEDICAL CONDITION] viability and a Life Vest (A Life Vest is a wearable, external defibrillator that is a treatment option for sudden [MEDICAL CONDITION] (SCA) that offers patients advanced protection and monitoring as well as improved quality of life) was placed on 7/17/17, then removed due to a suture preventing appropriate skin contact. It was replaced on 7/27/17 at the cardiologist's office. The facility Administrative Staff (Director of Nursing, Nurse Consultant, Administrator nor his Attending Physician (whom was also the Medical Director) were aware of the Life Vest being placed on R#188 which placed him at risk (as immediate follow up with a cardiologist was required; and the Life Vest needed to be reloaded after a treatment shock. A subsequent discharge could be ineffective, and could result in death, and potentially cause serious skin burns); as well as staff being at risk for incidental shocks by not having appropriate training and education. R#188, out of a census of 71 residents, was the only resident with an external defibrillator. He was in immediate danger of injury or death due to the facility's failures. Review of the contract between the facility and the Medical Director, dated June 2014, revealed the following, in pertinent parts: Duties and responsibilities of a Medical Director (Essential Functions). The Medical Director is responsible for implementation of resident care policies and the coordination of medical care in the facility. Specific duties and responsibilities . 1. Provide medical decision input to the Administrator and Governing Body of the facility. 1.1 Participate in developing resident care policies, as well as policies regarding services of physicians and other healthcare professionals providing treating the residents of the facility . 3.3 As set forth in this agreement, Medical Director shall review, respond to and participate in federal, stated. Local and other external surveys and inspections . 3.4 Medical Director shall at all times render Services in a competent, professional and ethical manner in accordance with prevailing standards of medical practice in the relevant community, perform professional and supervisory services in accordance with recognized standards of the medical profession. Review of R#188's Admission Minimum Data Set (MDS), dated [DATE], it indicated under Section B, items B0700 and B0800 that the resident was able to both understand others and make himself understood. Section C, item C0500 specified his Brief Interview Mental Status (BIMS) Summary Score was a 15 out of 15, which indicated he was cognitively intact. Section C, item C1310 indicated the resident had no signs or symptoms of [MEDICAL CONDITION] or acute mental status change. Section D, item D0300 indicated R#188's Total (Mood) Severity Score was 0 which indicated no depression. Section E, items E0100 through E1100 indicated the resident exhibited no signs or symptoms of [MEDICAL CONDITION] or behavioral symptoms (expressions of distress), and no rejection of care or wandering during the assessment's evaluation periods. He was coded as being totally dependent on staff for all Activities of Daily Living (ADLs) which included bathing, dressing and grooming. Life Vest Definition: A Life Vest is a wearable, external defibrillator that is a treatment option for sudden [MEDICAL CONDITION] (SCA) that offers patients advanced protection and monitoring as well as improved quality of life. It is worn outside the body (as opposed to an implantable cardioverter defibrillator (ICD). It continuously monitors the patient's heart with dry, non-adhesive [MEDICATION NAME] to detect life-threatening abnormal heart rhythms. If a life-threatening rhythm is detected, the device alerts the patient prior to delivering a treatment shock, and thus allows a conscious patient to delay the treatment shock. If the patient becomes unconscious, the device releases a Blue gel over the therapy [MEDICATION NAME] and delivers an electric shock to restore normal rhythm. The patient needs to be seen at the Emergency Department, to be evaluated by a cardiologist, following a treatment shock and the vest has to be reloaded with new [MEDICATION NAME], as they only release Blue gel once. A subsequent shock without reloading could result in a failed shock and skin burns. A telephone interview with the Medical Director (also the Attending Physician) for R#188, on 8/2/17 at 6:15 p.m., revealed he had been the Medical Director of the facility for approximately three years. When asked if he was familiar with the Life Vest, he indicated he was. He further revealed he was not aware R#188 had a Life Vest. He continued to indicate he was familiar with it and was surprised the resident had it applied and had been wearing it for five days without any staff intervention, including him being notified. The Medical Director also indicated he was not aware of any specific policy or procedures the facility had regarding the use of a Life Vest. Continued interview with the Medical Director revealed, when asked, what he would think the facility policy should address regarding the use of a Life Vest, he stated, In general it should allow for training, specifically any special safety instructions and required follow up that may be needed. When the Medical Director was made aware of the fact several staff members were aware R#188 had the Life Vest and had not reported nor documented it, his response was surprise and he stated, That was not what I was told. He further indicated the facility staff had told him no one knew R#188 had the Life Vest until it was identified by the surveyor. A Credible Allegation of Compliance was received on 8/3/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated the corrective plans and the immediacy of the deficient practice were removed on 8/3/17. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessment procedures to ensure any equipment a resident received was physician-ordered; all direct care staff were trained in the proper use/oversight of said medical equipment; and a policy/procedure was instituted to address the use (specifically) of an external defibrillator. This oversight process included the analysis of in-service materials and records on 8/3/17. Interviews were conducted with staff on 8/3/17 to ensure they demonstrated knowledge of facility Policies and Procedures governing external defibrillators. The resident's record was reviewed on 8/3/17 to ensure resident care and treatment, including physician orders [REDACTED]. All verification was confirmed by facility staff interviews, documentation and clincal record reviews. Allegation of Compliance Verification as follows: 1. Immediate Action Taken for Residents: 8/2/2017 at 12:00 p.m. 'Zoll LifeVest Company' did an In-Service for all working staff. In-services continue by the 'Clinical Nurse Consultant (CNC) and the Director of Nursing Services (DNS).' No staff will return to work until in serviced on 'LifeVest' and following up on doctors' orders. 'Zoll LifeVest Company' completed assessment of resident R#188 on 8/2/2017. This was verified via interview with the Life Vest Technician on 8/2/17 at approximately 2:30 p.m. Then on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of the training outline as well as a list of direct care staff that had obtained training that day. The NC also confirmed no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. A 100% audit was completed 8/2/17 to assure no other residents had an external defibrillator. All residents will be assessed upon admission to facility for external defibrillator. This was verified and confirmed through the interview with the NC on 8/2/17 at 4:00 p.m., all residents residing in the facility were checked for medical devices including any external defibrillator devices and no other resident was identified having such said device. Care Plan was updated 8/2/17 for R#188 to include LifeVest. This was verified and confirmed on 8/2/17 at 4:00 p.m. by review of the actual care plan for R#188. Activities of Daily Living (ADL) care record was updated on 8/2/17 R#188 to reflect LifeVest. This was verified and confirmed 8/2/17 at 4:00 p.m. by review of the actual ADL Care Record for R#188. LifeVest Information pamphlet in Medication Administration Record [REDACTED]. This was verified and confirmed on 8/2/17 by surveyor ensuring these things were in place on the MAR, ADL care record and R#188's closet door. Facility Clinical Start Up form will be used at 9:00 a.m. meeting to ensure follow up of all Medical Doctor (MD) appointments and all MD orders. This future implementation was verified to be put in place by interviews with the facility administration staff members. No form was made available, as it was a part of the Plan of Correction going forward. 2. Action taken to assure no other residents will be affected in the future: An immediate audit of 100% of resident's charts began on 8/2/17 to ensure all MD follow up orders have been implemented. This was verified and confirmed via interview with the NC on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of training outline as well as a list of direct care staff that had obtained training that day. The NC also stated no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. 8/2/17 In-Service on 'Life Vest' to ensure training was given to all direct care staff. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect 'Life Vest' care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. In-service staff on proper follow up for all MD appointments. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. 3. Monitoring: R#188 was put on one to one until all staff were in-serviced on LifeVest. This was done prior to the AOC and education done by the Life Vest Technician on 8/2/17 at 12:00 p.m. The facility made the surveyor aware after the fact. DNS and CNC will audit 10% of MD follow up appointment for one week. Then DHS and/or CNC will complete a random audit of doctor's appointment follow up orders weekly for four weeks. This was part of the going forward Plan of Correction. Facility will continue to monitor our performance improvement plan monthly in QAPI meetings. This was part of the going forward Plan of Correction.

Based on staff interview and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to services for residents who wore an external defibrillator device. This failure had the potential to affect one resident (R#188) of a sample of 29 residents with a census of 71 residents. The facility failed to ensure they had a policy or procedure in place to address the safe oversight of a resident with an external defibrillator (Life Vest). The failure resulted in no training for the direct care staff in regards to monitoring and/or caring for a resident wearing an external defibrillator device. The deficient practice resulted in an Immediate Jeopardy to the resident's safety, which began on 7/27/17. The Administrator, Nurse Consultant and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/3/17 at 9:35 a.m. in the area of F328. The Immediate Jeopardy was considered abated as of 2:35 p.m. on 8/3/17, as they had submitted an acceptable plan to remove the IJ related to F328. Cross reference to F328. Findings Include: Life Vest Definition: A Life Vest is a wearable, external defibrillator that is a treatment option for sudden [MEDICAL CONDITION] (SCA) that offers patients advanced protection and monitoring as well as improved quality of life. It is worn outside the body (as opposed to an implantable cardioverter defibrillator (ICD). It continuously monitors the patient's heart with dry, non-adhesive [MEDICATION NAME] to detect life-threatening abnormal heart rhythms. If a life-threatening rhythm was detected, the device alerts the patient prior to delivering a treatment shock, and thus allows a conscious patient to delay the treatment shock. If the patient becomes unconscious, the device releases a Blue gel over the therapy [MEDICATION NAME] and delivers an electric shock to restore normal rhythm. The patient needs to be seen at the Emergency Department, to be evaluated by a cardiologist, following a treatment shock and the vest has to be reloaded with new [MEDICATION NAME], as they only release Blue gel once. A subsequent shock without reloading could result in a failed shock and skin burns. On 7/31/17 at 4:55 p.m., review of R#188's clinical record, revealed no documentation either in Progress Notes, Physician order [REDACTED]. An interview with the Director of Nursing (DON) and the facility Nurse Consultant (NC) on 8/2/17 at 10:30 a.m., revealed neither of them were aware R#188 had the Life Vest on. The NC indicated it was facility protocol for anything unusual (like a change in condition, the appearance of unidentified medical equipment, etc.) was to be immediately documented on a form they used entitled Stop and Watch form (A 2-part form where changes regarding the resident was to be noted then passed on to nursing; or documented on the 24-hour Report). They further revealed R#188's Life Vest was never reported in Morning Stand Up meeting. When asked if they had a written policy regarding their protocol to use the Stop and Watch form, the NC stated they did not have one in place and that staff had been told verbally about the use of the form. An interview with the Administrator on 8/2/17 at 3:45 p.m., revealed she was unaware R#188 had a Life Vest on and she was not familiar with its use or required safety and oversight. She also indicated the facility did not have a policy or procedure in place to address the use of external defibrillators. When asked if there would have been any hesitation about accepting a potential resident with an external defibrillator, she stated, no. She further revealed it was the facility protocol for staff to use the Stop and Watch form to document changes in condition, which would include an observation of medical equipment not otherwise noted. They did not have a written policy for the use of the Stop and Watch form. She indicated the facility had monthly Quality Assurance (QA) meetings and provided agendas to document that. There was no evidence they had discussed developing a policy to address external defibrillators and were not aware their procedure for the Stop and Watch program was not working. A telephone interview with the Medical Director (also the Attending Physician) for R#188, on 8/2/17 at 6:15 p.m., revealed he had been the Medical Director of the facility for approximately three years. When asked if he was familiar with the Life Vest, he indicated he was. He further revealed he was not aware R#188 had a Life Vest. He continued to indicate he was familiar with it and was surprised the resident had it applied and had been wearing it for five days without any staff intervention, including him being notified. The Medical Director also indicated he was not aware of any specific policy or procedures the facility had regarding the use of a Life Vest. Continued interview with the Medical Director revealed, when asked, what he would think the facility policy should address regarding the use of a Life Vest, he stated, In general it should allow for training, specifically any special safety instructions and required follow up that may be needed. When the Medical Director was made aware of the fact several staff members were aware R#188 had the Life Vest and had not reported nor documented it, his response was surprise and he stated, That was not what I was told. He further indicated the facility staff had told him no one knew R#188 had the Life Vest until it was identified by the surveyor. A Credible Allegation of Compliance was received on 8/3/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated the corrective plans and the immediacy of the deficient practice was removed on 8/3/17. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessment procedures to ensure any equipment a resident received was physician-ordered; all direct care staff were trained in the proper use/oversight of said medical equipment; and a policy/procedure was instituted to address the use (specifically) of an external defibrillator. This oversight process included the analysis of in-service materials and records on 8/3/17. Interviews were conducted with staff on 8/3/17 to ensure they demonstrated knowledge of facility Policies and Procedures governing external defibrillators. The resident's record was reviewed on 8/3/17 to ensure resident care and treatment, including physician orders [REDACTED]. All verification was confirmed by facility staff interviews, documentation and clincal record reviews. Allegation of Compliance Verification as follows: 1. Immediate Action Taken for Residents: 8/2/2017 at 12:00 p.m. 'Zoll LifeVest Company' did an In-Service for all working staff. In-services continue by the 'Clinical Nurse Consultant (CNC) and the Director of Nursing Services (DNS).' No staff will return to work until in serviced on 'LifeVest' and following up on doctors' orders. 'Zoll LifeVest Company completed assessment of resident R#188 on 8/2/2017. This was verified via interview with the Life Vest Technician on 8/2/17 at approximately 2:30 p.m. Then on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of the training outline as well as a list of direct care staff that had obtained training that day. The NC also confirmed no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. A 100% audit was completed 8/2/17 to assure no other residents had an external defibrillator. All residents will be assessed upon admission to facility for external defibrillator. This was verified and confirmed through the interview with the NC on 8/2/17 at 4:00 p.m., all residents residing in the facility were checked for medical devices including any external defibrillator devices and no other resident was identified having such said device. Care Plan was updated 8/2/17 for R#188 to include LifeVest. This was verified and confirmed on 8/2/17 at 4:00 p.m. by review of the actual care plan for R#188. Activities of Daily Living (ADL) care record was updated on 8/2/17 R#188 to reflect LifeVest. This was verified and confirmed 8/2/17 at 4:00 p.m. by review of the actual ADL Care Record for R#188. LifeVest Information pamphlet in Medication Administration Record [REDACTED]. This was verified and confirmed on 8/2/17 by surveyor ensuring these things were in place on the MAR, ADL care record and R#188's closet door. Facility Clinical Start Up form will be used at 9:00 a.m. meeting to ensure follow up of all Medical Doctor (MD) appointments and all MD orders. This future implementation was verified to be put in place by interviews with the facility administration staff members. No form was made available, as it was a part of the Plan of Correction going forward. 2. Action taken to assure no other residents will be affected in the future: An immediate audit of 100% of resident's charts began on 8/2/17 to ensure all MD follow up orders have been implemented. This was verified and confirmed via interview with the NC on 8/2/17 at 4:00 p.m. the Nurse Consultant provided copies of training outline as well as a list of direct care staff that had obtained training that day. The NC also stated no direct care staff would be allowed to work again until they had one to one training from either the NC or DON. The 8/2/17 In-Service on LifeVest to ensure training was given to all direct care staff. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. In-service staff on proper follow up for all MD appointments. This was verified and confirmed on 8/2/17 at 4:00 p.m. by the NC. Training outline to reflect Life Vest care and education was offered and reviewed by the surveyor and found to meet the AOC requirements. 3. Monitoring: R#188 was put on one to one until all staff were in-serviced on LifeVest. This was done prior to the AOC and education done by the Life Vest Technician on 8/2/17 at 12:00 p.m. The facility made the surveyor aware after the fact. DNS and CNC will audit 10% of MD follow up appointment for one week. Then DHS and/or CNC will complete a random audit of doctor's appointment follow up orders weekly for four weeks. This was part of the going forward Plan of Correction. Facility will continue to monitor our performance improvement plan monthly in QAPI meetings. This was part of the going forward Plan of Correction.