Every finding on record at Retreat, The

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Infection Prevention and Control Program Plan, the facility failed to use appropriate infection control practices when providing respiratory therapy for one resident (R) (R41) out of seven residents sampled. Specifically, A nebulizer facemask was laying on the dresser on top of a ziplock bag uncovered. This deficient practice had the potential to cause an infection.Findings include:Review of the policy titled Infection Prevention and Control Program Plan , revised 09/01/2025, revealed The Infection Prevention and Control Program of [NAME] Health Services, INC shall ensure that this organization develops, implements and maintains an active, organization wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, residents, visitors and healthcare workers, and to optimize use of resources. Review of the electronic medical record (EMR) revealed resident (R) 41 was admitted to the facility on [DATE] and pertinent diagnoses including but was not limited to moderate intellectual disabilities (Primary), mild intermittent asthma with (acute) exacerbation, dysphagia, unspecified, Review of R41 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13, which indicates R41 was cognitively intact. Section GG, functional status, revealed R41 required moderate assistance for activities of daily living (ADLs). Section I, active diagnosis, included but not limited to pulmonary issues.Section O, included oxygen therapyReview of R41 care plan last reviewed on 03/31/2026 indicated a problem of R41 is receiving scheduled nebulizers due to an acute exacerbation of asthma. Goals included but not limited to Ms. [NAME] will not require an ED visit/hospitalization for respiratory decompensation over the next two weeks. Interventions included but not limited to albuterol nebs as ordered, and notify the MD if dyspnea, low pulse ox, bluish discolorations to the lips or any signs or symptoms of respiratory distress/decompensation. Review of the Physician's Orders for R41 included but was not limited to:Order dated for 02/9/2026 ipratropium-albuterolsolution for nebulization; 0.5 mg-3 mg(2.5 mgbase)/3 mL; amt: 3ml; inhalationFour Times A Day09:00 AM, 01:00 PM, 05:00 PM, 09:00 PMOrder dated for 01/10/2026 o2 at 2 LPM via nasal cannulaEvery 8 Hours04:00 PM, 12:00 AM, 08:00 AM Observation and interview on 04/28/2026 11:26 AM revealed R41 sitting up in wheelchair resting with eyes closed. Responds to verbal stimuli. She voices no concerns. She is receiving oxygen at 2ml/hr. Nebulizer at bedside with tubing lying on top of a ziplock bag. Observation on 04/29/2026 at 5:02 PM revealed R41 is not in room, nebulizer mask remains sitting on top of ziplock bag open to air. R41 was observed in dining room. Observation on 04/30/2026 at 9:19 AM R41 was sitting up in wheelchair. Nebulizer mask is lying on the dresser beside the ziplock bag. LPN AA entered the room. She confirmed that the mask was on the dresser and not bagged. Interview on 04/30/2026 at 1:10 PM the Assistant Director of Nursing (ADON) stated the nurse probably was lying the mask on the plastic bag to allow it to dry. The ADON confirmed that laying on the plastic bag is not appropriate. It needs to be covered to reduce germs, bacteria and infections. Interview on 04/30/2026 1:13 PM with the Administrator revealed that the respiratory tubing and mask should be stored in a ziplock bag.

Based on observations, staff interviews, and a review of the facility's policy titled Food Storage, the facility failed to ensure that expired food items were discarded in the refrigerator and dry food storage pantry. The deficient practices had the potential to place 46 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include: A review of the facility's undated policy titled Food Storage revealed the Procedure section included, . 7. b. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS (temperature controlled food) food should be consumed, sold, or discarded. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. During a kitchen tour on [DATE] at 7:42 am with the Assistant Dietary Manager (ADM), observations in the double refrigerator revealed one metal serving container labeled Tomato Slice with an expiration date of [DATE], eight one-gallon containers labeled Lemonade with an expiration date of [DATE], and six one-gallon containers labeled Tea with an expiration date of [DATE]. The ADM confirmed the findings in the refrigerator. Observations of the bread storage racks revealed seven loaves of sandwich white bread with expiration dates of [DATE]. Observations of the dry storage pantry revealed four 12-ounce cans of evaporated milk with an expiration date of [DATE]. The ADM confirmed the expired bread and cans of evaporated milk. In an interview on [DATE] at 1:41 pm, the ADM stated she was responsible for the expired foods not being discarded. She further stated she was focused on serving food and managing multiple tasks. She stated that she, the Dietary Manager (DM), and a Dietary Aide were responsible for checking food dates. In an interview on [DATE] at 1:58 pm, the DM stated that food items should be discarded on the expiration date.

Based on observation, staff interviews, record review, and review of the facility's policy titled Floor Stock and Medication Administration, the facility failed to ensure no expired medications were stored in one of one medication storage rooms. This deficient practice had the potential to place the residents at risk of receiving medications with altered effectiveness. The facility census was 51 residents. Findings include: Review of the facility's policy titled Floor Stock, revision date 9/2024, revealed the Policy section included The pharmacy department is responsible for controlling floor stock medications within this hospital. The Procedure section included, . Medications contained in floor stock are stored under the conditions listed by the manufacturer to ensure stability. Review of the facility's policy titled Medication Administration, revision date 6/2023, revealed the Policy section included, . The expiration date of all medications shall be checked before administration. During an observation of the medication storage room with the Director of Nurses (DON) on 3/2/2025 at 10:00 am, one container of naproxen 220 milligrams (mg) (a medication used to treat pain or fever) with an expiration date of 1/2025 and one container of vitamin B1 100 mg with an expiration date of 2/2025 were observed in the medication storage room. The DON confirmed that the expired medications were stored in the medication storage room. In an interview on 3/3/2025 at 2:12 pm, the DON stated the pharmacy stocked the medication storage room. The DON stated that the pharmacist and the nurses should review the medications to ensure that no expired medications were stocked in the medication storage room. In an interview on 3/3/2025 at 5:45 pm, the Administrator stated the nurses and the pharmacist should review the medication expiration dates.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled Hand Hygiene and Enhanced Barrier Precautions (EBP), the facility failed to ensure effective infection control procedures were followed during wound care for one of three residents (R) (R34) with pressure ulcers. The deficient practice had the potential to place R34 at risk of an increased potential for cross-contamination and spread of infection. Findings include: Review of the facility's policy titled Hand Hygiene, revision date June 2024, revealed the Policy section included, All staff shall use the hand-hygiene techniques as recommended by the CDC (Center for Disease Control and Prevention). Always after removing PPE (Personal Protective Equipment). Review of the facility's policy titled Enhanced Barrier Precautions (EBP), effective date June 2024, revealed the Definition section stated, Enhanced Barrier Precautions: Infection control intervention designed to reduce transmission if multi-drug resistant organisms (MDROs), which employs targeted gown and glove use during high contact resident care activities. The Policy section included, EBP are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, and unhealed surgical wounds . Review of R34's medical record revealed diagnoses including, but not limited to, pressure ulcer of sacral region stage 3. Review of R34's Physician Orders revealed an order dated 1/30/2025 for Clean stage 3 area to sacrum with normal saline, apply medi-honey gel and cover with sacrum dressing every other day and PRN (as needed) until healed. Observation of wound care on 3/2/2025 at 10:30 am revealed Registered Nurse (RN) AA and Licensed Practical Nurse (LPN) BB provided wound care to R34. Observations during the wound care procedure revealed that RN AA prepared the supplies by cleaning the resident's bedside table and the supply tray. She wore gloves during the cleaning of the equipment. Once she had cleaned the equipment, she removed the gloves and did not sanitize her hands before putting on another pair of gloves. During the procedure, RN AA removed the dirty wound dressing and changed gloves without sanitizing her hands before putting on the clean pair of gloves and providing treatment and dressing to the wound. Neither RN AA nor LPN BB wore a gown during the procedure. In an interview on 3/2/2025 at 11:15 am, RN AA stated that all residents on wound care did not need to be on EBP. She verified that neither she nor LPN BB had worn a gown during wound care for R34. She further verified she did not perform hand hygiene between removing dirty gloves and putting on clean gloves. In an interview on 3/3/2025 at 2:04 pm, the Assistant Director of Nursing (ADON) stated that EBP should be followed during wound care to prevent the spread of infections. She further stated that hand hygiene should be performed before and after resident care and between glove changes while providing care. In an interview on 3/2/2025 at 11:28 am, the Infection Control Coordinator stated that residents with pressure ulcers and chronic wounds were placed on EBP. She stated that staff was required to wear PPE, including gowns, during high-contact care. In an interview on 3/2/2025 at 11:59 am, the Director of Nursing (DON) stated that EBP was implemented when the resident had a wound or indwelling medical device. The DON stated PPE was readily available and staff had received education on EBP.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure a medication error rate of less than 5 percent. There were 30 opportunities with three medication errors for three residents (R) (R13, R49, R6) observed for medication administration. The medication error rate was 10.0 percent. This deficient practice had the potential to place R13, R49, and R6 at risk of decreased or increased therapeutic effects from the medications administered. Findings include: Review of the facility's policy titled Medication Administration, revision date 6/2023, revealed the Policy section included, Medications shall be administered only upon the order of providers, dentists or podiatrists, who are members of the medical staff, are authorized members of the house staff or have been granted clinical privileges to write such orders and under the guidelines of their respective scopes of practice. The Medication Administration Record shall be compared with the patient's medical record prior to the preparation of any medication at least one (1) time each shift. The individual administering the medication shall verify the medication selected for administration is the correct medication based on the medication order and the medication product label. The medication nurse shall ensure that the correct medication is administered by checking the physician's order and the medication label. 1. Review of R13's medical record revealed diagnoses including, but not limited to, hypokalemia and gastro-esophageal reflux disease. Review of R13's Physician's Orders revealed an order dated 6/13/2024 for vitamin D3 125 micrograms (mcg) (5000 international units [IU]) one tablet daily. Observation of medication administration on 3/2/2025 beginning at 9:00 am revealed Registered Nurse (RN) CC administered Calcium 60 mg, 10 mcg (400 IU) to R13. 2. Review of R49's medical record revealed diagnoses including, but not limited to, anorexia and anemia in chronic kidney disease. Review of R49's Physician's Orders revealed an order dated 1/25/2025 for sodium bicarbonate 325 milligrams (mg) tablet, two tablets to equal 650 mg twice a day. Observation of medication administration on 3/2/2025 beginning at 9:00 am revealed RN CC administered sodium bicarbonate 325 mg, one tablet to R49. 3. Review of R6's medical record revealed a diagnosis of vitamin D deficiency. Review of R6s Physician's Orders revealed an order dated 2/5/2025 for vitamin D3 capsule 25 mcg (1,000 IU) one capsule daily. Observation of medication administration on 3/2/2025 beginning at 9:00 am revealed RN CC administered calcium 600 mg 10 mcg (400 IU) to R6. In an interview on 3/2/2025 at 4:30 pm, RN CC confirmed she administered calcium 600mg, 10mcg (400 IU) to R13, and the physician's order was for vitamin D3 125 mcg (5000 IU). She confirmed she administered sodium bicarbonate 325mg, one tablet, to R49, and the physician's order was for sodium bicarbonate 325mg, two tablets. She further confirmed she administered calcium 600 mg 10 mcg (400 IU) to R6, and the physician's order was for vitamin D3, 25 mcg (1000IU). In an interview on 3/2/2025 at 4:45 pm, the Director of Nursing (DON) reviewed and verified the medication errors. In an interview on 3/3/2025 at 2:09 pm, the Assistant Director of Nursing (ADON) stated the nurses should verify the medication being administered with the electronic medication administration record (eMAR) and ensure the correct medication dosage was being administered to the right resident at the right time.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan for one resident with a diagnosis of urinary tract infection (R12), one resident with a diagnosis of atrial fibrillation receiving anticoagulant therapy (R15), and one resident (R11) with a diagnosis of diabetes mellutis receiving insulin from a sample of 16 residents. Findings Include: 1. Record review of the most recent Quarterly Minimum Data Set (MDS) for R12 dated 10/11/2023 revealed under section I - Active Diagnoses revealed a Urinary Tract Infection (UTI) within the last 30 days. Record review of the Electronic Medical Record (EMR) revealed R12 had an order for Cefuroxime Axetil 500mg (milligrams) twice a day for 10 days, and an order for Macrobid 100mg twice a day for seven days for UTI. Review of a progress note dated 09/20/2023 revealed the attending physician's assessment included a new order for Levaquin 500 mg by mouth daily for seven days for UTI. Review of R12's care plans with a revision date 10/23/2023 revealed there was not a care plan to address the UTI diagnosis and antibiotic usage. Interview on 11/12/2023 at 7:45 am with the MDS Coordinator revealed that R12 had a UTI, and she was on antibiotics. The MDS Coordinator stated that R12 was diagnosed with a UTI on 9/20/2023. She confirmed that a care plan to address the R12 diagnosis of UTI and antibiotic usage had not been developed. MDS Coordinator further revealed that a care plan with interventions should have been developed. She further stated that she is responsible for all care plans. The MDS Coordinator revealed that she has been in the position for a year and a half and that she is learning MDS. Interview on 11/12/2023 at 8:41 am with the Director of Nursing (DON) revealed that her expectations for care plans is that if there are any change in condition or new medications, or new diagnoses that require interventions such as medications or diet change the care plan coordinator should update the care plans. DON further stated that a care plan should have been developed related to R12 UTI and antibiotic usage. 42464 2. Record review of Electronic Medical Record (EMR) for R15 revealed a diagnosis including but not limited to atrial fibrillation. Record review of R15's Physician orders revealed an order for apixaban (anticoagulant) 2.5 milligrams (mg) twice daily. Record review of R15's care plan revealed residents' diagnosis of atrial fibrillation and usage of anticoagulant therapy was not addressed on the comprehensive care plan. Interview on 11/12/23 at 10:15 a.m. with Registered Nurse (RN) MDS Coordinator revealed resident does not have a care plan in place to address diagnosis of atrial fibrillation or anticoagulant usage. She stated both should have a care plan. Interview on 11/12/23 at 10:19 a.m. with DON revealed R15 should have a care plan in place to address the residents diagnosis of atrial fibrillation and anticoagulant usage. The DON stated facility does not have a policy for comprehensive care plans. 45813 3. Record review of the Electronic Medical Record (EMR) for R11 revealed a diagnosis including but not limited to type 2 diabetes mellitus with diabetic chronic kidney disease Record review of the most recent Annual MDS for R11 dated 9/27/2023 revealed insulin orders and received insulin injections 7 of 7 days during the lookback period. Record review of R11's physician order report revealed an order for Levemir (insulin detemir) solution 100 unit/ml (milliliters) 25 units subcutaneous at bedtime with a start date of 4/22/2019. Record review of R11's Medication Administration Record (MAR) for October and November 2023 revealed Levemir insulin 25 units subcutaneously was documented as administered nightly at 9 PM as ordered by the physician. Review of a progress note dated 10/30/2023 revealed the attending physician's assessment included resident had a diagnosis of type 2 diabetes with hyperglycemia and was on Levemir. Record review of R11's care plans with a revision date 10/3/2023 revealed there was not a care plan to address the diabetes diagnosis and insulin usage. Interview on 11/12/2023 at 8:10 am with RN MDS Coordinator confirmed that a care plan to address the resident diabetes diagnosis and insulin usage had not been developed. The RN MDS Coordinator revealed that a care plan with interventions probably should have been developed. She further stated because resident was on a Regular diet and did not have any complications related to her diabetes the care plan was not developed. Interview 11/12/2023 at 8:41 a.m. with the Director of Nursing (DON) revealed her expectations for care plans is that if there are any change in condition or new medications, or new diagnoses that require interventions such as medications or diet change the care plan coordinator updates the care plans. She further revealed R11 was a diabetic and receives insulin therapy therefore, she should have a care plan developed related to diabetes. Interview 11/12/2023 at 9:17 a.m. with Assistant Director of Nursing (ADON) revealed she participates in the care plan meetings. The ADON further revealed that during the meetings, residents problems, diagnoses and current medications are reviewed, and care plans are updated and added as deemed appropriate. The ADON stated if a resident has a diagnosis of diabetes and was receiving treatment such as insulin there should be a care plan developed for that.

Based on interviews, record review, and facility policy review, it was determined the facility failed to provide cardiopulmonary resuscitation (CPR) for a resident who had an order for full code (all resuscitation procedures will be provided to keep a person alive if their heart stops beating or they stop breathing) for 1 (Resident #1) of 5 residents reviewed for CPR. Specifically, Resident #1 had an order for full code and was found unresponsive, without a pulse or respirations, on [DATE] and staff did not provide CPR. This had the potential to affect 12 of 44 residents who resided in the facility and had elected full code. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The IJ began on [DATE] when CPR was not provided for Resident #1, who was a full code, when Resident #1 was found to be unresponsive. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Hospital Administrator were notified of the IJ and provided the IJ template on [DATE] at 10:05 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 12:03 PM. The surveyor performed onsite verification that the Removal Plan had been implemented. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. It was determined that the facility had completed implementation of the Removal Plan prior to the start of survey, and therefore, the IJ was considered past noncompliance. Findings included: Review of the facility's policy, titled, Code Blue, last revised in [DATE], indicated, Any signs of cardiac arrest or respiratory distress within The Retreat Nursing Home shall be treated according to the established standards of the American Heart Association except in those incidences where the physician has specific orders in place. Further review of the policy indicated, Procedure: The first person who responds shall assess the situation. If no pulse or respiration is found, initiate the first response procedures according to the American Heart Association BLS [Basic Life Support] guidelines. - Initiate CPR - Retreat [sic] over house page-CODE BLUE Rm # [room number] (Repeat Twice) - Activate the emergency alarm by removing the AED [automated external defibrillator] from the cabinet located [in] the central area of the facility. A review of Resident #1's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses that included congestive heart failure, type 2 diabetes mellitus, polyneuropathy, atherosclerotic heart disease, peripheral vascular disease, dysphagia, and seizures. The Face Sheet indicated the resident had an advance directive for full code. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #1 participated in the assessment. Review of physician's orders indicated that Resident #1 had an order, dated [DATE], that indicated, Advance Directive/Code Status: Full Code. A review of Resident #1's Care Plan, revised on [DATE], indicated the resident's advance directive status was Full Code. The approaches instructed staff to start cardiopulmonary resuscitation (CPR) should cardiac arrest occur and send the resident to the emergency department (call 911). Review of a death in facility MDS, dated [DATE], revealed Resident #1 was discharged due to death in the facility. Review of a Progress Note, dated [DATE] and written by Registered Nurse (RN) #3, revealed that at approximately 6:00 PM, a certified nurse aide (CNA) reported Resident #1 was unresponsive. The progress note indicated that RN #3 assessed Resident #1 and found no respirations, no pulse, the resident's skin was cool to touch, and there were no signs of life. The progress note indicated that RN #3 immediately called the hospital emergency room (ER) Doctor who came to the bedside to assess the resident. (Note that the hospital is located next to the facility.) According to progress note, the ER Doctor assessed Resident #1 and pronounced the resident deceased at 6:02 PM. RN #3 notified the Director of Nursing (DON) at 6:11 PM. The medical director and family member were also notified by phone. Resident #1's body was released to the funeral home at 8:45 PM. Review of Physician's Progress Notes, dated [DATE] at 6:02 PM and written by the ER Doctor, revealed he was called at 5:57 PM to assess Resident #1 due to staff indicating the resident had no vital signs and was not breathing. The progress note indicated on exam, pupils are fixed and dilated. No corneal reflex. No breath sounds and heart sounds heard on auscultation. Pt [Patient] pronounced dead at 1802 [6:02 PM] on [DATE]. Review of a written statement, dated [DATE] and written by CNA #1, revealed CNA #1 found Resident #1 unresponsive and called Licensed Practical Nurse (LPN) #2, who alerted RN #3. Review of a written statement, dated [DATE] and written by LPN #2, revealed that just before 5:35 PM, CNA #1 notified her that Resident #1 was not responding. The statement indicated that LPN #2 went to Resident #1's room, called the resident's name and tapped on their arm, but got no response. According to the statement, LPN #2 went to retrieve the crash cart, found RN #3 in the hallway, and told RN #3 they needed to call a code. LPN #2's statement indicated that RN #3 said Resident #1 was already gone and was cold. RN #3 then phoned the ER Doctor. The statement indicated that when the ER Doctor arrived, LPN #2 restated that Resident #1 was a full code and asked if CPR should be started, and the ER Doctor said not to start CPR because the resident was already gone. Review of a written statement, dated [DATE] at 7:35 PM and written by RN #3, indicated that when she phoned the ER Doctor regarding Resident #1, she notified him that Resident #1 was a full code and asked if CPR should be started, the ER Doctor replied that he would come to see the resident immediately. The note indicated that once the ER Doctor arrived and assessed Resident #1, he said not to initiate CPR. Review of the 5-day investigation report, dated [DATE], revealed that CNA #1 found Resident #1 unresponsive on [DATE] around 5:50 PM. CNA #1 called for LPN #2 who was at the nurses' station. LPN #2 went to Resident #1's room to assess the resident and determined Resident #1 was unresponsive. LPN #2 called RN #3, who was assigned to provide care for Resident #1. RN #3 arrived at Resident #1's room at 5:53 PM and found Resident #1 unresponsive with no pulse, no respirations, and no verbal response. RN #3 phoned the hospital ER Doctor who immediately arrived at Resident #1's room. The ER Doctor found no respirations and no pulse, and the resident's pupils were fixed. The ER Doctor pronounced Resident #1 deceased at 6:02 PM. The Director of Nursing and the Administrator were notified shortly thereafter. Resident #1 had elected and had an order for full code and CPR was not initiated. RN #3 received basic life support (BLS) recertification on [DATE] and LPN #2 received BLS recertification on [DATE]. Both nurses were suspended pending the investigation and ultimately terminated. During an interview on [DATE] at 9:20 AM, the Director of Nursing (DON) described the incident on [DATE] that involved Resident #1. The DON stated CNA #1 was picking up meal trays from resident rooms and found Resident #1 unresponsive. CNA #1 called for LPN #2, who was at the nurses' station. LPN #2 arrived at Resident #1's room and tried to rouse Resident #1. At this time, the nurse assigned to Resident #1, RN #3, arrived at the resident's room. RN #3 called the hospital ER Doctor. The ER Doctor arrived, checked vitals, and pronounced Resident #1 expired. At 6:10 PM, RN #3 notified the DON that Resident #1 had expired. The DON said that she asked RN #3 if CPR had been conducted and RN #3 stated that CPR had not been initiated because the ER Doctor had pronounced Resident #1 expired. The DON stated that when she asked the nurses why CPR was not started, they did not have a real reason. The DON stated all the nursing staff were up to date on CPR training because they had just renewed training in [DATE]. The DON stated the facility had been running mock codes since 2021, so she could not understand what happened when the staff found the resident unresponsive and did not call code blue or start CPR. During an interview on [DATE] at 11:45 AM, CNA #1 stated she saw Resident #1 around 4:00 PM on [DATE] when Resident #1 was going down the hall with CNA #4 to take a shower. Later, CNA #1 reported she was picking up meal trays. Resident #1's room was the last room. CNA #1 stated she entered the room and was talking to Resident #1's roommate. CNA #1 picked up the roommate's meal tray, placed it on the tray cart in the hallway outside the room, then went back into the room to retrieve Resident #1's tray. CNA #1 stated she was looking at the tray, not Resident #1, as she walked around the privacy curtain. When she asked Resident #1 if the resident was finished eating, Resident #1 did not respond to her question. CNA #1 looked at Resident #1, who was sitting up in bed with their eyes closed. CNA #1 stated she ran out of the room to find RN #3. She did not see RN #3, so she returned to the room and tried rousing Resident #1. When Resident #1 did not respond, CNA #1 went to get LPN #2 who was at the nurses' station. LPN #2 told CNA #1 to get a cold washcloth and the CNA went to the whirlpool room to get the washcloth. When CNA #1 returned to Resident #1's room with the cold washcloth, LPN #2 was coming out of the room and told CNA #1 that Resident #1 had fully coded. LPN #2 left to get RN #3 while CNA #1 stayed in the resident's room. CNA #1 recalled an activities assistant was also in the resident's room, and the activities assistant stated Resident #1 was gone. CNA #1 stated that LPN #2 tried to page for a full code, but LPN #2 did not know how to use the intercom system. RN #3 entered the resident's room and then made a motion indicating that Resident #1 was gone. CNA #1 stated she recalled seeing the crash cart in the room beside the bed. CNA #1 stated the ER Doctor then arrived, and she saw him signing a paper. CNA #1 stated she did not see LPN #2 or RN #3 assessing Resident #1 because she was not in the room at the time. During an interview on [DATE] at 12:30 PM, the Assistant Director of Nursing (ADON), who also served as the staff education coordinator, stated they kept a code status list and the signed advanced directives at the nurses' station. The code status list was also maintained in the automated external defibrillator (AED) case and on the crash cart. The individual resident code status was also posted on the resident's closet door. The ADON stated she was not involved in this incident but stated that when a resident was found unresponsive and was designated full code, a staff member should announce Code Blue over the intercom system to alert staff to perform CPR; the intercom system also notified the hospital next door. Staff would then immediately start CPR and continue performing CPR until relieved by hospital staff. During an interview on [DATE] at 1:00 PM, the ER Doctor stated he was called on the ER phone from the facility and was told the resident was unresponsive with no vital signs. He immediately walked over to the facility and into the resident's room. He estimated it took him two to three minutes to get there. When he arrived and assessed Resident #1, Resident #1 was cold to the touch, pupils were dilated and nonreactive, and there were no heart sounds. The ER Doctor stated in his assessment that it was too late to administer CPR. He stated that normally when he was called to the facility the nursing home staff had already initiated CPR if the resident was designated full code. During an interview on [DATE] at 4:50 PM, the Administrator stated that before the evening meal on [DATE], RN #3 went to the resident's room to administer medications for Resident #1, but CNA #4 was helping Resident #1 to get dressed, so RN #3 planned to return later for medication administration. The Administrator said that at 5:30 PM, RN #3 returned to Resident #1's room for medication administration. Resident #1 was eating, and RN #3 did not notice anything unusual. The Administrator stated that based on staff statements and camera footage, no one else entered the room until CNA #1 went into the room to pick up Resident #1's meal tray and found Resident #1 unresponsive. During an interview on [DATE] at 1:30 PM, CNA #4 stated she worked 3:00 PM to 11:00 PM on [DATE]. CNA #4 said she assisted Resident #1 to bathe right before the 5:00 PM meal and Resident #1 seemed their normal self. While she was assisting Resident #1 with dressing, she recalled that RN #3 entered the resident's room to administer medications and then indicated she would return after Resident #1 was dressed. After assisting Resident #1 to dress, CNA #4 went to the dining room to help assist other residents with the evening meal. CNA #4 stated it would have been around 5:00 PM when she left Resident #1's room. On [DATE] at 2:00 PM, RN #3 was interviewed regarding the incident on [DATE] involving Resident #1. RN #3 stated that when she arrived at Resident #1's room, she shook the resident and called their name, trying to rouse the resident. RN #3 stated she checked Resident #1's carotid and radial pulses and did a sternum rub. RN #3 stated Resident #1 was cool to the touch and had no rigidity when she was checking the resident's vital signs. RN #3 stated that after she assessed the resident, she went to the nurses' station, called the ER Doctor, and told him Resident #1 was a full code and was unresponsive. RN #3 stated she asked the ER Doctor if staff should start CPR, and the ER Doctor responded that he would be right there. RN #3 said when the ER Doctor arrived, he checked Resident #1's pupils with a light, listened to Resident #1's heart with a stethoscope, and pronounced Resident #1 dead. RN #3 reiterated that when she called the ER Doctor on the phone and told him that Resident #1 was a full code and unresponsive, she asked if staff should start CPR, and the ER Doctor said he would be right over to see the resident. RN #3 stated she asked the ER Doctor again in the resident's room if they should start CPR, and the ER Doctor said, No. RN #3 stated she was terminated by the facility. During an interview on [DATE] at 3:37 PM, Activities Assistant #9 stated she was present shortly after Resident #1 was found unresponsive. She said she was the staff member who opened the closet door to check Resident #1's status and saw the resident was a full code. She said she checked Resident #1's carotid pulse and there was no pulse, and Resident #1 was cold and pale. Activity Assistant #9 stated she was there when the ER Doctor arrived. She stated the nurses asked the ER Doctor if they should start CPR, and he assessed Resident #1 for vital signs and checked the resident's pupils and pronounced Resident #1 deceased . She believed it was about eight to nine minutes between the time she was made aware of the resident being unresponsive and the ER Doctor's assessment of Resident #1. Removal Plan The following IJ Removal Plan was provided by the facility and accepted by the State Survey Agency on [DATE] at 12:03 PM: 1. On [DATE] at approximately 5:50 PM, a certified nursing assistant (CNA) went in Resident #1's room to pick up a dinner tray and found the resident was not responsive. The CNA reported to the licensed practical nurse (LPN) at the nurses' station that the resident was not responding. The LPN went to the resident's room to assess. After finding the resident unresponsive, the LPN notified the registered nurse (RN) assigned to the resident. The RN went into the resident's room at 5:53 PM and found the resident unresponsive with no pulse, no respirations, and no verbal response. The RN phoned the emergency room (ER) doctor at hospital who immediately came to the resident's room. The doctor found no respirations, no pulse, and pupils were fixed and dilated. The doctor pronounced the resident deceased at 6:02 PM. 2. The Director of Nursing (DON) and Administrator responded immediately to the facility. After interviews with staff, the DON immediately began re-education with staff on the date of the incident, [DATE], to include the code blue policy and procedure, location of resident's code status, call a code, and utilization of the overhead paging system. The facility conducted an ad hoc meeting to discuss the event on the evening of [DATE]. All licensed nurses and certified nursing assistants on duty attended, which included the two nurses involved in the incident. The two nurses involved were immediately removed from the schedule on [DATE] and subsequently terminated on [DATE]. 3. On [DATE], the DON and Assistant Director of Nursing (ADON) began code blue in-services for licensed nurses and certified nursing assistants which included what to do if a staff member finds a resident with signs of cardiac arrest or respiratory distress. The first person who responds shall assess the situation. If no pulse or respirations is found, immediately check resident's code status. If the resident is a full code, initiate CPR. CPR can be initiated by a RN or LPN, with a BLS certification. The nurse does not wait for the physician before initiating CPR. The staff is also trained on irreversible signs of death as outlined in our Code Blue policy. As of [DATE], there was a total of 24 full time licensed nurses and certified nursing assistants available for work. As of [DATE], 95.8% of full-time licensed nurses and certified nursing assistants received training. This included 5 of 5 registered nurses, 7 of 7 licensed practical nurses, and 11 of 12 certified nursing assistants. The remaining PRN (as needed) staff who have not received training will be re-educated prior to the next scheduled shift. Any licensed nurse or CNA (including agency staff) not receiving the code status education due to scheduled time off or FMLA (Family and Medical Leave Act) will be in-serviced prior to their next scheduled shift. New hire nurses and CNAs will be educated on the 1st shift of orientation. Prior to [DATE], code blue education with the mock codes were provided monthly by the ADON. 4. All staff have current Basic Life Support Certifications (BLS) on file. As of [DATE], 100% of licensed nurses and CNAs, which included 12 of 12 RNs, 10 of 10 LPNs, and 23 of 23 certified nursing assistants have BLS certification. In [DATE] and [DATE], we conducted on-site American Heart Association (AHA) BLS training by an AHA BLS instructor. 5. A mock code blue was conducted on [DATE]. Prior to the [DATE] incident, mock code blues were conducted monthly by the ADON. 6. On [DATE], the DON, following the Mortality Review Policy and Procedure, completed the mortality review form with the interdisciplinary team The Mortality Review is when the team provides a forum to identify adverse patient outcomes and their contributing factors, openly discuss the situation and disseminate information learned from the review to maximize patient safety. The team includes the Medical Director, DON, and three administrative nurses. 7. A root cause analysis was started on [DATE] and completed on [DATE]. This meeting was held as an executive session under the QAPI [quality assurance performance improvement] meeting. The following were involved: the DON, Retreat Administrator, [NAME] Health Services Administrator, [NAME] Health Services Assistant Administrator, ADON, MDS/Care Plan Coordinator and the Medical Director. The outcome was a failure of the staff to initiate basic life support and call a code, complying with established and policy and procedure. During the interviews, the LPN could not provide a reason, even though she admitted she knew to start CPR. The RN stated the resident was gone and it was too late. Follow up interviews did not identify changes in their statements. 8. Code status audits have been completed monthly and will continue monthly by the ADON and the MDS/Care Plan Coordinator. The DON, Administrator or designee will provide oversight. Code Status audits are done monthly and include verification that the resident code status is on the electronic health record (EHR) banner, on the code status list in the crash cart, on the signed documents scanned into the EHR, on the signed documents in the resident information notebooks at the nurse's station, in the resident's orders, in the resident care plan and posted on the sign in the resident's closet. It includes verification that code status is correct and matches in all these locations. The last Code Status audit was done [DATE]. 9. The Administrator or DON will conduct oversight of the education and the audits daily until 100% of licensed nurses and certified nursing assistants receive the training which started on [DATE]. Additional training includes education on the code blue policy using scenarios with participants performing return demonstration of basic life support measures following facility policy and procedure. This training is provided by the ADON. As part of this education, a code blue documentation form is completed during the mock code to record the real time events performed, which allows for immediate feedback and correction of participants. Following the mock codes, participants complete a participant self-evaluation. In addition, on-site basic life support courses are provided. 10. All corrective actions will be completed on [DATE]. 11. The immediacy of the IJ was removed on [DATE]. Onsite Verification of Removal Plan Onsite verification of the Removal Plan was completed on [DATE] and [DATE]. In an interview on [DATE] at 9:45 AM, the Administrator stated that as part of their 5-day investigation and plan of correction, they reeducated all CNAs and nurses, conducted mock codes, educated staff on how to use the paging system, audited the code status list, and audited the staff CPR training. Resident code status was posted inside each resident's closet door, a full list of residents and their code status was kept on the crash cart and inside the AED case, and a full list of residents and their code status was kept at the nurses' station. Code status was also in the electronic medical record. The surveyor verified this was completed during the survey. In an interview on [DATE] at 12:30 PM, the Assistant Director of Nursing (ADON) stated they kept a code status list and the signed advanced directives at the nurses' station. The code status list was also maintained in the AED case and on the crash cart. The ADON stated that all staff were in-serviced on use of the intercom system; where to find code status, the crash cart, and the AED; and all staff were provided training on the procedures for immediately initiating CPR. The instructions for using the intercom were also placed near the phone. The surveyor verified this was completed during the survey. Review of the code blue in-service log provided by the DON on [DATE] revealed 31 of 45 total facility staff had received re-in servicing. Three of the 45 staff were on medical leave and seven staff were scheduled to work in the next few days and were currently being in-serviced by phone before their next shift. Of the 45 staff, there were four as needed staff who were not scheduled to work in the near future. On [DATE] mock code blue training exercises were conducted. During an interview on [DATE] at 9:20 AM, the DON stated all the nursing staff were up to date on CPR training because they had just renewed training in [DATE]. BLS certification was verified for 100% of direct care staff. Staff interviews were conducted to verify that training occurred. The interviews included the following: - During an interview on [DATE] at 11:45 AM, CNA #1 stated that on [DATE] following the incident, she underwent training on how to use the intercom, the procedures for code blue, where to find resident code status, and where to find the crash carts. - During an interview on [DATE] at 1:22 PM, RN #11 stated she was provided training the week before the survey on how to call a code blue; the location of the crash cart, AED, and resident code status lists; and the procedure for initiating CPR immediately. - During an interview on [DATE] at 3:00 PM, LPN #6 stated she received CPR and code blue training, but it was not on [DATE]; it was a day or so later, because she had not worked on [DATE]. She explained where to find the code status posted in resident closets, identified the location of the crash cart, and stated she was trained on using the intercom system to call code blue. She verbalized that CPR was to be initiated as soon as possible. - During an interview on [DATE] at 3:17 PM, CNA #7 stated she was re-in serviced on where to find code status, code blue procedures, and how to call a code blue on the intercom system. CNA #7 stated she felt confident responding to an unresponsive resident. - During an interview on [DATE] at 3:25 PM, CNA #8 stated she had received training the week before the survey on code blue procedures. Training included the importance of starting CPR immediately, where to locate code status (closet, chart, nurses station, and crash cart) and where the crash cart was located. - During an interview on [DATE] at 8:15 AM, Activities Assistant #10 stated she received training about responding to a code blue and understood how to use the intercom system and where to find code status for residents. - During an interview on [DATE] at 12:36 PM, RN #12, who worked as needed, stated she received re-in servicing prior to her shift. She said the training included the location of resident code status lists and crash cart, and code blue policies/procedures including how to call a code blue. RN #12 stated she was instructed to initiate CPR immediately and not stop until back up arrived. - During an interview on [DATE] at 4:00 PM, LPN #15, who worked full time, stated she received code blue training last week right after the incident with Resident #1. She was able to describe where to locate resident code status, crash carts and the AED, and stated she was instructed to start CPR immediately and not wait. - During an interview on [DATE] at 4:10 PM, CNA #16 stated she received training the week before the survey. CNA #16 knew the location of the crash cart and resident code status, could explain the CPR process, and knew that she was responsible for initiating CPR right away. During an observation on [DATE] at 4:38 PM, a mock code blue exercise was in progress. Staff participated in calling and responding to the code and administering BLS measures and CPR. Feedback was provided following the mock code and staff completed self-assessments. Two emergency room staff arrived in response to the mock code blue. It was verified that the Mortality Review was completed on [DATE] and the root cause analysis was completed as part of a QAPI meeting with executive personnel on [DATE]. The code status audit conducted by the ADON, dated [DATE], was reviewed and verified. Identification of code status and posting for sampled residents was reviewed and verified. Administrative oversight of the above measures was reviewed and verified. In an interview on [DATE] at 10:30 AM, the Administrator stated that in terms of the Removal Plan, if the ADON was not available to complete code list audits and update the code list, the MDS Nurse was responsible for ensuring the code list and audits were done. If the DON was not available to provide staff education regarding code blue policy/procedures, then the ADON ensured the training was done prior to a staff member's shift. Regarding mock codes, the Administrator stated if a staff person or group of staff performed subpar or voiced they had concerns on the self-evaluation, then staff were retrained. All corrective action was completed on [DATE]. The IJ was removed on [DATE].

Based on observation, record review, review of facility policy titled Cleaning and Disinfecting the Glucometer, and staff interviews, the facility failed to disinfect the glucometer between resident use for three of seven residents (R) (R#32, R#30, and R#37) observed for blood glucose monitoring. Findings include: Review of facility policy titled Cleaning and Disinfecting the Glucometer revised September 2020 revealed that if dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use. 1. Observation on 5/7/22 at 4:16 p.m. revealed Licensed Practical Nurse (LPN) AA was preparing the glucometer by scanning the label on the strips (unknown if cleaned prior to use) and went to obtain the blood glucose reading for R#32. LPN AA sanitized hands, used gloves, prepped the finger with alcohol and used an individual lancet. She then discarded the lancet in the sharp's container, removed gloves and sanitized hands. LPN AA returned to the medication cart, placed the glucometer on top of the medication cart and prepared one pill ([MEDICATION(S)] 10 mg) and three units of [MEDICATION(S)] insulin to administered to R#32. LPN AA administered the medications and returned to the medication cart. LPN AA did not clean the glucometer. 2. Continued observation on 5/7/22 at 4:25 p.m. LPN AA prepared the glucometer without cleaning it and went to obtain a blood glucose reading for R#30. The blood sugar was checked in the same manner as the previous resident. LPN AA returned to the medication cart, placed the glucometer on the medication cart and prepared one pill ([MEDICATION(S)] 800 mg) and two units of [MEDICATION(S)] insulin to administered to R#30. LPN AA administered the medications and returned to the medication cart. LPN AA did not clean the glucometer. 3. Continued observation on 5/7/22 at 4:34 p.m. LPN AA prepared the glucometer without cleaning it and went to obtain a blood glucose reading for R#37. LPN AA was never observed to clean the glucometer. Review of the clinical record for R#32, R#30, R#37 and the additional five residents that received blood glucose monitoring revealed no residents with bloodborne pathogens. Observations on 5/8/22 at 11:30 a.m. and 11:50 a.m. revealed LPN CC and LPN BB completed blood glucose monitoring for four additional residents with no concerns for cleaning/disinfecting. The machine was disinfected with the appropriate Sani-wipe for three minutes and was allowed to air dry. Interview with LPN AA on 5/8/22 at 12:01 p.m. revealed she cleaned the machine prior to starting the blood sugar checks and then after completing all three. She stated she did use the glucometer on three residents without cleaning the machine in between use. LPN AA stated she does not normally work the cart. She is the treatment nurse. LPN AA confirmed the machine should have been cleaned between each resident use. During an interview on 5/8/22 at 12:10 p.m., the interim Director of Nursing (DON) stated that she expects staff to clean the machine between each resident use and she revealed that LPN AA does not normally work the cart. She also confirmed there were no residents in the facility with blood borne pathogens. Review of the training information titled (name) System Training Checklist revealed nurse checkoffs for use of the glucometer. Part of the checkoff under cleaning and disinfecting was to clean and disinfect between each patient use. There was no checkoff sheet for LPN AA.

Based on record review and staff interview, the facility failed to provide Cardio-Pulmonary Resuscitation (CPR) as care planned for one resident (R) (R#1) of 11 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing Services (DON), and the facility's Health Services Administrator were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:46 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The IJ is outlined as follows: Closed record review for R#1 revealed that he had Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed that R#1 was found unresponsive and without pulse or respirations on [DATE] at 9:00 p.m. He was noted with emesis in his mouth, around his neck and on his T-shirt. Licensed Practical Nurse (LPN) AA called for assistance and another nurse and a Certified Nursing Assistant (CNA) came into R#1's room. The on-call Physician was notified at 9:01 p.m. and the Physician ordered the resident to be transferred to the emergency room (ER) which adjoined the facility. At 9:06 p.m., the ER was notified of the transfer and the resident's daughter was notified. R#1 was transferred to the ER at 9:10 p.m., 10 minutes after he was first found unresponsive. Review of the hospital ER Documentation dated [DATE] at 9:18 p.m. revealed that R#1 was DOA (Dead on Arrival) and in asystole (no electrical activity of the heart). Continued review of the ER Documentation revealed that there had been no pre-arrival CPR or rescue breathing performed prior to R#1 arriving in the ER. CPR with suctioning was initiated in the ER; however, R#1 was pronounced dead at 9:30 p.m. Although R#1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope and Severity (S/S): J) and 42 CFR 483.24(a)(3) -- CPR (F678 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.24(a)(3) - CPR (F678 S/S: J). An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of CPR. Findings include: A review of the closed medical record for R#1 revealed he was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for R#1 revealed that he had a POLST dated [DATE] to attempt CPR and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his care plan dated [DATE] revealed that R#1 was a Full Code and that all life sustaining measures were to be done with an intervention for nursing staff to start CPR should [CONDITION(S)] occur. Review of the Late Entry Nurse's Progress Note dated [DATE] at 1:30 a.m. revealed that at 9:00 p.m. on [DATE], LPN AA attempted to administer the resident his medications but found him unresponsive. The resident did not have respirations or a pulse. The on-call Physician was notified at 9:01 p.m. and ordered staff to transfer the resident to the ER. R#1 was transferred via stretcher to the ER at 9:10 p.m., 10 minutes after he was found unresponsive. Review of the hospital ER Documentation dated [DATE] at 9:18 p.m. revealed that the ER Physician assessed R#1 as presenting in cardiorespiratory arrest. Continued review revealed that there had been no pre-arrival treatment (such as CPR) conducted for R#1 and he had arrived at the ER with no CPR or rescue breathing being performed. Review of the Georgia Death Certificate dated [DATE] revealed that R#1 was pronounced dead on [DATE] at 9:30 p.m. The immediate cause of death was acute cardiorespiratory arrest due to acute aspiration. Telephone interview with LPN AA on [DATE] at 6:38 p.m. revealed that on [DATE] at 9:00 p.m., she had gone into R#1's room to administer his medications. The resident did not respond to his name or to touch. LPN AA revealed that she nor any other staff initiated CPR for R#1. LPN AA could not explain the reason CPR was not initiated for R#1. Nursing staff failed to implement the care plan to start CPR should [CONDITION(S)] occur for R#1 who was a Full Code. Cross refer to F678. The facility implemented the following actions to remove the IJ: 1. On [DATE] at 10:45 a.m. Resident #1 's care plan was reviewed as being a Full Code Status. On [DATE] at 9:00 p.m. Resident #1 was found unresponsive with emesis in mouth, no respirations or heart rate was present. CPR was not initiated. Resident #1 was a full code. Resident's physician was notified of resident's condition who gave orders to transfer to emergency room . At 9: 10 p.m. resident #1 was transferred to emergency room via stretcher without CPR in progress on the Full Code resident. 2. On [DATE] State Surveyor made current Director of Nursing aware of complaint regarding quality of care where a Full Code resident was not given Cardiopulmonary Resuscitation. 3. On [DATE] the MDS (Minimum Data Set) Coordinator completed 100% care plan audit on all residents to verify care plan matched the identified code status. Per the audit, 41 of 41 resident's care plan matched the code status that was noted in the physicians' orders and on the face sheet. 4. On [DATE] the Director of Nursing posted a list of code status to identify Full Code vs DNR (Do not resuscitate) at nurses' station in a location for nursing employees only. On [DATE] the Director of Nursing and Education Nurse started in-service for Licensed nurses and certified nursing assistants of code status list for easy access. 100% of licensed nurses and certified nursing assistants which included 8 of 8 Registered Nurse (RNs), 10 of 10 LPNs, and 20 of 20 certified nursing assistants received the information. Any licensed nurse or certified nursing assistant (including agency) not receiving the Code Status education due to scheduled time off or FMLA (Family and Medical Leave Act) will be in-serviced prior to next scheduled shift. New hire nurses and certified nursing assistants will be educated on first orientation shift. 5. During admission, readmission, significant change, per resident/authorized person's request, and quarterly care plan meetings, the Social Worker and MDS Coordinator will review advanced directive care plan for any changes to the resident's advanced directive care plan. If any changes to the resident's advanced directive, the MDS coordinator will update the advanced directive care plan after all DNR/POLST forms are validated and received. 6. All corrective actions will be completed on [DATE]. 7. The immediacy of the IJ will be removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Record review revealed that R#1 was found unresponsive and without pulse or respirations on [DATE] at 9:00 p.m. He had a POLST dated [DATE] to attempt CPR and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to initiate CPR and continue CPR prior to transferring him to the ER where more aggressive life sustaining treatment could be initiated. 2. During interview on [DATE] at 3:55 p.m., DON stated that she started working at the facility in [DATE] and was not aware of the incident of R#1 not receiving CPR. 3. Review of the Code Status Audit dated [DATE] revealed 41 residents code status matched in the electronic medical record, notebook, Physician Order, and care plan. R#7 was admitted to the facility on [DATE]. The Physician Order, EMR, and care plan revealed R#7 had a code status of DNR. R#8 was admitted to the facility on [DATE]. The Physician Order, EMR, and care plan revealed R#8 had a code status of DNR. R#9 was admitted to the facility on [DATE]. The Physician Order, EMR, and care plan revealed R#9 had a code status of full code. 4. Observation on [DATE] at 10:35 a.m. revealed residents' code status was posted at the nurse's station for view by clinical staff only. The code status for R#7, R#8, and R#9 were observed accurately posted at the nurse's station. Review of the in-service records dated ,d+[DATE] through [DATE] confirmed 8 RN's, 10 LPN's, and 20 CNA's received education on the code status list for easy access. Also verified via the following staff interviews on [DATE]: 11:30 a.m. with CNA CC, 11:35 a.m. with CNA DD, 11:45 a.m. with LPN FF, 12:00 p.m. with CNA GG, 12:05 p.m. with CNA HH, 12:35 p.m. with LPN II, 12:40 p.m. with RN JJ, 12:55 p.m. with RN KK, and 1:15 p.m. with CNA LL. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. There have been no new hires. 5. Record review revealed R#7 had a Quarterly MDS assessment dated [DATE]. The residents care plan was reviewed on [DATE] and indicated the resident is on hospice, has DNR order and POLST on file. Record review revealed R#8 had a Significant Change assessment dated [DATE]. The care plan was reviewed on [DATE] and indicated resident had DNR order and POLST on file. 6. All corrective actions will be completed on [DATE]. 7. The immediacy of the IJ will be removed on [DATE].

Based on record reviews, review of the facility's policy Code Blue, and staff interviews, the facility failed to provide Cardio-Pulmonary Resuscitation (CPR) for one resident (R) (R#1) of 11 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing Services (DON), and the facility's Health Services Administrator were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:46 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The IJ is outlined as follows: Closed record review for R#1 revealed that he had Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] to attempt CPR and a Physician's Order dated [DATE] for Full Code (meaning that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Further record review revealed that R#1 was found unresponsive and without pulse or respirations on [DATE] at 9:00 p.m. He was noted with emesis in his mouth, around his neck and on his T-shirt. Licensed Practical Nurse (LPN) AA called for assistance and another nurse and a Certified Nursing Assistant (CNA) came into R#1's room. The on-call Physician was notified at 9:01 p.m. and the Physician ordered the resident to be transferred to the emergency room (ER) which adjoined the facility. At 9:06 p.m., the ER was notified of the transfer and the resident's daughter was notified. R#1 was transferred to the ER at 9:10 p.m., 10 minutes after he was first found unresponsive. Review of the hospital ER Documentation dated [DATE] at 9:18 p.m. revealed that R#1 was DOA (Dead on Arrival) and in asystole (no electrical activity of the heart). Continued review of the ER Documentation revealed that there had been no pre-arrival CPR or rescue breathing performed prior to R#1 arriving in the ER. CPR with suctioning was initiated in the ER; however, R#1 was pronounced dead at 9:30 p.m. Although R#1 had a Physician's Order since [DATE] to attempt resuscitation in the event he had no pulse and was not breathing, staff failed to initiate CPR and continue CPR prior to transferring him to the ER where more aggressive life sustaining treatment could be initiated. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope and Severity (S/S): J) and 42 CFR 483.24(a)(3) -- CPR (F678 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.24(a)(3) - CPR (F678 S/S: J). An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of CPR. Findings include: Review of the facility policy Code Blue dated [DATE] revealed that all patients having a cardiac and/or respiratory arrest will be coded except in those incidences where the physician specifically orders otherwise. Personnel discovering a patient in full arrest will: call for help and have physician notified, initiate CPR, all other personnel will begin preparations for transfer to ER, appropriate personnel will immediately bring crash cart to area of code blue and continue CPR without interruption until relieved by hospital personnel or emergency personnel. Closed record review for R#1 revealed R#1 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his Annual Minimum Data Set (MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 9, indicating that he had some cognitive impairment. Continued review revealed that he required extensive to total assistance from staff for activities of daily living (ADL). Review of the medical record for R#1 revealed that he had a POLST dated [DATE] to attempt CPR and a Physician's Order dated [DATE] for Full Code. Review of his care plan dated [DATE] revealed that R#1 was a Full Code and that all life sustaining measures were to be done with an intervention for nursing staff to start CPR should cardiac arrest occur. Review of the Late Entry Nurse's Progress Note dated [DATE] at 1:30 a.m. revealed that at 9:00 p.m. on [DATE], LPN AA attempted to administer the resident his medications but found him unresponsive. R#1 was observed to have emesis in his mouth, around his neck and on his T-shirt. The resident did not have respirations or a pulse. LPN AA notified the other nurse and a certified nursing assistant for assistance. Continued review revealed that the on-call Physician was notified at 9:01 p.m. and ordered staff to transfer the resident to the ER. The ER was notified at 9:06 p.m. that R#1 was to be transferred. The resident's daughter was then notified that the resident was being transferred to the ER. Further review revealed that R#1 was transferred via stretcher to the ER at 9:10 p.m., 10 minutes after he was found unresponsive. Review of the hospital ER Documentation dated [DATE] at 9:18 p.m. revealed that the ER Physician assessed R#1 as presenting in cardiorespiratory arrest. R#1 had pale, cool extremities, fixed and dilated pupils and was in asystole. Continued review revealed that there had been no pre-arrival treatment done for R#1 and he had arrived at the ER with no CPR or rescue breathing noted. When the resident arrived at the ER, CPR was done, and the resident's airway was suctioned. There was no response from the resident, and he was pronounced dead at 9:30 p.m. Review of the Georgia Death Certificate dated [DATE] revealed that R#1 was pronounced dead on [DATE] at 9:30 p.m. The immediate cause of death was acute cardiorespiratory arrest due to acute aspiration. Review of a statement from CNA BB dated [DATE] at 2:15 p.m. revealed that she was the caregiver for R#1 on [DATE] and that she had last assessed R#1 thirty minutes prior (approximately 8:30 p.m.) to the resident being found unresponsive and he was OK at that time. Review of the Advanced Directives and Code Status Report dated [DATE] revealed that there were currently 11 of 41 residents in the facility who had Full Code status. Review of Basic Life Support (BLS) certificate dated [DATE] revealed that LPN AA had successfully completed the cognitive and skills evaluations for CPR and AED (automated external defibrillator) program. Continued review revealed that the recommended renewal date was [DATE]. Interview with the DON on [DATE] at 3:55 p.m. revealed that she became DON in [DATE] and was unaware of the incident with R#1. She stated that the facility was attached to the hospital ER by double doors and that there was no reason that nursing staff could not immediately initiate CPR for R#1 and push him in his bed to the ER for more aggressive treatment. Telephone interview with LPN AA on [DATE] at 6:38 p.m. revealed that on [DATE] at 9:00 p.m., she had gone into R#1's room to administer his medications. The resident did not respond to his name or to touch. She noted that he had vomited. She did not have a stethoscope, so she placed her hand on his chest and he was not breathing. Continued interview revealed that R#1 was cool to the touch but, did not feel ice cold. LPN AA stated that she called for help and the other nurse came and was notified that R#1 was not breathing. The other nurse left to obtain a stethoscope and a backboard. While the other nurse obtained a stethoscope and backboard, LPN AA called the on-call physician who ordered R#1 be sent to the ER. After assessing R#1 with the stethoscope, the other nurse notified LPN AA that R#1 did not have a heartbeat. Further interview with LPN AA revealed that she nor any other staff initiated CPR for R#1. LPN AA could not explain the reason CPR was not initiated for R#1. Interview with the Medical Director on [DATE] at 1:00 p.m. revealed that if a resident was a Full Code and was found by staff without a pulse or respirations, she would expect nursing staff to rush the resident to the ER which would take no more than two minutes. The resident would receive more aggressive treatment from Advanced Cardiovascular Life Support (ACLS) certified staff in the ER. She stated that it was unfortunate that LPN AA did not initiate CPR and ventilation immediately and rush the resident to the ER where the resident could receive more aggressive treatment. Interview with the facility's Health Services Administrator on [DATE] at 2:20 p.m. revealed that the nursing home DON was responsible for bringing any nursing home resident deaths to the quarterly Medical Staff Committee meetings for review. Review of the Medical Staff Committee meeting minutes dated [DATE] revealed that the previous nursing home DON reported six deaths from [DATE] through [DATE]. Continued review revealed that the deaths were reviewed by two Physicians; however, there was no additional documentation regarding deaths occurring after [DATE]. Interview with the facility Administrator on [DATE] at 9:30 a.m. revealed that there was not a quarterly Medical Staff Committee meeting following the [DATE] meeting due to COVID-19. Telephone interview with the Administrator on [DATE] at 9:47 a.m. revealed that she was notified by the previous DON that R#1 had died ; however, the previous DON did not notify her that nursing staff had failed to initiate CPR as per his code status. Continued interview with the Administrator revealed that she should have been notified by the previous DON. Nursing staff failed to initiate CPR and continue CPR without interruption until relieved by hospital personnel for R#1 who was Full Code. The facility implemented the following actions to remove the IJ: 1. On [DATE] at 9:00 p.m. Resident #1 was found unresponsive with emesis in mouth, no respirations or heart rate was present. CPR was not initiated. Resident #1 was a full code. Resident's physician was notified of resident's condition who gave orders to transfer to emergency room . At 9:10 p.m. Resident #1 was transferred to emergency room via stretcher without CPR in progress on the Full Code resident. 2. On [DATE] State Surveyor made current Director of Nursing aware of complaint regarding quality of care where a Full Code resident was not given Cardiopulmonary Resuscitation. 3. On [DATE] the MDS (Minimum Data Set) Coordinator completed 100% care plan audit on all residents to verify care plan matched the identified code status. Per the audit, 41 of 41 resident's care plan matched the code status that was noted in the physicians' orders and on the face sheet. 4. On [DATE] the Director of Nursing posted a list of code status to identify Full Code vs DNR (Do not resuscitate) at nurses' station in a location for nursing employees only. On [DATE] the Director of Nursing and Education Nurse started in-service for licensed nurses and certified nursing assistants of code status list for easy access. 100% of licensed nurses and certified nursing assistants, which included 8 of 8 Registered Nurse (RNs), 10 of 10 LPNs, and 20 of 20 certified nursing assistants received the information. Any licensed nurse or certified nursing assistant (including agency staff) not receiving the Code Status education due to scheduled time off or FMLA (Family and Medical Leave Act) will be in-serviced prior to next scheduled shift. New hire nurses and certified nursing assistants will be educated on first orientation shift. 5. On [DATE] at 9:00 p.m. the Director of Nursing updated the Code Blue Policy, New Code Blue Evaluation Form, and New AED (automated external defibrillator) policy completed and approved. 6. On [DATE] at 5:15 p.m. the Director of Nursing and Education Nurse started immediate mandatory in-service for current 3 p.m. - 11 p.m. nurses and CNAs. The in-service included revised Code Blue Policy, new Code Blue Evaluation Form, and new AED policy. The use of AED and scenarios were presented and discussed. The Director of Nursing and Education Nurse provided education for each licensed nurse and certified nursing assistant prior to the beginning of their shift. 100% of licensed nurses and certified nursing assistants, which included 8 of 8 RNs, 10 of 10 LPNs, and 20 of 20 certified nursing assistants received the information by [DATE]. Any licensed nurse or certified nursing assistant (including agency staff) not receiving the Code Status education due to scheduled time off or FMLA will be in-serviced prior to the next scheduled shift. New hire nurses and CNAs will be educated on first orientation shift. 7. On [DATE] the Basic life Support Certifications were started and completed by [DATE]. 100% of licensed nurses and certified nursing assistants, which included 8 of 8 RNS, 10 of 10 LPNs, and 20 of 20 certified nursing assistants received the information. One CNA is out on FMLA but will be BLS current prior to returning to work. 8. The Director of Nursing or Education Nurse will conduct a mock Code weekly rotating the shifts. First Mock Code Scheduled for Wednesday [DATE]. 9. On [DATE] the Director of Nursing created the Mortality Review Audit form for completion following any resident death. This form is used to audit the code status within the EMR (electronic medical record), care plans, POLST forms, and easy access list; audit for code documentation; audit for documentation prior to death. 10. On [DATE] the Director of Nursing reviewed the Code Blue Policy, Code Blue Evaluation Tool, AED Policy, and education provided to nurses and C.N.A.s with the Administrator. The administrator will conduct a daily audit for deaths, code status, CPR, and mortality review. A Quality Assurance Performance Improvement meeting will be held on Wednesday, [DATE] to review the audits. 11. All corrective actions will be completed on [DATE]. 12. The immediacy of the IJ will be removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Record review revealed that R#1 was found unresponsive and without pulse or respirations on [DATE] at 9:00 p.m. He had POLST dated [DATE] to attempt CPR and a Physician's Order dated [DATE] for Full Code. Staff failed to initiate CPR and continue CPR prior to transferring him to the ER where more aggressive life sustaining treatment could be initiated. 2. During interview on [DATE] at 3:55 p.m., DON stated that she started working at the facility in [DATE] and was not aware of the incident of R#1 not receiving CPR. 3. Review of the Code Status Audit dated [DATE] revealed 41 residents code status matched in the electronic medical record, notebook, Physician Order, and care plan. R#7 was admitted to the facility on [DATE]. The Physician Order, EMR, and care plan revealed R#7 had a code status of DNR. R#8 was admitted to the facility on [DATE]. The Physician Order, EMR, and care plan revealed R#8 had a code status of DNR. R#9 was admitted to the facility on [DATE]. The Physician Order, EMR, and care plan revealed R#9 had a code status of full code. 4. Observation on [DATE] at 10:35 a.m. revealed residents' code status was posted at the nurse's station for view by clinical staff only. The code status for R#7, R#8, and R#9 were observed accurately posted at the nurse's station. Review of the in-service records dated ,d+[DATE] through [DATE] confirmed 8 RN's, 10 LPN's, and 20 CNA's received education on the code status list for easy access. Also verified via the following staff interviews on [DATE]: 11:30 a.m. with CNA CC, 11:35 a.m. with CNA DD, 11:45 a.m. with LPN FF, 12:00 p.m. with CNA GG, 12:05 p.m. with CNA HH, 12:35 p.m. with LPN II, 12:40 p.m. with RN JJ, 12:55 p.m. with RN KK, and 1:15 p.m. with CNA LL. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. There have been no new hires. 5. Review of the facility policy titled AED Defibrillation and Code Blue revealed policies were reviewed as evidenced by signatures of the Administrator, DON, and Medical Director on [DATE]. 6. Review of the in-service records dated ,d+[DATE] through [DATE] confirmed 8 RN's, 10 LPN's, and 20 CNA's received education on Code Blue and AED policies. Also verified via the following staff interviews on [DATE]: 11:30 a.m. with CNA CC, 11:35 a.m. with CNA DD, 11:45 a.m. with LPN FF, 12:00 p.m. with CNA GG, 12:05 p.m. with CNA HH, 12:35 p.m. with LPN II, 12:40 p.m. with RN JJ, 12:55 p.m. with RN KK, and 1:15 p.m. with CNA LL. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. There have been no new hires. 7. Review of an Employment Profile List dated [DATE] revealed 8 RN's, 10 LPN's, and 20 CNAs were reviewed with month and year of expiration for BLS certification. Further review revealed BLS expiration date of [DATE] for CNA CC, CNA GG, CNA DD, and LPN II. RN KK had a BLS certification that expires [DATE]. RN MM had a BLS certification that expires [DATE]. The DON had ACLS (Advanced Cardiac Life Support) and BLS certification that expires [DATE]. 8. Review of the in-service record dated [DATE] revealed 16 signatures of participants during the mock code including but not limited to six CNAs, two LPNs, two RNs, the Medical Director and Physician Assistant. Scenarios were discussed and examples of what to do and what not to do were provided. Review of the Mock Code Evaluation dated [DATE] revealed criteria was met by nursing staff for the following: recognition of need for code blue (lays patient flat), initiates CPR (time compressions started), time mock code announced overhead, activates AED alarm, AED pads placed properly, ER notified of code, if applicable, 911 notified, on call Physician notified, other residents cleared from code site, if applicable, was patient dried from being wet and were roles made clear during code. 9. Review of the facility policy titled Mortality Review created [DATE] revealed that all resident deaths will be reviewed by the DON, Medical Director, and a minimum of three other team members. Review of the Mortality Review Audit form revealed from [DATE] until [DATE] there were no residents found unresponsive and no residents that expired. The Mortality Review Form is a form that addresses POLST Form Status, EMR Code Status, Care Plan Code Status, Easy Access List Code Status, and documentation of last interactions with the resident prior to death. 10. Review of the CPR Daily Audits dated [DATE] until [DATE] revealed there were no residents found unresponsive and no residents that expired. Review of a Daily Census Report dated [DATE] through [DATE] revealed all 41 residents remained in the facility. Review of the Quality Assurance and Performance Improvement (QAPI) sign in sheet revealed the Administrator, Medical Director, Physician Assistant, MDS Coordinator, DON and RN Education Nurse were in attendance on [DATE]. The updated policies were reviewed in addition to daily monitoring for compliance. Review of the Medical Staff Called Committee Meeting dated [DATE] revealed the Medical Director, two additional physicians, two physician assistants, the administrator and DON met to review the AED Equipment Policy, Code Blue Policy, Code Blue Evaluation Form, Mortality Review Policy and Mortality Review Form. The policies were noted as approved by the physicians. 11. All corrective actions will be completed on [DATE]. 12. The immediacy of the IJ will be removed on [DATE].

Based on record review, review of the facility's Abuse Policy and staff interview, the facility failed to thoroughly investigate an allegation of abuse for one resident (R) (R#4) of six residents reviewed. Findings include: Review of the facility Abuse Policy dated March 2017 revealed that once a complaint is identified involving alleged mistreatment, neglect or abuse the description of the alleged complaint is written on the investigation form including the type of allegation interviews will be conducted of all pertinent parties. Record review revealed R#4 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of her Admission Minimum Data Set (MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9, indicating that she had some cognitive impairment. Continued review revealed that she did not have any behaviors. Review of the Complaint Form dated 4/15/2021 revealed that R#4 said they throw her against the wall when they turn her, they push her tray up to her chest when they give her food, and that there was a team against her, and they are out to hurt her. Continued review of the Complaint Form revealed that the Attending Physician stated that the resident's remarks were discussed in PAR (Patients at Risk) meeting and the team decided that the remarks reflected the resident's continued behaviors, hallucinations and paranoia. Further review revealed that R#4 had no physical injuries to indicate abuse and that review of her medical record revealed she believed that people were attacking the facility with firebombs and the police wanted to arrest her. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed that the resident's son called staff on 3/31/2021 to notify them that R#4 told him they thought she was a white supremacist. On 4/7/2021, the resident's son notified staff that R#4 told him people were throwing firebombs at the building and that the police had come to the facility to arrest her. On 4/14/2021, R#4 was combative with care. On 4/14/2021, R#4 was treated again for a UTI. On 4/26/2021, the Attending Physician assessed R#4 as having altered mental status with hallucinations due to UTI which dramatically improved with antibiotic therapy. There was no evidence that interviews were conducted with staff and other residents regarding the R#4's allegations that they throw her against the wall when they turn her, and they push her tray up to her chest when they give her food. Interview with the Administrator on 5/4/2021 at 9:23 a.m. revealed that the allegations of abuse made by R#4 on 4/15/2021 were not thoroughly investigated to include statements from staff and cognitive residents in order to rule out abuse. She stated at that time that she did not obtain statements from staff and other residents because the Physician stated that the resident was hallucinating due to the UTI.

Based on observations, interviews and review of policies titled Food Storage, and Cleaning Ice Machine and Scoop, the facility failed to appropriately label leftover food items, discard expired leftovers and maintain a clean ice machine vent. This had the potential to affect 54 of 55 residents receiving an oral diet. Findings include: An observation tour on [DATE] at 10:24 a.m. with the Assistant Dietary Manager (ADM) AA revealed: the reach in refrigerator with an opened bag of cheese with no 'opened' and 'use by' date; an opened bag of salad with no 'opened' and 'use by' date; and the reach in freezer with two plates of pie without labels. The walk-in refrigerator revealed ham (dated [DATE]), corn bread (dated [DATE]), turkey (dated [DATE]), vegetable soup (dated [DATE]), and green beans (dated [DATE]) with no 'use by' date. The walk-in refrigerator further revealed an opened bag of an unlabeled/unidentified food product with no 'opened' and 'use by' date, and the ice machine vent heavy with dust. In an interview on [DATE] at 8:56 a.m. with ADM AA, she confirmed the food items noted above were not labeled with a 'use by' date and further reported that it is the expectation for the person who is storing the food item to label it and date it including a 'use by' date. In an interview on [DATE] at 9:03 a.m. with the Breakfast Cook BB, she reported when food items are stored, they need to be labeled by the person who is placing the item in the reach in and walk in freezers and refrigerators. She further reported the label should include the name of the food item, the date it is put in, and the use by date. In an interview on [DATE] at 10:05 a.m. with the ADM AA, she reported they clean the ice machine daily and the vent and filter are cleaned by the Engineering Department. In an interview on [DATE] at 10:07 a.m. with Engineering Manager, he reported the ice machine vent/filter is not on a cleaning schedule with a set time and date. He further reported he cleaned the vent this week. In an interview on [DATE] at 12:38 p.m. with the Administrator, she reported her expectation for food storage on delivery for foods that may need to be repackaged is to name it and date it, use an expiration date if it's not there, and initial. For leftovers they would follow their policy, which states leftover food is used within five days or discarded. She further reported this is probably what dietary does. A review of policy titled Food Storage revised [DATE] revealed on page two: 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 5 days or discarded. A review of the training/in-service book for dietary revealed a training dated [DATE] that included food items needing to be labeled. Training stated, Throw trash away. Clean carts and sanitize all carts. Label everything you put in refrigerator. Check temp on the first tray at the beginning and again at the end. Change gloves after every task. A review of the facility cleaning schedule revealed the ice machine is to be cleaned daily. A review of the facility policy titled Cleaning Ice Machine and Scoop revised on [DATE] revealed - Policy: The ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition.

Based on observation, record review, and staff interview, the facility failed to consistently label and date opened food items in the dry storage room, walk-in freezer, and resident nourishment refrigerator; failed to leave items submerged in the sanitizing compartment of the 4-compartment sink for the recommended amount of time on one of two observations; and failed to ensure the manufacturer's recommended level of sanitizer was used in the low temperature dish machine on two of two observations. There were 49 residents that consumed an oral diet, and the census was 51 residents. Findings include: 1. During observation in the dry storage room on [DATE] at 10:13 a.m., the following were observed on shelving that were not labeled with the contents, open or expiration dates: -An opened bag of croutons inside a clear plastic bag. -Two sealed and one opened bag of what appeared to be cracker crumbs inside a clear plastic bag. -One opened bag of vanilla wafer cookies inside a clear plastic bag and six unopened bags of vanilla wafers inside another clear plastic bag. During interview with the Dietary Manager (DM) at this time, she verified that these items were not labeled or dated. She further stated that when she received items from the food vendor, she removed them from the boxes and placed them on the shelving, with the top shelves containing the older foods. She further stated that they rotated the stock by using the items from the top shelves first, and verified she did not date foods after opening. During observation in the walk-in freezer after the above observations revealed that one of the shelves had numerous bags of frozen foods piled up, without any apparent organization. Observation of some of the bags on this shelf revealed the following: -One clear plastic bag of what appeared to be tater tots that were opened, but not labeled or dated. -One clear plastic bag of what appeared to be approximately 12 grilled chicken filets, not labeled or dated. -One clear plastic bag of what appeared to be four riblets, and the only discernable writing on the plastic bag appeared to be 130. -One clear plastic bag of what appeared to be six fish filets, not labeled or dated other than marked as fish. -One plastic bag of an opened unidentifiable cubed substance dated [DATE]. -One plastic bag of an unidentifiable diced substance that was not labeled or dated. -One plastic bag of what appeared to be breaded meat patties with a labeling of [DATE]. On [DATE] at 4:22 p.m., the DM stated that they had tried using labels to label opened foods, but the labels peeled off the bags. She further stated that they had tried marking the plastic bags with magic marker, but the writing would rub off. During observation with the DM in the walk-in freezer on [DATE] at 4:30 p.m., she stated that frozen foods were good for one year after the date they were opened. She further stated that depending on the item, opened foods in the dry storage were good for either three months or six months. She verified at this time opened clear plastic bags with frozen breaded chicken patties, cubed potatoes, tater tots, and chicken tenders, that had no labeling at all. During interview with the DM on [DATE] at 4:42 p.m., she stated that she had talked to the dietician about how to label opened food items, and provided a roll of labels that she said they had tried, but that these labels did not stick to the bags. During interview with the DM on [DATE] at 2:15 p.m., she stated that she called (the facility's food supplier), and was told that foods were good for nine to 18 months after opening, but was not told which foods expired when. She further stated that she knew how old a food was by looking at the order slip. She stated during further interview that the facility policies didn't say when foods expired, and that they just rotated everything. She verified that the opened items in plastic bags in the walk-in freezer were piled up and not organized in any particular order to know how old something was. Review of the facility's Food Storage policy and procedure with a date of origin of 1991 revealed the following: Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. During interview with the DM on [DATE] at 9:03 a.m., she stated that there were currently 49 of 50 long-term care residents that received an oral diet. 2. On [DATE] at 10:13 a.m., the low temperature dish machine was noted to be in use by Dietary Aide BB. After a rack of dishes had been washed, she was asked to check the sanitizer concentration, and verified the result indicated a chlorine level of 100. Observation of the sanitizer connected to the dish machine revealed that it was a hypochlorite solution. On [DATE] at 8:49 a.m., Dietary Aide FF was observed using the low temperature dish machine, and was asked to check the level of chemical after running a rack of dishes through. Observation of a small manufacturer's plaque affixed to the front top right side of the dish machine revealed that the chlorine concentration should be 50 PPM (parts per million). During interview with Dietary Aide FF, she stated that the testing strip should read between 100 to 200 to be satisfactory, and verified the manufacturer label recommended 50 PPM. Observation of the chemical level taken by Dietary Aide FF revealed the chlorine strip indicated the level was between 100 and 200, which was what she stated she wanted it to be. She was observed to run a second tray of dishes through the machine, and she obtained a reading of 200 at this time. During interview with the DM on [DATE] at 9:03 a.m., she verified that the dish machine used chlorine for sanitizing, and stated the level should be between 100 and 200. The DM was observed to check the chemical concentration of the dish machine at this time after a rack of dishes had run through, and verified a chlorine concentration of 200. During interview with the DM, she stated that she was unable to find a facility policy related to what the chlorine concentration of the dish machine should be. 3. On [DATE] beginning at 3:55 p.m., Cook CC was observed to prepare pureed beef pot pie in a blender for the five long-term care residents on a pureed diet. After all of the portions had been prepared, she was observed to wash the stainless steel blender jar in the 4-compartment sink. After washing and rinsing, she was observed to submerge the jar in the sanitizing compartment of the sink for 27 seconds before removing it, and the lid was submerged for eight seconds before being removed. Cook CC was observed to prepare pureed broccoli next using the same blender jar and lid, and was observed to submerge the jar and lid for 31 seconds in the sanitizing compartment of the 4-compartment sink when done. During interview with the DM on [DATE] at 4:18 p.m., she verified that a quaternary solution was used for the sanitizer in the 4-compartment sink, and stated that she left items submerged in the sanitizing compartment for two to three seconds before pulling it out to drain. Observation of a manufacturer's sign posted over the 4-compartment sink revealed directions to leave items submerged for one minute or as specified by product label. During interview with the DM on [DATE] at 9:03 a.m., she stated that she was unable to find a facility policy related to the 4-compartment sink. 4. During observation in the employee break room on [DATE] at 8:07 a.m., a refrigerator/freezer was seen that contained both employee and resident foods. Observed inside the freezer compartment revealed concerns with the following items, including not knowing if the items belonged to staff or residents: -One unlabeled large styrofoam cup with a lid approximately ,[DATE] full of crushed ice. -One unlabeled small styrofoam cup with a lid with an unknown and unfrozen purplish liquid inside. -One unopened half pint 2% milk carton (frozen), with an expiration date on the carton of [DATE]. -One unlabeled small styrofoam cup with a lid with what appears to be ice inside. -One unlabeled 5-quart barrel of vanilla flavored ice cream, one-quarter full. -Five individually wrapped ice cream treats inside a grocery bag with no expiration date on the individual packages; the treats were not labeled in any way. Observations inside the refrigerator revealed that all shelves were full of food and drinks, and insulated lunch bags. Further observations revealed the following items were not labeled or dated, and it was unknown if they belonged to residents or staff: -One styrofoam carton containing fresh cantaloupe labeled Trina H that was undated. -One unopened half pint carton of fat free chocolate milk with an expiration date of [DATE]. -One small styrofoam cup one-quarter full of an unknown liquid. -One small styrofoam cup labeled ,[DATE] SLW that had a lid on it and possibly contained fresh cherries. -One 12-ounce bottle of Mango Coconut Water, three-fourths full. -One 1-liter opened water bottle with a red-colored liquid inside, approximately three-fourths full. -One plastic bag inside a grocery bag containing an unknown substance with the appearance of reddish-colored meatballs. -One 1-gallon jug of 2% milk approximately half full with an expiration date of [DATE]. -One plastic 16-ounce carton of fresh strawberries inside a grocery bag. Review of a sign with a subject of Break Room Refrigerator and Counters taped to the front of the refrigerator dated [DATE] revealed: Reminder To All Employees: The break room refrigerator is used for resident's perishable food items and employee's meal time food items. All items must be labeled with name and date placed in the refrigerator. Housekeeping will clean out the refrigerator on Thursdays of each week. Any unlabeled items in the refrigerator or items with expired use dates will be disposed of. During interview with Housekeeper EE on [DATE] at 8:24 a.m., she stated that Housekeeping was responsible for cleaning out the refrigerator on Thursdays, and that she had come at this time to clean it out. She further stated that this was the only refrigerator/freezer, and and that it was used for both staff and resident food. She stated during continued interview that she cleaned out anything without a name or date on it, and/or if the food was over two days old. She further stated that the resident food had their name on it. During interview with the Administrator on [DATE] at 8:31 a.m., she stated that when something was put in the refrigerator for a resident, it was labeled with their name. She verified the unlabeled items in the refrigerator, including the bag of what appeared to be meatballs, and stated during interview that these must have been used during a resident activity and were leftovers. She verified that all food items in the refrigerator/freezer should be labeled and dated. The Administrator verified that the refrigerator was last scheduled to be cleaned out on [DATE], and that there was a gallon of milk inside that expired on [DATE]. Review of the facility's policy (undated) Nutritional Assessment of Patients revealed: Food stored on the unit will be labeled with date and patient's name.

Based on observation, staff interviews, and review of the facility policy Medication Administration the facility failed to store medication in a locked area inaccessible by residents. During a medication observation, Licensed Practical Nurse (LPN) DD left medication on top of the medication cart unattended. The facility census was 51 residents. Findings included: An observation of 07/25/18 at 8:03 a.m. LPN DD walked away from the medication cart leaving one white tablet in a plastic medication cup on top of the medication cart. LPN DD was away from the cart for approximately 1.5 minutes. LPN DD return to the cart and walk away for a second time for approximately ½ minute. The surveyor observed of one resident and two staff near the medication cart. An interview was conducted on 7/25/18 at 8:05 a.m. with LPN DD she confirmed that she had left a narcotic [MEDICATION NAME] 5/325 milligrams (mg) on top of the cart. LPN DD stated she should have not left the medication on top of the cart unattended. An interview was conducted on 07/26/18 at 01:28 PM with the Director of Nursing (DON) and Administrator regarding expectations of storage of narcotics. The DON stated her expectations that all narcotics are locked inside the narcotic box in the locked medication cart. Review of the policy titled, Medication Administration revision date 6/29/18 indicated controlled medications are to be stored in the locked narcotic box inside the locked medication cart prior to administration.

Based on observation, record review, resident and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessments related to bed rails used as restraints were accurate for 39 residents, including ten sampled residents (R) (R#25, R#29, R#21, R#43, R#35, R#32, R#40, R#16, R#3, and R#12). The facility census was 51 residents. Findings include: During interview with the MDS Coordinator on 7/23/18 at 1:50 p.m., she stated that according to the RAI (Resident Assessment Instrument) manual, if a resident could rise independently, any bed rail including small transfer bars were considered a restraint. Review of CMS's (Centers for Medicare and Medicaid Services) RAI MDS 3.0 Manual, Section P: Restraints, revealed that the intent of this section was to record the frequency over the 7-day look-back period that the resident was restrained. Review of the Steps for Assessment section noted that the device should be classified as a restraint only when it meets the criteria of the restraint definition. During interview with the MDS Coordinator on 7/23/18 at 2:19 p.m., she stated that none of the bed rails or transfer bars used in the facility met the criteria of a restraint. Review of the MDS Section P, Restraints and Alarms, provided by the MDS Coordinator at this time revealed: Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. During further interview, the MDS Coordinator stated that this did not apply to any of the residents who had bed rails, and that she was coding them as having a bed rail in Section P even though they did not meet the definition of a physical restraint for that resident. During interview with the MDS Coordinator on 7/23/18 at 4:28 p.m., she stated that the CMS Form-672 (Resident Census and Conditions of Residents) indicated that she assessed no residents in the facility as being physically restrained. She further stated that she had to code if a resident had bed rails in Section P of the MDS, even if they didn't act as a restraint for that resident. During interview with R#29 on 7/24/18 at 9:24 a.m., he stated that he used the bars on his bed to get out of bed, and that he could get out of the bed even with the bars up. Observation of his bed at this time revealed that he had two assist bars on each side at the top of the bed. Review of his Annual MDS dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13 to 15 indicates no cognitive impairment), and that he had a physical restraint of bed rail used daily. Observation of R#25's bed on 7/26/18 at 9:22 a.m. revealed that he had two one-quarter bed rails on each side at the top of the bed. Interview with R#25 at this time revealed that he used the rails to turn and to get out of bed, and that the bed rails did not keep him in the bed. Review of his Quarterly MDS dated [DATE] revealed that he had a BIMS score of 15, and was coded as having a physical restraint of a bed rail which was used daily. Review of the Matrix for Providers (CMS-802) provided for the survey team on 7/23/18 revealed that 39 of the 51 residents listed were marked as having a physical restraint.

Based on observation, and interviews the facility failed to maintain an environment free from dirty and/or dusty ceiling vents in one (1) of three (3) resident hallways, and in one (1) of one (1) dining rooms, and in one (1) of one (1) resident family rooms and failed to keep the environment free from broken floor tiles in one (1) of one (1) resident family rooms and in one (1) of one (1) resident family room bathrooms. The facility failed to ensure the bathroom sink was securely fastened to the wall in one (1) of one (1) resident family room bathrooms. Finding include: Observation on 02/15/16 at 10:30 a.m. revealed two (2) broken tiles in the floor of the resident family room and one (1) broken tile around the bathroom toilet in the resident family room bathroom. Observation on 02/17/16 at 07:45 a.m. of the large ceiling air vent in the dining room, directly above one large resident table, revealed the ceiling vent covered with black dirt and/or dust build up around the upper outer vent strips, and one area of chipped and flaking paint on the left corner of the ceiling air vent. Observation on the fourteen (14) - twenty-one (21) room hall revealed two (2) ceiling air vents with a heavy buildup of dirt and /or debris. Further observation revealed one (1) ceiling air vent in the resident family room with buildup of dirt and/or debris with speckled rust areas noted. Interview on 02/18/16 at 08:07 a.m. with MDS revealed that the resident family room is used for residents to meet and visit with their families and that the residents, and their families, use the family room and the family room bathroom. Observation on 02/18/16 at 3:00 p.m. revealed that one (1) bathroom sink in the resident family room bathroom was not securely fastened to the wall. Interview with, and observations with the Maintenance Director, on 02/18/16 at 5:35 p.m. revealed the Maintenance Director stated that when the staff observe or find something in the facility that needs to be fixed then they write it down in the notebook and that he checks the notebook daily for any items that need to be addressed and/or fixed. The Maintenance Director confirmed the ceiling vent in the dining room, directly over the residents table in the dining room, had a heavy buildup of black dirt, dust, and / or debris and had one area of chipped and flaking paint on the left side of the ceiling air vent. Further interview with the Maintenance Director revealed two (2) ceiling air vents on the fourteen (14) to twenty-one room hall with a heavy buildup of black dirt, dust and /or debris, and one (1) ceiling vent in the resident family room with buildup of dirt and /or debris. The Maintenance Director confirmed that each of these vents needed to either be taken down and scrubbed clean and repainted or they needed to be taken down and replaced with new ceiling air vents. Further interview and observations with the Maintenance Director revealed two (2) broken floor tiles in the resident family room and one (1) broken floor tile in the resident family room bathroom. The Maintenance Director confirmed these tiles were broken and that they needed to be taken up and replaced with new floor tiles. Further interview/observations with the Maintenance Director revealed one (1) bathroom sink in the resident family room bathroom with a crack between the sink and the wall with the left corner of the sink slightly loose from the wall. The Maintenance Director stated that this sink needed to be secured to the wall and then caulking needed to be placed to fill in the crack between the sink and the wall. The Maintenance Director stated that the ceiling air vents, floor tiles, or bathroom sink had not previously been written in the notebook as items that needed to be fixed.

Based on observations, record review, and staff interviews, the facility failed to ensure that chemicals and sharps were stored in a manner to make them inaccessible to residents in two (2) storage rooms on two (2) of four (4) halls. There were eleven (11) cognitively-impaired and independently-mobile residents in the facility. The facility census was forty-nine (49) residents. Findings include: During initial tour of the facility on 02/09/15 beginning at 9:45 a.m., the following storage concerns were observed: 1. A housekeeping closet (mop closet) across from room 11 was noted to be unlocked. Inside the closet was the following chemicals: A spray bottle with 20-ounces (oz.) of EcoLab Antibacterial All-Purpose Cleaner, with labeling on the bottle of "DO NOT DRINK." A 32-oz. bottle approximately one-fourth full of Lemon-Eze Creme Cleaner, labeled on the bottle that it caused eye and skin irritation. There was an EcoLab dispenser system on one wall that contained the following chemicals: Cleaner/Disinfectant; Odor Counteractant; Antibacterial All-Purpose Cleaner; and Heavy Duty Alkaline Bathroom Cleaner. The contents of the mop closet were verified by the Assistant Director of Nurses (ADON), who stated the closet should be kept locked at all times. Review of the Material Safety Data Sheets (MSDS) provided by the Housekeeping Supervisor noted the following precautions for the chemicals kept in the mop closet: -EcoLab Neutral Disinfectant Cleaner: DANGER! Causes digestive tract, eye and skin burns. Harmful if inhaled or swallowed. -EcoLab Antibacterial All Purpose Cleaner: Danger. Harmful if swallowed or in contact with skin. Causes severe skin burns and eye damage. -EcoLab HB Quat cleaner and disinfectant: Danger. Harmful if swallowed. Causes severe skin burns and eye damage. -EcoLab First Impression Juniper Splash Micro Aerosol: Warning. Causes serious eye irritation. May cause drowsiness and dizziness. -EcoLab Heavy Duty Alkaline Bathroom Cleaner and Disinfectant: Danger. Harmful if inhaled. Causes serious eye damage. 2. A clean utility room across from room 16 contained miscellaneous supplies which included the following: Six (6) 16-oz. bottles of hydrogen peroxide in a bin on a bottom shelf, and the bottles were labeled "Do not get into eyes." Several bins of unused syringes with needles in sealed paper sleeves. Seven (7) gallons of No Rinse Shampoo and Body Wash, labeled "In case of eye contact flush eyes with water." This was verified by the ADON, who stated she had worked at the facility for fifteen (15) years, and had never known this closet to be unlocked. During interview with the Administrator on 02/09/15 at 4:51 p.m., she revealed that the lock on the mop room door had been replaced so that it could not be unlocked from the inside. Review of a resident list provided by the ADON on 02/10/15 at 1:30 p.m. revealed that there were eleven (11) residents with severe cognitive impairment, per their most recent Minimum Data Set (MDS) assessment, who were independently mobile. During interview with the Housekeeping Supervisor on 02/12/15 at 9:52 a.m., she indicated that staff should keep the mop room door locked at all times.

Based on record review and staff interview, the facility failed to ensure that one (1) resident's (#63) blood pressure was taken prior to administration of her diuretic medication as per physician's orders [REDACTED]. Findings include: Record review for resident #63 revealed admission to the facility in February 2015 with a [DIAGNOSES REDACTED]. Review of the Physician Prescription Order dated 2/5/15 revealed [MEDICATION NAME] twenty (20) milligrams (mgs) every morning (am) and to hold if her blood pressure (BP) was less than 100/60. However, review of the fourteen (14) day Administration History Electronic Medication Administration Record [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 2/10/15 at 12:45 p.m., confirmed that the order to check the BP was over looked and left off the E-MAR, but revealed that the E-MAR is where staff should be documenting the BP.

Based on observation, record review and staff interview, the facility failed to store personal hygiene equipment in a sanitary manner in three (3) bathrooms on two (2) of five (5) units; failed to store oxygen equipment in a sanitary manner in three (3) rooms on two (2) of five (5) units; and failed to wash or sanitize hands when passing meal trays during two (2) of two (2) dining observations on one (1) of five (5) units. The sample size was twenty-four (24) residents. Findings include: 1. During dining observations at lunch on 02/09/15 at 12:35 p.m., Certified Nursing Assistant (CNA) "BB" was observed to move an overbed table and replace a velcro-attached stop sign across door of room [ROOM NUMBER], and then remove a resident lunch tray off the cart and entered room [ROOM NUMBER]. Upon further observation, the CNA was observed to touch the privacy curtain in this room, assist the resident in the B-bed to her recliner from the electric wheelchair, and pushed the wheelchair to the front of the room. "BB" then set up the resident's food tray, including handling the utensils and straw. During further observations, another CNA was noted to assist the resident in room [ROOM NUMBER]-A from his wheelchair to the recliner, push the wheelchair into the hallway, before setting up the lunch tray, including handling and placing the straw in his drink. "BB" or the other CNA observed never washed or sanitized their hands. During a second dining observation conducted on 02/10/15 at 12:23 p.m., CNA "CC" was observed to take a lunch tray into room [ROOM NUMBER], at which time she moved the overbed table and inserted a straw in the resident's tea. "CC" then obtained another tray from the cart, and took it to the resident in room [ROOM NUMBER]-B. "CC" moved the resident's walker, repositioned the overbed table, picked up the remote to turn off the television, unwrapped the straw and placed it in the drink, and picked up and handed the spoon to the resident. Upon further observation, "CC" pulled the door partially closed when she left the room, obtained another tray off the cart, and took it to the resident in room [ROOM NUMBER]-A. "CC" knocked on the door, assisted the resident to the recliner, pushed his wheelchair into the hall, pulled the privacy curtain back, positioned the overbed table, opened the napkin to expose the utensils. "CC" never washed or sanitized her hands during these observations. During interview with the Director of Nursing (DON) who is also the Infection Control Nurse on 02/11/15 at 1:04 p.m., she indicated that she would expect the staff passing meal trays to wash or sanitize their hands after coming out of each residents' room. Review of the facility's Feeding the Impaired Resident policy and procedure revealed that staff are to wash their hands thoroughly before serving another resident if you attend to a resident during the serving process. 2. During observations of the resident environment, the following concerns related to storage of personal hygiene items and oxygen equipment were noted: 02/09/15 at 9:45 a.m. in room [ROOM NUMBER]: There was an unlabeled toothbrush and denture toothbrush on the sink behind the faucet. This bathroom was shared by four residents. 02/09/15 at 11:58 a.m. in room [ROOM NUMBER]: There was an unlabeled toothbrush and comb on the shelf in the bathroom. This bathroom was shared by four residents. 02/09/15 at 12:19 p.m. in room [ROOM NUMBER]: The nebulizer machine was in the chair next to the resident's bed, the mask was uncovered, and lying against the back of the chair. On 02/11/15 at 8:46 a.m., Licensed Practical Nurse (LPN) "DD" was observed to give a nebulizer treatment to resident #11; the neb mask was obtained from inside the closed lid of the nebulizer machine, but the mask itself was not covered. 02/09/15 at 1:25 p.m. in room [ROOM NUMBER]-A: There was a t-tube mouthpiece attached to a nebulizer machine that was not covered. 02/09/15 at 1:26 p.m. in room [ROOM NUMBER]: There was an oxygen concentrator in the middle of the room against the wall, and the nasal cannula was draped on top of the concentrator, with the nasal prongs nestled inside the privacy curtain. 02/09/15 at 1:41 p.m. in room [ROOM NUMBER]: There were two unlabeled toothbrushes on the sink behind the faucet; this bathroom was shared by four residents. Observations conducted 02/11/15 at 11:58 a.m., the following was noted: room [ROOM NUMBER]: The nebulizer mask was uncovered and lying on the furniture next to the bed. room [ROOM NUMBER]: There was an unlabeled comb on the back of the sink. There was an unlabeled drinking glass on the shelf above the sink in the bathroom, which contained an unlabeled toothbrush. room [ROOM NUMBER]-A: The t-tube mouthpiece was lying on top of the nebulizer machine and not contained in a plastic bag. room [ROOM NUMBER]: The oxygen concentrator nasal cannula was on the floor, and the tubing was not labeled with the date. room [ROOM NUMBER]: There was one unlabeled toothbrush on the back of the sink. room [ROOM NUMBER]: There was one unlabeled toothbrush and one unlabeled denture brush on the sink behind the faucet; there was also dentures soaking in an unlabeled denture cup on the sink. During interview with the DON on 02/11/15 at 12:12 p.m., she verified the above observations, and indicated that she would expect staff to place items like toothbrushes and combs in a bucket in the resident's closet. Upon further interview, she revealed that she did not know if the oxygen concentrator in room [ROOM NUMBER] belonged to the A or B bed, and verified that the oxygen tubing had not been dated to indicate when it was obtained for the resident. The DON added that oxygen equipment should be stored in a plastic bag when not in use. During interview with LPN "DD" on 02/11/15 at 12:28 p.m., she revealed that after a resident finished a nebulizer treatment, the mask should be stored in the bag it came in. Review of facility's policies related to dentures and oxygen revealed the following: Dentures: When a denture cup is issued to a new resident, their name and room number will be put on the cup. Leave denture cup on the resident's bedside stand. Use Of Oxygen: The tubing should be kept off the floor.

Based on record review, and staff interview, the facility failed to ensure that one (1) resident (#45) had a [MEDICATION NAME] level drawn according to physician's orders [REDACTED]. Findings include: Review of the Physician order [REDACTED]. Record review of the resident's labs for January 2015 revealed no evidence of a [MEDICATION NAME] level being completed. Further review of the Physician Order's for February 2015 revealed that resident #45 receives [MEDICATION NAME] Extended Release (ER) two hundred fifty (250) milligrams (mg) at bedtime (hs). Interview with the Assistant Director of Nursing (ADON) on 2/10/15 at 2:08 p.m., revealed that there was no evidence of the [MEDICATION NAME] level for January 2015 had been done.