Every finding on record at Riceville Family Care and Therapy Center

Based on record review, staff interviews and policy review the facility failed to provide informed consent regarding the risk and benefits for as needed psychotropic medications (medications that affect brain activity, influencing mood, thoughts, behavior, and perception to treat mental health conditions) for 1 of 3 residents reviewed for psychotropic medications (Resident #7). The facility reported a census of 27 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented an admission date to the facility on [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS included diagnoses of atrial fibrillation (A-fib, occurs when the heart flutters and does beat correctly), dementia, insomnia, and mild cognitive impairment. The MDS reflected she took an antidepressant, antipsychotic and anticoagulant medications during the lookback period. Review of Resident #7's Nursing Home Notes Final Report written by her doctor on 12/16/25 documented to continue Seroquel (a psychotropic medication called an antipsychotic, that affects the brain) and trazodone (a psychotropic medication called an antidepressant, that affects the brain)Review of Resident #7's Medication Review Report signed by her doctor on 3/10/26 indicated she started taking two (2) antidepressant medications and one (1) antipsychotic medication on 12/9/26. Resident #7 continued to take them.Review of Resident #7's Medication Administration Record (MAR) for January and February 2026 documented she took her two (2) antidepressants and one (1) antipsychotic medications daily at bedtime. Review of Resident #7's Progress Notes from 12/9/25 to 3/18/26 lacked documentation of family consent and/or education of adverse side effects regarding the risk and benefits of receiving psychotropic medications.The Care Plan Focus revised 12/18/25 indicated Resident #7 had a medical need for medication due to multiple diagnoses. The Interventions instructed she used antidepressant and antipsychotic medications. The Interventions included what adverse side effects to monitor. In an interview on 3/19/26 at 12:28 PM the Director of Nursing (DON) revealed the facility didn't complete psychotropic medication consents with Resident #7's family until today (3/19/26). They should be completed upon admission or when they receive an order for them. In an interview on 3/19/26 at 12:33 PM the Administrator reported they recently reviewed psychotropic medication consents with the DON, but they have trained the floor nurses on it yet.Review of the facility's undated Drug Regimen Review policy lacked instruction on when to obtain informed consent and the facility's process to do so.

Based on record review, staff interviews, and policy review the facility failed to obtain an International Normalized Ratio INR lab test (measures how quickly the blood clots and primarily used to monitor patients on blood thinners like warfarin, a normal range is typically 1.1 or lower for people not on anticoagulant medication, but for those taking anticoagulants, the target range is usually 2.0 to 3.0 to ensure a balance between preventing clots and minimizing bleeding is maintained) for 1 of 1 residents reviewed for anticoagulants (Resident #7). The facility also failed to have their INR policy and procedure reflect the facility's procedure for INR lab tests. The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented an admission date to the facility on [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS included diagnoses of atrial fibrillation (A-fib, occurs when the heart flutters and does beat correctly), dementia, insomnia, and mild cognitive impairment. The MDS reflected she took an anticoagulant medication (affects the thickness of the blood) during the lookback period. Review of Resident #7's Nursing Home Notes Final Report written by her doctor on 12/16/25 instructed to continue use warfarin (anticoagulant medication).Review of Resident #7's INR Lab Test dated 12/19/25 instructed to check her INR again in 2 weeks (1/2/26).Review of Resident #7's Progress Note on 12/19/2025 at 1:50 PM revealed the facility received a new order to take warfarin 10 milligram (mg) dose on Sunday and Thursday and a 5 mg dose on Monday, Tuesday, Wednesday, Friday, and Saturday. The next INR should be checked in 2 weeks (1/2/26).Review of Resident #7's Progress Notes from 1/2/26 to 1/22/26 revealed and INR lab test was not completed. Review of Resident #7's Progress note on 1/23/26 at 7:46 AM revealed she was ordered to have her INR drawn on 1/2/26, but due to a technical issue (order entered but did not trigger) her INR did not get checked on 1/2/2. She remained on the same warfarin dosage since her last order received on 12/19/25. Her INR result from that morning was 2.4. Review of Resident #7's INR Lab Test dated 1/23/26 instructed to check her INR again on 2/23/26 with no order changes made. Review of Resident #7 Medication Administration Record (MAR) for January 2026 revealed she took warfarin without an order from 1/2/26 to 1/23/26. The Care Plan Focus revised 12/18/26 indicated Resident #7 had a medical need for medication due to multiple diagnoses. The Interventions instructed she used anticoagulant medications. In addition, the Interventions listed the adverse side effect to monitor. In an interview on 3/19/26 at 12:28 PM the Director of Nursing (DON) revealed the nurse who put the order in the computer did it incorrectly and it did not alert the staff to check the lab. She explained she provided individual training to the nurse involved when the error occurred. She would expect it checked as the order read on 1/2/26. In an interview on 3/19/26 at 12:33 PM the Administrator reported they provided training to the nurse involved. They would expect the order to be completed as ordered and not late.Review of the facility's Finger Stick INR Procedure & Policy dated 9/24/20 instructed the local hospital will be in charge of obtaining INRs. The policy directed to check the Appointment calendar daily for INRs. The Care Coordinator will audit the INR's weekly for accuracy.

Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) assessments for 3 of 6 residents reviewed (Residents #5, #13, and #15). The facility reported a census of 27 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impaired. The MDS include diagnoses of depression, anxiety, and dementia. The MDS lacked documentation Resident #5 received an anti anxiety medication during the 7-day lookback period. Resident #5's November and December 2024 Medication Administration Record (MAR) documented Resident #5 received Buspirone (an anti anxiety medication) during the seven day look back period. 2. Resident #13 MDS assessment dated [DATE] identified a BIMS score of 10, indicating moderately cognitive impaired. The MDS include diagnoses of depression, anxiety, unspecified mood disorder, and dementia. The MDS lacked documentation Resident #13 received an anti anxiety medication during the 7-day lookback period. Resident #13's December 2024 MAR reflected they received buspirone (an antianxiety medication) during the 7-day lookback period. 3. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 8, indicating severely impaired cognition. The MDS included diagnoses of depression, anxiety, and dementia. Resident #15's December 2024 MAR reflected they received buspirone during the 7-day look back period. During an interview on 3/6/25 at 8:48 AM the MDS Coordinator reported she compared the medications to the orders in Electronic Health Record to make sure they are correct. She reported she followed the RAI manual. She reported she have coded buspirone wrong and has been coding it as an antidepressant not an antianxiety like she should. The RAI Manual page N 6 under Coding Instructions directed to code medications according to the pharmacological classification, not how they are being used.

Based on clinical record review and staff interview, the facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for a new diagnosis of major depression for 1 of 1 residents reviewed (Resident # 13). The facility reported a census of 27 residents. Findings include: Resident #13 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS include diagnoses of depression, anxiety, unspecified mood disorder and dementia. Resident #13's PASRR dated 11/17/22 documented they didn't have a mental health diagnosis. Resident #13's Psychiatry Visit Note dated 1/3/25 documented they had major depressive disorder, insomnia, anxiety, and visual hallucinations. In addition, the note included the medication Resident #13 used for the mental health diagnoses. During an interview on 3/4/25 at 1:14 PM, the Director of Nursing (DON) reported the transferring facility completed Resident #13's PASRR prior to admission. The DON reported they should have completed a new PASRR with the diagnosis of major depression, the added and changed medications due to the increase in mood and behaviors.

Based on clinical record review, staff interviews, and policy review the facility failed to provide to the resident or their representative a summary of the baseline care plan for 4 out of 4 residents reviewed (Residents #125, #126, #9,and #23). The facility reported a census of 24 residents. Findings include: 1. Resident #125's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #125 required partial/moderate assistance with bed mobility and transfers. The MDS included diagnoses of hypertension (high blood pressure), renal disease (kidney), arthritis, anxiety, and depression. The Clinical Census revealed Resident #125 was admitted on [DATE]. A facility form titled Riceville Family Care and Therapy Center Baseline Care Plan & Care Plan Summary dated 3/8/24 lacked documentation that a copy of the baseline care plan was given to or reviewed with Resident #125 or their resident representative. The sections of the baseline care plan titled Baseline Care Plan Summary and Review were not filled out and lacked signatures and dates from staff, resident, and/or resident representative. On 3/26/24 at 8:35 AM, the Director of Nursing (DON) acknowledged and verified Resident #125's baseline care plan had not been reviewed with the resident or their representative and a copy of the care plan had not been given. She stated if the review section of the baseline care plan form was not filled out then it was not completed. She stated the facility would need to QA (quality assurance) the process and provide reeducation to the staff. 2. Resident #126's entry MDS dated [DATE] identified Resident #126 entered the facility on 3/13/24 from the community. A facility form titled Riceville Family Care and Therapy Center Baseline Care Plan & Care Plan Summary dated 3/13/24 lacked documentation a copy of the baseline care plan was given to or reviewed with Resident #126 or their resident representative. The sections of the baseline care plan titled Baseline Care Plan Summary and Review were not filled out and lacked signatures and dates from staff, resident, and/or resident representative. 3. Resident #9's MDS assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS identified Resident #9 was dependent on staff for bed mobility and transfers. The MDS included diagnoses of hypertension (high blood pressure), renal disease (kidney), paraplegia (paralysis of legs and lower body), depression, and spinal stenosis (spaces inside the bones of the spine get too small). The Clinical Census revealed Resident #9 was admitted on [DATE]. A facility form titled Riceville Family Care and Therapy Center Baseline Care Plan & Care Plan Summary dated 1/19/24 lacked documentation a copy of the baseline care plan was given to or reviewed with Resident #9 or their resident representative. The sections of the baseline care plan titled Baseline Care Plan Summary and Review were not filled out and lacked signatures and dates from staff, resident, and/or resident representative. 4. Resident #23's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #23 required partial/moderate assistance with bed mobility, sit to stand transfers, and toilet transfers. The MDS included diagnoses of cancer, psychotic disorder, giardiasis (intestinal infection), coronary atherosclerosis (damage to heart's major blood vessels), and heart failure (inability to pump blood adequately). The Clinical Census revealed Resident #23 was admitted on [DATE] and discharged on [DATE]. A facility form titled Riceville Family Care and Therapy Center Baseline Care Plan & Care Plan Summary dated 1/30/24 lacked documentation a copy of the baseline care plan was given to or reviewed with Resident #23 or their resident representative. The sections of the baseline care plan titled Baseline Care Plan Summary and Review were not filled out and lacked signatures and dates from staff, resident, and/or resident representative. On 3/26/24 at 3:45 PM, the DON acknowledged and verified Resident's #126, #9, and #23 baseline care plans were not reviewed with the resident or resident representative and copies of the baseline care plan had not been given. A facility policy titled Baseline Care Plan Policy revised 2024 documented the purpose of the policy was for the facility to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The procedure directed the following: 1. Include the resident's involvement and choices in the care plan, especially goal setting. 2. The baseline care plan to be developed within 48 hours of a resident's admission and include the minimum health care information necessary to properly care for the resident. 3. The facility must provide to the resident and their representative with a summary of the baseline care plan that includes but not limited to: a. The initial goals of the resident b. A summary of the resident's medication and dietary instructions c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. d. Any updated information based on details of the comprehensive care plan as necessary.

Based on clinical record review, observations, and staff interview the staff failed to maintain dignity while standing over residents as they were assisted with their meals for 6 of 7 residents (Resident #7, #9, #11, #13, #16, and #21) observed that required meal assistance. The facility identified a survey of 27 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive loss. The Resident required limited assistance of one staff for eating. 2. The MDS dated [DATE] for Resident #9 showed a BIMS score of 00 indicating severe cognitive loss. The Resident required extensive assistance of one staff member for eating. 3. The MDS dated [DATE] for Resident #11 documented a BIMS score of 00 indicating severe cognitive loss. The Resident required extensive assistance of staff for eating. 4. The MDS for Resident #13 dated 11/01/22 showed a BIMS score of 00 indicating severe cognitive loss. The resident required total assistance of one staff member for eating. 5. The MDS dated [DATE] for Resident #16 documented a BIMS of 13 indicating intact cognition with unclear speech. The Resident required extensive assistance with eating. 6. The MDS dated [DATE] for Resident #21 documented a BIMS of 03 indicating severe cognitive loss. The Resident required extensive assistance of one staff member for eating. During an observation on 1/30/23 at 12:24 p.m. Staff E, Certified Nursing Assistant (C.N.A) stood to Resident #9's right side assisting him to take bites of food. Staff F, C.N.A. stood between Resident #21 and Resident #16 rotating assisting between the two residents with bites of food and drink. During an observation on 1/30/23 at 12:25 p.m. Staff F went to get a chair to sit next to Resident #21 to assist with the meal. Staff E remained standing over Resident #9 to assist with his lunch meal. During an observation on 1/30/23 at 12:26 p.m. Staff A, Registered Nurse (RN) approached Resident #9 to administer his medications. Staff E moved from her standing position to allow Staff A to administer the medications. Staff A did not direct Staff E to sit to assist Resident #9 with his meal. During an observation on 1/30 23 at 12:29 p.m. Staff G, C.N.A., approached Resident #9 and stood over him to assist him with taking bites and drinks of his lunch meal. During an observation on 1/30/23 at 12:30 p.m. Staff F went over to assist Resident #13 and Resident #7 standing between them and looking down at them as she assisted them with bites of food. During this time the Administrator walked through the dining room to get her lunch in a black plastic container from the kitchen, then left the dining room. The Administrator did not direct any of the staff assisting with the dining to sit down with the residents. During an observation on 1/30/23 at 12:32 p.m. Staff E stood to Resident #7's right side looking down at the resident and assisted with a hand over hand assist to take drinks of fluids. During an observation on 1/30/23 at 12:33 p.m. Staff E approached Resident #21 and stood by her side looking down at her giving her bites of food, then went back to Resident #13 and stood over Resident #13 with her left hand on hip and using her right hand to give Resident #13 bites of food. During an observation on 1/30/23 at 12:34 p.m. Staff F obtained a wheeled stool to sit down side by side with Resident #13 and Resident #7 to assist them with their lunch meals. During an observation on 1/30/23 at 12:34 p.m. Staff G remained standing by Resident #9's right side assisting him with his lunch meal. Staff E stood between Resident #21 and Resident #16 assisting them with their lunch meal. Staff F stood by Resident #13 assisting with the meal. Staff G obtained a wheeled stool and sat by Resident #9 to assist with his meal. Staff H sat side by side with Resident #7 assisting with her lunch meal. During an observation on 1/31/23 at 12:17 p.m. Staff F stood over Resident #16 as she assisted the Resident with bites of her lunch meal. During an observation on 1/31/23 at 1:38 p.m. Staff F stood over Resident #11 as she assisted him with the meal. Staff E stood looking down on Resident #21 as she assisted her with the meal. During an interview on 2/01/23 at 3:41 p.m. Staff B, C.N.A. and Staff C, C.N.A. both reported they have received training in assisting residents with meals. They would sit with the resident to assist them with their meal. During an interview on 2/01/23 at 3:55 p.m. Staff D, LPN, reported she believes the C.N.A.'s have been trained to sit by the resident when assisting with meals. She reported it is not dignified to stand over a resident when assisting them with a meal. During an interview on 2/01/23 at 4:00 p.m. the Director of Nursing reported staff are trained to sit down face to face and assist residents with the meal. She expects staff to sit with the resident, provide meal assistance to one resident at a time and engage the resident in conversation for dignity. The Assisting the Residents to Eat (Assisted and Independent) Policy, undated, provided by the facility documented a purpose to provide a pleasant meal experience for all residents. The Procedure directed the staff to sit next to the resident at eye level. Talk to the resident, not to other staff.

Based on clinical record review, observation, and staff interview the facility inaccurately coded active diagnosis on the Minimum Data Set (MDS) Assessment for 2 of 14 residents (Resident #2 and #77) reviewed. The facility identified a census of 27 residents. Findings include: 1. A Electronic Health Record (EHR) Census showed Resident #2 admitted to the facility on [DATE]. A Hospital Discharge Summary Brief Overview dated 4/29/22 for Resident #2 documented a principal problem of acute respiratory failure with hypoxia and community acquired pneumonia. The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented an active diagnosis of pneumonia in section I. The MDS dated [DATE] documented an active diagnosis of pneumonia in section I. The MDS dated [DATE] documented an active diagnosis of pneumonia in section I. The MDS dated [DATE] for Resident #2 documented and active diagnosis of pneumonia in section I. A Medication Review Report signed by the Provider on 11/01/22 lacked documentation of any current treatment for active pneumonia. A review of the Medication Administrative Records (MARs) for November 2022 and December 2022 lacked documentation of physician orders for the treatment of active pneumonia. During an interview on 1/30/23 at approximately 2:30 p.m. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) reported they would look into why Resident #2 had pneumonia coded on his past MDS's as he had not been receiving treatment for pneumonia. During an observation on 1/31/23 at 8:25 a.m. Resident #2 propelled his wheelchair independently from his room to the dining room. He greeted the surveyor and stated he was heading to the dining room to get a good breakfast. Resident #2 did not exhibit a cough, shortness of breath, ashen skin color, or utilize oxygen. During an interview on 2/01/23 at 9:53 a.m. the Director of Nursing reported they had done a MDS assessment correction to Resident #2's MDS to remove the diagnosis of pneumonia and moved the pneumonia to a historical diagnosis. She reported the pneumonia diagnosis should not have been coded as it had not been a current diagnosis. She reported they are starting a quality assurance and performance improvement (QAPI) plan on the MDS coding. The MDS Assessment Coordinator Policy, undated, provided by the facility under #3 directed each individual who completes a portion of the MDS Assessment must certify the accuracy of that portion of the assessment by: a. dating and signing the MDS assessment; and b. identifying each section completed. Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action and such incident must be promptly reported to the administrator. The Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019, page (one) 1-8 documents an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the interdisciplinary team completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Long-Term Care Assessment Instrument 3.0 User's Manual Version 1.17.1 October 2019, Chapter 3, section I, Active Diagnosis, coding instruction on page I-8 of the manual directs to code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring (nursing monitoring includes clinical monitoring by a licensed nurse (e.g., serial blood pressure evaluations, medication management, etc.), or risk of death during the 7-day look-back period. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. 2. An EHR census for Resident #77 showed Resident #77 returned to the facility from hospitalization on [DATE] on Medicare Part A Skilled Services. The MDS dated [DATE] for Resident #77 showed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive loss. The Resident required extensive assistance with bed mobility, dressing, personal hygiene and eating. The MDS identified a diagnosis of a right femur fracture and receiving hospice care services. The MDS further documented Resident #77 at risk of a pressure ulcer and identified the use of a pressure reducing device for the chair, bed, turning and repositioning program and application of applications of dressing/ointments other than to feet. The MDS lacked documentation Resident #77 had the presence of an unhealed pressure injury at section M0210 and lacked documentation of the number and stage of the pressure injury in section M0300. A Progress Note dated 11/16/22 at 6:40 p.m. by Staff A, Licensed Practical Nurse (LPN) documented an open area to Resident #77's coccyx measuring 1.8 cm (L) x 1.0 cm (W) x 0.1 cm (D). The wound bed assessed to be dark purple in color with granulation tissue. The wound edges were well defined and intact. A facsimile was sent to the Provider to update on the Resident's condition and the daughter informed of the open area to the coccyx. A Skin Condition Record dated 11/16/22 documented a open pressure injury wound to the coccyx with a treatment to cleanse wound, pat dry, cut calcium alginate and place in the wound. Cover the wound with an ABD pad dressing and secure with paper tape. Change the Alginate dressing every 3 days as needed. The Skin Condition Record documented the following measurements: a. 11/25/22 2.6 centimeters (cm) in length (L) x 1.7 cm width (W) with small serous purulent exudate with slough to the wound bed; peri-wound bed red with normal edges to the wound. b. 11/30/22 2.5 cm (L) x 2.4 cm (W) x 1 cm depth (D) with purulent exudate with biofilm to the wound bed; peri-wound bed red with boggy wound edges. A note documented the Resident had been started on Bactrim Double Strength x 5 days. c. 12/07/22 coccyx wound 2.7 cm (L) x 2.2 cm (W) x 1.2 cm (D) with purulent exudate. The peri-wound exhibited a red/blue color. A note documented a stage 4 pressure ulcer with a 0.9 cm tunnel at the 12 O'clock position and a tunnel 1.5 cm at the 3 O'clock position. d. 12/14/22 wound 2.6 cm (L) x 2.1 cm (W) x 2 cm (D) with purulent exudate and necrosis to the wound bed with slough present in the peri-wound with boggy wound edges. A note documented stage 4 with a 0.9 cm tunnel at 12 O'clock and a 1.6 cm tunnel at the 3 O'clock position. The EHR census sheet documented Resident #77 admitted into hospice care on 12/08/22. During an interview on 2/01/23 at 9:53 a.m. the Director of Nursing reported Resident #77 should not have been coded as hospice care on her return MDS as she had been readmitted on skilled nursing services after her hospitalization . She reported the pressure ulcer should have been coded on the MDS. It had been missed.

Based on record review and staff interview the facility failed to provide eight consecutive hours of Registered Nurse, RN, coverage seven day a week. The facility reported a census of 26 residents. Findings include: The Director of Nursing (DON) reviewed actual staffing schedules for 7/1/22-present and identified the following dates that the facility failed to provide eight consecutive hours of Registered Nurse coverage: 7/31/22, 8/18/22, 10/1/22 and 10/2/22. In an interview on 10/20/22 at 11:30 a.m., the DON confirmed that she was aware of the responsibility of the facility to provide 8 hours of Registered Nurse coverage 7 days a week. The DON stated that they had been trying to hire nurses, and were using agency staff but had been very difficult to secure RN coverage for the facility. Reviewed staffing sheets provided with surveyor and confirmed no RN coverage on the dates identified. During an interview on 10/18/22 at 1:20 p.m. Staff A, RN stated that she had been working a lot of extra shifts to provide RN coverage. Staff A stated the facility definitely lacked RN coverage.

Based on observations, staff interviews and CDC recommendations, the facility failed to demonstrate proper infection control practices for cleaning reusable equipment when leaving a room with transmission based precautions to reduce the risk of spreading infections. The facility reported a census of 18 residents. Findings include: Observation on 6/2/21 at 11:19 AM revealed Staff C, Registered Nurse (RN), walked out of a transmission based precaution room with the following items: stethoscope, blood pressure cuff, pulse ox, and thermometer. Staff C, walked through the hall to the nurse's station and placed the items on the counter of the nursing station by the sink. Staff C sanitized hands, and walked over and stood by the medication cart located at the nurse's station. When asked if items had been sanitized Staff C responded no and stated she was going to sanitize them. Staff C then stepped back over to the counter where the items had been placed and placed paper towels next to the dirty items on a shared countertop. All items cleansed with disinfecting wipes and placed on top of paper towels. Staff C did not cleanse the countertop area where dirty items had been placed. Staff C asked Staff Housekeeping, to get her a new container of disinfecting wipes. Staff C sat down at the nurse's station desk without cleaning the countertop where the dirty items had been placed. Staff D returned with new container of sanitizing wipes, placed her left hand on the counter where the dirty items had been placed and placed the wipes under the sink for storage. After continuous observation from 11:19 AM to 11:23 AM, Staff C left the nurses station without cleaning the counter top. No communication occurred between the staff to indicate the counter top remained contaminated. In an interview on 6/2/2021 at 02:37 PM Staff F, Licensed Practical Nurse (LPN) and Infection Preventionist, stated the facility followed Center for Disease Control (CDC) guidelines. Staff F further revealed extra supplies of blood pressure cuffs, stethoscopes, thermometers, and pulse oximeters available. Staff F advised that for residents on transmission-based precautions, the expectation would be that staff leave supplies in the room until the resident were off precautions and sanitize those supplies with Sani wipes. Staff F stated extra supplies to be kept in the room and cleansed with Sani wipes when the precautions were done. In an interview on 6/2/2021 at 03:45 PM, the Administrator stated she expected the blood pressure cuff, pulse ox, stethoscope, and thermometer be kept in the isolation room until finished, if possible, or sanitizes them if they are removed from the room to be used. The Centers for Disease Control and Prevention website titled, Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, visited 6/3/21 and updated 2/23/21, revealed dedicated medical equipment should be used when caring for patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies. -

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff B). The facility reported a census of 18 residents. Findings include: The personnel file for Staff B, Certified Nursing Assistant (CNA), recorded a start date of 5/4/21. The file lacked documentation of the Iowa Criminal Background Check and dependent adult/child abuse registry check. Staff B gave authorization on 4/29/21 for Iowa Criminal Background check and dependent adult/child abuse registry check. The facility did not complete the criminal and abuse registry check. On 6/02/21 at 07:30 a.m., interview with the Administrator stated the background check for Staff B was completed on 6/1/21 and was not completed before Staff B started working. The Administrator reported the person responsible for completing background checks has only been in the position for about 2 months. The Administrator further revealed Staff B was the last employee hired, and is no longer allowed to work until they are cleared to work. Review of the policy titled. Abuse Prevention and Identification- Screening and Reference review, dated 12/2016, revealed the facility would complete an Iowa criminal background check and dependent adult and child abuse registry check on all prospective employees prior to hire, and other individuals engaged to provide services to residents in a manner prescribed under 58.11(3). On 6/02/21 at 01:48 p.m., interview with the Administrator stated she would expect the facility to have background checks done prior to hire. -

Based on observations and staff interview, the facility failed to post accurate nurse staffing data in a prominent location and visible to residents and visitors. The facility reported a census of 18 residents. Findings include: Observation on 06/01/21 at 12:34 p.m., revealed the Daily Staff Posting of hours dated 05/26/21. At 04:11 p.m., observation revealed still no current posting available for 06/01/21. Observation on 06/02/21 at 10:28 a.m., revealed the Daily Staff Posting of hours dated 6/1/21. At 12:41 p.m., observation revealed still no current posting available for 6/2/21. At 01:16 p.m., observation revealed Daily Staff Posting of hours sheet dated 6/2/21 behind the nurses desk on clipboard only visible to nurses, and staff at the desk and not to residents, visitors, or the general public. An interview on 06/02/21 01:48 p.m., with the Administrator stated she would expect the facility to have the Daily Staff Posting hours visible for anyone to see and not behind the nursing desk. During the interview she stated that the facility does not have a policy for posting staffing hours.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Supervisor had the required qualifications in the absence of a full-time Dietician. The facility reported a census of 18 residents. Findings include: The Dietary Supevisor had a start date of 6/25/20. During an interview 6/3/21 at 9:20AM the Dietary Supervisor revealed she is not a Certified Dietary Manager (CDM). The Dietary Supervisor further revealed the previous Administrator had her take an 8 hour Learn2Serve Food Safety Management Principles course with a completion date of 10/30/20 and had believed that to be the Certified Dietary Management course. During an interview 6/3/21 at 10:25AM the Administrator confirmed the Dietary Supervisor was not a CDM. -

Based on observations, record review, and staff interview, the facility failed to provide the correct menu items approved by the Dietician for 18 out of 18 residents and failed to record menu changes. The facility reported a census of 18 residents. Findings include: The lunch-approved menu for 6/2/21 included the following items: a) Brown Sugar Glazed Pork Chops b) Baked Sweet Potato c) Pea Salad d) Bread/Margarine e) Summer Swirl Cake f) Milk During an observation 6/2/21 between 12:05PM and 12:50PM, Staff H, Cook, served the following items: a) Hamburger with bun b) Grilled cheese sandwich c) Baked beans d) Pasta salad e) Oreo cheesecake During an interview 6/2/21 at 12:50 PM, Staff H, Cook, revealed she had permission to change the lunch menu for the day from the Dietary Supervisor and received permission to serve grilled cheese sandwiches from the nurse on duty after Staff H, Cook, ran out of the hamburgers she had been serving. Review of menus titled Spring Summer 2020 Base Menu Plain Language from Martin [NAME]., signed by the Dietician 10/23/20 and compared to food documented on the food temperature logs 5/16/21-6/2/21 revealed the menus had been changed on 37 occasions during that time period. During an interview 6/03/21 09:20 AM the Dietary Supervisor revealed she is not documenting when there are changes to the menu. During an interview 6/3/21 at 10:25 AM, the Administrator acknowledged it would be an expectation the Dietary Supervisor would be documenting changes to the menu per regulation. -

Based on observation, record review and staff interview, the facility failed to notify the ombudsman for 1 of 1 resident (#1) reviewed. The facility reported a census of 18. Findings include: Record review showed Resident # 1 was hospitalized [DATE] and returned to the facility on [DATE]. Review of the ombudsman notification list for March and April 2021 does not include any information for Resident #1 During an interview on 6/2/21 at 4:23 p.m., the Assistant Director of Nursing (ADON) stated there was no other list she was aware of. -

Based on clinical record review, facility policy review and staff interview, the facility failed to document physician and family notification for a significant weight change for one of two residents reviewed. (Resident #15) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #15 had a non-subscribed weight loss of 5 percent (%) in the last month and had [DIAGNOSES REDACTED]. A Progress Note (Nutrition/Dietary Note) dated 6/17/19, showed the resident had a significant weight loss of 8% in one month. Staff are to continue to monitor daily weights and daily intake records of the resident. The note failed to address any notification of the resident's change in condition to the physician and family. Progress Notes for nursing staff failed to address any notification to the resident's family or physician. During interview on 7/17/19 at 8:30 a.m., the Dietary Director reported the Dietician comes in every Friday and keeps a written paper log on the residents. During interview on 7/17/19 at 8:39 a.m., the DON (Director of Nursing, Registered Nurse) reported being unable to find documentation for family or physician notification. During interview on 7/17/19 at 9:10 a.m., the DON reported staff discussed with the family and physician regarding the weight loss, but they do not have any written documentation. The facility's Weight Loss Policy showed the Procedure included to complete a weight loss notification and notify the physician, family and/or the Durable power of Attorney (POA) and Dietary.

Based on observation and dietary menu review and resident interview, the facility failed to ensure resident cold liquids was at or below 41 degrees Fahrenheit and resident hot food was reheated to 165 degrees F and maintained at 135 degree and failed to ensure dietary staff utilized proper food handling. The facility census was 26 residents. Findings include: 1. During preparation of the lurch meal on 4/9/18 at 11:30 a.m., Staff B, cook pureed one steak in a blender with hot water and food thickener. Staff B reported the temperature of the meat after the process was 125 degrees Fahrenheit (F). Staff B heated the bowl of meat in the microwave to a temperature of 142.5 degrees F. and placed the covered bowl on the steam table. Prior to service, the surveyor requested the food temperature be retaken. The temperature at 12:05 p.m., was 130 degrees F. The cook again reheated the meat in the microwave to 146 degrees F. The meat was not brought to an internal temperature of 165 degrees nor held at 135 to 155 degrees. During observation of the noon meal on 4/9/18, Staff B, cook placed her bare hands in the inside of the bowls in which she then served food. During the meal service, Staff B touched near her mouth and continued to serve without washing her hands. During lunch service on 4/9/18, milk was placed in glasses and served at 11:40 a.m., onto the tables without the resident present. When the resident came to the table for lunch at 12:00 p.m., the temperature of the milk was 48.6 degrees F (above 41 degrees F) During Resident Council meeting on 4/9/18 at 1:10 p.m., two of three residents stated the milk was not always cold especially when staff set it on the table early.

Based on clinical record review and staff interview, the facility failed to do a recapitulation of the residents stay for one of one resident discharged home. (Resident #30). The facility census was 26 residents. Findings include: 1. The Admission Record dated 12/15/17, documented Resident #30 had [DIAGNOSES REDACTED].>3-part fracture of surgical neck of right humerus, heart failure and hypertension. A facsimile dated 1/15/18 at 10:15 a.m., signed by the physician documented patient may be discharged . Discharge Instructions for care with no date, documented you are being discharged home and to follow up with doctor for an x-ray on 1/17/18. The Progress notes failed to documented the recapitulation of stay for the resident since admission on 12/15/17. During interview on 4/11/18 at 12:10 p.m., the director of nursing confirmed the clinical record lacked documentation of the recapitulation of the residents stay.

Based on clinical record review and staff interview, the facility failed to notify the resident or resident representative in writing in a timely manner of Medicare A services discontinuing for one of three residents reviewed (Resident #18). The facility census was 26 residents. Findings include: 1. A Skilled Nursing Facility Beneficiary Protection Notification Review documented Resident #18 received Medicare Part A Skilled Services starting 12/27/17, with the last covered day of service 1/17/18. The facility failed to ensure a Skilled Nursing Facility Notice of Medicare Non-Coverage (form ) was provided. During interview on 4/10/18 at 10:50 a.m., Staff D, Minimum Data Set Coordinator confirmed the resident did not receive the second form .

Based on clinical record review and staff interview, the facility failed to provide residents/families with a written copy/summary of the initial/base line care plan after admission for two of residents reviewed. (Resident #21 & #12). The facility census was 26 residents. Findings include: 1. Clinical record review revealed Resident #21 was admitted to the facility on [DATE]. An initial/base line care plan was in the chart but was not dated when completed. There was no documentation the resident or family/POA was provided with a written copy of the baseline care plan. During interview on 4/11/18 at 11:20 a.m., the Assistant Director of Nursing (ADON) stated she offered a written summary of the baseline care plan to the resident but the resident did not want it. The ADON did not have documentation it was offered to the resident. 2. Clinical record review revealed Resident #12 was admitted on [DATE]. An initial/ base line care plan was in the chart but was not dated when completed. The chart did not have documentation the resident or family/POA was provided a written copy of the baseline care plan. During interview on 4/11/18 at 2:12 p.m., the ADON stated she had no documentation the baseline care plan was given to the resident representative. She did not know why the baseline care plan was not dated when completed.

Based on clinical record review, staff and physician interviews, the facility failed to ensure staff were educated and demonstrated proper use of e-tank oxygen administration to ensure delivery of oxygen as ordered for one of two residents reviewed with orders for continuous oxygen. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 25 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of [DATE] for Resident #1 identified the resident had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had Brief Interview for Mental Status (BIMS) score of 9 out of 15, which meant the resident had moderate cognitive impairments. The resident had fluctuating inattention, and relied on staff to assist with locomotion on and off the unit. The resident had shortness of breath (SOB) with exertion, when sitting at res, and when lying flat. The Care Plan revised [DATE] documented the resident had impaired physical mobility, weakness, a risk for falls manifested by a fall history at home. The resident had completed occupational therapy after a pacemaker placement. The Care plan identified Resident #1 had dyspnea with exertion and a need for oxygen (O2). The care plan approaches included the following: a. O2 at 3 liters (L) per nasal cannula (n/c) except with transfers, ambulation and showers. b. O2 at ,[DATE] L per n/c as needed (PRN). A Riceville Family Care Center and Therapy Center Order Listing form signed by a physician [DATE], indicated the resident as on O2 at 2 L per n/c and ,[DATE] L per n/c PRN SOB. A Medication Administration Record [REDACTED]. May have off for transport, ambulation and showers (dated [DATE]) and O2 at ,[DATE] L per n/c PRN for SOB. A Long Term Medical Supply Oxygen Tank Log form, indicated a portable e-tank # 8 as signed out to the resident on [DATE]. Nurses' Progress Notes, written by Staff B (nurse), dated [DATE] at 9:30 a.m., documented the Housekeeper (Staff A) informed Staff B prior to taking the O2 concentrator to the resident's room, the resident looked as if she was not breathing. Upon entering the resident's room, Staff B found the resident ' s head tilted back seated in the wheelchair. The resident's skin was pale, his/her lips were pale in color, with the resident ' s mouth open and limbs flaccid. The housekeeper and a CNA (Staff C) were in the room and the Housekeeper was asked to get the DON. Resident #1 had O2 nasal cannula in nares and hooked up to portable O2 tank (e-tank). Staff switched O2 from portable O2 (e-tank) to the O2 concentrator at this time. The resident had a faint pulse palpated. Staff B, the DON and another nurse continued to monitor the resident for several minutes, only detecting a faint apical/radial pulse. Staff B held the resident ' s head up strait and DON sent staff to notify resident's family. Staff transferred the resident into his/her bed with a Hoyer lift and O2 on via nasal cannula in bilateral nostrils. After resident positioned in bed and there was no apical pulse or respiration, staff pronounced the resident as deceased at 9:50 p.m. The oxygen concentrator was then shut off and tubing removed from bilateral nares. The nurses' progress note dated [DATE] at 10:00 a.m. to 10:05 a.m. documented the resident's family and physician alerted of the resident's death. During an interview [DATE] at 1:25 p.m., a Physician confirmed he would have expected staff to maintain a functioning oxygen system and the resident not having oxygen could have contributed to his/her death. A Death Record signed by a physician [DATE], documented the resident's principal cause of death as critical [DIAGNOSES REDACTED]. The facility investigation included the following: On [DATE], Staff B's (nurse) written statement documented the housekeeper ( Staff A) took the resident's O2 concentrator to his/her room and reported the resident appeared asleep but barely breathing. Upon entering the room, she (Staff B) found the resident sitting in the wheelchair facing towards the closet door, and his/her skin was pale. Resident #1's lips were pale in color and limbs flaccid. The O2 was on via nasal cannula in bilateral nares. Staff B attempted to awaken Resident #1 and then checked the resident's pulse. Staff B asked the DON to come to the resident's room. Staff B documented she checked the portable O2 tank (e-tank) but only glanced at it and did not remember if it was empty or not. Staff B did not recall saying it was empty or not. Staff B reported she began doing an assessment right away prior to telling the housekeeper to get the DON. Staff B documented later in the afternoon of [DATE], the DON called her into her office and showed her Resident #1's O2 tank (e-tank) was over half full; and the tank had been checked out [DATE]. After looking at the O2 tank and the sign out sheet, Staff B documented she (should) not have said, the tank was empty. A written statement from the housekeeper (Staff A) on [DATE], documented at 9:30 a.m., she noticed Resident #1's concentrator (oxygen) was still by his/her spot at the table and took it to his/her room. When she arrived at the room, she thought the resident was asleep, then noticed he/she was doing small gasps for air and his/her face had a grayish tint. She immediately obtained the charge nurse (Staff B) and told her what she had seen. As staff B was checking Resident #1, she stated the oxygen tank located on the resident ' s wheelchair was empty. Staff B asked her to get the DON and she ran down the hallway. A short while later Staff C asked her when are they supposed to check the oxygen tanks? Review of a typed statement (not dated) from the Director of Nursing (DON), included the following documentation. At the time of the resident's death the housekeeper (Staff A) reported she thought the oxygen tank (e-tank) had been empty because she thought she heard the nurse (Staff B) state that information. Upon investigation nurse (Staff B) reported she did not remember telling anyone the oxygen tank (e-tank) was empty. The CNA (Staff C) that transported the resident down to her room after breakfast states she turned the oxygen tank (e-tank) on. Upon further investigation the DON noted that the oxygen tank (e-tank) was over half way full and functioned without any problems. A full tank would last approximately 5.41 hours and a full tank at 4 Liters would last 2.5 hours. A brand new oxygen tank was pulled for Resident #1 on [DATE] and the resident had a concentrator that she used the majority of time. During an interview [DATE] at 1 p.m., Staff A, housekeeper stated after break she noticed an O2 concentrator in the dining room, knew it had been the resident's so she took it to his/her room. When she entered the resident's room she thought the resident had been sleeping in the wheelchair because he/she had been leaning down in the chair with his/her head tilted back and mouth open. The staff member thought the resident had been breathing at that time but looked gray in color and could not see the resident's chest moving. She went to get Staff B, Licensed Practical Nurse (LPN) who returned to the resident's room with the staff member and Staff C, CNA. Staff B checked to see if the resident had been breathing as Staff C went around and looked at the e-tank and confirmed it as empty. Staff B checked the e-tank and confirmed it as empty as well. At that point Staff A had been directed to exit the resident's room. During an interview [DATE] at 1:53 p.m., Staff B (nurse) indicated following break at 9:30 a.m. she had been at the nurse's station and observed Staff A take the resident's oxygen concentrator to his/her room. Staff A returned to the nurse's station and reported to her the resident did not look good, appeared sleeping and had been barely breathing. Staff B went to the room and found the resident slouched down in the wheelchair, head back, mouth open and eyes closed. The staff member looked at the e-tank and thought it had been empty but never checked to see if there had been air flow. The first thing the staff member did was rub the resident's chest for a response but received no reaction. The staff member requested Staff A get the DON as she assessed for pulses which were faint but present. When the DON arrived with Staff G, LPN they were able to feel a faint pulse as well. The staff members changed the resident from the e-tank to the concentrator and transferred the resident via a Hoyer sling device from the wheelchair to the bed. When the staff positioned the resident for comfort they were no longer able to palpate a pulse at which time the resident had been pronounced deceased . The staff member also confirmed there had been an incident on [DATE] where the resident had been in the activity room when someone assisting with activities reported the resident's oxygen as off and they did not think the resident looked very good. When Staff D brought the resident to the nurse's station staff already had the resident connected to oxygen and the resident had been in no respiratory distress. During an interview [DATE] at 12 p.m., Staff B confirmed when the e-tank had been shut off the needle registered in the refill section of the gauge which looked like the tank had been empty and that had been her observation in the resident's room the morning of the incident. During an interview [DATE] at 2:25 p.m., Staff C, reported working since March of 2016 as a CNA. Regarding the incident that occurred on [DATE], Staff C indicated at 9:10 to 9:30 a.m. she changed the resident from the O2 concentrator to the portable e-tank, and shut the concentrator off, unplug and unhook the tubing connected to the E-tank and turned the dial to 5 liters. She could hear the O2 flow but did not check to see how much O2 had been in the e-tank. She confirmed she heard air come out of the resident's tank but did not see how much oxygen was in the tank. Staff C reported the whole trip down to the resident ' s room, the resident was in good spirits and she had no troubles. Staff C left the room, Resident #1 was still on the E-tank and she gave Resident #1 his/her call light. Staff C left to answer an alarm and was gone about ,[DATE] minutes and observed Staff A running out of the resident's room when she returned. She observed the resident still positioned in the wheelchair but with his/her head tilted back as if sleeping. She called the resident's name, tapped on the shoulders and kept repeating his/her name with no response. The nurse, Staff B came to Resident #1's room and completed vitals and said he/she felt a faint heart beat and said, Oh my God, there's no oxygen in the tank. Staff C never looked at the E-tank but heard oxygen coming out when Staff B said the E-tank was empty. The DON then came to Resident #1's room and at that point Staff C had been asked to leave the resident's room. Staff C said she had no clinical training on oxygen E-tanks in CNA school or when she was orientated at the facility. Staff C stated she does not even know where the E-tanks are stored and she knows nothing about the key device to turn on the machine, until the surveyor showed her (when the surveyor demonstrated proper usage.) Staff C stated she was suspended over the situation and the Administrator stated we take these things seriously. Staff C reported she did not check the E-tank, and she never looked to see if full or empty. Staff C reported she did not even know what the red line meant. Staff C reported she would not know how to check them. Staff C reported she was familiar with the concentrators, but not with the E-tanks. Staff C reported at the In-services, the nurse is now doing the change from concentrators to e-tanks. Staff C said nurses ' checks oxygen to make sure everything is connected correctly. Staff C indicated she had no clinical training on how to manage e-tanks. Additionally she reported she knew nothing about the key device that turned on the e-tank. During an interview [DATE] at 3:53 p.m., the DON confirmed she never checked the e-tank when the resident had been found unresponsive and failed to listen to the oxygen/air flow. During an interview [DATE] at 3:17 p.m., Staff G confirmed she never checked the e-tank when the resident had been found unresponsive and never heard any oxygen/air flow. During an interview [DATE] at 12:20 p.m., Staff G, LPN confirmed when an e-tank had been shut off it registered empty. During an interview [DATE] at approximately 2:15 p.m., Staff D, CNA confirmed there had been times she failed to put on another resident ' s oxygen on (Resident #2). The staff member also confirmed there had been an incident in the activity room where the oxygen tubing for Resident #1 had not been placed and/or had fallen off the concentrator. By the time she arrived Staff E, CNA placed the resident back on the oxygen but the resident had still been a little SOB. The staff member recalled the resident's pulse oximetry at 90%. During an interview [DATE] at 4 p.m., Staff D indicated she did not remember having been trained on how to manage an e-tank. During an interview [DATE] at approximately 12:15 p.m., a community member confirmed on [DATE] he/she assisted the facility with community coffee in the facilities activity room when a CNA brought the resident to the activity, plugged in the oxygen concentrator and left. The resident attended the activity for approximately 45 minutes when the community member noticed he/she did not look very good. The resident appeared to look like he/she was in respiratory distress. The community member noticed the oxygen tubing had been disconnected from the humidifier and there had been a pool of water on the floor. The resident's son had been present and they connected him/her to the e-tank and staff took the resident out of the activity room. The facility reported Resident #1 as the only resident using a portable oxygen tank (e-tank). During an interview [DATE] at 12:25 p.m., the DON confirmed if the e-tank had been shut off it registered empty. When questioned if it would have been reasonable to say if Staff B looked at the tank and it had been on the refill section the tank could have been shut off, the DON stated I do not know . The DON reported she did not look at the e-tank until after the resident had passed away and left the building. At which time the Administrator and her checked the e-tank, turned the device on and could not hear any oxygen/air flow. They then called their Corporate Nurse, she came to the facility that same day, the dial still showed ,[DATE] full, she turned the E-tank to ,[DATE] Liters and said she could hear oxygen flowing and she never adjusted the gauge. The DON also confirmed the agency staff who worked at the facility had not been educated/in-serviced on how to change a resident from an oxygen concentrator to an e-tank and vice-versa. During an interview [DATE] at 4:05 p.m., Staff E indicated she did not think she had been trained/orientated on how to manage an e-tank prior to this incident. During an interview [DATE] at 11:35 a.m., Staff E confirmed prior to the incident CNA ' S changed residents from oxygen concentrator to e-tanks and vice versa. During an interview [DATE] at 4:25 p.m., Staff H, CNA with Nurse finder's agency. This was her 3rd time working at the facility. She did not know the facilities expectations with portable E-tanks. During an interview [DATE] at 11:45 a.m., Staff F confirmed prior to the incident CNA'S changed residents from oxygen concentrator to e-tanks and back again. On [DATE] at 4 p.m. - Staff D, CNA was asked if staff had been orientated on how to use an E-tank (portable oxygen tanks) and responded, when a situation came up, she just learned it. Staff D reported she did not remember being trained on E-tanks. The investigation determined the facility did not have a policy to guide staff on the procedure to change a resident from a concentrator to a portable oxygen tank (e-tank). On [DATE], the facility abated the Immediate Jeopard when they implemented a policy effective [DATE] and educated staff of the provisions including the following: Effective [DATE], when a resident on an oxygen concentrator and is transferred to a portable oxygen tank, the following procedure will be followed: Certified nurse aides (CNA) will not be switching residents from concentrators to portable oxygen tanks. Certified nurse aides may transport residents to and from destination after the nurse has hooked the resident up to the portable tank. The Charge Nurse needs to change the resident from concentrator to portable oxygen tank and switch oxygen over and verify that they are properly hooked up. When switching to a portable oxygen tank the nurse shall verify that there is oxygen left in the tank. Tanks are to be used when transporting a resident, and are not to be used in place of a concentrator. The DON would provide ongoing monitoring of the policy.