Every finding on record at Riverside Rest Home

Based on observation, interview, and record review, it was determined that the facility failed to follow manufacturers' instructions for medication administration in 1 of 2 insulin administration observations. (Resident identifier is #111). Findings include: Review on 4/8/2026 of the manufacturer's' instructions for Novolog solution, To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units. Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0 . Observation on 4/8/2026 at approximately 8:30 a.m. with Staff A (Licensed Practical Nurse) during medication administration revealed Staff A did not prime the insulin pen with 2 units before administering 14 units of insulin to Resident #111. Interview on 4/8/2026 at approximately 8:35 a.m. with Staff A confirmed the above findings. Review on 4/8/2026 of Resident #111's medical record revealed an order for Novolog FlexPen Subcutaneous Solution . inject 14 units subcutaneously one time a day, dated 4/4/2026.

Based on interview and record review, it was determined that the facility failed to have an water management plan that included an assessment and control measures to identify and prevent the growth and spread of Legionella and other opportunistic waterborne pathogens in a facility with a census of 164 residents. Findings include: Interview on 4/8/2026 at approximately 9:50 a.m. with Staff C (Infection Preventionist) revealed that he/she monitors the facility for empty rooms and flushes them on a weekly basis. Staff C was not able to provide a water management plan. Interview on 4/8/2026 at approximately 10:30 a.m. with Staff B (Maintenance Director) revealed that the facility did not have a water management plan that included an assessment of the facility identifying areas that opportunistic waterborne pathogens could grow and spread or that included control measures to prevent the growth of opportunistic pathogens and how to monitor them. Review on 4/8/26 of facility policy titled Legionnaires' Disease, no date of when it had been written, reviewed, or updated, revealed: Prevention: Maintenance: Ensure water systems are maintained, in an effort to eliminate bacteria. Equipment is maintained by manufacturer's guidelines. Equipment addition, repair etc.as needed and/or recommended. Boiler temps are monitored and logged twice a day and kept within range specified by location . There was no assessment that identified areas that opportunistic waterborne pathogens could grow and spread. The control measures mentioned did not include established ways to intervene when control limits were not met.

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standard for 1 of 7 residents observed for medication administration (Resident identifier is #84). 38218 Findings include: [NAME], [NAME] A., and [NAME]. Clinical Nursing Skills & Techniques. 10th ed. St. Louis, Missouri: Elsevier, 2022, page 602, .Medication Administration: .3. Stay with the patient until the medication is taken. Provide assistance as necessary. Do not leave medication at bedside without a health care provider's order . Observation on 2/12/25 at approximately 7:50 a.m. to 8:00 a.m. on Unit 5 (Dementia Unit) revealed Staff D (Licensed Practical Nurse) preparing Resident #84's morning medications and putting them in a boost drink at the medication cart. Staff D added chocolate syrup to the drink. Further observation revealed Staff D brought Resident #84's morning medications mixed in a chocolate drink to Resident #84 in the dining room. Staff D then told Resident #84, Drink your chocolate milk, and left the chocolate drink with medications on the dining room table with Resident #84. Staff D left the dining room and Resident #84 was left unattended to take his/her medication. Interview on 2/12/25 at approximately 8:00 a.m. with Staff D confirmed the above observation. Review on 2/12/25 of Resident #84's latest BIMS (Brief Interview for Mental Status) assessment, dated 1/21/25, revealed a score of 2 indicating severe cognitive impairment. Review on 2/12/25 of Resident #84's February 2025's Medication Administration Record revealed the following morning medications that were in Resident #84's drink: Lactulose solution (laxative)15 mls (milliliters), Miralax powder (laxative)17 gm (grams), Sertraline (antidepressant) 75 mg (milligrams), and Acetaminophen (analgesic) 650 mg.

Based on observation and interview, it was determined that the facility failed to ensure that expired medications were removed from stock in 1 of 3 medications rooms observed. Findings include: Observation on 2/11/25 at approximately 9:00 a.m. of the Unit 4 medication room revealed an open bottle of Lantus Insulin with a discard date of 2/7/25 in the medication refrigerator. Interview on 2/11/25 at approximately 9:00 a.m. with Staff A (Registered Nurse) confirmed the above findings. Review on 2/12/25 of the facility policy, titled Care/Cleaning/Storage of Medication Rooms, dated 06/2023 revealed: .3. Maintain medications up until the expiration dates.4. Check for proper storage and expiration dates .

Based on interview and record review, it was determined that the facility failed to follow physician orders for timely laboratory services for 1 of 1 resident reviewed for psychotropic medication side effects in a final sample of 31 residents (Resident identifiers is #143). Findings include: Review on 2/12/25 of Resident 143's active physician's orders, dated 2/5/25, revealed the following: -LFT (Liver Function Test) and CBC (Complete Blood Count) with differential on 2/6/25. Interview on 2/12/25 at 12:30 p.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed the above orders were placed on 2/5/25 for Resident #143. Interview on 2/12/25 at 1:02 p.m. with Staff O (Assistant Director of Nursing) confirmed that Resident #143's labs had not been obtained. Interview further revealed that the [Company name omitted] comes every Tuesday and Thursday and there were 2 missed opportunities for the blood work to be obtained. Review on 2/12/25 of the facility's policy, Laboratory Services, revised on 12/27/2023, revealed .Blood draws are scheduled twice weekly, every Tuesday and Thursday and as needed for stat labs .Obtain a Physician Order for appropriate Lab Studies. Order transcription into the electronic health record under orders. Notify unit clear via email of labs as ordered by physician. The Unit Clerk enters the order information into [Company name omitted] portal. Unit Clerk writes on unit calendar the date lab to be drawn .

Based on observation, interview, and record review, it was determined that the facility failed to implement the facility's infection control policies contact precautions for 2 residents reviewed for transmission based precautions in a final sample of 31 residents (Resident identifiers are #13 and #113). Findings include: Resident #113 Observation on 2/11/25 at approximately 8:35 a.m. revealed Staff E (Unit Aide) entering Resident #113's room with a face mask and gloves on. Further observation revealed Staff E left the resident's room with a face mask and gloves on. Interview on 2/11/25 at approximately 8:35 a.m. with Staff E revealed that he/she did not know that Resident #113 was on contact precautions. Interview on 2/11/25 at approximately 8:55 a.m. with Staff A (Registered Nurse) revealed that Resident #113 was on contact precautions for norovirus. Staff A confirmed that Staff E should wear a gown along with gloves and mask prior to entering a room with contact precautions. Observation on 2/11/25 at approximately 12:15 p.m. revealed Staff K (Licensed Nursing Assistant (LNA)) delivered Resident #113's lunch tray to his/her room wearing a mask and gloves. Staff K was not wearing a gown. Observation on 2/12/25 at approximately 8:00 a.m. of Resident #113's room revealed Staff L (LNA) putting blankets on Resident #113's bed and hanging up clothing with a mask and gloves. Staff L was not wearing a gown. Observation on 2/12/25 at approximately 8:30 a.m. revealed Staff M (LNA) entering Resident #113's room with his/her breakfast tray wearing only a mask. Staff M was not wearing gloves or a gown. Interview on 2/12/25 at approximately 2:15 p.m. with Staff I (Infection Preventionist) confirmed that Resident #113 was on contact precautions 38218 Observation on 2/11/25 at approximately 12:00 p.m. in the hallway on Unit 4 revealed a face mask placed on a railing. Interview on 2/11/25 at approximately 12:00 p.m. with Staff A revealed that he/she was unsure if the face masked was used or not. 45419 Resident #13 Observation on 2/11/25 at 12:24 p.m. of Resident #13's room revealed signage on the door of the room stating Contact Precaution .Gowns, [NAME] gown upon entry into the room or cubicle . Further observation revealed Staff B (LNA) entering Resident #13's room wearing gloves, a surgical mask, and no gown. Interview on 2/11/25 at approximately 12:26 p.m. with Staff B revealed that he/she was not aware that he/she needed to don gown prior to entering the resident's room with contact precautions to deliver food. Interview on 2/12/25 at 1:00 p.m. with Staff I revealed that he/she reports that the facility is in outbreak for suspected Norovirus or gastrointestinal illness. Interview further revealed that the facility followed the CDC guidelines for infection control and precautions and that the facility had modified the CDC guidance for their facility. Review on 2/12/25 of the Facility Policy/Procedure Titled: Procedures for Airborne, Contact, and Droplet Isolation. (Modified from CDC Guidelines) Contact Precautions .Wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident, resident items, or environmental surfaces or if the resident is incontinent. Review on 2/12/25 of Key Infection Control Recommendations for the Control of Norovirus Outbreaks in Healthcare Settings retrieved from https://www.cdc.gov/healthcare-associated-infections/media/pdfs/Norovirus-ControlRecomm-508.pdf revealed the following: Personal Protective Equipment (PPE) If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry). 51399

Based on observation, interview, and record review, it was determined that the facility failed to ensure resident medications had accurate labeling to facilitate the safe administration of medications in 1 of 4 medication carts and medications not discarded after expiration in 1 of 3 medication rooms observed (Unit 2: left medication cart; Unit 4: medication room) (Resident Identifiers are #27 and #32). Findings include: Unit 2: left medication cart Observation on 1/9/24 at 9:45 a.m. of Unit 2: left medication cart revealed 2 plastic medication cups with prepoured medications stacked together without resident and medication identifiers. Interview on 1/9/24 at 9:45 a.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed the above findings and revealed the medications were for Resident #27 and Resident #32. Staff A revealed they routinely prepour medications. Review of [NAME], [NAME] A., and [NAME] [NAME] Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 35 Page 719, revealed .7.d. Prepare medication for one client at a time . Unit 4: Medication Room Observation on 1/9/24 at 10:03 a.m. of the medication room revealed a Tuberculin Purified Protein Derivative vial labeled with an open date of 11/21 in the refrigerator. Interview on 1/9/24 at approximately 10:03 a.m. with Staff C (Registered Nurse) and Staff B (LPN) confirmed the above findings. Review on 1/9/24 of the manufacturer's instructions for Tuberculin Purified Protein Derivative revealed .Vials in use for more than 30 days should be discarded .

Based on observation, interview and record review it was determined that the facility failed to follow physician's orders for 1 out of 1 resident observed for tube feeding during medication administration. (Resident identifier is #125) Findings Include: Standard: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 12/15/22 at 10:40 a.m. of Resident #125 medication administration record revealed the following order One 8 ounce container of Jevity 1.5 [ feeding formula] with 200 ml [milliliter] of H2O [water] flush before and after each bolus feed via PEG [Percutaneous Endoscopic Gastrostomy] tube at 0500 [5:00 a.m.], 1100 [11:00 a.m.], 1600 [4:00 p.m.], and 2200 [10:00 p.m.] . Observation on 12/15/22 at 10:40 a.m. of Resident #125's gastrostomy tube feeding administration with Staff A (Registered Nurse) revealed that Staff A administered the Jevity 1.5 formula via the Resident #125's gastrostomy tube without administering the 200 ml water flush. Interview on 12/15/22 at 10:40 a.m. with Staff A confirmed the above findings. Review on 12/15/22 at 12:30 p.m. of the facility policy titled General Care and Maintenance of Gastrostomy Tubes dated 06/19/2018. Care during feedings: .4. Flush tube with ordered amount of water before and after each feeding and medication administration and/or every 4 hours during a continuous feeding.

Based on observation, interview and record review, it was determined that the facility failed to ensure that food is stored in accordance with professional standards for food safety for 5 out of 6 kitchenettes (Unit 1B, Unit 2, Unit 3, Unit 4, North kitchenette) and 1 out of 2 kitchens ([NAME] house kitchen/cafe) observed. Findings include: Unit 4 kitchenette Observation on 11/18/21 at approximately 12:20 p.m. at the unit 4 kitchenette revealed 1 opened thickened lemon flavored water with no opened date. Review on 11/18/21 of the opened thickened water manufacturer's instruction on the box container revealed that after opening, thickened water may be kept up to 7 days under refrigeration. Interview on 11/18/21 at approximately 12:20 p.m. with Staff R (Licensed Practical Nurse (LPN)) confirmed above findings on unit 4 kitchenette. Unit 3 kitchenette Observation on 11/18/21 at approximately 12:25 p.m. at the unit 3 kitchenette revealed 1 opened thickened cranberry juice with no opened date and 1 opened thickened apple juice with no opened date. Review on 11/18/21 of the opened thickened apple and cranberry juice manufacturer's instruction on the box container revealed that after opening, thickened juice may be kept up to 7 days under refrigeration. 1B unit kitchenette Observation on 11/8/21 at approximately 1:00 p.m. at the 1B unit kitchenette revealed 1 opened thickened apple juice with no opened date and 1 opened thickened orange juice with no opened date. Review on 11/8/21 of the opened thickened apple and orange juice manufacturer's instruction on the box container revealed that after opening, thickened juice may be kept up to 7 days under refrigeration. Interview on 11/8/21 at approximately 1:00 p.m. with Staff M (LPN) confirmed the above findings in 1B unit kitchenette. Unit 2 kitchenette Observation on 11/8/21 at approximately 1:30 p.m. at unit 2 kitchenette revealed 1 opened thickened cranberry juice with no opened date and 1 opened thickened orange juice with no opened date. Review on 11/8/21 of the opened thickened cranberry and orange juice manufacturer's instruction on the box container revealed that after opening, thickened juice may be kept up to 7 days under refrigeration. Interview on 11/8/21 at approximately 1:30 p.m. with Staff Q (Licensed Nursing Assistant) confirmed the above findings on Unit 2 kitchenette. [NAME] house kitchen/cafe and north kitchenette Observation on 11/8/21 at approximately 2:20 p.m. with Staff S (Food Manager) revealed that the temperature of the refrigerator with milk, yogurt, and other food items in the kitchen/cafe was 43 degrees Fahrenheit on one thermometer and 45 degrees on another thermometer that were found inside the refrigerator. Further observation revealed that the temperature for the north kitchenette refrigerator with juices, milk, and supplemental shakes was 52 degrees Fahrenheit. Review on 11/8/21 of the [NAME] house kitchen appliance temperature log for the kitchen/cafe refrigerator revealed the following: 11/1/21 refrigerator temperature was 45 degrees Fahrenheit 11/4/21 refrigerator temperature was 43 degrees Fahrenheit Further review of the kitchen house appliance temperature log revealed to report to hospice house manager or charge nurse if the temperature reading is 3 degrees above of below target temperature. If appliance consistently registers 5 degrees above or below target temperature for greater than 24 hours provisions must be made to keep refrigerated food below 40 degrees Fahrenheit but above 0 degrees Fahrenheit and freezer items must be kept at or below 0 degrees Fahrenheit. Review on 11/8/21 of the [NAME] house kitchen appliance temperature log for the small refrigerator in the kitchen/cafe revealed the following temperatures: 11/5/21 54 degrees Fahrenheit 11/6/21 60 degrees Fahrenheit 11/7/21 52 degrees Fahrenheit 11/8/21 48 degrees Fahrenheit Review on 11/8/21 of the [NAME] house kitchen appliance temperature log for the north kitchenette refrigerator revealed the following temperatures: 11/5/21 54 degrees Fahrenheit 11/6/21 60 degrees Fahrenheit 11/7/21 52 degrees Fahrenheit 11/8/21 48 degrees Fahrenheit Interview on 11/8/21 at approximately 2:30 p.m. with Staff F confirmed above findings on [NAME] house kitchen/cafe north kitchenette and temperature logs for the refrigerators. Staff F was unable to provide any documentation of any follow up on the above findings in the temperature logs and the temperatures of the refrigerators. Staff F stated that he/she was aware that the temperatures on the refrigerators were registering above the targeted temperature as mentioned on the temperature logs. Staff F stated that temperatures for the refrigerator and freezer should be below 40 degrees Fahrenheit and 0 degrees Fahrenheit, respectively, as what was noted on the kitchen appliance temperature log. Review on 11/9/21 of the facility's policy titled, food handling and safety potentially hazardous food guidelines, with an updated date of 1/17, revealed .ALL FOOD ITEMS MUST BE LABELED WITH THE OPEN/MADE DATE, WHAT THE ITEM IS, AND THEN BE LABELED WITH THE USE BY DATE BASED ON THE FOLLOWING GUIDELINES .ALL STAFF MUST ADHERE TO THE FOLLOWING GUIDELINES FOR FOOD STORED IN ANY REFRIGERATOR . Review on 11/10/21 of the FDA (Food and Drug Administration) Food Code, dated 2017, page 92, revealed that .3-501.12 Time/Temperature Control for Safety Food .(A) Under refrigeration that maintains the FOOD temperature at 5 oC [degrees Celsius] (41 oF [degrees Fahrenheit]) or less .

Based on interview and record review, it was determined that the facility failed to provide the correct Notice of Medicare Non-Coverage (NOMNC) Form and the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form prior to the last covered day of Part A services for 3 out of 3 residents reviewed for Beneficiary Protection Notification. (Resident identifiers are #2, #41, #285). Finding include: Review on 11/9/21 of Resident #2, Resident #41, and Resident #285's beneficiary notice forms provided by Staff A (Admissions Coordinator) revealed that the facility was using a UR (Utilization Review) Committee Determination of Continued Stay form and CMS form to notify residents of their rights and protections prior to their last covered day of Medicare A. Interview on 11/9/21 at approximately 2:00 p.m. with Staff A revealed that he/she was responsible for generating and sending the notices when residents come off of Medicare A. Staff A stated the facility was not using CMS- (SNF ABN) or CMS- (NOMNC), but instead used CMS form (NOMNC) and a facility form titled UR Committee Determintation of Continued Stay.

Based on observation, interview, and record review, it was determined that the facility failed to implement resident's care plan in regards storing smoking materials in a locked compartment for 3 residents out of 5 residents observed for smoking in a final sample size of 32 residents. (Resident identifiers are #11 #14, and #63.) Findings include: Resident #14 Interview on 11/8/21 at 9:15 a.m. with Resident #14 revealed that they kept their cigarettes and lighter in their shirt pocket all day and leaves their cigarettes and lighter at the top of their nightstand overnight. Observation on 11/8/2021 at 9:15 a.m. in Resident #14's room revealed that Resident #14 was sitting in their room in their bedside chair, cigarettes and lighter were in their top left pocket of their shirt. Observation on 11/9/2021 at 1:30 p.m. with Staff I (Licensed Practical Nurse) revealed that Resident #14's cigarettes were in the unlocked top drawer on their nightstand. Interview on 11/9/21 at approximately 1:30 p.m. with Staff I confirmed above findings on 11/9/21. Staff I stated that residents who smoke were assessed to keep their smoking materials (i.e. cigarette and lighters) in their room should keep it in a lock box or drawer. Interview on 11/10/2021 at 12:03 p.m. with Resident #14 revealed that they stored their cigarettes and lighter on the top of their nightstand and not in the top drawer of the nightstand that has the lock. Review on 11/10/2021 of Resident #14's Smoking Assessment Tool - V3 dated 6/3/2021, 8/25/2021, 11/06/2021 revealed that .11. The resident demonstrates safe use and storage of all smoking materials and understands the importance of safeguarding the lock box key to ensure other residents are not able to access their smoking materials. (locked drawer may be substituted for locked box) . The box was checked YES. Further review also revealed under Section C .Decision .3. Where will lighter and cigarettes be stored? . Resident (in locked box/drawer) . Reviewed on 11/10/21 of Resident #14 current smoking care plan with an update date of 9/11/21 revealed that Resident #14 may keep smoking materials in a lock box in their room. Interview on 11/10/21 at approximately 11:50 a.m. with Staff G (Unit Manager) confirmed the above care plan and smoking assessment. Resident #11 Observation on 11/8/21 at approximately 11:19 a.m. in Resident #11's room revealed that Resident #11 was laying bed watching TV (television) and their wheelchair across room out of reach. Further observation revealed that there were open pack of cigarettes and 3 lighters in an open bag attached to their wheelchair. Interview on 11/8/21 at approximately 11:19 a.m. with Resident #11 revealed that they store their cigarettes and lighter in the open bag on the wheelchair all day and overnight. Observation on 11/9/21 at approximately 1:30 p.m. with Staff I revealed that Resident #11 had a lock box in the top drawer of their dresser. Further observation revealed that Resident #11's cigarettes and lighter were in an open bag hanging on Resident #11's wheelchair. Interview on 11/9/21 at approximately 1:30 p.m. with Staff I confirmed the above finding for Resident #11 on 11/9/21. Staff I stated that Resident #11's smoking materials should be locked in a lock box. Interview on 11/9/21 at approximately 1:30 p.m. with Resident #11 revealed that they only keep money in the lock box. Resident #11 denied keeping cigarettes or lighters in the lock box. Review on 11/9/21 of Resident # 11's smoking assessment dated [DATE] revealed .3. Where will lighter and cigarettes be stored? 1. Resident (in lock box/drawer) . Review on 11/10/21 of Resident #11's current smoking care plan with revision date of 9/13/21 revealed that Resident #11 was provided a lock a box to store their smoking materials. Interview on 11/10/21 at approximately 12:25 p.m. with Staff T (Assistant Director of Nursing) confirmed the above smoking care plan for Resident #11. Resident #63 Observation on 11/8/21 at approximately 11:24 a.m. in Resident #63's room revealed that Resident #63 was watching TV. Observation revealed that Resident #63 had an open pack of cigarettes and a lighter in their shirt pocket. Further observation revealed that Resident #63 had no lock box, the drawers and closets were unlocked. Interview on 11/8/21 at approximately 11:24 a.m. with Resident #63 revealed that they do not have a locked box or drawer in their room and they keep their cigarettes and lighter on their nightstand or in their pocket. Observation 11/9/21 at approximately 1:30 p.m. with Staff I revealed that Resident #63's cigarette and lighter were in Resident #63's shirt pocket. Further observation revealed that Resident #63 had no lock box. Observation revealed that Resident #63's drawers and closet were unlocked. Interview on 11/9/21 at approximately 1:30 p.m. with Staff I confirmed the observation on 11/9/21. Staff I stated that Resident #63 should have a lock box for their smoking materials. Review on 11/10/21 of Resident #63's smoking assessment dated [DATE] and 11/2/21 revealed .3. Where will lighter and cigarettes be stored? 1. Resident (in locked box/drawer) . Review on 11/10/21 of Resident #63's current smoking care plan with revision date 11/9/21 revealed that Resident #63's smoking supply and smoking materials should be kept in a lock box. Interview on 11/10/21 at approximately 12:25 p.m. with Staff T (Assistant Director of Nursing) confirmed the above smoking care plan for Resident #63.

Based on interview and record review, it was determined that the facility failed to ensure that a resident was free of significant medication error resulting in an actual harm that is not immediate where one resident became unresponsive requiring medical emergency intervention after administration of a wrong concentration of opioid infusion medication for 1 resident out of 3 residents reviewed for opioid infusion therapy. (Resident identifier is #1.) Findings include: Review on 8/12/21 of Resident #1 medical record revealed that Resident #1 was admitted on [DATE] at the facility's hospice house for continuation of hospice services related to end-stage [CONDITION(S)] ([CONDITION(S)]). Review on 8/12/21 of Resident #1's July 2021 EMAR (Electronic Medication Administration Record) revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 8/12/21 of Resident #1's nurses note dated 7/24/21 at 5:21 p.m. written by Staff D (Registered Nurse) revealed that Resident #1 was lying in bed, arousable, stupurous, able to sit up in bed and took scheduled oral medications in applesauce. Resident #1 had [MEDICATION(S)] CADD pump infusing 3 mg/hr and 3 mg bolus every 15 minutes as needed. Further review revealed that Resident #1's [MEDICATION(S)] CADD pump was change at 6:20 p.m. and Resident #1's friend visited but Resident #1 did not wake up for him/her. Review also revealed that Resident #1's 8:00 p.m. medications were held as Resident #1 was not arousable and at 10:00 p.m. Resident #1 remained unarousable. Review on 8/12/21 of Resident #1's nurses note dated 7/25/21 at 8:42 a.m. revealed the following: - On 7/24/21 at 11:00 p.m., Resident #1 was not responsive to touch or voice, minimal response with movement and irregular breathing with a respiration rate of 11 breaths/minute. Upon checking the CADD pump at shift change it was noted that the [MEDICATION(S)] concentration of the CADD cassette was 10 mg/ml instead of 1 mg/ml, which the CADD pump was calibrated for the [MEDICATION(S)] 1 mg/ml CADD cassette. -On 7/24/21 at 11:22 p.m., Resident #1's [MEDICATION(S)] concentration was change to reflect physician order. Resident #1's O2 (oxygen) saturation was 78% (percent) on 3 liters of oxygen and respiratory rate of 9. Supervisor was notified of the error by Staff D. -On 7/25/21 at 12:05 a.m., Resident #1's physician was called, no order to stop CADD pump. Physician was to call Resident #1's family to discuss option of [MEDICATION(S)] (Opiate reversal agent). -On 7/25/21 at 12:40 p.m. Resident #1's [MEDICATION(S)] CADD pump was stopped. Resident #1's pulse was 100, respiratory rate of 7, blood pressure of 96/80 and O2 saturation of 82% on 3 liters of oxygen. - On 7/25/21 at 1:00 p.m., Resident #1's physician arrived at the facility. Physician spoke to Resident #1's family to discuss option. - On 7/25/21 at 2:00 p.m., Resident #1 received [MEDICATION(S)] 0.8 mg subcutaneously. - On 7/25/21 at 2:05 p.m., Resident #1 had no response and had a respiratory rate of 10. Resident #1 received [MEDICATION(S)] 0.4 mg via nasal. -On 7/25/21 at 2:10 p.m., Resident #1 had minimal responsiveness and opening his/her eyes briefly. -On 7/25/21 at 2:14 p.m., Resident #1 received second dose of [MEDICATION(S)] 0.4 mg via nasal with minimal improvement on responsiveness and respiratory rate of 10 and irregular breathing. -On 7/25/21 at 2:19 p.m., Resident #1 received third dose of [MEDICATION(S)] 0.4 mg via nasal. Resident #1 became more responsive, agitated, combative, and trying to get out of bed. - On 7/25/21 at 2:50 p.m., Resident #1 received an oral dose of [MEDICATION(S)] (antipsychotic) 1 mg for severe agitation and Resident #1 spit most of it out. Further review also revealed that Resident #1's mother and durable power of attorney came in the facility after above mentioned event and spoke to physician. Resident #1's was transferred to a hospital per family's request. Resident #1 left the facility at 3:50 a.m. Review on 8/12/21 of Resident #1's physician note dated 7/25/21 revealed that that Resident #1 overdose about 27 mg of [MEDICATION(S)] per hours for almost 5 hours and that his/her clinical situation was the result of high dose of [MEDICATION(S)]. Interview on 8/12/21 at approximately 8:40 a.m. with Staff C (Registered Nurse) revealed that [MEDICATION(S)] CADD pumps and cassettes are checked by 2 nurses every shift and rate changes only. Review on 8/12/21 of Resident #1's infusion administration record for [MEDICATION(S)] revealed that the Medication/Concentration had 1 mg/ml crossed off and 10 mg/ml written above. Further review revealed that on 7/24/21 at 6:20 p.m. the [MEDICATION(S)] cassette was changed with Staff D's initial. No other nurse's initials documented. Interview on 8/12/21 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that Staff D failed to verify Resident #1's [MEDICATION(S)] concentration prior to changing it on the CADD pump.

Based on interview and record review, it was determined that the facility failed to ensure that licensed nurses have the specific competencies to care for resident related to opioid infusion therapy via the CADD (Continuous Ambulatory Delivery Device) pump on hospice residents for 8 out of 8 licensed nurses reviewed. (Staff identifiers are C, D, E, F,G,H,I and J.) (Resident identifier is #1.) Findings include: Review on 8/12/21 of Resident #1's physician note dated 7/25/21 revealed that that Resident #1 overdose about 27 mg of [MEDICATION(S)] per hours for almost 5 hours and that his/her clinical situation was the result of high dose of [MEDICATION(S)]. Interview on 8/12/21 at approximately 8:40 a.m. with Staff C (Registered Nurse (RN)) revealed that on 7/23/21 evening shift Resident #1 overdose on [MEDICATION(S)] and received 4 doses of [MEDICATION(S)]. Staff C stated that on 7/23/21 at approximately 6:00 p.m. Staff D changed the [MEDICATION(S)] cassette on the CADD pump and had placed a [MEDICATION(S)] 10mg/ml (milligram/milliliter) cassette instead of the [MEDICATION(S)] 1mg/ml cassette. Staff C also stated that the CADD pump was calibrated for the [MEDICATION(S)] 1mg/ml cassette. Interview on 8/12/21 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that licensed nurse training and competency were completed online. Staff A was unable to provide any documentation of competency for Staff C, Staff D (RN), Staff E (RN), Staff F (RN), Staff G (RN), Staff H (RN), Staff I (Licensed Practical Nurse (LPN)) and Staff J (LPN) on opioid infusion therapy and use of CADD pumps prior and after event mention above Cross reference F760: Residents are Free of Significant Med Errors.

Based on medical record review, interview and observation, it was determined that the facility failed to ensure an interdisciplinary team assessed a resident to determine if it was clinically appropriate to self-administer medications for 1 resident in the final survey sample of 39 residents. (Resident identifier is #152.) Findings include: Observation on 3/10/20 at 9:31 a.m. revealed that Resident #152 had 3 different respiratory medications at their bed side. None of the medications found at bed side were over the counter medications. The medications found were as follows: *[MEDICATION NAME] HFA Inhalation 2 puffs inhale orally every 4 hours as needed for Dyspnea; wheezing related to [MEDICAL CONDITION] *Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (microgram/inhale) 1 puff inhale orally one time a day for [MEDICAL CONDITIONS] *Fluticase Propionate diskus 250/50 ([MEDICATION NAME] Diskus Aerosol power Breath Activated 250/50 MCG/DOSE-1 puff inhale orally two times a day related to [MEDICAL CONDITION] Rinse mouth after use.) Interview on 3/10/20 at 9:40 a.m. with Staff T (Unit Manager) revealed the physician will write an order to self administer or nursing will write a note stating resident can self administer, but the facility does not do formal self-administration assessments. Review on 3/12/20 of the policy titled: Self-Administration of Medication, with a revision date of 04/2007, revealed Once the IDT (Interdisciplinary Team) has determined the Resident capable of medication self administration, and with a corresponding order from a physician, Residents may keep over the counter medications at their bedside. These over the counter medications do not have to be kept in a locked box. These Residents will receive instructions to inform Nursing Staff as to when medications have been self Administered. Interview on 3/10/20 at 1:00 p.m. with Staff B (Director of Nursing) revealed there was no documentation of an assessment of Resident #152's ability to self-administer medications.

Based on interview, record review, and policy review, it was determined that the facility failed to meet professional standards regarding following physician orders [REDACTED]. (Resident identifier is #115.) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 3/12/19 of Resident #115's active physician orders [REDACTED].#115 had physician orders [REDACTED]. Review on 3/12/20 of Resident #115's January 2020 Electronic Medication Administration Record [REDACTED]. Further review of Resident #115 January 2020 EMAR revealed that Resident #115 did not receive [MEDICATION NAME] PRN per physician order [REDACTED]. Review on 3/12/20 of Resident #115's February 2020 EMAR revealed that Resident #115 had the following blood sugar level results: 194 on 2/7/20, 227 on 2/8/20, 168 on 2/15/20, 164 on 2/20/20, 213 on 2/22/20, 176 on 2/24/20, and 188 on 2/25/20. Further review of Resident #115's February 2020 EMAR revealed that Resident #115 did not receive [MEDICATION NAME] PRN per physician order [REDACTED]. Review on 3/12/20 of Resident #115's March 2020 EMAR revealed that Resident #115 had a blood sugar level results of 189 on 3/2/20. Further review of Resident #115 March 2020 EMAR revealed that Resident #115's did not receive [MEDICATION NAME] PRN per physician order [REDACTED].>Interview on 3/12/20 at 11:48 a.m. with Staff P (Registered Nurse Day Supervisor) confirmed the above findings. Staff P stated that Resident #115 should have received the [MEDICATION NAME] PRN on above dates.

Based on observation, interview, and medical record review, it was determined that the facility failed to provide necessary treatment to maintain good foot health for 1 resident out of a final survey sample of 39 residents. (Resident identifier is #28.) Findings include: Interview on 3/9/20 at 11:00 a.m. with Resident #28 revealed a complaint of not having his/her toenails cut in one year and that his/her hammer toe and toenails were painful. The resident stated he/she had not been seen by the podiatrist in over one year. Review on 3/9/20 of Resident #28's care plan dated 3/23/19 revealed Resident #28 was admitted to the facility on [DATE]. Continued review revealed Resident #28 required extensive assistance with personal hygiene and had [DIAGNOSES REDACTED]. There were no documented problem, goals or interventions regarding resident #28's feet and/or toenails. Observation on 3/9/20 at 1:18 p.m. with Staff I (Registered Nurse Charge Nurse) of Resident #28's bilateral feet revealed toenails were long, with some curving down; and they were yellow and thick. During the observation, Resident #28 complained his/her toenails were long and painful and that the podiatrist had been in the prior week, but had walked right by me. The resident complained he/she had not been seen by a podiatrist in one year. Review on 3/10/20 of Resident #28's physician's orders [REDACTED]. Further review of Resident #28's medical record revealed there was no documentation that Resident #28 had been seen by a podiatrist since before the resident was admitted on [DATE]. Interview on 3/11/20 at 2:00 p.m. with Staff M (RN) reported Resident #28 had not been seen by a podiatrist since 2/28/19. Staff M further stated in general the LNAs (licensed nursing assistants) should be providing toenail care with weekly showers unless contraindicated by a diagnosis. Staff M stated the facility did not document nail care anywhere in the medical record, including in Resident #28's medical record. Staff M stated that the Podiatry group comes to the facility monthly to provided services to the residents, but that Resident #28 had not been seen. Staff M stated that Resident #28's toenails had been cared for on his/her shower day. Review on 3/11/20 of a listing of residents the podiatry provider treated at the facility was reviewed for the following dates (9/6/19; 10/17/19; 11/14/19; 12/23/19; 1/16/20; 3/3/20) and did not list Resident #28 as being treated or as having refused treatment. Review on 3/13/20 of Resident #28's medical record revealed a document titled Request for Service for podiatry that had been signed by the Resident #28's responsible party on 2/5/20. Interview on 3/13/20 at 10:03 a.m. with Staff N (Licensed Practical Nurse) revealed Resident #28 had been asking to see a podiatrist for about one month. Staff N stated he/she had trimmed Resident #28's right toenails on 3/12/20. Staff N stated the left foot had not yet been done. Review on 3/13/20 of the facility's policy and procedure revised 4/07 read, in part, POLICY: .Licensed Nursing Staff will provided routine screening of Resident's feet. Routine preventative foot care will be provided or supervised by our Nursing staff . PURPOSE: .To promote comfort PROCEDURE: .3. Check and cut toenails monthly and prn (meaning as needed) . 5. Address problem on Resident Care Plan and in nurses notes until problem is resolved

Based on observation, interview, record review, and policy review, it was determined that the facility failed to ensure that resident environment remains as free of accidents hazards as possible related to smoking for 3 residents out of 4 residents in the final sample that smoked. (Resident identifiers are #19, #96, and #144.) Findings include: Review on 3/12/19 of facility's policy titled Smoking, Revised date 01/07/2020, revealed that .The facility will properly assess those residents who choose to smoke with a consistent assessment tool upon admission or start of smoking, quarterly, and as needed .If the resident refuses to allow the lock box to be randomly checked by the social worker and/or licensed nurse, their materials, will be relinquished and stored in the nurse's station .All assessment decisions will be updated in the resident's individualized plan of care . Resident #19 Review on 3/12/20 of Resident #19's smoking care plan dated 12/10/19 revealed that the social worker will complete a smoking assessment upon admission, quarterly and PRN (as needed) to ensure safety. Further review of Resident #19's smoking care plan dated 12/10/19 revealed that Resident was able to smoke independently without supervision and Resident #19 was able to safely use and maintain smoking materials in a lock box in Resident #19's room. Resident may keep smoking materials in a lock box in their room and is agreeable for random checks by social worker and licensed nurse staff to ensure the box is locked ensuring no other residents have access to his/her smoking materials. Review on 3/12/20 of Resident #19's smoking assessment dated [DATE] revealed that Resident #19 was safe to smoke without supervision and does not require adaptive equipment. Review on 3/12/20 of Resident #19's smoking assessment dated [DATE] revealed that Resident #19 requires supervision as Resident #19 does endanger self and others related to smoking. Resident #19 requires supervision as Resident #19 does burn furniture, clothing, skin, self or others. Resident #19 did not agree to allow the social worker and/or licensed nurse to randomly check cigarette materials for proper securement in a lock box and so Resident #19's smoking materials should be kept in the nurses station. Further review of Resident #19's smoking assessment dated [DATE] revealed that Resident #19's smoking materials were to be stored in a lock box/drawer in Resident #19's room. Review on 3/12/20 of Resident #19's paper and electronic medical records revealed that Resident #19 had no smoking assessments for September 2019 and December 2019 per Resident smoking care plan and facility's smoking policy. Interview on 3/12/19 at 11:48 a.m. with Staff P (Registered Nurse Day Supervisor) confirmed above findings on Resident #19's smoking care plan and assessments. Staff P stated that the smoking care plan dated 12/10/19 did not reflect Resident #19's smoking assessment dated [DATE]. Staff P also stated that as Resident #19's smoking assessment dated [DATE] showed that Resident #19 did not agree to allow Social Worker and/or Licensed Nurse to randomly check to ensure that lock box is secured, Resident #19 should not be able to keep their smoking materials in their room per the smoking assessment dated [DATE] and the facility smoking policy. Staff P stated that Resident #19 had smoking materials in their room. Interview on 3/13/20 at 2:15 p.m. with Staff B (Director of Nursing) confirmed the above findings related to Resident #19's smoking assessment. Staff B stated that Resident #19 should have had a smoking assessment done in September 2019 and December 2019. Staff B also stated the MDS (Minimum Data Set) coordinator identified the smoking assessment not being done for the past 2 quarters on 3/9/20 and all smokers in the facility had a smoking assessment done on 3/9/20. No observation on 3/9-13/20 of Resident #19's lock box in their room as Resident #19 declined observations and interviews. Review of the facility's policy titled Smoking, revised 1/7/20 read, in part, Policy: . The facility will properly assess those residents who choose to smoke with a consistent assessment tool upon admission or start of smoking, quarterly, and as needed . Procedure: . Social Worker 3. Upon admission, quarterly, and as needed the resident will have a smoking assessment to include and determine: Resident's capabilities and deficits to determine whether or not supervision is required Identification of storage and access to smoking materials Storage of Smoking Materials: .b. If the assessment reveals the resident is not safe to keep their own smoking materials, smoking materials will be stored in the nurses' station All assessment decisions will be updated in the resident's individualized plan of care 8. All residents and staff will be responsible for following the identified plan of care and appropriate resident specific interventions. Resident #144 Observation on 3/9/20 at 9:41 a.m. revealed Resident #144 smoking in the smoking room on Unit 4. Resident #144 stated he/she was allowed to keep their lighter and cigarettes on him/her. Interview at this time revealed Resident #144 was observed walking back down the hall way toward his/her room with a lighter and box of cigarettes in his/her front shirt pocket. Observation on 3/10/20 at 2:01 p.m. revealed Resident #144 coming off the elevator onto Unit 4 with his/her lighter and box of cigarettes in his/her shirt pocket. Review on 3/11/20 of Resident #144's hand written 1/31/2020 Smoking Assessment Tool revealed question #6b. Resident required staff to light cigarette was checked as Yes with the written comment Staff should secure lighter and/or matches. Continued review under Question #11 revealed The resident demonstrates safe use and storage of all smoking material and understands the importance of safeguarding the lock box key to ensure other residents are not able to access their smoking materials was checked No, must keep smoking material at the nurses station. Additionally, hand written on this assessment was . Degree of cognitive impairment with limited insight. Hx (history) includes at least one episode of smoking in bed while hospitalized . This assessment was signed as completed by Staff J (Social Worker). Review on 3/11/20 of Resident #144's electronic Smoking Assessment Tool dated 1/31/20 revealed at question #11 The resident demonstrates safe use and storage of all smoking material and understands the importance of safeguarding the lock box key to ensure other residents are not able to access their smoking materials was answered No, must keep smoking materials at the nurses station. This assessment was signed by Staff O (Licensed Practical Nurse), MDS (Minimum Data Set)/Restorative). Review on 3/12/20 of Resident #144's care plan revised on 2/18/20 revealed under Goal: (Name omitted) will smoke in a manner that does not put themselves or others at risk for accident or injury. Continued review revealed under Interventions: Smoking material to be kept at nurses station. Interview on 3/12/20 at 11:48 a.m. with Staff P (Registered Nurse (RN)) confirmed that based on the 1/31/20 smoking assessments Resident #144's cigarettes and lighter should be secured at the nurses' station. Staff P did not see that any other smoking assessments had been completed in Resident #144's medical record. Interview on 3/12/20 at 11:54 a.m. with Staff N (Licensed Practical Nurse) confirmed that Resident #144 is only assessed to smoke in the smoking room on the unit and the cigarettes/lighter are to be kept at the nurses' station for safety. When told observation had been made of Resident #144 carrying both the box of cigarettes and lighter, Staff N stated he/she had discussed with Resident #144 that they must be kept at the nurses' station. Resident #96 Review on 3/9/20 of Resident #96's medical record revealed a Smoking Assessment Tool dated 6/10/19 completed by Staff J (Social Worker) on 6/10/19. Continued review of Resident #96's medical record revealed the next Smoking Assessment tool was dated as completed by Staff Q (MDS/Restorative RN) on 3/9/20, eight months after 6/10/19. Both assessments reviewed revealed that Resident #96 required supervision and assistance with smoking. Review on 3/10/20 of Resident #96's care plan initiated 7/23/19, revised on 7/31/19, 10/22/19 and 1/21/20; revealed under Focus (name omitted) has been properly assessed and is able to smoke with staff supervision . Continued review under interventions revealed Social worker will complete a smoking assessment upon admission, quarterly, and PRN to ensure resident safety. Interview on 3/11/20 at 10:20 a.m. with Staff K (Admissions) revealed that Staff J (Social Worker) was the Social Worker responsible for Resident #96's unit, but was out of the country and unavailable to be interviewed. Interview on 3/12/20 at 11:48 a.m. with Staff P (RN) confirmed that no additional smoking assessments between 6/10/19 and 3/9/20 were in Resident #96's medical record. Staff P confirmed that smoking assessments should be completed at least every three months.

Based on interview, medical record review, facility policy and procedure review, it was determined that the facility failed to re-assess a resident for the risks of entrapment and possible risks and benefits of bed rails for 1 out of 1 resident reviewed for side rails in a final survey sample of 39 residents. (Resident identifier is #114.) Findings include: Review on 3/11/20 of Resident #114's nursing notes revealed the following nursing note: On 2/21/20 at 10:40 p.m., LNA (Licensed Nursing Assistant) reported area of concern to right distal upper arm. Area noted to have an abrasion with small areas open and bleeding, measuring 5/5 cm (centimeter). LNA reported that when put to bed, the resident's arm was away safely from edge of bed and side rail. During rounds, arm was wedged in side rail/bed edge . Review on 3/13/20 of Resident #114's quarterly review revealed that the 1/2 side rail was checked off as enhancing equipment. Interview on 3/13/20 at approximately 10:45 a.m. with Staff B (Director of Nursing) revealed that there was no re-assessment for need/safety of the side rails. Staff B stated I would have expected to see that the side rails were re-evaluated after the incident as to why it happened, how it happened and if the side rails are still needed. Review on 3/13/20 of the facility policy and procedure titled, Side Rails, revision date 4/2017 revealed: It is the policy of (Facility name omitted) to individualize the sure of side rails by ongoing assessments for the Resident's physical, functional and cognitive abilities in regard to [DIAGNOSES REDACTED]. .9. change in physical, cognitive behavioral, and side rail status changes; IDT (interdisciplinary team) to discuss appropriateness and any changes necessary to side rail use or positioning at Resident Care Conference . Review on 3/13/20 of Resident #114's care plan revealed the following: Focus: (pronoun omitted) has partial rails on bed to ensure opportunity to grasp rails for bed, mobility, positioning, transfers and personal care. This does not impede exit and thus is not a restraint, revision date 1/28/20. .Interventions .Review side rails quarterly at care plans and PRN (as needed) for potential for further reduction and appropriateness of present status.

Based on medical record review, observation and interview, it was determined that the facility failed to secure all medications in a locked storage area, failed to have a secondary lock on secure controlled medications, and failed to properly document medication administration to ensure missing does can be readily detected for 4 residents out of a final survey sample of 39 residents. (Resident identifiers are #33, #40, #161, and #37.) Findings include: Review on 3/13/20 at 7:39 a.m. of Resident #151's medical record revealed that the MAR (Medication Administration Record) had an order written [REDACTED]. Review of the MAR and corresponding narcotic book for February 2020 and March 2020 revealed it was noted that the MAR and narcotic counts did not match on the following occations:. On 2/4/20, the medication was signed out from the narcotic book at 9:00 p.m, but not documented on the MAR. On, 2/14/20 at 6:00 a.m., the medication was signed out of the narcotic book, but not documented on the MAR. On 2/29/20 at 12:25 p.m., the medication was signed out of the narcotic book, but not documented on the MAR. On 3/2/20 at 9:00 a.m., the medication was signed out of the narcotic book, but not documented on the MAR. Interview on 3/13/20 with Staff B (Director of Nurses) revealed the narcotic book and the MAR should be documented at the same time. There should not be any discrepancies . Observation on 3/12/20 when entering the nurses station on Unit 5 revealed that the medication storage room door was left open with no facility staff around. Over the next 15 minutes three different staff members, Staff U (Licensed Nurse Assistant (LNA)) Staff V (LNA), Staff W (LNA), entered the nurses station with the medication room door wide open. The medication refrigerator which holds the narcotic medication was found to be unlocked. These medications were as follows: *[MEDICATION NAME] oral 2 mg per 2 ml (milliliters) 30 ml bottle and dropper x 3 (Resident #33, Resident #40 and Resident #161,) *Dronabinolol 2.5 mg 24 tabs. (Resident #161.) *The emergency kit holding ABHR ([MEDICATION NAME] & [MEDICATION NAME]) suppository x 4, [MEDICATION NAME] 100 mg supp (suppository) x 4, [MEDICATION NAME] inj (inject) 2 mg/ml x 8 At end of this observation, Staff X (Licensed Practical Nurses) came to the nurses station area, because one of the LNAs that was at the nurses station notified Staff X that the room was left unlocked and accessible.

Based on observation, interview, record review, it was determined that the facility failed to ensure that a resident with complicated feeding problems was not assisted by feeding assistants for 1 of 10 residents observed during a dining observation. (Resident identifier is #110.) Findings include: Observation on [DATE] at approximately 7:56 a.m. revealed Staff G (Unit Aide) was feeding Resident #110 breakfast. Review on [DATE] of the facility's list of residents who require assistance for food/liquid intake, dated [DATE] revealed that Resident #110 was listed as a resident with swallowing concerns and was not eligible to receive assistance from paid feeding assistants/non-licensed staff. Review on [DATE] at approximately 1:45 p.m. of The NH Board of Nursing Online Licensing revealed that Staff G's LNA (Licensed Nursing Assistant) license expired [DATE]. Interview on [DATE] at approximately 1:30 p.m. with Staff B (Director of Nurses) revealed that Staff G was an LNA previously at the facility, about 18 months ago (pronoun omitted) changed positions from LNA to Unit Aide, because of the heavy lifting. There was never a break in service. Staff B confirmed that Staff G had not taken the Paid Feeding Assistance Program. Staff B did was not aware that Staff G's license had expired and was no longer licensed personnel. Interview on [DATE] at approximately 12:45 p.m. with Staff B confirmed that Resident #110 was on the list of residents who should not be assisted by paid feeding assistants due to swallowing issues and should not be assisted by paid feeding assistants.