Every finding on record at Rocket City Rehabilitation and Healthcare Center

Based on observations, interviews, resident record review, and review of a facility policy titled Comprehensive Care Plans, the facility failed to develop and implement a care plan with person-centered safety interventions addressing Resident Identifier (RI) #27's noncompliance with the facility's non-smoking policy, including smoking and vaping inside the facility unsupervised in his/her room from 11/15/2022 through 02/13/2023. Facility staff did not know what to do or how to respond on occasions when RI #27 was found using a vape or smoking in his/her room. This failure affected RI #27, one of 23 sampled residents for whom care plans were reviewed. In addition, this failure placed all 109 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/24/2023 at 5:05 PM, the facility's Administrator, Employee Identifier (EI) #1 and the [NAME] President (VP) of Clinical Operations, EI #36, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy findings in the area of Comprehensive Resident Centered Care Plan, F656-Develop/Implement Comprehensive Care Plans. Findings include: A review of the policy titled Comprehensive Care Plans, reviewed 04/14/2021, revealed: . POLICY STATEMENT A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. .GUIDELINE: . 4. Each resident's Comprehensive Care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems . RI #27 was admitted to the facility on [DATE] with diagnoses to include Depression, Bipolar Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, Seizures, and Hemiplegia (paralysis of one side of the body) affecting Dominant Side. During the survey, document review and interviews with staff revealed RI #27 had multiple documented episodes of non-compliance with the facility's non-smoking policy, including vaping and smoking in his/her room and hiding vaping and smoking materials from facility staff. This noncompliance was documented to have occurred from 11/15/2022 through 02/13/2023, despite repeated education to RI #27 on the facility's non-smoking policy. Cross reference F689 and F867. Review of RI #27's comprehensive care plans revealed the first care plan related to RI #27's noncompliance was created on 01/26/2023 by EI #15, the MDS/Care Plan Coordinator. This care plan documented: .Problem Start Date: 01/26/2023 Category: Behavioral Resident demonstrates non-compliance with physician orders and/or plan of care as evidenced by: continuing to vape in (his/her) room despite being asked not to . On 01/26/2023 at 3:57 PM, EI #15, the MDS/Care Plan Coordinator, was interviewed. When asked at what point RI #27 first demonstrated noncompliant behavior, EI #15 said since 11/15/2023, according to the progress notes. When asked what had been done to address the concern of noncompliance with the facility's non-smoking policy, EI #15 said they offered a nicotine patch, but RI #27 continued to vape, so the patch was discontinued. EI #15 confirmed RI #27's care plan addressing non-compliance with the facility's non-smoking policy was not initiated until 01/26/2023. When asked why a care plan had not been developed prior, EI #15 said she thought progress notes were effective enough. When asked when a care plan should have been initiated, EI #15 said on 11/15/2023, when RI #27's noncompliance was first noted. EI #15 said the risk of not developing a care plan would be harm to the resident. EI #15 further stated the facility policy for person-centered care plans had not been followed. On 01/26/2023 at 4:46 PM an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked, what was the smoking/vaping policy for the facility. EI #2 said the facility was non-smoking, meaning no smoking or vapes were allowed. EI #2 was asked when she first became aware of RI #27 vaping in his/her room. EI #2 replied, she could not remember the exact date, but indicated they notified the doctor and got RI #27 a nicotine patch. However, EI #2 said RI #27 continued to use a vape, so they had to discontinue the nicotine patch. When asked what interventions were put in place to address RI #27's noncompliance after the nicotine patch was discontinued, EI #2 said she did not think they did anything different. EI #2 was asked when a care plan should have been put in place. EI #2 said immediately after finding the vape. When asked why that was not done, EI #2 said EI #15, the MDS/Care Plan Coordinator, did not do it. EI #2 further stated the facility policy for person-centered care plans had not been followed. On 02/18/2023 at 11:00 AM, the surveyor conducted another interview with EI #2, the DON. When asked what interventions were currently in place to address RI #27's noncompliance with the facility's non-smoking policy, EI #2 said they were offering snacks of choice, a smoke detector in RI #27's room (initiated 02/13/2023), and an in-room sitter for RI #27 (initiated on 02/15/2023). EI #2 said prior interventions had not prevented RI #27 from continuing to be noncompliant, but indicated they had had no further instances since 02/13/2023. An interview was conducted with EI #6, the Medical Director, on 02/19/2023 at 2:30 PM. EI #6 indicated he participated in a discussion in December 2022 regarding interventions that may help address RI #27's noncompliance with the facility's non-smoking policy. EI #6 said he did not recall making any suggestions, but they were trying to come up with options. EI #6 said the nicotine patch was discontinued due to RI #27 continuing to vape, and indicated medications for smoking cessation were not an option for RI #27. When asked what the facility could have done about RI #27 continuing to violate the facility's non-smoking policy, EI #6 said there were really only two options: one being to change the policy, which was not a good idea, or to find alternate placement that would be a better fit. EI #6 indicated that after multiple violations of the facility's non-smoking policy, they should have discussed transferring RI #27 out of the facility for his/her own well-being, as well as for the safety of others in the facility. When asked what approaches could have been attempted to prevent the continued noncompliance, EI #6 said they could have initiated the one on one (in-room sitter) sooner. An interview was conducted with EI #1, the Administrator, on 02/17/2022 at 1:39 PM. EI #1 stated the facility had a meeting in December 2022 to discuss the concern of RI #27's noncompliance with the facility's non-smoking policy. However, when asked if they had discussed a need for a care plan addressing these continued behaviors, EI #1 said she did not recall discussing a care plan. EI #1 further stated she did not remember anyone saying RI #27 would need a care plan in place for his/her behavior of noncompliance related to smoking and vaping. EI #1 acknowledged the facility had a breakdown in the care plan process, and said the facility was not aware there no care plan addressing RI #27's noncompliance until it was brought to the facility's attention during the survey. This deficiency was cited as a result of complaint/report numbers AL00043096 and AL00043372. ****************** The facility submitted an acceptable Removal Plan on 02/26/2023 for F656 that outlined the following: 1. Comprehensive Care Plan education was provided by SCC (Signature Care Consultant) on 01/25/2023 to DON, the MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. Care Planning residents with behaviors education was completed on 01/25/2023 by the Special Projects MDS RN and on 02/25/2023 by the VPCO (Vice President of Clinical Operations) to the DON, MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. The facility developed a care plan on 01/26/2023 for behaviors non-compliant with physician orders and facility policies as evidenced by vaping in her room. The facility updated the plan of care continually with appropriate interventions to address noncompliance with the facility's nonsmoking policy with person-centered safety interventions for RI #27 for noncompliance with the facility's nonsmoking policy. The following are the revisions and interventions to R#27's plan of care: -Vape materials were confiscated, and a nicotine patch was ordered on 11/24/2022. - The Administrator discussed non-compliant behavior in violation of facility policy with R#27 on 02/22/2023 and is documented in the progress note. - A room search was completed on 02/18/2023 and documented in the progress notes with R#27's consent and she was present. - Social Services Director (SSD) educated R#27 on the non-smoking policy 02/22/2023, RI#27 signed the Smoke Free/Non-Smoking policy and was given a copy and a copy was uploaded into the Matrix medical record. - Laundry staff continue to monitor resident clothing and personal items for any burn holes. All Laundry staff was educated by the housekeeping supervisor on 02/21/2023. All housekeeping staff and the HCSG (Healthcare Services Group) housekeeping supervisor were educated by the HCSG (Healthcare Services group) District manager for Housekeeping and Laundry on 02/25/2023. The education included how to audit resident personal laundry for burn holes, soot, or tears and report their findings to the laundry supervisor. - Education to a friend on 12/7/2022 by a staff nurse on not bringing vape or smoke materials into the facility. - Psych referral for non-compliant behavior and evaluation on 1/11/2023, and 12/28/2022. - Collaboration with DHR and Gateway for discharge planning on 12/30/2022, 01/17/2023, 2/6/2023, 2/7/2023, 2/13/2023, 2/15/2023, and 2/16/2023. - Provide snacks as a diversion to smoking on 01/27/2023. - Education to family (Father) by SSD on 02/13/2023 on the non-smoking facility policy and not bringing vape or smoke materials into the facility. - Maintenance placed a smoke detector in the room on 02/13/2023. - 1:1 supervision implemented 02/15/2023 and continues. - 30-day Discharge planning initiated 02/15/2023. 2. All residents residing in the facility were at a safety risk and fire hazard due to a lack of appropriate safety measures developed for residents with noncompliance on the plan of care. All staff in all departments were interviewed by the Staff Development Coordinator (SDC) on 02/17/2023, 02/18/2023, and 02/19/2023 to identify any other residents with behaviors that are non-compliant with the Facility Smoking/Non-Smoking Policy facility. Any resident identified with non-compliant behavior to the Facility Smoking/Non-Smoking policy has a behavior monitoring plan and care planned and implemented. - All residents were interviewed by a member of the interdisciplinary team (IDT) the interdisciplinary team consisted of the SSD, DON, Admissions Liaison, Admissions Coordinator, Life Enrichment Director, SDC, ADON, Unit Manager, Medical Records, and MDS coordinator. These were completed on 02/21/2023 on smoking choices. - Five residents were identified as a smoker or requesting to smoke met with the SSD and signed the Non-Smoking policy. This was completed on 02/21/2023. - Any resident identified as a smoker or requesting to smoke have behavior monitoring implemented observing for any non-compliant behaviors related to not smoking/vaping in the facility and the plan of care revised with approaches and interventions to monitor and manage those residents' behaviors. This was completed on 02/21/2023. - The Interdisciplinary team consisting of the DON, SSD, Administrator, Life Enrichment Director, Signature Care Consultant (SCC), and [NAME] President of Clinical Operations (VPCO) completed an Interdisciplinary Psychotropic review/Behavior meeting on 02/17/2023 and 02/18/2023 to identify and discuss residents displaying challenging behaviors, as well as those residents receiving psychoactive medications. Residents with behavior issues have Target Behaviors identified on the EMAR for documentation. Behavior management care plans were reviewed to evaluate goals and the effectiveness of the interventions and revised as necessary. 3. Comprehensive Care Plan education was provided by SCC (Signature Care Consultant) on 01/25/2023 to DON, the MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. This education focused on care plans are ongoing and revised as information about the resident and the resident's condition or behavior change. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. b. Changing goals. c. When the desired outcome is not met. d. When the resident has been readmitted to the facility from a hospital stay; and e. At least quarterly - Care Planning residents with behaviors was completed on 01/25/2023 by the Special Projects MDS RN and on 02/25/2023 by the VPCO (Vice President of Clinical Operations) to the DON, MDS coordinator & each department manager responsible for MDS assessments/evaluations upon admission, quarterly, annually & with significant change. This education focused on care plans are ongoing and revised as information about the resident and the resident's condition or behavior change. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. b. Changing goals. c. When the desired outcome is not met. d. When the resident has been readmitted to the facility from a hospital stay; and e. At least quarterly The Governing Body consisting of the Chief Nursing Officer (CNO), Senior [NAME] President of Operations (SVPO), Senior [NAME] President (SVPC), [NAME] President Operations (VPO), and [NAME] President of Clinical Operations (VPCO) reviewed and granted the approval of the Comprehensive Care Plans policy on 01/25/2023 created on 04/06/2015, revised last on 07/19/2018, and reviewed 04/14/2021 by the Senior Clinical Leadership team consisting of the Chief Nursing Officer (CNO), Senior [NAME] President of Clinical Operations (SVPCO), [NAME] President of Regulatory (VPR), and the [NAME] President of Operations (VPO). - The Comprehensive care Plan policy was in-serviced at the Signature Whitesburg Gardens on 01/25/2023 by the Signature Care Consultant (SCC) to the to DON, the MDS coordinator & each department manager responsible for MDS assessments/evaluations. The VPCO trained the Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) on 02/20/2023 on the Comprehensive Care Plan policy. The VPCO educated the Comprehensive Care Plan policy to the following disciplines on 02/25/2023: Staff Development Coordinator (SDC), ADON, DON, Department Managers for Housekeeping, Maintenance, Dietary, Admissions, Social Services, Business Office, Life Enrichment and/ or Administrator. - The VPCO reviewed the Comprehensive Care Plan policy and prepared and reviewed the training for staff on Comprehensive Care Plans policy on 02/24/2023. - In-servicing will be completed on 02/26/2023 with all LPNs, RNs, MACs, and C.N.A.s, therapy, and all department managers by the SDC, VPCO, and/or department manager. This education focused on care plans are ongoing and revised as information about the resident and the resident's condition or behavior change. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition. b. Changing goals. c. When the desired outcome is not met. d. When the resident has been readmitted to the facility from a hospital stay; and e. At least quarterly - The Director of Nursing (DON) provides oversight five days a week to the nurse/Interdisciplinary Team to ensure care plans are reviewed and updated with changes. - The DON was educated on of DON responsibilities in providing oversight to the nurse/Interdisciplinary Team (IDT) to ensure care plans are reviewed and updated with changes and re-educated on 02/24/2023 by the VPCO. ****************** On 02/26/2023 at 11:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/26/2023 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on interviews, record review, review of the facility's RESIDENT HANDBOOK & (and) ADMISSION DOCUMENTS, review of an article published by the United States Food and Drug Administration titled E-Cigarettes, Vapes, and Other Electronic Nicotine Delivery Systems (ENDS), and review of two reports to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System, the facility failed to develop, implement, and revise effective person-centered safety interventions for Resident Identifier (RI) #27, a resident found to have multiple documented episodes of noncompliance with the facility's non-smoking policy dating back to 11/15/2022, including smoking inside the facility unsupervised and falling asleep with ENDS, also known as vapes, in his/her hand. On 02/06/2023, RI #27 was observed lighting a cigarette in the presence of Employee Identifier (EI) #22, a Certified Nursing Assistant (CNA), who then left the room and the resident unattended to notify EI #23, the Charge Nurse. When the Charge Nurse arrived to RI #27's room, she found a lighter, vape and a pack of cigarettes in RI #27's neck pillow. EI #23 also observed around three to four burned cigarettes in a cup on a table beside RI #27's bed. Seven days later, on 02/13/2023, while providing care, another CNA, EI #24, found a previously lit cigarette in RI #27's bed. EI #24 also found a cup on RI #27's over-the-bed table containing ashes and approximately three to five cigarette butts RI #27's behavioral care plan was not created until 01/26/2023, and did not address smoking cigarettes or provide guidance to staff on how to respond if RI #27 was found smoking or vaping. This deficient practice placed all 109 residents residing in the facility in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/24/2023 at 5:05 PM, the facility's Administrator, Employee Identifier (EI) #1 and the [NAME] President (VP) of Clinical Operations, EI #36, were provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F689-Free of Accident Hazards/Supervision/Devices. The immediate jeopardy began on 11/15/2022 and continued until 02/26/2023. Findings include: Cross Reference F656 and F867. On 01/18/2023, the State Survey Agency received an anonymous complaint via the Alabama Department of Public Health Online Incident Reporting System. This report indicated the facility was non-smoking, but RI #27 had fallen asleep while vaping and had 30 plus vapes and cigarettes confiscated. The complainant indicated these thing had been reported to the Administrator, EI #1, and the Director of Nursing (DON), EI #2, but nothing had been done. On 02/15/2023, the State Survey Agency received a second anonymous complaint via the Alabama Department of Public Health Online Incident Reporting System. This report indicated RI #27 was smoking in his/her room. The report further indicated RI #27 had cigarettes and a lighter, which was recently found in his/her pillow case and taken away. The complainant alleged these concerns were reported to EI #1, the Administrator, and EI #2, the DON, but RI #27 continued to smoke in his/her room. Review of an undated article published by the United States Food and Drug Administration (FDA) titled E-Cigarettes, Vapes, and Other Electronic Nicotine Delivery Systems (ENDS), revealed the following: .E-cigarette Problems and Potential Violations There are no safe tobacco products, including ENDS. In addition to exposing people to risks of tobacco-related disease and death, FDA has received reports from the public about safety problems associated with vaping products including: Overheating, fires, and explosions Lung injuries Seizures and other neurological symptoms . These problems can seriously hurt the person using the ENDS product and others around them. The facility's RESIDENT HANDBOOK & ADMISSION DOCUMENTS, revised 08/01/2021, documented the following: . Certain Items Are Not Allowed In Your Room, Ever. Any type of smoking or vaping materials or items, including lighters. Smoking Our Facility is (a) smoke-free facility . RI #27 was admitted to the facility on [DATE] with diagnoses to include Depression, Bipolar Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, Seizures, and Hemiplegia (paralysis of one side of the body) affecting Dominant Side. RI #27's most recent quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/22/2022, revealed RI #27 scored a 14 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #17, a Licensed Practical Nurse (LPN) providing care for RI #27 on the 6 AM - 6 PM shift: . 11/15/2022 8:40 (8:40 AM) . While returning to resident's room to update (him/her) on (his/her) labs staff discovered (him/her) with a vape in (his/her) hand. (He/She) quickly attempted to tuck it into the folds of (his/her) arms but handed it over, without any issues, when staff requested the vape. Staff notified DON of issue at 8:39 AM. Currently awaiting any instruction for further action . 11/15/2022 13:33 (1:33 PM) .Upon entering room staff noticed an orange object in resident's left hand. When asked to show staff (his/her) hands resident attempted to hide the object underneath (him/her). (He/She) eventually grabbed the object after staff asked three times and staff noticed it was another vape. Staff confiscated another vape for the second time today, notifying DON and administrator. After confiscating first vape staff was instructed to notify (Medical Director, EI #6) of resident smoking in (his/her) room and to request order for Nicorette patches or gum. MD notified but no response has been received . 11/15/2022 16:44 (4:44 PM) Resident was under the impression that (he/she) would be able to go outside to smoke. Staff informed resident that, per administrator, the facility is 100% smoke free and (he/she is) unable to go outside to smoke. (He/She) informed staff that (he/she) had cigarettes in (his/her) room in addition to the two vapes that were confiscated earlier during the shift. (He/She) surrendered (his/her) cigarettes without and (any) issues but told staff that (he/she) wants to be able to have them back when (he/she) goes out for doctor's appointments or with family. Staff informed (him/her) that (his/her) request would be discussed with management . 11/19/2022 11:49 (11:49 AM) .Resident was asleep in bed and unable to (be) awakened. Staff noticed vape cartridge in resident's hand as (he/she) slept. Attempted to awaken resident to request the vape and re-enforce no smoking policy. Due to failed attempts to awaken resident staff managed to remove vape form (from) resident's hand as (he/she) slept. After confiscating vape staff notified DON and administrator of the issue at hand . 11/24/2022 12:07 (12:07 PM) Offgoing nurse informed staff of resident vaping in room prior to shift change . Staff informed MD (medical doctor) of resident's continued vaping . 11/29/2022 14:30 (2:30 PM) Staff went to respond to resident's call light. Upon entering resident's room staff found (RI #27) sitting on the edge of (his/her) bed vaping. Resident did not notice staff until (he/she) was asked to hand over the vape. Resident asked staff to let (him/her) keep the vape. (He/She) was informed, once again, that Signature Healthcare is a smoke free facility. (He/She) then asked if staff could pretend she didn't catch vaping and just allow (him/her) to put it away. Staff informed (RI #27) that we could not do that and the vape must be taken and reported. (He/She) handed staff the vape without any issues . After leaving resident's room staff reported to DON . 12/07/2022 13:50 (1:50 PM) Resident had a visitor earlier during the shift. Staff noticed (RI #27) completing a list of things that (he/she) wanted (his/her) guest to purchase for (him/her). After the guest exited (RI #27's) room nursing staff introduced herself and asked for the guests name. (RI #27's guest) was educated on the no smoking policy being enforced at the facility and explained that guests are not allowed to bring cigarettes or vapes into the facility on resident's behalf. She stated that she does not ''buy those kinds of things. I only buy (him/her) snacks, drinks and other junk food. Several hours later staff found a vape in (RI #27's) top bedside drawer tucked inside a sock. Vape was handed to the administrator who informed staff to take another peek while (he/she is) not in (his/her) room to see if (he/she) had any other vaping devices. After inspecting resident's room further staff found a brown paper bag containing four more vaping devices. The brown bag was turned into DON before resident returned to (his/her) room . 12/21/2022 9:06 (9:06 AM) During morning med pass staff entered resident's room to find (him/her) asleep with a vaping device in (his/her) hand. Staff attempted to awaken resident to administer medications and remove vape from resident's room. However, after several attempts, resident continued sleeping. Staff removed vaping device from resident's hand and allowed (him/her) to continue resting undisturbed . 12/27/2022 10:55 (10:55 AM) . Upon entering resident's room (he/she) quickly tucked something inside (his/her) gown. When asked if (he/she) was vaping (he/she) immediately said no. But, when asked to remove the object (he/she) had just hidden, (he/she) removed a vaping device from the roll of (his/her) gown. Staff removed vape and reported the event to DON and administrator . 12/27/22 16:28 (4:28 PM) Upon entering resident's room staff found (him/her) with a vape in (his/her) hand. Staff held out hand for (him/her) to hand it over. (He/She) complied but became belligerent . Staff took the second vape today to the DON and reported what had transpired . 12/28/2022 15:00 (3:00 PM) (EI #31), CNA, went into resident's room and discovered (him/her) in bed with a vaping device. She confiscated the vape and turned it in to the administrator . 12/31/2022 16:12 (4:12 PM) Staff found resident sleeping with vape on (his/her) stomach during morning med pass. Vape removed from (his/her) possession and DON notified of findings . 01/05/2023 11:48 (11:48 AM) Resident found sleeping with vape in (his/her) hand this morning when staff went into (his/her) room during med pass . 01/14/2023 9:48 (9:48 AM) During morning med pass resident was found asleep with a vape in (his/her) hand. (He/She) handed it to staff without any issues. Within an hour staff went into the room . While passing (RI #27's) bed staff noticed (him/her) asleep with another vape in (his/her) hand. Staff called out to (him/her) to ask (him/her) to hand over the vape. (He/She) then stated Why did you come back in here to bother me again? Staff explained that while providing care to (his/her) roommate another vape was spotted in (his/her) hand when glancing at (him/her). (He/She) then stated Well don't look at me then. I can't afford to keep buying these things. (He/She) handed staff the second vape without any issues. Findings were reported to DON and administrator . 01/19/2023 9:06 (9:06 AM) During morning med pass staff saw a vaping device inside of (RI #27's) neck pillow. (He/She) handed staff the device without any issues. Vape turned in to DON . 01/19/2023 17:41 (5:41 PM) Second vaping device removed from resident's room prior to shift change . On 02/19/2023 at 9:05 AM, an interview was conducted with EI #17. EI #17 said 11/15/2022 was the first time she recalled seeing RI #27 with a vape. EI #17 confirmed multiple occurrences of finding vapes and a pack of cigarettes in RI #27's possession. When asked if she also found a lighter at the time she found cigarettes, EI #17 said she did not see one at that time, but had not looked. EI #17 said she thought a lighter was found in RI #27's room at a later time. EI #17 indicated she reported all findings of vapes and cigarettes and turned the items in to the DON or the Administrator and documented them in RI #27's progress notes. When asked if EI #1 and EI #2 gave her further instructions on how to address RI #27's noncompliance each time they were notified, EI #17 said she was told to continue providing education on Signature Healthcare of Whitesburg Gardens being a smoke-free facility, which she was already doing, and to confiscate the vapes and document what had been done. EI #17 also indicated she was instructed to search RI #27's room on only one occasion in December 2022, but was not provided any instructions or training on how to conduct the search. On 02/19/2023 at 1:34 PM, a telephone interview was conducted with EI #31, the CNA that found a vape in RI #27's possession on 12/28/2022. EI #31 said on that day she was walking down the hall and smelled a fruity smell. EI #31 said she walked in RI #27's room and saw RI #27 laying there with eyes closed with a vape on his/her chest. EI #31 said when she touched RI #27, RI #27 immediately opened his/her eyes. EI #31 said she informed RI #27 this was a non-smoking facility and he/she was not supposed to have the vape. EI #31 said she went and informed EI #17 and also notified EI #1 and EI #2. EI #31 said she had personally confiscated three vapes off of RI #27. EI #31 recalled one day when RI #27 was in his/her room vaping and blowing the smoke out of his/her nose and mouth, blowing it everywhere. The surveyor asked EI #31 if she thought RI #27 understood the risk of vaping and smoking in the facility. EI #31 said she thought RI #27 did know the risks, but RI #27 was just going to do what he/she wanted to do. When asked if she had ever been in-serviced on what to do if she saw any vapes, cigarettes or lighters in RI #27's room, EI #31 said staff had been told to take them from RI #27 and turn them in to EI #1 and EI #2. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #26, an LPN providing care for RI #27 on the 6 PM - 6 AM shift: . 11/24/2022 4:56 (4:56 AM) At approx. (approximately) 0430 (4:30 AM), CNA notified the nurse of a resident having a vape in (his/her) hand holding it, the nurse went to the resident's room and turned on the light and the resident had (his/her) back turned away from the door towards #B bed with a vape in (his/her) hand up to (his/her) face, the nurse asked (him/her) what does (he/she) have in (his/her) hand? and asked for the vape which was warm to touch, nurse once again educated the resident on smoking in the facility and smoking while having a nicotine patch on (him/her) person, resident . just shrugged (his/her) shoulders, nurse notified DON and attempted to notify MD of the above and no answer of the phone will have on coming nurse to notify MD . 01/07/2023 18:34 (6:34 PM) CNA informed this nurse of the resident lying in bed with (his/her) hand on (his/her) chest, holding a vape, vape was confiscated, the administrator was notified, DON was notified via text, resident was again educated on not smoking in the facility, (he/she) then stated ya, I know will continue to monitor during my shift . 01/10/2023 5:03 (5:03 AM) CNA instructed this nurse to come into the resident's room, upon arrival CNA pointed to the foot of (his/her) bed, while he had (RI #27) on (his/her) side performing peri care pointed to the foot of her bed, while he had (him/her) on (his/her) side performing peri care and the nurse picked up a vape with tissue wrapped around it with a hair tie, DON notified, administrator, notified, vape was confiscated and placed in a clear bag to be given to administrator, will continue to monitor during my shift . 01/17/2023 4:02 (4:02 AM) The resident was seen . with a hand on (his/her) chest and a vape in (his/her) hand with Kleenex wrapped around it with a hair tie. The nurse confiscated and informed DON . On 02/21/2023 at 12:38 PM, a telephone interview was conducted with EI #26. EI #26 said she had confiscated several vapes from RI #27 and felt RI #27 was putting all the residents in jeopardy and the facility was not doing anything about it. EI #26 said administrative staff knew RI #27 was using the vape and just kept telling the staff to take them away from RI #27. EI #26 said on 11/24/2022, she went in to administer RI #27's medications and observed RI #27 laying in bed with a vape in his/her left hand. EI #26 said she immediately confiscated the vape and educated RI #27. EI #26 said she told RI #27 smoking was not allowed, and he/she could start a fire. EI #26 said she called EI #1 and EI #2 and put the vape in a bag and left the bag at the nurses station. EI #26 said on 01/07/2023 and 01/10/2023, a CNA, EI #37, informed her he observed RI #27 with a vape in his/her hand. EI #26 said each time she would confiscate the vape and notified EI #1 and EI #2. EI #26 said the last time she observed RI #27 with a vape was on 01/17/2023. When asked what she had been told to do if she observed RI #27 with a vape, EI #26 said the only thing the nurses were told to do was to leave the vapes on the cart and there was nothing administration could do about RI #27 having the vapes. EI #26 said she had never personally seen RI #27 with a cigarette lighter or cigarettes, but the first time she observed RI #27 with a vape, the vape was hot and you could tell RI #27 had just used it. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #15, an LPN providing care for RI #27 on the 6 AM - 6 PM shift: .01/08/2023 15:05 (3:05 PM) CNA notified the nurse that the resident was vaping in (his/her) room Nurse educated resident that this facility was a non smoking one. Resident verbalized understanding. Resident was asked if (he/she) had any more which (he/she) denied. DON and administrator notified. Will continue to monitor and follow current orders . 02/19/2023 at 12:21 PM, an interview was conducted with EI #15. EI #15 said on 01/08/2023, she was told by EI #31, a CNA, RI #27 was vaping in his/her room. EI #15 said she confiscated the vape and took it to the DON's office. When asked what the DON (EI #2) instructed her to do, EI #15 said nothing. EI #15 said she was just told to leave the vape in EI #2's office. EI #15 said she educated RI #27 the facility was a non-smoking facility. When asked if she had ever smelled any smoke in RI #27's room, EI #15 said yes, but could not provide a date. The surveyor asked EI #15 if she knew the source of the smoke, and EI #15 said what she smelled would have come from a vape, because it did not smell like a cigarette. EI #15 said she probably told the nurse on the hall at that time, but could not recall. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #23, an LPN providing care for RI #27 on the 6 PM - 6 AM shift: . 02/06/2023 5:11 (5:11 AM) At 2:45am, I was notified by CNA, that when she went in resident's room, resident was lighting a cigarette, with a lighter. This nurse went and asked resident for lighter and the cigarette. Resident gave me and (an) empty plastic cup. The cup obtained (contained) a few cigarettes. Resident refused to give me the lighter. I then help my CNA provide ADL care to resident. When I went to remove neck pillow, to turn resident, I found, a pack of cigarettes, a vape, and a lighter. I removed all iteams (items) from neck pillow. I then educated resident on the facilities (facility's) policy on no smoking and the dangers of smoking in the facility. Resident understood. (EI #6, the Medical Director), the administrator, notified. DON attempted to be notified. Message left . 02/06/2023 5:23 (5:23 AM) All cigarettes, vape, lighter and empty cup with cigarettes, placed in 600 hall narc (narcotic) box. Will notify dayshift nurse . On 02/17/2023 at 7:15 PM, an interview as conducted with EI #23. EI #23 said on 02/06/2023 at 2:45 AM she was notified by a CNA, EI #22, that when she went in RI #27's room to perform ADL (Activities of Daily Living) care she witnessed RI #27 with a cigarette lighter, attempting to light a cigarette. EI #23 said EI #22 asked for the lighter and cigarette and RI #27 did not comply so she came and got her. EI #23 said EI #22 reported RI #27 was trying to smoke in the room. EI #23 said when she and EI #22 entered RI #27's room, she asked RI #27 if he/she was trying to smoke in the facility, and RI #27 stated I don't know what you are talking about. EI #23 told RI #27, I did see you with a lighter and a cigarette. EI #23 said RI #27 would not give her the lighter or cigarettes, and when she looked on the bedside table, she saw a cup containing approximately three to four burned cigarettes, which appeared to have already been smoked. EI #23 said she asked RI #27 a second time to give her the cigarettes and lighter, and RI #27 again said, I don't know what you are talking about so she told RI #27 she was going to help the CNA do ADL care. EI #23 said when EI #22 pulled the covers down, she picked up RI #27's neck pillow and felt a lighter, a vape, and a pack of cigarettes in the neck pillow. EI #23 said before she left the room, she educated RI #27 about the dangers of smoking in the room and then she took the items to the narcotic box on the med cart and locked them up. EI #23 said she notified EI #6, the Medical Director, EI #1 and EI #2. EI #23 said EI #6 did not give any instructions or orders, and EI #2 said to keep them locked in the med cart and she would get them when she returned to work. When asked what was the risk to RI #27 and the other residents in the facility if RI #27 was smoking cigarettes and vaping in her room, EI #23 said RI #27 took a lot of medications and often falls asleep, which could result in a fire. EI #23 also said RI #27's roommate did not need to inhale second hand smoke. On 02/20/2023 at 1:22 PM, a telephone interview was conducted with EI #22, the CNA working on 02/06/2023. EI #22 said she had just completed her rounds when RI #27 put on his/her call light. EI #22 said she went in RI #27's room, RI #27 was in the bed laying on his/her back and had a cigarette in his/her right hand. EI #22 said RI #27 reached over to the bedside table and grabbed the lighter that was sitting there. EI #22 said RI #27 reached over like it was nothing, got the lighter off the table and lit his/her cigarette. EI #22 said RI #27 then puffed two hard times and blew the smoke out. The surveyor asked EI #22 what she did at that time. EI #22 said she immediately left the room. EI #22 said it startled her, so she walked out to get the nurse. When asked if she asked RI #27 for the cigarette or lighter before she exited the room to notify the nurse, EI #22 said no. When asked why she left RI #27 with a lit cigarette, EI #22 said she was shocked. EI #22 said she had never seen a resident just light a cigarette and smoke it on the inside of the building like it was nothing. EI #22 said when she left the room RI #27 still had the lit cigarette in his/her mouth. EI #22 said when she informed the nurse of everything that happened, the nurse immediately went to the room and she went back with the nurse. When asked how long it took for them to return to the room, EI #22 said maybe three to four minutes. EI #22 said RI #27 tried to deny smoking in the facility. EI #22 said the nurse asked RI #27 for the cigarette, and RI #27 said he/she did not have one. EI #22 said you could smell the cigarette smoke and the nurse found a cigarette lighter and a smoked cigarette in a cup on the table. EI #22 was asked if she had been provided any information about RI #27 being non-compliant with the facility's non-smoking policy. EI #22 said no. EI #22 said she was just informed of RI #27's level of care. EI #22 said she had not received any in-services on monitoring RI #27 and had not been instructed on what to do if she saw RI #27 with a lighter, cigarette or vape. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #27, an LPN providing care for RI #27 on the 6 AM - 6 PM shift: . 02/06/2023 10:03 (10:03 AM) Nurse gave evidence of vapor and cigarettes to Social Worker of facility. All facility nursing supervisor aware . EI #27 was interviewed on 02/20/2023 at 4:20 PM. EI #27 said she had never seen RI #27 with vapes, cigarettes or a lighter, but indicated some had been turned in to her. EI #27 could not recall the specifics but said she usually documents a progress note about what happened and who she notified. When asked what the facility had instructed staff to do if they observed RI #27 with vapes, cigarettes or cigarette lighters in his/her room, EI #27 said they had been told to notify EI #1, the Administrator, or EI #2, the DON. EI #27 said nothing had been put in place related to RI #27's noncompliance, other than to turn any of these items in to the Administrator when they were found. EI #27 stated at this point, RI #27's noncompliance was a safety concern. EI #27 further explained she had not received any training from the facility related to monitoring RI #27's noncompliance until 02/20/2023. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #28, the Social Service Designee (SSD): . 02/06/2023 12:45 (12:45 PM) The SSD and Assistant SSD spoke with resident regarding violations of the facility smoking policy again. Resident denied the cigarette being (his/hers). Resident admitted to only Vaping . On 02/18/2023 at 9:07 AM, an interview was conducted with EI #28. EI #28 was asked when she started working with RI #27 concerning his/her non-compliance. EI #28 said she started visiting with RI #27 each morning sometime in December, but did not make any documentation. The surveyor asked EI #28 if the interventions put in place to prevent RI #27 from vaping and smoking/having cigarettes in his/her room were successful. EI #28 said not completely because RI #27 still had vapes and/or cigarettes in his/her room. EI #28 was asked could she think of any other interventions that could have worked better or stopped the behavior. EI #28 said finding a nursing home that allowed smoking, or maybe placing RI #27 on one on one earlier. When asked what were the dangers of smoking and vaping in the facility, EI #28 said it was a fire hazard and second hand smoke was dangerous. EI #28 said, if a fire started, it could affect all residents in the building. 02/19/2023 at 10:00 AM, a follow-up interview was conducted with EI #28. When asked what she discussed when she met with RI #27, EI #28 said she discussed with RI #27 that the facility policy did not allow smoking in the building and that it was a safety concern to smoke or vape. EI #28 said RI #27 always denied being noncompliant, despite staff confiscating the items. EI #28 was asked how her conversations with RI #27 changed, as the noncompliance continued. EI #28 said they did not change, she just continued to tell RI #27 the facility did not allow smoking or vaping. A review of RI #27's Resident Progress Notes revealed the following entries were made by EI #25, an LPN providing care for RI #27 on the 6 PM - 6 AM shift: . 02/13/2023 3:56 (3:56 AM) At 03:30 (3:30 AM) residents call light went off and the assigned cna went to answer it. While doing patient care, the cna saw a used cigarette in the residents bed and cigarette buts (butts) in a cup on the residents over bed table. No burns noted to the residents body or bed. The administrator and DON were notified. Will continue to monitor the rest of shift for any signs of cigarette smoke . 02/19/2023 at 11:17 AM, the surveyor conducted an interview with EI #25. EI #25 said on the on the morning of 02/13/2023, RI #27 put the call light on at 3:30 AM and EI #24, the CNA that was assigned to RI #27, went down to see what RI #27 needed. EI #25 said about 3:45 AM, she was sitting at the nurses station when EI #24 called her and said she needed to show her something. EI #25 said she got up and met EI #24 in the hallway and EI #24 had a cigarette in her hand. EI #25 said EI #24 found the cigarette in RI #27's bed. EI #25 said EI #24 informed her RI #27 had some cigarette butts in a cup on the over bed table as well. EI #25 said she went to RI #27's room to make sure RI #27 and RI #27's roommate were okay. EI #25 said she wanted to make sure RI #27 had not dropped any ashes on him/herself or in the bed. When asked what her observation was when she entered the room, EI #25 said she saw the cigarette butts in a cup on top of the over bed table. EI #25 said it was probably about three or four cigarette butts in the cup. EI #25 said she did not ask RI #27 anything about the butts or cigarettes. The surveyor asked EI #25 if she had ever educated RI #27 about the facility's non-smoking policy. EI #25 said she had, probably about a month prior, when someone found a vape in RI #27's room. When asked how RI #27 responded, EI #25 said RI #27 just said okay. The surveyor asked EI #25 what she did with the cigarette on 02/13/2023. EI #25 said she put in in a Ziploc bag and another nurse called EI #1 and EI #2 and told them what had been found. EI #25 said she documented what happened and put this on the 24 hour report. When asked if this was the first time she put anything on the 24 hour report pertaining to RI #27 and his/her non-compliance with the facility's non-smoking policy, EI #25 said it was. On 02/19/2023 at 4:20 PM, a telephone interview was conducted with EI #24, the CNA providing care to RI #27 on 02/13/2023. EI #24 said she went to RI #27's room on 02/13/2023 because her call light was on. EI #24 said RI #27 said he/she needed changing. EI #24 said when she rolled RI #27 to his/her left side to provide care, she saw a cigarette in the bed. EI #24 said it was a smoked cigarette and more than half of the cigarette had been smoked. EI #24 said she did not see a lighter or smell any smoke at that time. When asked if she saw any other cigarette butts, EI #24 said when she moved RI #27's over the bed table, a cup containing cigarette butts fell to the floor. EI #24 said there was cigarette ash and about four or five cigarette butts in the cup. EI #24 said she had also previously seen RI #27 asleep with a vape in his/her hand. When asked what she did when she saw RI #27 with the vape, EI #24 said she did not do anything or tell anyone because she did not know RI #27 could not have it. 29671 Review of RI #27's comprehensive care plans revealed the first care plan related to RI #27's noncompliance was created on 01/26/2023 by EI #15, the MDS/Care Plan Coordinator. This care plan documented: .Problem Start Date: 01/26/2023 Category: Behavioral Resident demonstrates non-compliance with physician orders and/or plan of care as evidenced by: continuing to vape in (his/her) room despite being asked not to . On 01/26/2023 at 3:57 PM, EI #15, the MDS/Care Plan Coordinator, was interviewed. When asked at what point RI #27 first demonstrated noncompliant behavior, EI #15 said since 11/15/2023, according to the progress notes. When asked what had been done to address the concern of noncompliance with the facility's non-smoking policy, EI #15 said they offered a nicotine patch, but RI #27 continued to vape, so the patch was discontinued. EI #15 confirmed RI #27's care plan addressing non-compliance with the facility's non-smoking policy was not initiated until 01/26/2023. When asked why a care plan had not been developed prior, EI #15 said she thought progress notes were effective enough. When asked when a care plan should have been initiated, EI #15 said on 11/15/2023, when RI #27's noncompliance was first noted. EI #15 said the risk of not developing a care plan would be harm to the resident. On 02/18/2023 at 11:00 AM, the surveyor conducted an interview with EI #2, the DON. When asked the safety risks associated with RI #27 smoking and vaping in the facility, EI #2 said fire and second hand smoke. When asked what interventions were cu [TRUNCATED]

Based on interviews, review of a policy titled Quality Assurance/Performance Improvement (QAPI) Program Policy, and review of the facility's 12/23/2022 and 01/25/2023 QUALITY PERFORMANCE/PEER REVIEW FACILITY PLAN OF ACTION/CONTINUOUS QUALITY IMPROVEMENT, the facility's QAPI committee failed to thoroughly implement the 12/23/2021 and 01/25/2023 action plans, which included an action item for laundry staff to monitor residents clothing to evaluate for burn holes, soot, and evidence of smoking. This failure placed all 109 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death, due to the ongoing resident safety risk and fire hazard. On 02/24/2023 at 5:05 PM, the facility's Administrator, Employee Identifier (EI) #1 and the [NAME] President (VP) of Clinical Operations, EI #36, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy findings in the area of Quality Assurance and Performance Improvement (QAPI), F867-QAPI/Quality Assessment and Assurance (QAA). Findings include: During the survey, document review and interviews with staff revealed Resident Identifier (RI) #27 had multiple documented episodes of non-compliance with the facility's non-smoking policy, including vaping and smoking in his/her room and hiding vaping and smoking materials from facility staff. This noncompliance was documented to have occurred from 11/15/2022 through 02/13/2023, despite repeated education to RI #27 on the facility's non-smoking policy. Cross reference F656 and F689. The facility policy titled Quality Assurance/Performance Improvement (QAPI) Program Policy, reviewed and revised 10/19/2022, documented: PURPOSE STATEMENT: To provide a process that will enhance the care and experience for all residents . POLICY STATEMENT: It is the intent of the facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate and improve the quality and appropriateness of resident care. QAPI supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improving the organization's overall performance with addressing care and management systems. DEFINITIONS . Quality Assurance and Performance Improvement (QAPI) is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and date-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving. Quality Assurance (QA) is the specification of standards for quality of service and outcomes, and systems throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is ongoing, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. Performance Improvements (PI) (also called Quality Improvement- QI) is the continuous study and improvement of processes with the intent to improve services or outcomes and prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systematic problems or barriers to improvement . GUIDELINES . 6. The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. 7. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. 12. Based on audit findings, plans will be developed, and tasks assigned to appropriate Stakeholders to include required completion dates. The facility's 12/23/2022, QUALITY PERFORMANCE/PEER REVIEW FACILITY PLAN OF ACTION/CONTINUOUS QUALITY IMPROVEMENT, documented: PROBLEM AREA IDENTIFIED: Problem/Opportunity: Resident not compliant with No Smoking policy . 4-Step Action Plan: . 2. Measures put in place and systemic changes you will make to ensure the deficient practice does not reoccur: .Laundry to monitor residents clothing to evaluate for burn holes, soot, evidence of smoking . There was no DATE COMPLETED listed on this action plan. The facility's 01/25/2023, QUALITY PERFORMANCE/PEER REVIEW FACILITY PLAN OF ACTION/CONTINUOUS QUALITY IMPROVEMENT, documented: PROBLEM AREA IDENTIFIED: Problem/Opportunity: Resident not compliant with No Smoking policy . 4-Step Action Plan: . 2. Measures put in place and systemic changes you will make to ensure the deficient practice does not reoccur: .Laundry to monitor residents clothing to evaluate for burn holes, soot, evidence of smoking . There was still no DATE COMPLETED listed on this action plan. An interview was conducted with EI #32, Laundry Attendant, on 02/21/2023 at 4:55 PM. EI #32 stated she had not been told anything about observing RI #27's clothing when they come to the laundry. An interview was conducted with EI # 33, Laundry Aide, on 02/22/2023 at 9:51 AM. EI #33 stated she was not informed to observe RI #27's clothes for burn holes and soot until the day before, 02/21/2023. An interview was conducted with EI #34, Laundry Aide, on 02/22/2023 at 10:42 AM. EI #34 stated she was not told anything about monitoring RI #27's clothes. An interview was conducted with EI #21, Laundry Supervisor, on 02/22/2023 at 12:28 PM. When asked what she was told regarding RI #27's clothing, EI #21 stated she was instructed to check for holes and burn marks for all residents, not just RI #27. EI #21 said the Administrator, EI #1, and EI #2, Director of Nursing (DON), told her to do this during a safety meeting, she believed was about a month prior. EI #21 also stated she was told to instruct her workers to make sure they check for holes in clothes. When asked to provide the documentation of where she informed or educated her staff on the need to do this, EI #21 provided documentation of education dated the day prior, 02/21/2023. An interview was conducted with EI #1, the Administrator, on 02/16/2023 at 11:39 AM. EI #1 stated QAPI first discussed RI #27's noncompliance with the facility's non-smoking policy during the 12/23/2022 QAPI meeting. She stated the team discussed interventions they were working on to try to get RI #27 to comply with the policy and they were trying to identify the source of RI #27's vaping and smoking materials. EI #1 said QAPI next discussed RI #27 during the 01/25/2023 QAPI meeting. A follow-up interview was conducted with EI #1 on 02/17/2022 at 1:39 PM. During the interview, EI #1 acknowledged the QAPI committee failed to identify RI #27 did not have a care plan addressing the continued noncompliance with the facility's non-smoking policy. Another interview was conducted with EI #1 on 02/23/2023 at 4:31 PM. EI #1 stated EI #21, the Laundry Supervisor, was responsible for informing her laundry staff they were to look for burn holes, soot and evidence of smoking. When asked when laundry staff had been informed, EI #1 said she did not recall EI #21 saying staff had been inserviced, but she was of the impression EI #21 had told them. When asked why laundry staff were reporting they had not been told, EI #1 said she did not know. EI #1 said EI #21 should have educated her staff after the 12/23/2023 QAPI meeting. EI #1 indicated inservice records related to monitoring RI #27's clothing for burn holes, soot and evidence of smoking would be evidence staff were informed. When asked the importance of monitoring clothing for burn holes, soot or evidence of smoking, EI #1 said it would help determine if the resident had been smoking in his/her room and could indicate a risk of causing harm. EI #1 stated she was the one responsible for ensuring the facility's QAPI action plan was fully implemented, and indicated they should have gone through each item on the action plan to ensure everything was being done. This deficiency was cited as a result of complaint/report numbers AL00043096 and AL00043372. ***************************************************** The facility submitted an acceptable Removal Plan on 02/26/2023 for F867 that outlined the following: 1. Four laundry staff were educated by the HCSG housekeeping supervisor on 02/23/2023 to look for burn holes, soot, and evidence of smoking. The HCSG Housekeeping/Laundry District Manager re-educated six laundry staff and the HCSG housekeeping supervisor on 02/25/2023 to look for burn holes, soot, and evidence of smoking. The HCSG Housekeeping/Laundry District Manager educated the HCSG Housekeeping supervisor on her responsibilities for training laundry staff and monitoring residents' clothing for damage and other reasons such as cigarette burns. This was completed on 02/25/2023. 2. All residents have the potential to be affected. The QAPI committee meet on 02/22/2023 to assess and revise action plans to promote resident safety due to RI #27's noncompliance with the facility's nonsmoking policy. 3. The [NAME] President of Clinical Operations (VPCO) educated members of the QAPI Committee (Administrator, Medical Director, DON, MDS coordinator, Maintenance Director, Registered Dietician, Business Office Manager (BOM), Admissions Coordinator, HCSG Housekeeping and Laundry Supervisor, SDC, Life Enrichment Director, and Assistant Business Office manager) on 02/24/2023 and 02/25/2023, regarding the QAPI process. - The education was to ensure the facility's QAPI committee understands the importance of developing and implementing effective plans to ensure problems are corrected, reducing residents' risk for safety and hazards. This was completed on 02/24/203 and 02/25/2023. The QAPI team analyzed data from the citations, audits, and interviews to ensure effective plans and interventions are in place. - The Quality Assessment and Assurance Committee (QAPI) meeting was held on 02/24/2023 and 02/25/2023, to complete a systematic, interdisciplinary, comprehensive, root cause analysis of the performance improvement action plans related to the Non-Smoking policy, Care Planning behaviors, Behavior Health policy, Accidents, and Supervision, Contraband Policy, QAPI, and non-compliant smokers process to reduce the risk of a hazard related to a fire. This included education provided by the VPCO. - On 02/24/2023 and 02/25/2023 the QAPI committee consisting of the Administrator, Medical Director, DON, MDS coordinator, Maintenance Director, Registered Dietician, Business Office Manager (BOM), Admissions Coordinator, HCSG Housekeeping and Laundry Supervisor, SDC, Life Enrichment Director, and Assistant Business Office manager led by the VPCO evaluated the effectiveness of the action plans for non-compliant smokers and developed a plan of correction addressing if necessary additional education and additional audits required. - The Plan of correction for QAPI (F867) is to review all action plans related to F656, F689, F740, F835, F837, and F867 and use root cause analysis to determine the effectiveness of the action plans and revise the plans with different interventions and approaches when compliance is not achieved for the established thresholds. Based on audit findings, plans will be developed, and tasks assigned to appropriate Stakeholders to include required completion dates. The Administrator provides oversight to the QAPI committee and program. The Administrator was trained on 02/24/2023 by the VPCO on the QAPI Program Policy. ********************** On 02/26/2023 at 11:15 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 2/26/2023 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on observation, interview, the facility's policies for Staff Attire, Food Preparation, and Food Storage: Cold Foods, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure food safety by: 1.) Employee Identifier (EI) #7 not wearing a beard covering over his mustache while serving the breakfast meal on [DATE], 2.) keeping boiled eggs with a use by date of [DATE] in the Walk-in Cooler on [DATE], 3.) keeping Temperature Control for Safety (TCS) food in the Station #2 resident refrigerator at 53 (degrees) Fahrenheit (F) and the freezer at 15 F on [DATE], and 4.) the Station #1 resident refrigerator having no thermometer for staff to monitor the temperature on [DATE] and [DATE]. This had the potential to affect all residents receiving meals from the facility's kitchen. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . Hair Restraints ,d+[DATE].11 Effectiveness. (A) . FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. The facility's policy for Staff Attire revised ,d+[DATE], included the following: Policy Statement All employees wear approved attire for the performance of their duties. Procedures 1. All staff members will have their . facial hair properly restrained. The facility's policy for Food Preparation revised ,d+[DATE], included the following: Policy Statement All foods are prepared in accordance with the FDA Food Code. Procedures . 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. During a kitchen observation on [DATE], the assembly of breakfast trays for residents was observed from the first tray assembled at 7:00 AM to the last cart of trays leaving the kitchen at 8:35 AM. EI #7, the Assistant Dietary Manager, served food from the steamtable onto plates and bowls for the residents and performed additional food related tasks during this time. During the entire resident breakfast tray assembly process, EI #7 wore his beard cover pulled down below his mouth so that his moustache was exposed. EI #7 was interviewed on [DATE] at 9:17 AM. When asked why a beard cover should be worn during food production and service, EI #7 said to prevent hair from falling into the food. EI #5, the Dietary Manager, was interviewed on [DATE] at 5:22 PM. EI #5 said, when foodservice staff did not cover facial hair during food preparation and service, cross-contamination would be a problem if hair fell into the food and contaminated it. EI #4, the Registered Dietitian, was interviewed on [DATE] at 5:25 PM. EI #4 said hair in one's food was unsightly and unprofessional. EI #4 further said it could cause a gag reflex or appetite loss. 2.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) . refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: . (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1 . ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17 (A) . The facility's policy for Food Preparation, revised ,d+[DATE], included: Policy Statement All foods are prepared in accordance with the FDA Food Code. Procedures . 17. all TCS foods that are to be held for more than 24 hours at a temperature of 41 F or less, will be labeled and dated with a 'prepared date' (Day 1) and a 'use by' date (Day 7). On [DATE] at 9:15 AM, an observation of the Walk-in Cooler in the kitchen was made with EI #5, the Dietary Manager. Inside a box of commercially prepared, peeled, boiled eggs was an opened package containing six eggs. The package of boiled eggs was labeled as being opened on ,d+[DATE] ([DATE]) and dated with a discard date of ,d+[DATE] ([DATE]). EI #5 said these should not be in here, they should have been thrown away. EI #5, the Dietary Manager, was interviewed on [DATE] at 5:22 PM. EI #5 was asked about the package of boiled eggs, labeled as opened on [DATE] and with a use by date of [DATE], which were in the Walk-in Cooler on [DATE]. EI #5 said the boiled eggs were clearly expired and needed to be thrown out. EI #4, the Registered Dietitian, was interviewed on [DATE] at 5:25 PM. When asked about the package of boiled eggs with the with a use by date of [DATE] that were in the Walk-in Cooler on [DATE], EI #4 said there was potential for cross-contamination and possibly Salmonella (a food-borne illness bacteria). 3.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . Temperature and Time Control ,d+[DATE].11 Frozen Food. Stored frozen FOODS shall be maintained frozen. ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 C [Centigrade] (41 F) or less. The facility's policy for Food Storage: Cold Foods, revised ,d+[DATE], included the following: Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures . 2. All perishable foods will be maintained at a temperature of 41 F or below . 3. Freezer temperatures will be maintained at a temperature of 0 F or below. On [DATE] at 5:35 PM, the residents' refrigerator on Nursing Station #2 was observed with EI #13, a Licensed Practical Nurse (LPN). EI #13 said the refrigeration temperature was 54 degrees Fahrenheit and the freezer was 15 degrees Fahrenheit. When asked what should the refrigerator's temperature be, EI #13 replied 32 to 41 degrees Fahrenheit. When asked what should the freezer's temperature be, EI #13 said no greater than zero degrees Fahrenheit. EI #13 said nine ice cream sandwiches and three individual chocolate/vanilla ice creams were in the freezer. Upon being asked how did the ice cream feel, EI #13 said it was not solid and she was able to squeeze it easily. EI #13 further said the ice cream needed to be thrown away. When asked how did the ice cream sandwiches feel, EI #13 said soft, not frozen. EI #13 said ice cream should be frozen solid and you should not be able to squeeze it. EI #13 said the refrigerator should never be 54 degrees Fahrenheit. EI #13 did not know how long the temperature had been 15 degrees Fahenheit in the freezer and 54 degrees Fahrenheit in the refrigerator. EI #13 said the risk of the freezer being 15 degrees Fahrenheit and the refrigerator being 54 degrees Fahrenheit was the food inside not being at the proper temperature. EI #13 said the refrigerator contained a 46-ounce jar of apple sauce that was 75% full, a box containing three chicken fingers, one 8-ounce nutritional shake, three individual coffee creamers, two small containers of Yoplait peach/strawberry yogurt, and a 46-ounce container of thickened apple juice. EI #13 was asked what was the risk of the freezer not being 0 degrees F or below and the refrigerator not being between 32 to 41 F. EI #13 said the residents could get sick. During an interview on [DATE] at 2:50 PM, EI #5, the Dietary Manager, said the 54 degree temperature reading for the Nursing Station #2 residents' refrigerator was too high. EI #5 said everything in the refrigerator was compromised due to biological growth. During an interview on [DATE] at 3:07 PM, EI #4, the Registered Dietitian, said the items in the Nursing Station #2 residents' refrigerator were at risk for causing food borne illness due to an unsafe temperature range. 4.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . Temperature and Time Control ,d+[DATE].11 Frozen Food. Stored frozen FOODS shall be maintained frozen. ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 C [Centigrade] (41 F) or less. The facility's policy for Food Storage: Cold Foods, revised ,d+[DATE], included the following: Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures . 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. On [DATE] at 6:08 PM, the residents' refrigerator on Nursing Station #1 was observed with EI #12, a LPN. Upon being asked what was the temperature of the refrigerator, EI #12 said she did not know because there was no thermometer. When asked why was there no thermometer, EI #12 said she did not know. EI #12 further said night shift checked the refrigerators. On [DATE] at 8:00 AM, the residents' refrigerator on Nursing Station #1 was observed with EI #2, the Director of Nursing. When asked what was the temperature in the refrigerator, EI #2 said she did not know. EI #2 further said there was no thermometer in the refrigerator and she did not know why there was no thermometer. Upon being asked how was staff supposed to know what the temperature was inside the refrigerator, EI #2 said she did not know. EI #2 said the risk of not checking the refrigerator temperature was the food not being at the correct temperature. During an interview on [DATE] at 2:50 PM, EI #5, the Dietary Manager, said without a thermometer in the refrigerator you cannot verify the temperature and therefore cannot verify that the food is being kept at a safe temperature. During an interview on [DATE] at 3:07 PM, EI #4, the Registered Dietitian, said the Nursing Station #1 residents' refrigerator needed to be in a safe temperature range, otherwise the food items were at risk for foodborne illness. EI #4 said the refrigerator temperature needed to be monitored via a thermometer.

Based on interviews, record reviews and review of a facility policy titled, Contraband Discovery Policy, the facility failed to ensure staff did not search Resident Identifier (RI) #27's room on 12/07/2022 without first obtaining RI #27's consent. This deficient practice affected RI #27, one of one sampled resident reviewed for for improper room searches. Findings include: A facility policy titled Contraband Discovery Policy, revised 10/18/2022, documented: .Use for conducting inspections and searches, with consent, of current residents and residents' rooms under circumstances where there is reasonable suspicion that the resident may be concealing contraband. For purposes of this policy . non-compliant use of tobacco products as per the facility smoking policy is considered contraband. GUIDELINES: 1. If facility staff identify items or substances that pose risks to residents' health and safety and are in plain view, they may confiscate them. 2. Facility staff should not conduct searches of a resident or their personal belongings, unless the resident, or their representatives agrees to a voluntary search and understands the reason for the search. 3. Obtain consent from resident and/or resident representative to search resident's body or personal possessions. 6. Inform the resident and/or resident representative that he/she and or his/her room will be searched and the reason for the search. Give the resident the opportunity to surrender the suspected contraband and to the extent possible, give the resident the opportunity to be present during the search. RI #27 was admitted to the facility on [DATE]. Review of RI #27's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/22/2022, indicated RI #27 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated RI #27 was cognitively intact. RI #27's Resident Progress Notes, documented: .12/07/2022 13:50 (1:50 PM) . staff found a vape in (RI #27's) top bedside drawer tucked inside a sock. vape was handed to the administrator who informed staff to take another peek while (he/she's) not in (his/her) room to see if (he/she) had any other vaping devices. After inspecting resident's room further staff found a brown paper bag containing four more vaping devices. The brown bag was turned into DON before resident returned to (his/her) room . This note was made by Employee Identifier (EI) # 17, Licensed Practical Nurse (LPN). RI #27 was interviewed on 02/21/2023 at 5:18 PM. RI #27 stated he/she never gave staff permission to search his/her room. EI #17 was interviewed on 02/19/2023 at 9:05 AM. EI #17 stated in December she was told to search RI #27's room. She stated RI #27 was at therapy, and she saw something in his/her open drawer. She stated it was a sock with something sticking out of it. EI #17 stated she walked over and looked at the sock and tried to close the drawer. EI #17 said when she did this, she felt the shape of a vape inside the sock, so she removed it and took it to EI #1, the Administrator. According to EI #17, EI #1 instructed her to go ahead and search RI #27's room. EI #17 indicated EI #18, Certified Nursing Assistant (CNA) was also present at the time the search was conducted. A follow-up telephone interview was conducted with EI #17 on 02/22/2023 at 12:29 PM. EI #17 stated she did not obtain consent from RI #27 prior to searching the room. She stated EI #1 never told her she needed to. EI #18, CNA, was interviewed on 02/20/2023 at 5:39 PM. She stated she did witness EI #17 search RI #27's room in early December 2022. EI #18 stated RI #27 was in therapy at the time of the search. She stated EI #17 went in RI #27's room and searched a purple backpack, while she stood outside the the room to keep watch. During an interview with EI #1, Administrator, on 02/23/2023 at 4:31 PM, EI #1 acknowledged searching RI #27's room without his/her consent would be a violation of resident rights. This deficiency was cited as a result of complaint/report numbers AL00043096 and AL00043372.

Based on interview, record review and review of a facility policy Pre-Admission Screening and Resident Review (PASRR), the facility failed to ensure a Level II PASRR evaluation for Resident Identifier (RI) #37 was completed as indicated when the Level I PASRR screening determined a Level II PASRR was necessary. This affected RI #37, one of one resident sampled for PASRR requirements. Findings include: A facility policy titled, Pre-Admission Screening and Resident Review (PASRR) with a review date of 08/01/2018, documented, . PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. GUIDELINE: .2. Those individuals who test positive at Level 1 are then evaluated in depth, called Level II PASRR. The results of this evaluation result in determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. RI #37 was admitted to the facility 12/28/2020 and readmitted on [DATE] with diagnosis to include Bipolar Disorder. RI #37's OBRA PASRR LEVEL I CATEGORICAL DETERMINATION FOR NF (Nursing Facility) CONVALESCENT CARE ADMISSION ONLY dated 10/03/2022, documented, After a Quality Assurance Review, this NF applicant requires a Level II Evaluation due to the documented serious mental health diagnosis of Bipolar Disorder but meets the terms of a Categorical Determination for Convalescent Care and may be admitted to a NF to complete the Level II Evaluation . Employee Identifier (EI) #20, Business Office, was interviewed on 02/22/2023 at 11:52 AM. EI #20 stated RI #37 has a diagnosis of Bipolar. When asked who was responsible for making the referrals to the appropriate designated authority when a Level II PASRR is needed, EI #20 stated it was usually the Social Worker's job, but she was not trained yet, so it would be up to the Administrator who she assigned to that task. EI #20 stated they were reviewing that chart and noted RI #37's Level II PASRR was not in there. EI #20 stated once RI #37 was admitted to the facility, the OBRA office should have been notified that a Level II was needed. EI #20 stated the concern for RI #37 not having a completed Level II PASRR was that it was needed to make sure the facility was appropriate, and that this was the right setting for the resident.

Based on observations, interviews, record review and review of a facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection, the facility failed to ensure Resident Identifier (RI) #30 had orders for oxygen and his/her oxygen tubing/humidifier bottle was labeled/dated. This deficient practice affected RI #30, one of five sampled residents receiving respiratory services. Findings include: Review of a facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection, revised 11/2011, revealed the following: Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment . Steps in the Procedure Infection Control Considerations Related to Oxygen Administration . 3. Mark bottle with date and initials upon opening and discard after twenty-four (24) hours . 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed . RI #30 was admitted to the facility on [DATE] with diagnoses of Shortness of Breath and Wheezing. A review of RI #30's Physician Order Report dated 01/16/2023 - 02/16/2023, revealed RI #30 did not have an order for oxygen. On 02/14/2023 at 5:36 PM, the surveyor observed RI #30's oxygen infusing via nasal cannula at 2 liters. The oxygen tubing was connected to a humidifier bottle and there was no date on the oxygen tubing or humidifier bottle. On 02/15/2023 at 8:36 AM, RI #30's oxygen tubing and humidifier bottle remained undated. On 02/16/2023 at 10:43 AM, RI #30 was observed in a wheelchair being taken to therapy. There was a portable oxygen tank in use at this time and the oxygen tubing remained undated. On 02/17/2023 at 11:17 AM, RI #30 was observed sitting on the side of the bed. The oxygen infusing. The oxygen tubing remained undated. On 02/17/2023 at 11:50 AM, Employee Identifier (EI) #29, a Registered Nurse escorted the surveyor to RI #30's room. The surveyor asked EI #29 did he see a date on RI #30's oxygen tubing/humidifier water bottle. EI #29 said no. EI #29 said there should be a date on the tubing/bottle. When asked the rational for labeling the tubing/humidifier, EI #29 said so the nurses would know when to change it again. On 02/21/2023 at 5:37 PM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). When asked if RI #30 had a physician's order for the oxygen, EI #2 looked a RI #30's Physician Orders and said she did not see one. EI #2 said a resident using oxygen should have an order for the oxygen. The surveyor asked EI #2 why would it be important for a resident to have a physicians order for the use of oxygen. EI #2 said to ensure the resident was getting the right amount of oxygen.

Based on observations, interviews, record review and review of a facility policy titled, Medication Ordering and Receiving From Pharmacy Provider, the facility failed to ensure medications were available at scheduled medication times for Resident Identifier (RI) #30. This deficient practice affected RI #30, one of four residents reviewed for medication availability. Finding include: 1) Review of a facility policy titled, Medication Ordering and Receiving From Pharmacy Provider, dated 01/2022, revealed the following: . POLICY Medications and related products are received from the provider pharmacy on a timely basis. The nursing center maintains accurate records of medication order and receipt. PROCEDURES . a. All new medication orders are transmitted to the pharmacy. e. New medications . If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Timely delivery of new orders is required so that medication administration is not delayed. g. New admission orders: When transmitting medication orders for a newly admitted resident, the pharmacy should be given date of birth, social security number, attending physician . RI #30 was admitted to the facility 01/24/2923. On 01/25/2023 at 8:45, the AM medication pass for RI #30 was observed. EI #9, Registered Nurse prepared Eliquis, Norvasc, Atorvastin, Vitamin D 400 Units, Magnesium Oxide, Multivitamin, and Potassium. She indicated to the surveyor RI #30's Lasix, Metoprolol, Protonix and Doxycycline were not in the cart. A review of Admission orders received to the facility on [DATE] at 11:09 AM indicated the Metoprolol, Protonix, Doxycline and Lasix were on the on the admission/discharge orders. A review of the Pharmacy sheet indicated the orders received to the Pharmacy 1/24/23 at 1:56 PM. On 1/25/23 at 10:45 AM an interview with EI #12, the admitting nurse revealed she got the orders before the resident arrived she entered the information in the system then called to ensure the pharmacy received them. EI #12 was asked what medication were ordered; she said all the ones on the discharge from hospital list. EI #12 was asked why was the Lasix, Protonix, Metoprolol and Doxycycline not delivered; she said she did not know, it was ordered. EI #12 was asked what should be done if medication not available; she said notify the Pharmacy and the Doctor. EI #12 was asked what was being done to ensure medications were available. She was asked what time did she send it to the Pharmacy; she said before 3:00 PM. EI #12 was asked when should resident medications not be available. EI #12 said they should always be available. EI #12 was asked how often were new resident medications not available. She said a few times. On 1/25/23 at 12:05 PM an interview was conducted with EI #9. EI #9 was asked what medications that were due on the morning pass were not available; she said the Lasix, Protonix, Metoprolol and Doxycycline. EI #9 was asked how often new resident medications were not available; she said she had only worked there about a week and it had occurred a few times. EI #9 was asked what did she do when medications were not available; she said call pharmacy, and if needed call the doctor, and she told the unit manager. EI #9 was asked what was the harm in resident medications not available. EI #9 said doctors orders were not followed if medications were not given due to being unavailable. On 01/26/2023 at 5:00 PM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked what was the policy for medications to be available. EI #2 said it should be available for the medication pass. EI #2 was asked if RI #30 was admitted on [DATE] before 3:00 PM when should medications have been available. EI #2 said that night around 8:00 PM. She was asked to read off the medications ordered and then asked if the Lasix, Protonix, Metoprolol and Doxycline were on the list; she said yes. EI #2 was asked why those medications were not available for the morning medication pass; she said she was not sure. EI #2 was asked how often medications were not available for new residents. She said they have had the problem for several weeks and they were working on it. EI #2 was asked if they were working on it and medications were still not available was there still a problem; she said yes. 02/20/2023 at 6:42 PM, a follow-up interview was conducted with EI #2. EI #2 said the problem with medications not being available were the medications upon admission. EI #2 said when residents were admitted in the evening, the next morning they would not have all their medications for the medication pass. When asked why this was, EI #2 said the way their system was set up, if residents are not in the building by 5 PM so that the orders can be activated, the order is not transmitted to the pharmacy in time for the night time delivery. This deficiency was cited as a result of the investigation of complaint/report number AL00043096.

Based on observations, interviews, medical record review, and review of facility policies titled, Expired Medications and Medication Storage Controlled Medication Storage, the facility failed to ensure: 1) a stock bottle of expired Multivitamin was not left on a medication cart; and 2) liquid Lorazepam 2 mg (milligram)/ml (milliliter), belonging to Resident Identifier (RI) #s 70, 85, 56, 217, 110, 48 and 72 were stored in a permanently affixed compartment in the refrigerator. These deficient practices affected one of four medication carts observed, and six residents with their liquid Lorazepam stored in the refrigerator. Findings include: 21055 1) Review of a facility policy titled, Expired Medications, with a reviewed date of 10/01/2018, revealed the following: . PROCEDURE: . 2. Nursing inspects containers regularly for expiration dates. Nursing also does frequent inspections of Medication carts for expired drugs . On 02/16/2023 at 9:52 AM, the surveyor observed Employee Identifier (EI) #16, Licensed Practical Nurse (LPN)/Unit Manager, prepare medications. EI #16 searched the medication cart drawer and removed a container of Multivitamin (MVI), a stock medication. The container of MVI was dated with an open date of 08/20/2022, and the expiration date on the container was 01/2023. The surveyor asked EI #16 should the container of MVI be on the medication cart. EI #16 said no. When asked what could potentially occur when an expired medication is administered, EI #16 said there was a potential for the medication to lose its strength. The surveyor asked EI #16 what should happen when a medication/vitamin expires. EI #16 said it should be taken off the medication cart and discarded. On 02/21/2023 at 5:15 PM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). When asked where expired stock medications should be stored, EI #2 said there were bags and boxes in the medication room to put expired medications in. EI #2 said expired medications should be pulled out and never left in the medication drawer on the medication cart. The surveyor asked EI #2 when expired medications should be pulled off the medication cart. EI #2 said as soon as they have been identified as being expired. When asked who would be responsible for ensuring expired medications are not left on the medication cart, EI #2 said the nurse who is preparing to give the OTC (Over The Counter), the nurse management does random cart checks, and the pharmacy consultant does monthly checks as well. The surveyor asked EI #2, with those three processes in place, should there ever be an expired OTC medication on the cart. EI #2 said no. 2) Review of a facility policy titled, Medication Storage Controlled Medication Storage, dated 11/2017, revealed the following: . POLICY Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing center in accordance with federal, state and other applicable laws and regulations. PROCEDURES . 4. Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator . Resident Identifier (RI) #70 was admitted to the facility on [DATE]. RI #70's Physician Order Report dated 01/23/2023 - 02/23/2023, revealed RI #70 had an order for Lorazepam (Ativan) - Schedule IV concentrate 2 mg/ml give 0.25 ml by mouth every 2 hours as needed for anxiety/behaviors. RI #85 was admitted to the facility on [DATE]. RI #85's Physician Order Report dated 01/23/2023 - 02/23/2023, revealed RI #85 had an order for Lorazepam - Schedule IV concentrate 2 mg/ml administer 0.25 ml as needed for anxiety/restlessness. RI #56 was admitted to the facility on [DATE]. RI #56's Physician Order Report dated 01/23/2023 - 02/23/2023, revealed RI #56 had an order for Lorazepam - Schedule IV concentrate 2 mg/ml give 0.5 ml by mouth sublingual every 2 hours as needed for agitation. RI #217 was admitted to the facility on [DATE]. RI #217's Physician Order Report dated 01/25/2023 - 02/25/2023, revealed RI #217 had an order for Lorazepam - Schedule IV concentrate 2 mg/ml give 1 ml oral as needed for agitation. RI #110 was admitted to the facility on [DATE]. RI #110 had expired and was not in the facility. RI #110's Physician Order Report dated 01/25/2023 - 02/25/2023, revealed RI #110 had an order for Lorazepam - Schedule IV concentrate 2 mg/ml give 0.25 ml sublingual every 4 hours as needed for anxiety. RI #48 was admitted to the facility on [DATE]. RI #48 had expired and was no longer in the facility. RI #72 was admitted to the facility on [DATE]. On 02/23/2023 at 10:36 AM, the surveyor observed the medication room on the 3rd station with Employee Identifier (EI) #13. EI #13 unlocked the refrigerator and the surveyor observed boxes of Lorazepam 2 mg (milligrams)/ml (milliliters) belonging to RI #s 70, 85, 56, 217, 110, 48 and 72. The surveyor asked EI #13 should the boxes of Lorazepam be in a locked compartment affixed to the shelf in the refrigerator. EI #13 said she had seen it that way in several places she had worked, but she was not sure how it should be stored at this facility. On 02/23/2023 at 11:39 AM, the surveyor showed the Unit Manager, EI #16, the boxes of Lorazepam in the medication refrigerator. The surveyor asked EI #16 where the Lorazepam should be stored. EI #16 said in a locked box in the refrigerator. When asked why it should be stored in a locked box, EI #16 said for safety. On 02/23/2023 at 11:53 AM, the surveyor conducted an interview with EI #2, the Director of Nursing. When asked how the liquid Lorazepam in the refrigerator should be stored, EI #2 said in a locked refrigerator. The surveyor asked EI #2 if the Lorazepam should be stored in a permanently affixed compartment. EI #2 said not as long as it was behind two locks. On 02/24/23 at 10:13 AM, the surveyor conducted a telephone interview with EI #11, the pharmacist. When asked what Schedule of drug was Lorazepam, EI #11 said it was a Schedule IV. The surveyor asked how the liquid Lorazepam should be stored in the refrigerator. EI #11 said it should be in a separate, locked container in the refrigerator. This deficiency was cited as a result of the investigation of complaint/report number AL00043096.

Based on interview, medical record review, the 01/13/2023 diet order for Resident Identifier (RI) #50, the 01/24/2023 breakfast tray ticket for RI #50, and the facility's policy for Dining and Food Preferences, the facility failed to ensure RI #50 received large portions for breakfast on 01/24/2023. This had the potential to affect all residents receiving meals from the facility's kitchen. Findings Include: The facility's policy for Dining and Food Preferences, revised 9/2017, included the following: Policy Statement Individual dining, food, and beverage preferences are identified for all residents/patients. Procedures . 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, . and preferences. RI #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include End Stage Renal Disease, Gastro-esophageal Reflux Disease, Non-pressure Ulcer of Buttock Limited to Breakdown of Skin, Dementia, Anemia, Nausea with vomiting, and Vitamin Deficiency. RI #50's diet order, dated 01/13/2023, was for a Regular Diet with Special Instructions: Renal, 1500 ml (milliliters) per day fluid restriction, and large portions at breakfast. RI #50's Breakfast tray ticket for Tuesday, Menu Week 4, Day 24 on 01/24/2023 was reviewed and no instructions for large portions were found on the ticket. During an interview with Employee Identifier (EI) #4, the Registered Dietitian, on 01/24/2023 at 4:07 PM, it was confirmed that the Large Portions for Breakfast instruction was not printed on the breakfast tray ticket for RI #50. EI #4 said she did not understand why the ticket was not correct. EI #4 further said breakfast was important for RI #50 because it is the only meal that the resident really eats.

Based on interview, medical record review, the diet orders for Resident Identifier (RI) #60, RI #39, and RI #50, the tray tickets for breakfast, lunch, and dinner on 1/24/2023, and the facility's policies for Therapeutic Diets, Fluid Restriction, and Dining and Food Preferences; the facility failed to ensure RI #60, RI #39, and RI #50 received meals according to their therapeutic diet orders. This had the potential to affect all residents receiving meals from the facility's kitchen. Findings Include: The facility's policy for Therapeutic Diets, revised 9/2017, included the following: Policy Statement All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician . Definitions 'Therapeutic diet' is defined as a diet ordered by a physician . as part of the treatment for a disease or clinical condition. The facility's policy for Fluid Restriction, revised 9/2017, included the following: Policy Statement A fluid restriction will be implemented only as part of a therapeutic diet prescription. The facility's policy for Dining and Food Preferences, revised 9/2017, included the following: Policy Statement Individual dining, food, and beverage preferences are identified for all residents/patients. Procedures . 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order . 1.) RI #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Cognitive Communication Deficit. RI #60's diet order, dated 09/20/2022, was for a CCD (Consistent Carbohydrate Diet) Renal with Special Instructions: fluid restriction 1200 for Dietary 1 glass per tray 480 ml (milliliters) from Nursing NAS (No Added Salt). RI #60's breakfast, lunch, and dinner tray tickets for Tuesday, Menu Week 4, Day 24 on 01/24/2023 were reviewed. The tray tickets indicated RI #60 was to receive a CCD Renal diet with NAS and a 1000 ml fluid restriction. The breakfast tray ticket included 8 ounces (240 ml) 2 % (percent) Milk and 4 ounces (120 ml) Cranberry Juice as fluid. The lunch tray ticket included two 8-ounce glasses of water for 16 ounces (480 ml) and 6 ounces (177 ml) Decaffeinated Coffee or Tea as fluid. The dinner tray ticket included two 8-ounce glasses of water for 16 ounces (480 ml) and 6 ounces (177 ml) Decaffeinated Tea as fluid. Employee Identifier (EI) #4, the Registered Dietitian, was interviewed on 01/24/2023 at 4:07 PM. EI #4 said the tray tickets for RI #60 were wrong. EI #4 said the tray tickets should indicate a 1200 ml fluid restriction and one 8-ounce glass (240 ml) of fluid per tray. EI #4 said an additional 4 ounces (120 ml) of Cranberry Juice was later approved for breakfast, but the remaining liquid was to be used for snacks and medication pass. EI #6, the Medical Director, was interviewed on 01/25/2023 at 12:20 PM. EI #6 said the diet order instructions were not being followed for RI #60. 2.) RI #39 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. RI #39's diet order, dated 01/13/2023, was for a CCD with Special Instructions: Renal diet. RI #39's breakfast, lunch, and dinner tray tickets for Tuesday, Menu Week 4, Day 24 on 01/24/2023 were reviewed. The tray tickets indicated RI #39 was to receive a CCD diet. EI #4, the Registered Dietitian, was interviewed on 01/24/2023 at 4:07 PM. EI #4 said the tray tickets for RI #39 were wrong because Renal was not included. EI #6, the Medical Director, was interviewed on 01/25/2023 at 12:20 PM. EI #6 said, if the Renal diet was not included, RI #39 could get too much protein and sodium, which could cause further deterioration of the patient's kidney function. 3.) RI #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include End Stage Renal Disease, Dependence on Renal Dialysis, Dementia, and Other Disorders of Electrolyte and Fluid Balance. RI #50's diet order, dated 01/13/2023, was for a Regular Diet with Special Instructions: Renal, 1500 ml per day fluid restriction, and large portions at breakfast. RI #50's breakfast, lunch, and dinner tray tickets for Tuesday, Menu Week 4, Day 24 on 01/24/2023 were reviewed. The tray tickets indicated RI #50 was to receive a Regular diet. RI #50's tray tickets also included Needs High Potassium foods. EI #4, the Registered Dietitian, was interviewed on 01/24/2023 at 4:07 PM. EI #4 said the tray tickets for RI #50 were wrong because the resident was supposed to be on a Regular Renal diet with a 1500 ml fluid restriction. EI #4 said she did not know why the tray tickets indicated Needs High Potassium foods and further said that was concerning. EI #6, the Medical Director, was interviewed on 01/25/2023 at 12:20 PM. EI #6 said it is usually not the case for high potassium foods to be used in kidney disease. EI #6 further said we are trying to prevent excessive electrolytes and protein in the individual's system via the Renal diet and Dialysis.

Based on observation, interviews and review of FUNDAMENTALS OF NURSING POTTER PERRY, the facility failed to ensure a Certified Nursing Assistant (CNA) changed her gloves and performed hand hygiene before applying a clean brief during incontinent care for Resident Identifier (RI) #110. This affected RI #110, one of one resident observed for incontinent care. Findings include: A review of Fundamentals of Nursing Potter Perry 10th Edition Chapter 40 Pages 892 - 899 revealed . Bathing and Perineal Care . Equipment . Clean gloves, . (4) Remove soiled gloves and discard in trash a. wash back (1) Perform hand hygiene and apply clean pair of gloves . (5) . Clean, rinse and dry area thoroughly . Remove contaminated gloves . perform hand hygiene. RI #110 was admitted to the facility on [DATE]. On 01/25/2023 at 3:15 PM, Employee Identifier (EI) #10, a CNA was observed performing pericare for RI #110. EI #10 gathered her supplies, washed her hands and put on gloves. EI #10 cleaned RI #110's front and back, then with the same contaminated gloves, placed and secured a clean brief on RI #110. On 01/25/2023 at 3:25 PM, an interview was conducted with EI #10. EI #10 was asked when should she change her gloves during pericare. EI #10 said she should change between the dirty and clean task. EI #10 was asked what should she have done after she cleaned the back side of RI #110, and before placing the clean brief on RI #110. EI #10 said she should have removed the gloves, washed her hands, and put on a clear pair of gloves. EI #10 was asked if she changed her gloves, washed her hands after cleaning RI #110, before she placed the clean brief on RI #110. EI #10 said no. EI #10 was asked what would the harm be in using the same gloves to clean the peri area then place a clean brief on RI #110. EI #10 said cross contamination. On 1/26/2023 at 3:30 PM an interview was conducted with EI #3, Registered Nurse/Infection Preventionist. She was asked what was the policy for glove changes during pericare. EI #3 said they were to change after providing the pericare, they should wash their hands and put on new gloves, then place the clean brief. EI #3 was asked when should the CNA clean a resident, then with the same gloves, place the clean brief. EI #3 said they should not. EI #3 was asked when should the CNA wash their hands. EI #3 said before starting, between glove changes; she should have cleaned the resident, removed her gloves and washed her hands. EI #3 said the CNA should have put on new gloves then placed the clean brief. EI #3 was asked what was the harm in the CNA using the same gloves to clean a resident then placing a clean brief. EI #3 said it could contaminate the clean brief, it would be cross contamination.

Based on observations, interviews and record review, the facility failed to ensure: 1. A licensed staff member did not write on a dressing that Resident Identifier (RI) #44 was wearing during the wound care observation on 06/24/21, and a Certified Nursing Assistant (CNA) did not stand while feeding RI #79. This affected RI #44, one of two sampled residents observed during wound care and RI #79 one of four residents observed during dining. Findings include: RI #44 was admitted to the facility on [DATE]. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #44's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6-24-21 at 4:45 PM an observation was made of RI #44's sacral area during wound Care. Employee Identifier (EI) #2 was observed dating and initialing the wound dressing after it was placed on RI # 44. On 6/24/21 at 07:51 AM, an interview was conducted with EI #2. During the interview, EI #2 stated, she dated the wound dressing after it was placed on RI # 44's sacral area. EI #2 was asked what harm could have been caused to the resident. EI #2 stated that it could have possibly caused further injury to the pressure injury and now she realized that it was a dignity concern as well. 2. RI #79 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #79's Quarterly Minimum Data Set with an Assessment Date of 05/16/21, revealed RI #79 had a Brief Interview for Mental Status (BIMS) score of 00 indicating severely impaired cognitive status and was totally dependent on staff for eating. On 06/24/21 at 06:11 PM surveyor observed EI #5 standing while feeding RI #79 during mealtime. On 06/24/21 at 2:51 PM, an interview was conducted with EI #5. During the interview EI #5 was asked, were you supposed to stand or sit when feeding a resident. EI #5 replied, sit. EI #5 was asked, were you standing or sitting while feeding RI #79. EI #5 replied, standing. EI #5 was asked, how would it make you feel if someone was standing and feeding you. EI #5 replied, uncomfortable. On 06/25/21 at 7:56 AM, an interview was conducted with EI #2, a license staff member. EI #2 was asked, when feeding a resident should you sit or stand. EI #2 replied, sit for dignity issues. EI #2 was asked when should you stand. EI #2 replied, you should not stand unless the resident is standing.

Based on interviews, record review, review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, review of the facility's investigative file and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) # 149's cell phone was not taken by Employee Identifier (EI) # 17, Certified Nursing Assistant (CNA) without permission and for personal use. This deficient practice affected RI # 149, one of one sampled residents having their own cell phone in their room. Findings Include: The facility's policy titled, Abuse Neglect and Misappropriation of Property, with a last revised date of 05/08/19, revealed the following: . Definitions: Misappropriation of Resident Property: Is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . RI # 149 was admitted to the facility on [DATE] and readmitted on [DATE] and discharged from the facility on 05/28/2021. The ADPH Online Facility Report Incident dated 03/22/2021, identified . Incident Type .Misappropriation of Resident Property .Incident Detail . Narrative summary of Incident: Phone was plugged in another room. Researching the phone gallery indicated the phone belonged to (Name of resident) RI #149. Further investigation of Cash App, Facebook, Onshift, messaging, calls and cover photo indicates (Name of employee) EI #17 had been using RI #149 phone for personal reasons. The facility's investigative file dated 3/24/2021 included an interview with EI #17, regarding the cell phone located with her information and RI #149's information. EI #17 indicated she had used RI #149's phone saying that her phone was broken and she just used her cash app to get some gas to go home. When asked if RI #149 knew she used the resident's phone she said she didn't know. She wasn't sure if the resident was paying attention or not. When EI #17 was asked if she downloaded Cash App, she replied she did. When asked if she downloaded the onshift App, EI #17 replied she may have. EI #17 indicated she forgot to sign out of the phone and both phones sync (synchronize) which allowed messaging, emails, photos, and other information on RI #149's phone. On 06/23/2021 at 6:10 p.m., an interview was conducted with EI #18 , a CNA. EI #18 said, EI #19, another CNA found the resident's cell phone and she told EI #19 to take it to EI #1 the Administrator. EI #19 asked EI #18 how this phone get into this room. EI #18 told EI #19 she did not know. EI #18 said she took the cell phone to EI #1 and showed her how to find who the owner of the phone was. EI #18 said she also showed the EI #1 how to see who had been using the cell phone. EI #18 said the cell phone belong RI #149. EI #18 also said that the resident was unaware the cell phone was missing and rarely used the phone. On 06/23/2021 at 7:01 p.m., an interview was conducted with EI #19. EI #19 stated one day she was changing RI #91 and the phone was charging behind the resident's door. She (EI #19) took the phone to EI #1 after showing it to EI #18. EI #19 stated the resident had asked her to charge the cell phone, this is when she noticed the cell phone was missing. RI #149 told her somebody was getting the cell phone repaired. EI #19 stated she found the cell phone during her 4:00 p.m. rounds. On 06/24/2021 at 2:41 p.m., an interview was conducted with EI #1. EI #1 stated EI #19 found the resident's phone. EI #1 stated EI #19 said the cell phone was plugged into an outlet in another resident's room. EI #1 said EI #19 showed her the pictures of RI #149's family on the cell phone. EI #1 said, EI #19 asked EI #18 is she could show EI #1 the other pictures on the cell phone. This is when EI #1 said she became aware of the following information belonging to EI #17. EI #18 showed her (EI #1) pictures of EI #17 on the cover of the cell phone. EI #18 also showed EI #1 my profile and messages that stated, Having to call out. Woke up to my daughter throwing up with fever (EI #17 last name). EI # 1 stated this statement was what made her feel like EI #17 used the phone off of the facility's property. EI #1 stated then EI #18 showed her the apps. EI #1 stated one app was the PayActiv. This app showed you your pay stub and if you wanted to borrow money before payday you could. EI #1 stated she showed her OnShift. This was where the employees get their schedule. EI #1 stated the last thing EI #18 showed her was the Cash App. This was where you can pay others online. EI #1 stated that EI #17 admitted to her that she had used RI #149's cell phone because her phone had a broken screen. This deficiency was cited as a result of the investigation of complaint/report AL 346.

Based on interview, record review, and a review of facility the policy titled, Weight Monitoring the facility failed to ensure Resident Identifier (RI) #201's weight was obtained on admission and the week of 6/21/2021. This had the potential to affect one of four residents sampled residents whose weights were reviewed for potential weight loss. Findings Include: A facility policy titled Weight Monitoring with a last revised date of 7/11/18 revealed: . POLICY STATEMENT To identify residents who are at nutritional risk. Resident weight will be monitored weekly upon admission/readmission for four weeks . GUIDELINE: 1. New admissions and readmissions will be weighed upon admission and weekly X 4. The admission weight is the baseline weight (#1) and there are to be 4 more weekly weights obtained to total 5 consecutive weights. RI #201 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of documented weight revealed RI #201 weight was documented on 6/14/2021. No other weights were recorded. On 6/24/21 at 4:56 PM an interview was conducted with Employee Identifier (EI) #3, Registered Nurse (RN). EI #3 was asked, when were weights documented for EI #201. RI #3 replied, 6/14/21. EI #3 was asked, who performed weight measurements and when. EI #3 replied, either the Certified Nursing Assistants (CNA) or nurses together. It was done when it was flagged on Electronic Medication Administration Record (eMAR) and was usually on dayshift. EI #3 was asked, how did those staff know who to weigh and when. EI #3 replied, it flagged on eMAR and nurse delegated to CNA if appropriate. EI #3 was asked, did RI #201's weights flag on eMar. EI #3 replied, yes, on 6/9/21, 6/16/21, and 6/23/21. EI #3 was asked, what was documented on those days regarding those weights. EI #3 replied, it was documented as on hold by EI #11, RN all three times. EI #3 was asked, why would she have documented it as on hold. EI #3 replied, she did not know. On 6/25/21 at 7:22 AM an interview was conducted with EI #14, CNA. EI #14 was asked, who was responsible for weighing residents. EI #14 replied, the CNAs. EI #14 was asked, how did the CNAs know who to weigh. EI #14 replied, the Dietitian manager EI #7 gave them a list. EI #14 was asked, had RI #201 been on that list. EI #14 replied, he/she could have been on one of her off days. EI #14 was asked, had she ever weighed RI #201. EI #14 replied, no. EI #14 was asked, would RI #201 refuse to be weighed. EI #14 replied, she did not think so. On 6/25/21 at 9:54 AM an interview was conducted with EI #11, RN. EI #11 was asked, when was RI #201 weighed. EI #11 replied, the orders were to weigh on admission and then weekly times four weeks. EI #11 was asked, why was it documented on 6/9/21, 6/16/21, and 6/23/21 that the weight was on hold. EI #11 replied, she was told not to document weights and always document it as on hold; the eMar flags from order. EI #11 was asked, what was the process for weighing residents. EI #11 replied, the dietitian makes a list on Tuesday and gives it to each station, the nurses looked at the list and let CNAs now who to weigh, the CNAs take the resident to the dietitian's office where the scale was and weighed the resident and the dietitian documented it. EI #11 was asked, who was responsible to ensure residents were weighed as ordered by physician. EI #11 replied, it was a team effort. On 6/25/21 at 12:23 PM an interview was conducted with EI #7, Dietary Manager. EI #7 was asked, who was responsible for obtaining weights. EI #7 replied, nursing; the restorative nurse did previously, but they quit about three months ago. EI #7 was asked, when were residents weighed. EI #7 replied, new admits were weighed weekly for four weeks and then monthly unless triggered for weight loss and the weight loss residents stay weekly. EI #7 was asked, who compiled the list of residents who needed weights measured. EI #7 replied, she did. EI #7 was asked, why was RI #201 not on the list. EI #7 replied she had been working in the kitchen non-stop due to lack of staff. EI #7 was asked, when was RI #201 weighed. E I#7 replied, the only documented weight was June 14th. E I#7 was asked, when should RI #201 have been weighed. EI #7 replied, on admission and then weekly. EI #7 was asked, what was the current process for identifying residents who require weekly or monthly weights, communicating which residents need to be weighed, staff measuring resident's weight, and documenting weight. EI #7 replied, new admits were weighed upon admission and then weekly, if weights were stable week to week and after four weeks and resident had not gained/lost three percent in one week then they were changed to monthly; every resident should be weighed at least monthly; she made a list weekly by hall and posted it for nursing to obtain weight; nursing staff brought resident in wheelchair to dietary managers office and used wheelchair scale to measure weight; bedbound residents were weighed using a lift; the staff weighing the resident wrote it down or verbally told her and she entered the weights into the Electronic Health Record (EHR). On 6/25/21 at 3:18 PM an interview was conducted with EI #2, RN, Director of Nursing. EI #2 was asked, what was the facility's process for obtaining resident's weights. EI #2 replied, on admission all residents are weighed within 24 hours and then weekly for 4 weeks. EI #2 was asked, who obtained the weights. EI #2 replied, the CNAs. EI #2 was asked, how was that communicated with the CNAs. EI #2 replied, the dietitian made a list of residents that needed weekly weights and gave the list to the charge nurse who delegated to the CNAs. EI #2 was asked, what was the potential harm to a resident when not weighed but once within 16 days after being admitted . EI #2 replied, potential of unmonitored weight loss.

Based on observation, interview, and record review the facility failed to ensure Resident Identifier (RI) #22's tube feeding was administered as prescribed. This affected one of three residents sampled for tube feeding. Findings Include: RI #22 was admitted to the facility on [DATE] and last readmitted on [DATE]. RI #22 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Special Instruction: DIRECTIONS: GIVE 60 MILLILITER (ML) PER HOUR X 20 HOURS WITH FLUSH of 50 ML OF WATER PER HOUR X 20 HOURS VIA GASTRIC TUBE. START AT 10AM STOP AT 6AM DAILY . On 6/25/21 at 7:15 AM an observation was made of RI #22's tube feeding being administered via pump, [MEDICATION(S)] 1.5 infusing at 60ml/hour with 50 ml/hour water flush. On 6/25/21 at 7:34 AM an interview was conducted with EI #4, Licensed Practical Nurse (LPN). EI #4 was asked, what was the order for tube feeding for RI #22. EI #4 replied, it was [MEDICATION(S)] 1.5 at 60 ml/hour with a 50 ml flush of water ever hour; the dayshift nurse hangs and starts at 10 AM and night shift nurse stops and takes it down at 6 AM. EI #4 was asked, why was it not being administered as ordered. EI #4 replied, she did not know why EI #15, Registered Nurse hung a new bottle instead of taking it down. EI #4 was asked, who was responsible to ensure residents receive tube feeding as ordered. EI #4 replied, the nurse. EI #4 was asked, what was the potential harm for resident when tube feeding was not stopped at 6 am as ordered. EI #4 replied, the resident could vomit from stomach being too full and possibly aspirate. On 6/25/21 at 7:53 AM an interview was conducted with EI #15. EI #15 was asked, who was responsible to ensure tube feedings are administered as ordered. EI #15 replied, the nurse. EI #15 was asked, when should RI #22's tube feeding infuse. EI #15 replied, it stopped at 6 AM and restarted at 10 AM. EI #15 was asked, who was responsible for stopping tube feeding at 6 AM today. EI #15 replied, me. EI #15 was asked, why was it important to turn tube feeding infusion off at 6 AM and restart at 10 AM. EI #15 replied, it gave the body a chance to process the food. EI #15 was asked, why was it not stopped this morning at 6 AM. E I#15 replied, he got behind because there was a code last night. On 6/25/21 at 8:22 AM an interview was conducted with EI #2, RN, Director of Nursing. EI #2 was asked, when should tube feeding orders be followed. EI #2 replied, all the time. EI #2 what was the potential harm when a resident gets tube feeding beyond the ordered time. EI #2 replied, the resident could have increased residual and weight gain.

Based on observations, interviews, and a facility policy titled, Comprehensive Care Plans the facility failed to ensure a care plan was implemented for pain on Resident Identifier (RI) #9. A review of facility policy, last revised on 7-19-18, revealed, Comprehensive Care Plans . POLICY STATEMENT A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. This affected RI #9, one of one resident observed for pain management. RI #9 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/22/21 at 5:48 PM Resident Identifier (RI) #9 pushed call button and a Certified Nursing Assistant (CNA) answered the call light, RI #9 asked for pain medication. On 6/25/21 at 2:47 PM RI #9 stated it hurt in the shoulder, RI #9 was asked, how bad was your pain on a scale of 1-10, 10 being the most. RI #9 replied, about an eight. On 6/25/21 at 02:41 PM interview was conducted with Employee Identifier (EI) #18, Certified Nursing Assistant (CNA). EI #18 was asked, how long have you worked here. EI #18 replied, One year. EI #18 was asked, did RI #9 complain of pain. EI #18 replied, every evening about 5:00 or 5:30 PM. EI #18 was asked, when RI #9 called you into the room did RI #9 complain of pain. EI #18 replied, yes. EI #18 was asked, who did you tell. EI #18 replied, a nurse, whoever was on this hall and if they were not on the hall, she would tell the other nurse. EI #18 was asked, how often did the resident complain of pain. EI #18 replied, every evening RI #9 complained of pain. On 6/25/21 at 2:53 PM an interview was conducted with EI #4, Licensed Practical Nurse (LPN). EI #4 was asked, have you ever taken care of RI # 9. EI #4 replied, yes. EI #4 was asked, did RI #9 complain of pain. EI #4 replied, yes. EI #4 was asked, what did you do if resident had pain. EI #4 replied, RI #9 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/25/21 at 3:48 PM an interview was conducted with EI #19, LPN. EI #19 was asked, how long have you worked here. EI #19 replied, November. EI #19 was asked, what shift do you work. EI #19 replied, 6:00AM-6:00PM. EI #19 was asked, have you taken care of RI #9. EI #19 replied, yes. EI #19 was asked, did RI #9 ever complain of pain. EI #19 replied, yes. EI #19 was asked, how often did the resident have pain. EI #19 replied, every morning with regular meds. EI #19 was asked, what did you give RI #9 for pain. EI #19 replied, [MEDICATION(S)]. EI #19 was asked, how often did RI #9 get that for pain. EI #19 replied two times a day. EI #19 was asked, did you follow a care plan for RI #9's pain. EI #19 replied, she did not know if pain was on RI #9's care plan. On 6/25/21 at 4:20 PM an interview was conducted with EI # 3. EI #3 was asked, who was responsible for ensuring residents care plans are implemented and specific to resident's needs. EI #3 replied, Minimal Data Set (MDS) coordinators and Assistant Director of Nursing (ADON). EI #3 was asked, when should a resident with pain have interventions care planned to address pain. EI #3 replied, when pain was noted. EI #3 was asked, did RI #9 have care planned interventions that address the resident's pain. EI #3 replied, RI #9 did now. EI #3 was asked, when was that care plan implemented. EI #3 replied, 6/25/21. EI #3 was asked, why did RI #9 not have care planned interventions that addressed pain. EI #3 replied, because the MDS coordinator is human.

Based on interview, record review, and review of facility policy titled Dental Services the facility failed to assist Resident Identifier (RI) #201 to a scheduled dental appointment on 6/21/2021. Findings Include: A facility policy titled Dental Services with a last reviewed date of 6/15/18 revealed: POLICY STATEMENT The facility must assist residents in obtaining routine . dental care. GUIDELINE: . 5. The facility will assist the resident in making appointments and arranging for transportation to and from the dentist's office. RI #201 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 24-Hour Report Book revealed: for the date 6/17/21 and 6/20/21 that RI #201 had a dental appointment on Monday 21st and was to be ready at 11:00 AM. On 6/23/21 at 12:30 PM, RI #201's family reported to the surveyor that since the resident was admitted he/she has missed three dental appointments. An immediate observation was made of RI #201's oral cavity. RI #201 was observed to have two loose teeth on the bottom. On 6/23/21 at 6:18 PM an interview was conducted with Employee Identifier (EI) #11, Registered Nurse. EI #11 was asked, who was responsible for scheduling appointments and transportation for residents. EI #11 replied, the nurse who was first notified of the need scheduled appointments as needed. EI #11 was asked, where was it documented. EI #11 replied, it was documented in nursing notes and 24-hour report, it was also reported during walking rounds. EI #11 was asked, how would surveyor know which appointments were scheduled for RI #201. EI #11 replied, it would be in nursing notes or 24-hour report. EI #11 was asked, did RI #201 have any appointments in 24-hour report book. EI #11 replied, on 6/20/21 the book has recorded, RI #201 appointment on Monday June 21. Dentist appointment. Transportation service will pick up and that is the only appointment in the book except today's reschedule 6/28/21. EI #11 was asked, when did RI #201 miss a dental appointment. EI #11 replied, he/she did today because transportation service never came. On 6/24/21 at 3:30 PM an interview was conducted with EI #12, Licensed Physical Therapist Assistant. EI #12 was asked, what could she report about RI #201's dental appointment. RI #12 replied, on 6/21/21, she knew about the appointment and RI #13, Certified Occupational Therapist Assistant (COTA) was helping with bath, the nurse was helping with changing sacral dressing, and the family was bringing clothes; she thought, transportation service had been scheduled for the appointment at 1:00 and one hour before was their standard arrival time. Transportation service arrived at 11:15 and would not wait. The nurse, tried to call to get them to come back, but was not successful. EI #12 added, RI #201 would have been ready by 12:00. On 6/24/21 at 3:34PM an interview was conducted with RI #13, COTA. RI #13 reported, she assisted with RI #201's bath before the appointment, transportation service arrived at 11:15am and RI #201 was not ready, so the transportation service left. On 6/25/21 at 9:25 AM an interview was conducted with a representative of the transportation service. The representative was asked, what was the schedule for pickup on 6/21 for RI #201. The representative reported, 11:15 pickup time for 12:15 appointment. On 6/25/21 at 3:26 PM an interview was conducted with EI #2, RN, Director of Nursing. EI #2 was asked, what was the facility's policy for ensuring residents were able to go to the dentist as needed. EI #2 replied, the facility had to assist in ensuring the resident gets to the appointment. EI #2 was asked, what happened with RI #201's dental appointment on 6/21/21. EI #2 replied, she was on the hall Monday and transportation service was there and she told the nurse that the transportation service was there; she went to check on the resident's status and she was dressed and in the bed. EI #2 was asked, when residents are scheduled for an appointment and has transportation service pickup, what was the facility's procedure. EI #2 replied, the appointment is normally 24-Hour Report book for when they will be picked up; the CNAs get them up early and 45 minutes to an hour before the scheduled pick-up time staff have the resident in the lobby ready because we have a history of transportation service leaving our patients. EI #2 was asked, why did some staff think the pickup was at 12:00 when it was written in book that it was at 11:00. EI #2 replied, the nurse assigned to RI #201's care was not a regular nurse in that area, a charge nurse called out, and the unit supervisor was not available.

Based on observation, interviews, and a review of a facility policy titled, Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier(EI) #5, Certified Nursing Assistant (CNA) washed her hands before feeding Resident Identifier (RI) #90. This affected RI #90, one of four residents sampled for meal observations. Findings include: A review of the facility's policy, Handwashing/Hand Hygiene revised August 2019, includes, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non antimicrobial) and water for the following situations: . p. Before and after assisting a resident with meals; . RI #90 was admitted on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/21 at 6:19 PM, EI #5, CNA was observed feeding another resident, taking the tray and placing it on a dirty cart without washing or sanitizing his/her hands before going into RI #90's room. EI #5 then started to feed RI #90. On 6/23/21 at 6:21 PM an interview was conducted with EI #5. EI #5 was asked, how long have you worked here. EI #5 replied, six years. EI #5 was asked, when did you wash your hands before entering RI #90's room to feed RI #90. EI #5 replied, before the trays came out. EI #5 was asked, did you wash or sanitize your hands before going into RI #90's room. EI #5 replied, no. EI#5 was asked, what can happen if you do not wash your hands before feeding a resident. EI #5 replied, cross contamination. On 6/25/21 at 7:56 AM an interview with EI #2, Director of Nursing (DON) was conducted. EI #2 was asked, when should you perform hand hygiene. EI#2 replied, before and after you touch a resident and if your hands are soiled. EI #2 was asked, when should you perform hand hygiene before feeding a resident. EI #2 replied, you should perform hand hygiene before doing anything to the resident.

Based on observations, interviews, and review of the facility's policy titled, Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), washed and/or sanitized her hands after she removed gloves, before putting on a new pair of gloves. The facility further failed to ensure EI #2, a Registered Nurse (RN) did not place medications into her bare hands before she put them into a medication cup and did not administer medication that had been dropped in the medication cart. These deficient practices affected Resident Identifier (RI) #1, RI #2, and RI #3, three of seven residents observed for the medication administration. Findings include: 1) The facility's policy titled, Handwashing/Hand Hygiene, revised August 2015, documented Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62%alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . m. After removing gloves . During medication pass observation on 8/18/2020 at 9:21 AM, EI #1, an LPN did not wash or sanitize her hands after she removed her gloves before putting on a new pair of gloves when she administered medications to RI #1. In an interview on 8/18/2020 at 9:34 AM, EI #1, an LPN was asked what should be done when gloves are removed. EI #1 said sanitize your hands. When asked if she did that, EI #1 replied no. On 8/18/2020 at 1:25 PM, EI #3, the Infection Control Nurse stated the staff should perform hand hygiene after taking gloves off and before putting gloves on. 2) During medication pass observation on 8/18/2020 beginning at 10:13 AM, EI #2, a RN was observed to prepare RI #2's and RI #3's medications by popping them from the blister pack into her bare hands before she placed them into a medication cup. One of the medications for RI #3 fell into the medication cart and EI #2 picked it up, placed it into the medication cup and administered it to RI #3. In an interview on 8/18/2020 at 11:45 AM, EI #2, a RN stated the proper way was to pop the medications into a medication cup and not her hand. When asked if she had picked the medication up that fell into the medication cart and administer it to RI #3, EI #2 said she had because she didn't want to waste the medication. EI #2 said she should have popped another pill to administer to RI #3. On 8/18/2020 at 1:25 PM, EI #3, the Infection Control Nurse, was asked if it was acceptable to pop medications out of the package into your hand and then place it in the medication cup to administer to a resident. EI #3 replied, only if that person has on gloves. When asked if it was acceptable to drop a medication into the drawer of the medication cart, retrieve it, and administer it to the resident, EI #3 replied no.

Based on record review and interviews, the facility failed to notify Resident Identifier (RI) #34's physician when she experienced a change in condition on [DATE] and [DATE]. RI #34 experienced a change in condition when she had an elevated temperature of 102 F (Farenheit) on [DATE] and 101.8 F on [DATE], in addition to being "hot and clammy." RI #34 was transported to the hospital on [DATE] and was admitted with a [DIAGNOSES REDACTED]. On [DATE] and [DATE], RI #36 began to experience a change in condition with an elevated temperature and blood sugar. Later on in the afternoon of [DATE], RI #36's niece had to insist that the resident be tranferred to the local hospital for evaluation. RI #36 was transferred and admitted to the local hospital on [DATE] with [DIAGNOSES REDACTED].#36, two of 11 residents sampled for change of condition. Findings include: 1) RI #34 was initially admitted to the facility on [DATE] and expired, at the facility, on [DATE]. Her diagnoses, as of [DATE], included Altered Mental Status,[MEDICAL CONDITION], Respiratory Disorder, Traumatic Shock, Acute [MEDICAL CONDITION], and Urinary Tract Infection. RI #34's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], noted the resident as having short-term memory problems, no long-term memory problems, and modified independence for daily decision-making. RI #34 was noted as requiring total assistance with Activities of Daily Living (ADLs) and was incontinent of bowel and bladder. [DIAGNOSES REDACTED]. On [DATE] at 8:00 PM, a notation was recorded on a "Resident Progress Note" by Employee Identifier (EI) #4, Registered Nurse (RN), indicating RI #34's status: "...skin hot & clammy. Air conditioner on & pt (patient) covered in blanket. Temp (temperature) 102 ..." There was no notation indicating the physician was notified of RI #34's condition. On [DATE] at 2:45 PM, a notation was recorded on a "Resident Progress Note" by EI #4, indicating RI #34's status: "...T (temperature) - 101.8, P (pulse) - 116, R (respiration) - 50 ...Tylenol 500 mg (milligrams) given for fever ...Note Hx (history) of [MEDICAL CONDITION] fib (fibrillation) irregular heartbeat noted." There was no notation indicating the physician was notified of RI #34's condition. On [DATE] at 7:10 AM, a RN noted on the "Resident Progress Notes" indicating RI #34's status: "... Res (resident) was noted to be unresponsive @5:30 AM. Res v/s (vital signs) ,[DATE] b/p (blood pressure), 48 resp (respiration), 101.3 Temp, 140 pulse ... M.D. (physician's name) notified @ 5:35 A.M. writer instructed to call residents husband to find out if he wanted resident to be transported to Hosp (hospital) for eval (evaluation). Writer spoke with (RI #34's husband's name) @ 5:40 AM ... he said to send res (resident) out to be evaluated ... " Review of the facility's "Patient Transfer Form" dated [DATE], indicated RI #34 was transported to a local hospital due to, "...rapid respirations, temp. 101, lethargic." Hospital records indicated RI #34 was admitted on [DATE] with the following Diagnoses: [REDACTED]. RI #34 was discharged back to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:30 AM, the surveyor interviewed EI #4 by telephone. EI #4, a former employee, confirmed that she worked at the facility during August of 2010 on the ,[DATE] shift. EI #4 remembered on [DATE], RI #34 was "running a fever" and had "abnormal" vital signs, as well as rapid respirations. EI #4 stated she could not remember the specific circumstances on [DATE]. EI #4 recalled mentioning RI #34's signs and symptoms to the "head nurse," but could not remember who was on duty at the time. EI #4 stated she told the supervisor because she was "...uncomfortable with the situation..." and "...thought it was important to follow up." EI #4 remembered asking RI #34 if the fever was abnormal for her, but recalled RI #34 could not express herself clearly. She then recalled asking RI # 34's husband, who responded that RI #34 had not been feeling well "lately". EI #4 stated she requested the "head nurse" to "go back and check" on RI #34. A review of the "Daily Staffing Assignments" for [DATE] and [DATE] revealed, EI #5 was the Registered Nurse Supervisor for the ,[DATE] shift on both days. On [DATE], at 2:50 PM, the surveyor interviewed EI #5. EI #5 reported she remembered RI #34 being at the facility and remembered when she went to the hospital in August of 2010. EI #5 stated she did not specifically remember RI #34's condition on [DATE] or [DATE]. After requesting EI #5 review the Nurse's Note from [DATE], the surveyor asked EI #5, "Do you remember (EI #4) telling you she was worried about (RI #34's) fever and symptoms?" EI #5 responded, "No." After requesting EI #5 review the Nurse's Note from [DATE], the surveyor asked EI #5, "Do you remember (EI #4) telling you she was worried, again, about (RI #34's) fever and symptoms?" EI #5 responded, "No." EI #5 was asked, "Do you see on ,[DATE] or ,[DATE] where it was documented that another staff member was told about (RI #34's) condition?" EI #5 responded, "No." Pertaining to the above interview: The surveyor asked EI #5, "Do you see any symptoms on that note for ,[DATE] that would cause concern?" EI #5 responded, "Yes. Temp 102 ...clamminess." EI #5 was asked, "Do you see any symptoms on that note for ,[DATE] that would cause concern?" EI #5 responded, "Yes. Temp 101.8 and respirations of 50, pulse 116." The surveyor asked, "Under these circumstances, what would you have done?" EI #5 responded she would have called the doctor and told him or her the vital signs. EI #5 also stated, "She (EI #4) should have notified" the physician and EI #5 confirmed she did not see where on either day the physician was notified of RI #34's condition. The surveyor asked, "Would (EI #4) have had to consult with you, as being the RN in charge, before calling the doctor?" EI #5 responded, "No, she could use her own nursing judgment." 2) On [DATE], the State Agency received an anonymous complaint dated [DATE] which documented " ... (RI #36) who receives her nutrition via a tube in her stomach was sent to the hospital with dehydration. Her niece had to insist that she be sent to the hospital ... ." Resident Identifier (RI) #36 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In a phone interview on [DATE] at 6:00 PM, RI #36's niece stated that for two days she reported to the nursing staff that RI #36 was not coherent and she feared the resident had another stroke. RI #36's niece stated that she had to threaten the staff to call the doctor before the nursing staff sent the resident to the hospital. According to RI #36's niece, she spoke with two different nurses on [DATE] and [DATE] and they both told her they were waiting on the physician to call back. RI #36's niece stated that she insisted they call the doctor and that she wasn't going anywhere until RI #36 was transferred to the hospital for evaluation. A review of RI #36's "Resident Progress Notes" documented: "[DATE] 6:30pm ... Resident is resting quietly in bed at this time in (no) acute distress ... niece visited this evening and had some concerns about resident not being coherent, nurse assessed resident, she was responsive, alert + (and) oriented to name, v/s (vital signs) were Bp (blood pressure) - ,[DATE], Temp (temperature) 97.0, Resp (respiration) - 18, pulse 98 O2 (oxygen) sat (saturation) - 93%, B/S (blood sugar) 375, 10 units of Insulin administered, will continue to monitor ... [DATE] 7pm ... B/S is 200, Resp - 20, pulse 92, Temp 97.2 Bp ,[DATE], O2 sat 93%, will continue to monitor ... [DATE] 0400 (4:00 AM) ... Resident in bed (with) HOB (head of bed) (up) at 45(degree), no s/s (signs/symptoms) of distress noted. Vital sign BP = ,[DATE], P (pulse) 100 R (respiration) = 20 T (temperature) = 102.9 O2 sat 90 via room air. Medicated (with) [MEDICATION NAME] ,[DATE]mg (milligram) per [DEVICE]. Vital sign recheck at 5AM this time temp decreased to 101, BP = ,[DATE] P = 102 and O2 sat 90%. Call light in reach. Will cont (continue) to monitor ... ." In an interview on [DATE] at 4:55 PM, Employee Identifier (EI) #20, a Registered Nurse (RN) acknowledged that she wrote RI #36's progress note dated [DATE] 4:00 AM. The state surveyor asked EI #20, what was going on with RI #36. According to EI #20, she stated that when she came in on the ,[DATE] shift, she had gotten a report from EI #19 that RI #36 had been running a temperature, the doctor had been called and a urine specimen had been collected. EI #20 stated she checked on RI #36 every two hours but she only documented one time. The state surveyor then asked EI #20, how was RI #36. EI #20 answered that RI #36 was not in any distress, she was only running a high temperature of 102.9. EI #20 commented that she medicated RI #36 for her elevated temperature and it came down a little to 101. The state surveyor asked EI #20, if she notified the physician. EI #20 replied, "no because no need to notify physician she (RI #36) was getting better at that time and the 1st shift nurse (EI #19) had called him, he was already aware." A review of the facility's "24 Hour Report of Resident Change in Condition" dated [DATE] documented " ... (RI #36) ... Monitor V/S + (and) B/S ... ." The column labeled "MD Notified" was left blank. The "24 Hour Report of Resident Change in Condition" dated [DATE] documented " ... (RI #36) ... Monitor (change) in status V/S ... (local hospital) [DATE] ... ." The column labeled "MD Notified" was left blank. A review of RI #36's "Resident Progress Notes" documented: "[DATE] 7A ... Resident is (up) at 45(degree) in bed in (no) acute distress, resp is even, non labored, skin is warm/dry, v/s Bp ,[DATE], pulse 99, Temp 101, respiration 18, O2 sat 93%, B/S 375. Insulin 10 units administered, will continue to monitor ... [DATE] 9AM ... Resting quietly in bed in (no) acute distress, denies any pain or discomfort v/s are Bp ,[DATE], P - 97, Temp - 102, Resp 20 B/S 371 O2 sat 93%. Tylenol 500 mg administered via [DEVICE], (local hospital) paged, will continue to monitor ... [DATE] 11:30 AM ... Resting in bed at this time, resp is even non labored, skin is warm and dry to touch. V/S are Bp - ,[DATE], P - 95, Temp 98.1, Resp - 18 O2 sat 96%, B/S - 281, unable to reach (local hospital), ADL (activities of daily living) care provided, call light within reach ... [DATE] 1:45 (PM) ... Physician (name) notified, ordered for chest x-ray, CBC (complete blood count) and UA (urinalysis) and to place on doctor's list for Monday and continue to monitor closely ... [DATE] 3pm ... Family requested for patient to be sent to hospital (name), patient is transferred to (local hospital) via ambulance at 2:55pm for alter status ... ." In an interview on [DATE] at 12:22 PM, EI #19, a Licensed Practical Nurse (LPN) was asked, did she recall caring for RI #36. EI #19 answered, "Yes I do." The state surveyor asked EI #19, why was RI #36 sent to the hospital on [DATE]. EI #19 replied, "The family insisted for her to be sent out." EI #19 commented that RI #36 family said RI #36 use to be more coherent than what she was. The state surveyor asked EI #19, what did she do. EI #19 responded, "I told her (RI #36's niece) I did the (assessment), v/s looking good I said we could do some lab work and see what it says but the family said no she wanted her (RI #36) send out because she (RI #36 niece) thought she (RI #36) had a stoke but I said it wasn't a stoke according to her v/s, it wasn't anything major." The state surveyor then asked, what did RI #36's niece say when she reported this to her. EI #19 answered, "She insisted that she wanted her out, then I told the supervisor (EI #21) and she said if the family wanted her to go out, send her out ... ." EI #19 explained that RI #36's blood sugar of 375 was not normal and that she only administered Insulin per the Sliding Scale. EI #19 stated that she would only have to call the physician if RI #36's blood sugar is greater than 400. EI #19 further explained that when she came in on the 2nd shift on Saturday ([DATE]) she started monitoring RI #36 because the resident had an elevated temperature and blood sugar. According to EI #19, then on Sunday ([DATE]), RI #36 was still being monitored for an elevated temperature and blood sugar. Even though RI #36's niece insisted that the resident be sent to the hospital, and the resident had an elevated temperature and blood sugar, EI #19 stated that she reported to RI #36's niece that RI #36's vital signs were not bad and the facility should continue to monitor the resident's condition. The state surveyor asked EI #19, had she attempted to notify a doctor before speaking with EI #22 at 1:45 PM. EI #19 answered "No." The state surveyor then asked EI #19, if there was a need to notify the physician when RI #36 experienced an elevated temperature and she answered "yes ... ." When the state surveyor asked EI #19, was there a change in RI #36's condition, EI #19 replied "Not a big change." The state surveyor then asked, why did it take RI #36's family to insist that the resident be sent out to the hospital. EI #19 replied, "According to my nursing judgment I wanted to do lab work, thought it was an infection we could treat because BS (blood sugar) and temp rising." According to the local hospital report dated [DATE], RI #36 arrived at the emergency room at 3:23 PM. RI #36's "History and Physical" documented " ... Chief Complaint: Altered mental status with generalized weakness worse on the right side ... History of Present Illness: The patient ... with a history of [MEDICAL CONDITION] with residual weakness worse on the right side ... On the morning of admission, she was reported to have continued symptoms of slurred speech and again just not acting herself. Her glucose level was 375 at the nursing home and was treated with sliding scale insulin. She had decreased verbal responses. Caregiver, (RI #36's niece), requested that she be transferred to (local hospital) for evaluation. On arrival to (local hospital), she was found to be hypernatremic, dehydrated and still hyperglycemic (increase blood sugar) ... ." In an interview on [DATE] at 6:15 PM, EI #17, the Medical Director and RI #36's physician, was asked, when should the physician have been notified regarding RI #36's change in condition. EI #17 stated that when RI #36 spiked a temperature of 102, the doctor should have been notified. The facility's policy titled "Condition Change of a Resident" with a revision date of [DATE], documented " ... Resident change of condition is identified for proper treatment implementation. The physician is informed of resident events and/or change in resident's condition ... Significant Change A decline or improvement in a resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions ... Impacts more than one area of the resident's health status ... ." The facility's policy titled "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" with a revision dated [DATE] documented " ... Fever ... Immediate( High alert - within 1 hour) New onset temperature greater than 104 F regardless of any other symptoms, or temperature greater than 101 F with symptoms (unless under treatment already or physician already aware ... ." This deficiency is cited as a result of the investigation of complaint/report number AL 187.

Based on record review and interviews, the facility delayed treatment of [REDACTED].#34's physician that the resident experienced a change in condition on [DATE] and [DATE]. RI #34 experienced a change in condition when she had an elevated temperature of 102 F (Farenheit) on [DATE] and 101.8 F on [DATE], in addition to being "hot and clammy." RI #34 was transported to the hospital on [DATE] and was admitted with a [DIAGNOSES REDACTED]. Findings include: 1) RI #34 was initially admitted to the facility on [DATE] and expired, at the facility, on [DATE]. Her diagnoses, as of [DATE], included Altered Mental Status,[MEDICAL CONDITION], Respiratory Disorder, Traumatic Shock, Acute [MEDICAL CONDITION], and Urinary Tract Infection. RI #34's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], noted the resident as having short-term memory problems, no long-term memory problems, and modified independence for daily decision-making. RI #34 was noted as requiring total assistance with Activities of Daily Living (ADLs) and was incontinent of bowel and bladder. [DIAGNOSES REDACTED]. On [DATE] at 8:00 PM, a notation was recorded on a "Resident Progress Note" by Employee Identifier (EI) #4, Registered Nurse (RN), indicating RI #34's status: "...skin hot & clammy. Air conditioner on & pt (patient) covered in blanket. Temp (temperature) 102 ..." There was no notation indicating the physician was notified of RI #34's condition. On [DATE] at 2:45 PM, a notation was recorded on a "Resident Progress Note" by EI #4, indicating RI #34's status: "...T (temperature) - 101.8, P (pulse) - 116, R (respiration) - 50 ...Tylenol 500 mg (milligrams) given for fever ...Note Hx (history) of [MEDICAL CONDITION] fib (fibrillation) irregular heartbeat noted." There was no notation indicating the physician was notified of RI #34's condition. On [DATE] at 7:10 AM, a RN noted on the "Resident Progress Notes" indicating RI #34's status: "... Res (resident) was noted to be unresponsive @5:30 AM. Res v/s (vital signs) ,[DATE] b/p (blood pressure), 48 resp (respiration), 101.3 Temp, 140 pulse ... M.D. (physician's name) notified @ 5:35 A.M. writer instructed to call residents husband to find out if he wanted resident to be transported to Hosp (hospital) for eval (evaluation). Writer spoke with (RI #34's husband's name) @ 5:40 AM ... he said to send res (resident) out to be evaluated ... " Review of the facility's "Patient Transfer Form" dated [DATE], indicated RI #34 was transported to a local hospital due to, "...rapid respirations, temp. 101, lethargic." Hospital records indicated RI #34 was admitted on [DATE] with the following Diagnoses: [REDACTED]. RI #34 was discharged back to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:30 AM, the surveyor interviewed EI #4 by telephone. EI #4, a former employee, confirmed that she worked at the facility during August of 2010 on the ,[DATE] shift. EI #4 remembered on [DATE], RI #34 was "running a fever" and had "abnormal" vital signs, as well as rapid respirations. EI #4 stated she could not remember the specific circumstances on [DATE]. EI #4 recalled mentioning RI #34's signs and symptoms to the "head nurse," but could not remember who was on duty at the time. EI #4 stated she told the supervisor because she was "...uncomfortable with the situation..." and "...thought it was important to follow up." EI #4 remembered asking RI #34 if the fever was abnormal for her, but recalled RI #34 could not express herself clearly. She then recalled asking RI # 34's husband, who responded that RI #34 had not been feeling well "lately". EI #4 stated she requested the "head nurse" to "go back and check" on RI #34. A review of the "Daily Staffing Assignments" for [DATE] and [DATE] revealed, EI #5 was the Registered Nurse Supervisor for the ,[DATE] shift on both days. On [DATE], at 2:50 PM, the surveyor interviewed EI #5. EI #5 reported she remembered RI #34 being at the facility and remembered when she went to the hospital in August of 2010. EI #5 stated she did not specifically remember RI #34's condition on [DATE] or [DATE]. After requesting EI #5 review the Nurse's Note from [DATE], the surveyor asked EI #5, "Do you remember (EI #4) telling you she was worried about (RI #34's) fever and symptoms?" EI #5 responded, "No." After requesting EI #5 review the Nurse's Note from [DATE], the surveyor asked EI #5, "Do you remember (EI #4) telling you she was worried, again, about (RI #34's) fever and symptoms?" EI #5 responded, "No." EI #5 was asked, "Do you see on ,[DATE] or ,[DATE] where it was documented that another staff member was told about (RI #34's) condition?" EI #5 responded, "No." Pertaining to the above interview: The surveyor asked EI #5, "Do you see any symptoms on that note for ,[DATE] that would cause concern?" EI #5 responded, "Yes. Temp 102 ...clamminess." EI #5 was asked, "Do you see any symptoms on that note for ,[DATE] that would cause concern?" EI #5 responded, "Yes. Temp 101.8 and respirations of 50, pulse 116." The surveyor asked, "Under these circumstances, what would you have done?" EI #5 responded she would have called the doctor and told him or her the vital signs. EI #5 also stated, "She (EI #4) should have notified" the physician and EI #5 confirmed she did not see where on either day the physician was notified of RI #34's condition. The surveyor asked, "Would (EI #4) have had to consult with you, as being the RN in charge, before calling the doctor?" EI #5 responded, "No, she could use her own nursing judgment." This deficiency was written as the result of the investigation of complaint/report number AL 187.