Every finding on record at Sage Park Austin

Based on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 ancillary serving kitchen reviewed for kitchen sanitation.1. The facility failed to ensure DSA B maintained a sanitary environment in the ancillary serving kitchen on 07/14/2026. 2. The facility failed to ensure DSA B did not touch residents' food without performing proper hand hygiene on 07/14/2026.3. The facility failed to maintain an updated food handler's certification for DSA B. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.Findings include:Observation of the ancillary serving kitchen on 07/14/2026 at 9:38 a.m., revealed debris including silverware dust and dust found under a wheeled cart behind the door leading to the hallway. Also observed in the ancillary serving kitchen area were 5 table knives, one black cloth napkin, and a small black butter container lying next to DSA B's slide on sandals on the floor. No sanitation/cleansing solution were observed in 2 sanitizing buckets located in the ancillary serving kitchen. There was not any other sanitizing buckets located in the ancillary serving kitchen. The grouting throughout the kitchen area was dark grey / black in color and the floor was covered in a film of dust and food debris. Observation of the ancillary serving kitchen on 07/14/2026 at 12:00 p.m., revealed DSA B did not wash her hands after entering the ancillary serving kitchen area with the hot cart prior to donning (put on) gloves. No serving pan lids/covers were utilized to maintain temperature or prevent debris or dust from entering. Further observation revealed DSA B sanitized her hands prior to retrieving plates. She was repeatedly touching the hot cart door and hamburger buns of ready-to-eat items without proper hand hygiene and changing gloves. Also, she was touching fried fish and grilled chicken breasts with the same gloves.During an interview on 07/15/2026 at 12:20 p.m. with DSA E, she stated that she was working in this facility since this facility was new and opened about 30 years ago. She stated that the food serving area was cleaned every day and every shift. She stated she mops, cleans the warmer station, and toasters and she wipes off the counter tops twice a day; before residents' food to be delivered and after all residents left the dining area. DSA E stated that she uses the facility's approved sanitizers to clean the serving area. She stated that the uses, a little tester to test the food to be served for its temperature. DSA E stated that she has hand sanitizer to sanitize her hands when the gloves are removed and she washes her hands before starting to serve the residents' meals. DSA E stated that if she receives the serving area in unsanitary conditions, she reports it to her supervisor. She stated that not following hand hygiene and serving food without following infection control to the residents could make residents ill. Record review of DSA B staff file reflected not having a copy of food handler's certification. During an interview on 07/15/2026 at 1:30 PM with ED, he stated: DSA B food handlers expired back in April or May 2026. ED stated DSA B is updating the food handler's certification today, 07/15/2026. Record review of DSA B food handlers certification reflected to be dated 04/04/2024 and stated, expires in two years indicating the certification expired 04/04/2026. Record review of DSA B updated food handlers certification reflected to be dated 07/15/2026 and stated, expires in two years.Record review of DSA B job duties Wait Staff Culinary Department, with revised date 07/23/2024, reflected, Wait Staff Associates participate in providing a total quality dining service program for our residents. This includes a thorough understanding of food items available, resident dietary needs, proper serving guidelines, cleanliness expectations, and special diets. Assist with duties to ensure community meets sanitation standards.During an interview on 07/15/2026 at 4:30 p.m. with DSA F he stated that he had been working in the facility for 5 years, he was always serving meals for the residents all the time. His job was cooking food and dessert for the residents. He stated that he made sure that the residents were getting the right food and drinks according to their diet and doctor's order. He stated that he always clarifies the diet with the nurses for example; if someone who has diabetes and requests dessert follows the diet because it can make them very sick. DSA F stated that the steps before and during serving meals are washing hands first, putting gloves on, checking the right temperature of serving food. He stated it is important not to touch residents' food with hands or gloves, but to use utensils. DSA F stated he is responsible for cleaning the serving area and he usually takes pictures after he cleans the area. He stated if he received the serving area not cleaned, he reports it to his boss. He stated that that unsanitary serving area can make resident sick.During an interview on 07/16/2026 at 9:09 a.m. with DSS, he stated he was regional Dining Service Specialist. He stated he had been working there for 3 weeks. He stated that all residents' food is cooked in the main kitchen and was then sent to the ancillary serving area where one dining service specialist serves food for the residents; DSS stated that the dietary staff were expected to clean the serving area and the dining area. He stated that the proper steps of serving food to residents was to use scoops, gloves, make sure there was no cross contamination, not handle any food by hand/no bare hand contact. He stated staff were expected not to touch residents' food with the gloves that previously touched kitchen equipment or appliances to prevent cross contamination, or residents can get sick. He stated that residents could get nausea, diarrhea which eventually could cause malnutrition and dehydration. All cleaning/sanitizing supplies were stored in the main kitchen area. He stated that the executive chef was the person responsible for making sure staff clean and sanitizing kitchen, serving, and dining areas. He stated that not cleaning the kitchen could potentially cause transferring of bacteria. During an interview on 07/16/2026 at 9:14 a.m. with the EC, he stated the following: that food handlers' training went over food safety, proper handling, and when and who to report illnesses. EC stated the food handlers are responsible for keeping track of food handler's certification. EC stated it affects residents' quality of life if kitchen staff do not have an updated food handler's certification. EC stated it could affect the residents by making the residents not feel well, and they might not want to eat the food if kitchen staff do not have a food handlers' certification with the updated knowledge. EC stated it is important to keep the food handler's certification up to date every two years, so kitchen staff will know the new laws and any changes that may happen or apply to nursing homes. During an interview on 07/16/2026 at 9:31 a.m. with the EC, he stated that it was usually one staff member to serve food in the ancillary serving area to the residents. He stated that sometimes it could be 2 staff overlap because one staff was to deliver the food from the main kitchen. He stated the servers were expected to safely serve food for the residents. EC stated that the dietary services have 3 cooks in the kitchen, 2 dishwashers and 2 servers He stated that all servers were certified. The servers were expected to safely serve food for the residents. They are expected to keep the food serving area clean and in sanitary condition. EC stated that staff were expected to properly wash hands, to wear hair nets, and to properly use gloves. He stated that staff were expected to make sure the food served was at a proper temperature. Staff were expected to wash hands with soap and water and dry them well before starting to serve food. He stated that staff were expected to use separate tongs to move residents' food on the plate to avoid cross contamination. EC stated that population served in the facility is vulnerable to residents due to their age and health condition, and they can get GI problems, and their immune system is compromised. The kitchen staff was to keep a row meat separate from other foods to avoid cross contamination. EC stated that whoever is serving food in the axillary serving area is responsible for cleaning the serving and dining areas. He stated that he is the person responsible for overseeing staff following proper hand hygiene and to keeping kitchen, serving, dining areas in sanitary conditions. During an interview on 07/16/2026 at 11:09 a.m. with the EC, he stated he attempted to contact DSA B but she was not answering his calls or text messages in regard to State surveyors requesting to speak with her. EC stated the call is going to voicemail and there has not been a response to him via text message.During an interview on 07/16/2026 at 12:35 with DSA B, she stated that she was working in the facility for 2 years. She stated that her dietary services job duties were to prepare the food serving area in the skilled department and serving food to the residents. DSA B stated that she was responsible for making sure that the dishes are clean, what kind of food residents want, what they need and what they can eat. She stated that prior to starting to serve the food she was expected to wash her hands with soap and water and dry them well. She stated that hands were to be sanitized after removing gloves and before putting gloves on. DSA B stated that she always used gloves in the kitchen and serving areas throughout the day. She stated that she removes gloves after touching refrigerator or other kitchen equipment and sanitizes her hands. DSA B stated that not following proper hand hygiene may cause cross contamination of food, residents can get viruses, they can sick. She stated that residents' immune systems are different due to their age. DSA B stated that the whole team was responsible for cleaning the kitchen, serving and dining areas. She stated that the serving satellite area had cleaning supplies; two red and green small backets with sanitizers. Staff were expected to use the proper sanitizing solution concentration that was tested, labeled, and safely stored to avoid getting physical cross contamination and getting it in the food. DSA B stated that that her dining services specialist certification expired yesterday. She stated that she was watching all kinds of food handler videos just for fun and to refresh her knowledge. She stated she was doing refresher courses through Relias (Healthcare and human services professionals with accredited online courses and certification refreshers). DSA B stated that EC was responsible for overlooking the kitchen, and the dining and serving area were kept clean and in sanitary condition. During an interview on 07/16/2026 at 12:47 p.m. with DSA B, she stated the following: she had worked at this facility for two years. DSA B stated her job functions involve helping prepare and serve food to residents in this nursing facility. DSA B stated she has been trained in food preparation and properly handling food through her food handlers training. DSA B stated food handlers training further went over food temperatures, personal hygiene, handling foods, food storage, and foodborne pathogens. DSA B stated she last received her certification for food handlers on 07/15/2026 as it expired on 07/15/2026. DSA B stated it's the responsibility of the kitchen management and herself to keep track of food handlers' certifications expiring. DSA B stated it's ultimately the EC responsibility to ensure all kitchen staff food handlers are up to date. DSA B stated it's important to keep food handlers up to date in order to follow rules and refrain from anything negative happening to residents when providing food services. DSA B stated not maintaining food handler's certification can affect the resident's quality of life by causing stomach pain, extreme health risks, affecting residents immune systems, and cross contamination causing foodborne illnesses.During an interview on 07/16/2026 at 2:05 p.m. with WLVN A, she stated the following: she had been working at this facility for two years. WLVN A stated kitchen staff not having up to date food handler's certification causes issues due to not being up to date on the current policies and procedures which can cause harm to a resident's wellbeing. WLVN A stated kitchen staff not having up to date food handler's certification can affect the resident's quality of life by potentially causing food poisoning. WLVN A stated it's the overall responsibility of the kitchen administration staff to ensure all kitchen staff are up to date on food handlers' certification to prevent foodborne illnesses.During an interview on 07/16/2026 at 2:09 p.m. with WLVN A, she stated that she worked there for 2 years. WLVN A stated that she expects food serving staff to wash their hands in between touching serving food if they touch any kitchen equipment. She stated that not following proper hand hygiene while handling residents' food can cause cross contamination and place residents at risk for getting sick, like food poisoning. She stated that she witnessed, in the past, that the dietary service staff has been washing hands and changing gloves. WLVN A stated that she would tell them, if she would witness staff was not following proper hand hygiene procedures. She stated that she witnessed that the dietary service staff were cleaning the serving and dining areas before and after serving food. She stated that failing to clean the serving and dining areas could decrease quality of residents' life by making them sick. An attempt was made to interview WNM on 07/16/2026 at 2:30 p.m. She was off site and not available. State surveyors attempted to speak via phone in which there was no answer. State surveyors left a detailed voicemail with contact information. State surveyors did not receive a response.During an interview on 07/16/2026 at 2:37 p.m. with the RWD, she stated the following: she had been working at this facility for one year. RWD stated kitchen staff not having an up to date food handler's certification could cause issues as the kitchen staff works with food and could be a risk to residents. RWD stated kitchen staff not having up to date food handler's certification can affect the resident's quality of life as the kitchen staff may not be following the key rules to handle food properly. RWD stated it's the overall responsibility of the dietary management to ensure kitchen staff are all up to date on food handlers' certification to prevent foodborne illnesses.During an interview on 07/16/2026 at 2:55 p.m. with the RWD, she stated she had been working in the facility for one year. RWD stated that she never witnessed dietary services staff not following hand hygiene because she would remind them to follow the proper hand hygiene procedures while serving meals for the residents. She stated that practicing good hygiene was to prevent cross contamination and spreading germs. She stated that not following hand hygiene procedures could make residents sick. During an interview on 07/16/2026 at 3:33 p.m. with the ED, he stated that he had been working in the facility for about 4 months. He stated that the kitchen staff were expected to properly do their job. Kitchen staff were expected to follow proper hand hygiene during cooking and serving food. He stated servers were expected to be changing their gloves anytime they left the food line. ED stated that the kitchen staff and servers were expected to do a general cleaning of the areas and keep it clean but for deep cleaning of the kitchen and serving areas he would involve the environmental services. He stated that not following proper infection control could cause cross contamination and potentially could make residents sick. During an interview on 07/16/2025 at 3:50 p.m. with the ED, he stated the following: he had been working at this facility for four months. ED stated kitchen staff not having up to date food handler's certification cause issues due to not being up to renewal standards or continuing up to date education. ED stated kitchen staff not having up to date food handler's certification can affect the resident's quality of life if there is an event for a resident getting sick. ED stated it's the overall responsibility of the EC to ensure kitchen staff are all up to date on food handlers' certification to prevent illnesses to residents. Review of the facility's document named Culinary Policy and Procedures #10.37 created on 01/01/2015 and revised on 07/10/2020 reflected: Building the Platform: Floors, walls, and ceilings free of dirt, litter, and moisture.Creating Purpose and Passion- Keeping floors, walls, and ceilings free of dirt, litter, and moisture are critical to providing a safe and sanitary food service environment.Developing the Potential.1 Floors: Prepare area and put away food and equipment. Sweep floors according to the schedule, then clean them using the correct chemical spray method or by mopping with the correct chemical.Don't forget corners and hard-to-reach spaces!Be sure to clean surfaces in the dining service areas after cleaning walls and ceilings, to remove fallen debris.Review of the facility's document named Handwashing Policy created on 01/01/2015 and revised on 07/10/2020 revealedBuilding the platform:Culinary associates will wash their hands frequently.Creating Purpose and PassionHand washing is perhaps the most critical aspect of good personal hygiene in food service. Associates should wash their hands with antibacterial soap and warm water for at least 20 seconds. When working with food, they should wash gloved hands as often as bare hands.Developing the Potential:Be sure to wash hands with soap and warm water for at least 20 seconds:1. When reporting to work and after breaks.2. Whenever hands are soiled.3. After using handkerchief, using the restroom, eating, using the phone, or smoking.4. After handling inventory.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable living environment to help prevent the development of communicable transmission diseases and infections for one (Resident #29) of ten residents reviewed for infection control. 1.The facility failed to ensure Resident #29 had a posted EBP sign on room door on 07/14/2026. 2. The facility failed to ensure PPE supplies were replenished in storage organizing pouch for Resident #29 on 07/14/2026.These failures could place residents at risk for transmission of disease and infection.Findings include:Record review of Resident #29's Face Sheet, dated 07/16/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses that included dementia (a group of symptoms that cause a decline in cognitive abilities severe enough to interfere with daily life), cognitive communication deficit (condition where a person's ability to communicate effectively is impaired due to underlying cognitive dysfunction), muscle weakness (a condition where muscles cannot generate the expected amount of force, making movements more difficult than usual), osteoarthritis (most common form of arthritis, happens when the protective cartilage that cushions the ends of the bones wears down over time).Record review of Resident #29's quarterly MDS assessment dated [DATE], reflected a BIMS Score of 7, which indicated severe cognitive impairment.Record review of Resident #29's Care Plan, dated 07/16/2026, reflected Resident #29 receiving IV therapy medication and Resident #29 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #29 to maintain current level of function with assistance in her ADL care needs. Observation on 07/14/2026 at 10:55 a.m., revealed there was no EBP sign posted on Resident #29's room door nor any PPE supply in storage organizing pouch.During an interview on 07/14/2026 at 11:00 a.m. with WLVN A, she stated there should be an EBP sign posted on Resident #29 room door as well as PPE supplies since Resident #29 is receiving IV medication. During an interview on 07/14/2026 at 11:24 a.m. with RWD , she stated the EBP sign and PPE supplies storage pouch broke off somehow without an explanation of Resident #29's room door last night, 07/13/2026, and nursing staff would be putting up new ones. Observation on 07/14/2026 at 11:25 a.m., revealed WLVN A put up a new EBP door sign along with a door hanging storage organizing pouch containing PPE supplies on Resident #29's room door. Record review of the EBP sign on 07/14/2026 at 11:25 a.m. put on Resident #29 room door reflected Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities; dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy, wound care, and any skin opening requiring dressing. Do not wear the same gown and gloves for the care of more than one person.During an interview on 07/14/2026 at 12:09 p.m. with Resident #29, she stated to had no concerns or worries. Resident #29 stated she had no complaints. During an interview on 07/16/2026 at 1:07 p.m. with Resident #29 stated she did not have issues with staff and EBP or PPE. During an interview on 07/16/2026 at 2:05 p.m. with WLVN A, she stated she had been working at this facility for two years. WLVN A stated had been trained on EBP. WLVN A stated EBP training went over residents who were on EBP protocol require certain usage of PPE while providing care to residents to prevent any infections. WLVN A stated it is important to follow EBP and PPE requirements due to preventing the chain of infections from potentially spreading from resident to resident. WLVN A stated not having an EBP sign posted and access to PPE supplies can cause an individual, who is not aware there are EBP protocols, to enter without knowing and not having the appropriate equipment to wear to prevent the spread of infections. WLVN A stated not having a posted EBP sign and or PPE supplies can affect the residents quality of life such as if there is a resident that is on EBP protocols, it can give the individual an infection and it is not clean practice when providing residents care services if the resident has an open wound or being provided IV treatment. WLVN A stated it's the responsibility for all staff who provide care to follow EBP protocols and utilize PPE for residents. WLVN A stated it was ultimately the overall responsibility of the WNM to ensure there is posted EBP signage and PPE supplies.An attempted interview on 07/16/2026 at 2:30 p.m. with the WNM, revealed she was off site and not available. State surveyors attempted to speak via phone in which there was no answer. State surveyors left a detailed voicemail with contact information. State surveyors did not receive a response. During an interview on 07/16/2026 at 2:37 p.m. with the RWD, she stated she had worked at the facility for one year. RWD stated she had been trained on EBP and PPE. RWD stated EBP training went over for example, that any resident who had an open wound, catheter, and peg tubes will be in EBP protocol, and any resident that is on EBP precaution measures should have a posted EBP signs along with PPE supplies on the resident room door. RWD stated it's important to follow EBP and PPE procedures due to it helping prevent any spread of infections and residents on EBP are more suceptible to getting exposed to other infections. RWD stated the last EBP in-service conducted was approximately a couple months ago. RWD stated Resident #29's EBP sign and PPE fell overnight in which the PPE was hung up inside the Resident #29 room without a EBP sign and it was not outside of the room upon State surveyors' arrival. RWD stated the PPE supply needed to be replenished. RWD stated not having an EBP sign posted on resident's room door or having access to PPE supplies can cause infection control issues for the residents and the individuals visiting or providing care to the residents on EBP protocols. RWD stated she and staff need to be diligent to keep a posted EBP sign along with refilling PPEs for residents on precaution measures. RWD stated its all-nursing staff and her responsibility, as RWD, to ensure there are replenished PPE accessible along with posted EBP signs for required residents on precaution measures. RWD stated not having posted EBP signs and replenished PPEs can affect the resident's quality of life by causing a resident to get infected during patient care and prolong the residents healing or discharge if the nursing staff or individual does not follow appropriate EBP and PPE protocols. RWD stated it's her expectation for all staff to follow EBP protocols and utilize PPE for residents on precaution measures. RWD stated it was her and the director's responsibility to ensure there are posted EBP signs and PPE supplies for infection control purposes.During an interview on 07/16/2025 at 3:30 p.m. with the ED, he stated he had been working at the facility for four months. ED stated he had read the EBP information and he did not provide resident care, but his expectation is for nursing staff to correctly follow EBP. ED stated EBP is not in his scope and falls within the nursing staff and the RWD's. ED stated it's important to follow EBP and PPE requirements due to preventing the spread of infection. ED stated not having EBP sign posted and access to PPE supplies can cause issues because it's to help protect the residents and individuals going into residents' rooms. ED stated not having posted EBP signs or replenished PPE supplies can affect the residents' quality of life as it can cause an illness for the residents. ED stated it's ultimately the overall responsibility of the RWD to ensure there is EBP signage and PPE supplies as well as to monitor the nursing staff. Record review of the facility's in-service education for EBP documentation dated 01/15/2026 reflected to have been provided and completed by all nursing staff. Review of the facility's policy on EBP in Nursing Homes, dated 03/20/2024, reflected, EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on observation, interview, and record review, the facility failed to protect and promote the rights of the resident, and to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #42) of 2 residents reviewed for Resident Rights and Dignity. On 07/12/2026 Resident #42 revealed he felt embarrassed when WCNA G came in and asked him, Why have you done this (accidentally spilled urine on floor and his bed, from his urinal)? This failure could decrease all residents' dignified existence, self-determination, and quality of life by not respecting their rights and dignity.Findings included: Record review of Resident #42's undated face sheet indicated Resident #42 was an [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with unspecified cirrhosis of liver (long-term inflammation of the liver), anemia, elevated white blood cell count, hyperlipidemia (elevated lipids in the blood), hypertension (high blood pressure), esophagitis, diabetes mellitus type 2, anxiety disorder, hypothyroidism (underactive thyroid disease), helicobacter pylori (a bacteria known to cause chronic inflammation (gastritis) and is a major contributor to the development of peptic ulcers), and gout (common form of arthritis). Record review of Resident #42's Care Plan dated 07/10/2026 reflected:Resident #42 was at risk for depression following a diagnosis of depression.The goal initiated on 07/13/26 reflected Resident #42 would be free of signs and symptoms of depression through the next review date.Interventions included: If Depression Screen is positive, contact provider for Suggestion Perform Depression Screening EvaluationResident #42 was at risk for Fatigue following Anemia status. The goal initiated on 07/13/26 reflected Resident #42 will experience reduction in fatigue through next review date.Interventions included: Determine level of needed assistance based on ADLs / IADLs evaluation Educate Resident / Representative on energy conservation techniquesResident #42 is at risk for ADL Self-Care Deficit: Bathing, Dressing, Feeding post hospitalization for cirrhosis of the liver. The goal initiated on 07/13/26 reflected Resident #42 Will Participate in Self-Care Activities through next review date.Interventions included: Evaluate Resident's ability to perform ADLs / IADLs Provide assistance with ADLs / IADLs as needed An observation on 07/14/26 at 10:05 a.m. revealed Resident #42 was resting in his bed with eyes closed. He was clean and well-groomed, and dressed appropriately for the setting. The room was clean and organized, and free of odors. An interview on 07/14/26 at 2:10 p.m. with Resident #42 revealed he felt embarrassed when WCNA G came in early morning on 07/12/26 and asked him, Why have you done this? Resident #42 stated he thought it was rude, and she did not come in and greet him first. He stated the urinal had fallen on the floor and the bed and floor had gotten wet. An interview on 07/14/26 at 2:15 p.m. with the RP who revealed Resident #42 had been in the facility for less than one week. The RP stated everything had been going okay with Resident #42's care, except for interactions with WCNA G and WCNA D. The RP stated on Sunday morning WCNA G came in to assist Resident #42 with changing his brief, and she stated, Why have you done this?. The RP stated she had not greeted them with good morning or anything, and Resident #42's urinal had accidentally fallen on the floor. The RP stated he understood WCNA D was attempting to provide privacy for Resident #42 while changing his brief but felt that he should have been given the option to stay in the room with his spouse. Review of a Grievance report dated 07/14/26 for Resident #42 reflected the RP spoke about service failures, one from WCNA D, who had asked the RP if he could step out of the room while she provided peri-care for Resident #42. The other service failure was WCNA G from night shift that he felt made a rude comment over the past weekend. The grievance investigation reflected starting from the customer service complaint from over the weekend, the WNM on duty spoke to Resident #42 and WCNA D was verbally counseled. WCNA D reported on 07/13/26 that she felt she offended Resident #42 and his RP and was spoken to about how to better communicate.The grievance resolution reflected: Team members were counseled on customer service. In-service for staff members on customer service.Contact with the RP reflected that he gave the staff a lot of praise for their hard work and pointed out the CNAs, nurses and therapy members he really liked. He expressed understanding on miscommunication with WCNA D and felt confident that customer service had improved with no new incidents at night. An interview on 07/16/2026 at 2:20 p.m. with WLVN A revealed she had worked in the facility for 2 years. She stated she had been trained in Resident Rights, which included the residents' right to autonomy, resident council meetings to discuss issues they might be having, and the right to informed medical decisions. WLVN A stated she had attended a training on Resident Rights in January 2026. She stated the policy for resident rights and customer service included being positive when talking with the residents, when providing care, preventing abuse, and following through with the things you say you are going to do. She further stated every staff should always provide good customer service. She stated if staff did not provide good customer service to the residents, it could make them feel berated, sad, and especially since they are here and away from home it's good to be positive and help them be motivated to participate in care and therapy. WLVN A stated that the ED, RWD, WNM and herself monitor the CNAs when providing care. She stated she monitored the CNAs on each shift, and if she sees a call light on, she will go to assist and ensure CNAs are treating residents with kindness and respect. She stated this was also an opportunity to check in with the residents to make sure their care was going well. Attempted a telephone interview on 07/16/26 at 2:30 p.m. with WNM with no answer. Left a voice message to return the call. An interview on 07/16/26 at 2:40 p.m. with the RWD revealed she had worked in the facility for one year. She stated she had received training on Resident Rights within the current quarter. She stated the training covered resident services, the right to choices, and the right to complain. She stated the policy for customer service was to treat everyone with respect, greet them with a smile, and find out what the residents' needs are. The RWD stated that all staff should provide good customer service to all of the residents every day, all day, and every time they interact with a resident. She further stated the residents may feel frustrated when they were not getting good customer service. She stated good customer service required a conversation with the resident, and good communication. The RWD stated WNM, the ED and herself monitor to ensure staff were providing good customer service, and this has been an ongoing conversation in morning meetings. She stated that when something has been brought to her attention, she will talk with the resident and conduct disciplinary action. The RWD stated the RP had become offended when WCNA D had asked him to step out to do Resident #42's peri-care early Sunday morning. She stated the RP did not understand WCNA D was trying to respect Resident #42's privacy. The RWD stated WCNA D told her she might have offended Resident #42 and his RP, as she was trying to provide privacy. The RWD stated she had given WCNA D a verbal warning. The RWD stated WCNA G did not say good morning to Resident #42 and his RP, and Resident #42 had expressed he felt like she scolded him. The RWD stated she was told Resident #42's urinal had fallen, and WCNA G asked Resident #42, Why did you do that? The RWD stated WCNA G was written up for that poor customer service that weekend. An interview on 07/16/26 at 2:40 p.m. with WCNA G revealed she had been trained in Resident Rights in January 20. She stated the training included the residents' right to autonomy, resident council meetings to discuss issues they might be having, and the right to informed medical decisions. WLVN A stated she had attended a training on Resident Rights During an interview on 07/16/26 at 3:30 p.m. with the ED revealed he had been working in the facility for 4 months. He stated he had received training on Resident Rights, and the training covered dignity and the right to have personalization in resident care. He stated the last training was held last Tuesday during a staffing meeting. The ED stated the policy for customer service was covered heavily during staff orientation, and all management came in to do their piece. The ED stated his part of the training covered ANE, HIPPA and other areas of Resident Rights. He stated all staff members should provide good customer service 24 hours a day, and seven days a week. He further stated the residents could feel disappointed if staff do not provide good customer service. He stated if there was something the facility had missed, his expectation was to apologize to the residents and ask what could be done to make it better. The ED stated he thought the RWD had done the right thing by going straight to Resident #42 and getting involved. Review of the facility's undated Policy & Procedure on Resident Rights reflected, The goal of the facility is to provide Residents with a holistic program that assures respect, dignity and compassion. The right to be treated with respect and dignity. The right not to be verbally or psychologically abused, humiliated, intimidated or punished. The right to expect the cooperation of the provider in achieving the maximum degree of benefit from those services available at the facility.

Based on interviews, and record reviews, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 (DSA B) of 6 staff.The facility failed to maintain an updated food handler's certification for DSA B. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings include:Record review of DSA B staff file reflected not having a copy of food handler's certification. During an interview on 07/15/2026 at 1:30 PM with ED, he stated: DSA B food handlers expired back in April or May 2026. ED stated DSA B is updating the food handler's certification today, 07/15/2026. Record review of DSA B food handlers certification reflected to be dated 04/04/2024 and stated, expires in two years indicating the certification expired 04/04/2026. Record review of DSA B updated food handlers certification reflected to be dated 07/15/2026 and stated, expires in two years.Record review of DSA B job duties Wait Staff Culinary Department, with revised date 07/23/2024, reflected, Wait Staff Associates participate in providing a total quality dining service program for our residents. This includes a thorough understanding of food items available, resident dietary needs, proper serving guidelines, cleanliness expectations, and special diets. Assist with duties to ensure community meets sanitation standards.During an interview on 07/16/26 at 9:14 a.m. with the EC, he stated that the food handlers training covered food safety, proper handling of food, and when and whom to report illnesses. EC stated the food handlers were responsible for keeping track of food handlers' certifications. EC stated if kitchen staff did not have an updated food handlers' certification it could affect residents' quality of life by making residents not feel well, and they might not want to eat the food if kitchen staff do not have a food handlers' certification with the updated knowledge. EC stated it is important to keep the food handler's certification up to date every two years, so kitchen staff know the new laws and any changes that may happen or apply to nursing homes. During an interview on 07/16/2026 at 11:09 a.m. with the EC, he stated he attempted to contact DSA B but she was not answering his calls or text messages in regard to State surveyors requesting to speak with her. EC stated the call is going to voicemail and there has not been a response to him via text message.During an interview on 07/16/2026 at 12:47 p.m. with DSA B, she stated that she had worked at this facility for two years. DSA B stated her job functions involve helping prepare and serve food to residents in this nursing facility. DSA B stated she has been trained in food preparation and properly handling food through her food handlers training. DSA B stated food handlers training further went over food temperatures, personal hygiene, handling foods, food storage, and foodborne pathogens. DSA B stated she last received her certification for food handlers on 07/15/2026 as it expired on 07/15/2026. DSA B stated it's the responsibility of the kitchen management and herself to keep track of food handlers' certifications expiring. DSA B stated it's ultimately the EC responsibility to ensure all kitchen staff food handlers are up to date. DSA B stated it's important to keep food handlers up to date in order to follow rules and refrain from anything negative happening to residents when providing food services. DSA B stated not maintaining food handler's certification can affect the residents' quality of life by causing stomach pain, extreme health risks, affecting residents' immune systems, and cross contamination causing foodborne illnesses.During an interview on 07/16/2026 at 2:05 p.m. with WLVN A, she stated she had been working at this facility for two years. WLVN A stated kitchen staff not having up to date food handler's certification could cause issues due to not being up to date on the current policies and procedures which can cause harm to a resident's wellbeing. WLVN A stated kitchen staff not having up to date food handler's certification can affect the resident's quality of life by potentially causing food poisoning. WLVN A stated it's the overall responsibility of the kitchen administration staff to ensure all kitchen staff are up to date on food handlers' certification to prevent foodborne illnesses.An attempt was made to interview WNM on 07/16/2026 at 2:30 p.m. She was off site and not available. State surveyors attempted to speak via phone in which there was no answer. State surveyors left a detailed voicemail with contact information. State surveyors did not receive a response.During an interview on 07/16/2026 at 2:37 p.m. with the RWD, she stated she had been working at this facility for one year. RWD stated kitchen staff not having an up-to-date food handler's certification could cause issues as the kitchen staff works with food and could be a risk to residents. RWD stated kitchen staff not having up to date food handler's certification can affect the resident's quality of life as the kitchen staff may not be following the key rules to handle food properly. RWD stated it's the overall responsibility of the dietary management to ensure kitchen staff are all up to date on food handlers' certification to prevent foodborne illnesses.During an interview on 07/16/2025 at 3:50 p.m. with the ED, he stated he had been working at this facility for four months. ED stated if the kitchen staff did not have the up-to-date food handler's certification it could cause issues due to not being up to renewal standards or continuing up to date education. ED stated kitchen staff not having up to date food handler's certification can affect the resident's quality of life if there is an event for a resident getting sick. ED stated it's the overall responsibility of the EC to ensure kitchen staff are all up to date on food handlers' certification to prevent illnesses to residents.

Based on observation, and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 of 1 ancillary serving kitchen area reviewed for environmental concerns.The facility failed to replace cracked floor tiles, detached and broken tile baseboards in the ancillary serving kitchen area. Findings include:Observation of the ancillary serving kitchen area on 07/14/2026 at 9:38 a.m. revealed several base boards consisting of terracotta-colored tiles were no longer adhered to the wall, cracked, and disrepair.During an interview on 07/15/2026 at 12:20 p.m. with DSA E, she stated that the tile baseboard came off partially about a year ago. She could not recall when the floor tile was cracked. She stated maintenance was notified about these issues. DSA E stated that it does not affect her or the residents because it is out of their way.During an interview on 07/16/2026 at 9:09 a.m. with DSS, he stated that the request to repair broken tile baseboards in the serving area was submitted in in TELS (Total Equipment Life-cycle Solutions) a week ago. He stated that the broken tiles and tile baseboards in the serving area could potentially cause mold. He could not recall for how long they were broken.During an interview on 07/16/2026 at 9:31 a.m. with the EC, he stated that broken tiles and baseboards in the dining area were reported in TELS. He stated the broken tiles were safety issues, it may cause physical hazards.During an interview on 07/16/2026 at 3:33 p.m. with the ED, he stated that the work request to replace broken floor tiles and tile baseboards was submitted previously in TELS and the facility's staff submitted another request today. ED stated that they did not have a maintenance person in the facility currently because he was let go about a week ago. He stated that the facility purchased tiles to replace the broken once in the serving area and they were to be fixed within few days. He stated that broken tiles were physical hazards.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 of 1 dining room reviewed for environment. The facility failed to ensure the roof/ceiling of the dining area did not leak during a rainstorm on 05/05/25. This failure placed residents at risk of discomfort and diminished quality of life. Findings included: Observation on 05/05/25 at 12:10 PM revealed the facility dining room had two main seating areas which both led into a side room with a slanted ceiling and windows wrapped around all sides. The ceiling was composed of large planks laid side by side, and the seam between the second and third planks dripped heavily into the room and onto the floor. The room did not contain residents but was visible from the resident seating areas, and several residents were heard to remark on the leak. The room did contain a hydration cart with an ice chest, ice scoop, and disposable cups. CNA B was heard telling the other staff in the dining area she would retrieve a wet floor sign and towels. Two minutes later, she returned, threw towels down on the wet area, and set up a yellow wet floor sign on top of them. As she walked by, she stated we have been complaining about this. During observation and interview on 05/05/25 at 02:40 PM, the MAINT looked at the ceiling and stated he could see it was leaking and that the water had a slight tint to it. He stated the room was referred to as the screen room because it was like a screened in porch but completely enclosed. It was still raining lightly at the time, and the leak was much lighter than it had been earlier during the heavy rain. The MAINT stated that was the first he had heard of the leak in the roof. He stated any of the staff could enter a work order into the electronic work order system, and he had no work orders for this leak. During an interview on 05/06/25 at 12:43 PM, CNA C stated it did not rain very often, but she had seen the ceiling leak in the screen room once. She stated they had alerted management about it, and she thought the MAINT knew because she had seen him looking around the area the week before. She stated she was not completely sure what he had been looking at, as it had not been raining that day, and the ceiling was not leaking at the time. CNA C stated they had to speak to the nurses to let them know there was a problem. She stated she was not actually sure exactly what they should have done if they saw something that needed to be repaired, but she had spoken to HK D, who used to be the supervisor of housekeeping and maintenance. CNA C stated HK D was the supervisor of those departments for so long that staff just went to her automatically. CNA C stated she was not sure if the CNAs had the ability to enter work orders directly into the electronic work order system. She stated she was not aware of anyone slipping on the water when the ceiling leaked or of any resident areas being contaminated. She stated the residents noticed when it leaked and did not like it. During an interview on 05/07/25 at 11:15 AM, HK D stated she used to be the maintenance director in the facility and was aware of the leaking roof in the dining area. She stated they had gone outside the last time it rained hard and put some glue in the cracks to stop it from leaking. She stated when it rained hard, the water started coming in again. She stated the staff tried to come tell her about needed repairs, and she always directed them to the electronic reporting system. She stated she had educated the staff on using the electronic maintenance concern reporting system, and all of them should have known they could use it. She stated she was not aware of any resident ever being affected by the leak. She stated the residents did not eat in that area, and most of them did not see the leak. During an interview on 05/07/25 at 01:17 PM, the ADON stated she had noticed the leaking in the roof of the screen room. She stated she had not directly reported the leak or entered a maintenance request into the electronic maintenance request system. She stated she had heard other staff say they had reported the leak. The ADON stated the new maintenance director (MAINT) had instituted the electronic system, and anybody was able to enter the information. She stated it was a very simple system. She stated no resident had been affected, and there had been no slips or injuries as a result of the leak. She stated the leak could have had a negative impact on residents in that someone could have walked through the area and fell. She stated a leaking ceiling was not a good look for someone to have in their home. During an interview on 05/07/25 at 01:33 PM, the DON stated her first day in the facility had been 03/20/25, and she was not familiar with the process for reporting maintenance requests. She stated she knew they had the electronic reporting system, and all the staff was able to use it. She stated she would want to report the issue face to face to the MAINT. She stated she was not aware there was a leak in the ceiling of the dining room and was only just hearing about it during this interview. She stated something like that needed to be reported right away and fixed right away. She stated the potential negative impact of a leak in the dining was mold growth, exposure to bacteria, and even hypothermia. During an interview on 05/07/25 at 01:52 PM, the ADM stated the process of reporting a maintenance need was through the electronic reporting system, and any staff could do that. He stated his first day as administrator was the day the State Agency entered for survey, so he had not been at the facility long enough to develop oversight into the maintenance of the facility environment. The ADM stated he did not think the failure could have a negative impact on residents, as they did not use that space in the facility. He stated observing the ceiling leaking could have had a psychosocial impact on residents. Review of the work order list dated 05/05/25 reflected no orders related to a leaking ceiling or roof. Review of undated facility policy titled Quality of Life reflected the following: Policy: residents are cared for in a manner and in an environment, that promotes maintenance or enhancement of each person's quality of life. Purpose: To provide residents with a safe, supportive, comfortable, homelike environment; freedom and encouragement to exercise personal choice over their surroundings, schedules, healthcare, and life activities; the opportunity to be involved with the members of their community inside, and outside the nursing home; and treatment with dignity and respect. Procedure: E. Creation of an environment that is: 1) Safe, clean, comfortable, and home like in which residences are allowed to use their personal belongings to the extent possible; 2) Maintenance of a sanitary, orderly, and comfortable interior.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 2 kitchens (main kitchen) reviewed for food service safety. The facility failed to ensure, on 05/05/25 that: - the ice cream freezer and dairy refrigerator surfaces were clean, - breakfast sausages and bacon were stored in a safe manner - milk and buttermilk were not stored in the facility dairy refrigerator past the Sell By dates. This failure place residents at risk of food-borne illness. Findings included: Observation on 05/05/25 at 09:26 AM reflected the following conditions in the facility kitchen: -an open cardboard box containing a plastic bag of breakfast sausages open to the air, not labeled or dated, in the walk-in refrigerator; -an upright, stainless steel, two-door ice cream freezer in the dry storage closet with sticky and crusted material covering the doors and door handles -a stainless steel pan of cooked bacon covered in plastic cling wrap and dated 05/04/25, was inside the facility oven -two gallons of milk in the dairy refrigerator dated 04/30/25 (one of which was open and partially used) and two gallons dated 05/01/25; six quarts of buttermilk dated 04/21/25 (one of which was open and partially used); and -crusted white substance covering the lowest shelf surface of the dairy refrigerator. During an interview and observation on 05/05/25 at 09:47 AM, the DM stated the expired dairy products should not have remained in the refrigerator and should have been discarded. He threw them away. During an interview on 05/06/25 at 02:04 PM, the LCK stated he had worked at the facility since 1996. He stated the expired dairy in the refrigerator was expired, and should not have been used, but should have been discarded. He stated the sausage in the walk-in refrigerator should have been sealed, labeled, and dated. He stated the bacon in the oven was not proper storage of hazardous foods, and he did not know why it was there. He stated the dairy delivery person brought more milk than they could use. He stated they never used buttermilk for anything, so he was not sure why the delivery person brought it. The LCK stated he doubted the milk had been used while it was expired, because the servers in the kitchen served from different containers of milk out of the serving refrigerator in a different area of the dining room. He stated the stainless-steel equipment should have been cleaned daily and maintained in a clean state and hazardous foods needed to be stored properly, labeled, and dated. He stated all the cooks, and the DM were responsible for ensuring compliance with food safety guidelines. He stated the potential negative impact of the failures was residents could get sick, and they had compromised immune systems, which could make illness more dangerous. During an interview on 05/06/25 at 02:14 PM, the DM stated he had started at the facility a little over a week prior, and there was a lot of work to do to get the dietary systems into place. He stated he wanted the equipment cleaned on a cleaning schedule, and the stainless steel surfaces to be on a daily schedule. He stated there was not currently a daily or deep cleaning schedule for the kitchen staff. He stated the expired dairy products were the result of the dairy purveyor dropping off too much dairy, but it was the staff's responsibility to discard it once it passed the expiration date. He stated he was responsible for everything in the kitchen, including any non-compliance with food safety guidelines. He stated he did not think there would have been any negative impact on the residents, as none of the foods would have been served. During an interview on 05/07/25 at 01:52 PM, the ADM stated it was his third day, and he had been involved in the full book survey process since his first day, so he did not know all of the processes in place to keep the kitchen in compliance with food safety guidelines. He stepped away for a few minutes, returned, and stated there was no process in place currently of daily audits or checks on expired foods or improperly stored foods. He stated the potential negative impact of non-compliance with food safety guidelines was residents could get sick. Review of undated facility policy titled Storage-Refrigerator and Freezer reflected the following: Policy: all foods used in the dietary department I received, stored, and issued in a timely fashion to reduce deterioration, contamination, and loss. Purpose: to ensure safety Procedure: 5. All walk in freezers and refrigerators are lit and kept clean. 12. leftover foods are put in the refrigerator in shallow pans (2 to 4 inches deep) So the interior temperature of the food chills quickly to less than 40°F. They are covered, dated, and labeled. They are not mixed with fresh foods. 13. Leftover foods are refrigerated immediately and used within 48 hours. 18. All food items in the refrigerators are properly dated, labeled, and placed in containers with lids.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed for garbage disposal. The facility failed to ensure the recycling and trash dumpster doors and windows were closed on 05/06/25. This failure placed residents at risk of pest infestation and disease. Findings included: Observation on 05/06/25 at 10:30 AM revealed the facility recycling dumpster was open at the top, and the facility trash dumpster was open at the top and on the side. Numerous flies were seen within the trash dumpster. Observation on 05/06/25 at 02:45 PM revealed the recycling and trash dumpsters were still open. There were still flies in the dumpster. During an interview on 05/06/25 at 02:04 PM, the LCK stated the kitchen trash was taken out by the dishwasher each day, but the nursing staff also used the dumpsters. He stated they were supposed to make sure the side and the top of dumpster was closed. He stated it was important to ensure they were closed so rodents, birds, and insects would not infest the trash and so trash would not fly out. He stated it was unsanitary to leave the dumpsters open. He stated it was everyone's responsibility to ensure the dumpsters were closed. During an interview on 05/06/25 at 02:14 PM, the DM stated the dumpsters should have been closed at the top and the sides. He stated they needed to be closed to prevent pests from getting in there. He stated the dumpster being open could create a bad smell for the residents and allow flies to get in and around the facility. He stated every employee should have responsibility for keeping them closed, but as the dietary manager, he needed to ensure they were closed. He stated he was brand new to the facility and still trying to figure out systems to ensure compliance. During an interview on 05/07/25 at 01:52 PM, the ADM stated the dumpsters needed to be shut according to policy. He stated there would be no potential impact in residents, because they did not go out into that area. Review of undated facility policy titled Waste Removal reflected the following: Policy: the community shall arrange for all solid or liquid waste, garbage, and trash to be collected, stored, and disposed of in accordance with the rules of the applicable state Department of environmental protection. Purpose: to ensure safety Procedure: 4. Waste shall be stored in insect-proof, rodent proof, fireproof, non-absorbent, water type containers with tight fitting covers.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Nurse Cart) of 5 Medication carts reviewed for drug storage. The facility failed to ensure that expired insulin pens were removed from the Nurse Cart on 05/06/25. This failure could place residents at risk for ineffective diabetes treatments and infections from contaminated insulin pens. Findings included: Observation on 05/06/25 at 02:30 PM revealed the Nurse Cart belonging to LVN-A contained two insulin pens with opened dates of 03/07/25. The facility sticker placed on each pen when it was opened stated, discard 28 days after opening which would have made the expiration date of the 2 insulin pens 04/04/25. In an interview with LVN-A on 05/06/25 at 2:35 PM she stated the policy was to discard insulin pens 1 month after opening because they could have become contaminated. She stated the negative outcome to residents if not discarded was they could get an infection if the pens became contaminated and were used past the expiration date. She acknowledged the cart was her responsibility but did not answer additional questions. In an interview on 05/07/25 at 01:26 PM, the ADON stated the policy for opening a new insulin pen was to date the pen when it was opened on a sticker and store it in the nurse's medication cart. She stated the insulin pen could be used for 28 days after opening, then it expired. She stated discontinued or expired medications should be placed in the discharge box in the medication room and it was the responsibility of the nurse to check that. She stated it is important to date and discard the pen after the discard date to ensure it maintains the right strength of the medication. Expired insulin pens could cause infection, inflammation or the medication may not work effectively. She stated the negative outcome to residents if expired pens were not discard could be ineffective treatment for diabetes or it could cause an infection control issue if it became contaminated while left open for the extended time. In an interview on 05/07/25 at 01:41 PM, the DON stated she started working here in March of this year. She stated the policy for opening a new insulin pen was to date the label on the pen or put a label on it to indicated when the pen was opened. She stated the insulin pen could be used for 28 days after opening. The DON stated expired or discontinued medications should be given to her for destruction and it was the responsibility of the nursing staff to check this. She stated it was important to date and discard the pen after the discard date to prevent cross contamination. She stated the medicine could degrade after the expiration. She stated they could not know how long the insulin was good after it was removed from refrigeration. She stated the negative outcome to residents if the expired insulin was used could be failure to lower the residents blood sugar effectively. In an interview on 05/07/25 at 02:13 PM, the ADM stated the policy for insulin was that it can be used for 30 days after it was opened. He stated that expired or discontinued medications should be given to the DON to dispose of, and that it was the responsibility of the nurses to check the medication carts for this. He stated it was important to date and discard the pen after the discard date so they don't give a resident expired medication, but he did not know exactly what the clinical outcome would be if the resident was given expired insulin. A record review of the facility undated policy labeled Residents Services Manual-Medications Storage reflected expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of . A record review of the facility insulin sticker reflected that insulin was to be discarded 28 days after it was opened.

Based on observation, interview, and record review, the facility failed to ensure each resident received food that accommodated their preferences for 2 of 24 residents (Residents #177 and #178) reviewed for food and nutritional services. The facility failed to ensure that Residents #177 and #178 were provided hot sauce or salsa with their Cinco de Mayo meal of Mexican food by request and in accordance with their cultural preferences. The failure placed residents at risk of not having their cultural needs met. Findings included: Review of the undated face sheet for Resident #177 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: anemia (low blood iron), end stage renal disease (kidney disease), type two diabetes mellitus (trouble producing insulin leading to high blood sugar), peripheral vascular disease (poor blood circulation to the arms and legs often leading to trouble healing wounds in those areas), anxiety disorder, cognitive communication deficit (communication difficulties caused by impaired cognition), and depression. Review of EHR for Resident #177 reflected no MDS assessment had been completed. Review of the care plan for Resident #177 dated 05/05/25 reflected the following: (Resident #177) is at risk for malnutrition following ESRD. Resident intake of nutrients will meet metabolic needs. If malnourished, consult dietitian. Review of the undated face sheet for Resident #178 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction (paralysis on one side of the body after the brain was deprived of oxygen leading to an area of brain death), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of EHR for Resident #178 reflected no MDS assessment had been completed. Review of the care plan for Resident #178 dated 05/06/25 reflected the following: Carb controlled regular texture, thin liquids. Resident's dietary goal- maintain current weight. Dietary interventions- eats in dining room. Observation of the lunch meal service on 05/05/25 at 12:27 PM revealed Resident #177 was served a meal of chicken quesadilla, Mexican rice, refried beans, and salad. He asked for some hot sauce, and CNA B said to him, We don't have any hot sauce. Remember this morning at breakfast you asked, and we said we could not give you any? Resident #178 was served a plate with beef tacos, Mexican rice, refried beans, and salad. He asked for some hot sauce or salsa, and CNA B told him they did not have any to offer him. He said, How can I eat Mexican food without salsa? He had two FMs sitting at his table with him, and all three of them stated they identified as Hispanic and wanted to eat hot sauce with most meals but especially Mexican food. One of the visitors stated it was Cinco de Mayo, and they were serving Mexican food in honor of Cinco de Mayo, so they should have had hot sauce available. During observation of breakfast meal service and an interview on 05/06/25 at 08:15 AM, Resident #177 asked CNA C for hot sauce for his eggs. CNA C stated she was sure there was hot sauce available in the kitchen and told him she would go check as soon as she passed out all the other resident trays. Five minutes later, she came back from the kitchen (which was on the other side of the facility in the assisted living that shares a campus) with a bottle of hot sauce and gave it to Resident #177. He smiled broadly and thanked her. During an interview on 05/06/25 at 10:12 AM, Resident #177 stated Of course I like hot sauce! I'm a black man! I need flavor in my food! He stated he would survive, but some good hot sauce would make him like his food a lot more and probably eat more. During an interview on 05/06/25 at 12:43 PM, CNA C stated residents had particular preferences, and they often had a hard time getting staff to go the extra mile to obtain those preferences. She stated everyone knew Resident #177 had been asking for hot sauce ever since he came to the facility on [DATE]. She stated if a resident wanted something special, each staff member was responsible for taking the initiative to obtain it. During an interview on 05/06/25 at 01:10 PM, CNA B stated she had never seen hot sauce available for the residents. She stated she would ask the kitchen and they would say no they did not have any hot sauce. She stated when Residents #177 and #178 asked for hot sauce the day before, she did not ask the kitchen for any, because she had asked for it before and was told they did not have it. CNA B stated the CNAs were not allowed to go directly to the kitchen and had to ask the servers that work in the SNF satellite kitchen. CNA B stated if the aides did not listen to the servers and tried to walk up to the kitchen to ask for something themselves, they were told to send a server and they were sent back without the item. She stated she had worked at the facility for 13 years and did not remember the last time she tried to go to the main kitchen and ask for something. During an interview on 05/06/25 at 02:04 PM, the LCK stated they did not usually serve hot sauce, because most of the residents did not enjoy spicy foods, but he had heard that there were two residents wanting hot sauce in the SNF part of the building. He stated the process for ensuring cultural and other preferences was that, during admission, the nursing staff was to interview residents on their preferences. He stated the dietary information from that interview was to be sent to the kitchen to incorporate into meal service. He stated he had no information in his system about Residents #177 and 178 wanting hot sauce with their meals. He stated the CNAs could always get something from the kitchen, and there had never been a rule about them not approaching the kitchen. He stated if a resident wanted something additional with their food, they would always offer it if it was safe for the resident and would go get it from the store if they did not have it. He stated a potential negative impact of a resident not receiving the cultural food they wanted was they might become upset. He stated they tried to stress to all the staff that the residents often had few choices at this stage of their lives, and what they wanted to eat was one of the remaining choices. He stated it was very important to allow the resident to make those choices. During an interview on 05/06/25 at 02:14 PM, the DM stated the whole day on 05/05/2025 was about Cinco de Mayo, and he had residents asking about different types of Mexican foods. He stated the aides only needed to ask for something the residents wanted, and the kitchen would accommodate if the item was safe for the resident to eat. The DM stated the staff often did not want to go the extra mile to obtain the extra things the residents wanted, but the staff were required by the process to do that. The DM stated he was very new to the facility and had only been working there for a little over a week, but he could say that CNAs were welcome to come straight to the kitchen to ask for anything, including hot sauce. He stated the kitchen had hot sauce available, and if they did not have the type of hot sauce the resident wanted, they would get more. He stated the potential impact of not meeting a resident's cultural preferences for food was they could have mental anguish. He stated many of them already had disabilities, and to take away their sense of cultural identity was a form of torture. The DM stated he was responsible for ensuring resident preferences were accommodated, but he was still trying to put systems in place in the kitchen. During an interview on 05/07/25 at 01:17 PM, the ADON stated she heard Residents #177 and 178 asked for hot sauce for the first time on 05/05/25 and did not hear the staff's response. She stated she only knew they did not have hot sauce to offer the residents. She stated she was surprised to discover there was hot sauce in the facility all along and nobody tried to get it for the residents when they were eating Mexican food on Cinco de Mayo. The ADON stated there was no rule that CNAs could not go to the kitchen to ask for things. She stated the potential negative impact of not receiving cultural food preferences was the residents could enjoy their food less. During an interview on 05/07/25 at 01:33 PM, the DON stated she had not explored the facility system for ensuring diet preferences yet, as she was new and had been working on the nursing systems. She stated her practice and what she would expect of her staff would be they go ask the kitchen for anything the residents wanted. She stated the DM was responsible for that system, but he was also new. She stated a potential negative impact on the resident of not getting the cultural food they wanted was they might not feel regarded in the facility. During an interview on 05/07/25 at 01:52 PM, the ADM stated if residents had cultural dietary preferences, they only needed to ask the staff, and the staff had walkie talkies to request anything the residents requested from dietary. The ADM stated if it was something that the resident was safe to eat, given the diet they were on, the staff should have gotten it for them. If it was something the kitchen did not have available, the item should have been obtained. The ADM stated he had only been at the facility for three days, so he had not been able to monitor the system for compliance, but he felt the residents should receive what they asked for. He stated he could not think of a physical impact of the failure, but there could be a psychosocial impact of them not having their cultural needs met. Review of undated facility policy titled The Food Choices reflected the following: The overall dining experience for the residents includes the following components. Facility communities menu-- two separate seasonal select menus are developed with 5-week cycles, regional considerations, and diet extensions for heart healthy, no added sodium, consistent carbohydrate, Alzheimer's adapted, renal, modified texture and thickened liquid available. The menu program is a (web-based program) that is specifically developed with (food delivery company) and our Consultant Dietitian. The chef/dietary manager working with the residents in the food committee can adjust the menus based upon resident desire.

Based on observation and interview the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (Hall 100-A to 108A) of 3 halls reviewed for environment. The facility failed to remove an exposed blood soiled scalpel, needle, syringe, and 2 lancets from an unlocked and opened metal sharps container holder with no red, puncture resistant, leak-proof safety container insert on a wound treatment cart. This failure could place residents and staff at risk for injury. Findings included: An observation on 05/07/24 at 11:15 AM on Hall 100-A to 108-A a wound treatment cart was seen with its metal biohazard sharps containment door unlocked and wide open; there was not a red, puncture resistant, leakproof safety container insert in the metal containment and there were 5 items observed sitting at the bottom of the metal exposed containment which included an exposed size 15 scalpel with blood visible on the blade, 2 lancets, a needle, and a used medication syringe. The bottom of the metal container and its door were soiled with a dark yellow substance that appeared tacky and viscous in texture . An observation and interview with the ADON on 05/07/24 at 11:23 AM revealed that the ADON and wound care physician were doing wound care rounds and the ADON stated it was the wound care physician who placed the sharps items in the unlocked open containment box. The ADON stated it was her expectation that all metal containments on the med carts or wound treatment carts remain secured (locked) and hold a red, puncture resistant, leak-proof safety container insert were sharps can be safely disposed of. The ADON stated that any of the nurses can replace the red inserts and dispose of full containers properly in the biohazard room. She stated she should have caught that considering she was doing the wound treatment rounds that day with the wound treatment doctor which happens every Tuesday. The ADON stated that a potential negative outcome to residents by leaving sharps in an open unsecured location is the potential for somebody to get a hold of them which would lead to an accidental stick or injury. The ADON was observed pushing the wound treatment cart to the nurse's station where she said she would dispose of the sharps items properly and clean the metal containment bin. An interview with the DON (who was also filling in for the Administrator that day) on 05/07/24 at 03:05 PM she stated it was her expectation that there was individual biohazard containers on every cart and that they be used according to policy. The DON said that every metal container should have the inner red insert and the metal container should be clean and sharps should be disposed of appropriately in the inner puncture proof container which should also be removed when full and changed. The DON said they do weekly rounds to ensure the sharps containers are checked and changed, but she also said it was her expectation that the nurses assigned to the med carts or treatment carts also check it regularly and change it as needed. The DON stated they have a biohazard room which is secured, and all biohazard material should be sent there for disposal. The DON said it is not approved for anyone to leave sharps in a metal bin without the inner red puncture resistant container. The DON said that a potential negative outcome to leaving sharps in an unsecured location would be a resident could have an accidental needle stick or injury from the cart which is also an infection control issue. She stated the used syringe was identified as a Lovenox syringe. The DON identified the ADON as the facility infection preventionist. Record review of the undated facility Sharps Injury Prevention and Engineering Controls policy revealed: Policy: It is the policy of [this facility] to comply with OSHA regulations regarding sharps injury prevention. Purpose: To assist in decreasing the risk of workplace injury associates. Procedure: - The community will focus on needlestick prevention by eliminating unnecessary needles and sharps wherever possible and not recapping needles. - Puncture resistant, leakproof containers, color coded red will be utilized to discard contaminated items such as sharps, broken glass, scalpels, lancets, or other items that could cause a puncture wound. - The Wellness Director will inspect, maintain, and replace sharps disposal containers to prevent overfilling.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Hall 100-A to 108A) of 3 halls reviewed for infection control practices. The facility failed to remove an exposed blood soiled scalpel, needle, syringe, and 2 lancets from an unlocked and opened metal sharps container holder with no red, puncture resistant, leak-proof safety container insert on a wound treatment cart. These failures could place residents and staff at risk for blood/ bodily fluid exposure, contamination, and the spread of infection. Findings included: An observation on 05/07/24 at 11:15 AM, on Hall 100-A to 108-A a wound treatment cart was seen with its metal biohazard sharps containment door unlocked and wide open; there was not a red, puncture resistant, leakproof safety container insert in the metal containment and there were 5 items observed sitting at the bottom of the metal exposed containment which included an exposed size 15 scalpel with blood visible on the blade, 2 lancets, a needle, and a used medication syringe. The bottom of the metal container and its door were soiled with a dark yellow substance that appeared tacky and viscous in texture . An observation and interview with the ADON on 05/07/24 at 11:23 AM, revealed that the ADON and wound care physician were doing wound care rounds and the ADON stated it was the wound care physician who placed the sharps items in the unlocked open containment box. The ADON stated it was her expectation that all metal containments on the med carts or wound treatment carts remain secured (locked) and hold a red, puncture resistant, leak-proof safety container insert were sharps can be safely disposed of. The ADON stated that any of the nurses can replace the red inserts and dispose of full containers properly in the biohazard room. She stated she should have caught that considering she was doing the wound treatment rounds that day with the wound treatment doctor which happens every Tuesday. The ADON stated that a potential negative outcome to residents by leaving sharps in an open unsecured location is the potential for somebody to get a hold of them which would lead to an accidental stick or injury. The ADON was observed pushing the wound treatment cart to the nurse's station where she said she would dispose of the sharps items properly and clean the metal containment bin. An interview with the DON (who was also filling in for the Administrator that day) on 05/07/24 at 03:05 PM she stated it was her expectation that there was an individual biohazard container on every cart and that they be used according to policy. The DON said that every metal container should have the inner red insert and the metal container should be clean and sharps should be disposed of appropriately in the inner puncture proof container which should also be removed when full and changed. The DON said they do weekly rounds to ensure the sharps containers are checked and changed, but she also said it was her expectation that the nurses assigned to the med carts or treatment carts also check it regularly and change it as needed. The DON stated they have a biohazard room which is secured, and all biohazard material should be sent there for disposal. The DON said it is not approved for anyone to leave sharps in a metal bin without the inner red puncture resistant container. The DON said that a potential negative outcome to leaving sharps in an unsecured location would be a resident could have an accidental needle stick or injury from the cart which is also an infection control issue. She stated the used syringe was identified as a Lovenox syringe. The DON identified the ADON as the facility infection preventionist. Record review of the undated facility Infectious waste, Handling Of policy revealed: Purpose: The purpose of this procedure is to provide a definition of and guidelines for handling infectious waste. Procedure: - Infectious waste includes human blood and blood soiled articles, contaminated items (i.e., soiled dressings), items contaminated with feces body fluids and disposable sharps (i.e., needles/ scalpels). - Sharps are considered infectious waste, placed in approved sharps containers, and sent for eventual incineration. - Disposable items contaminated with residents' excretions or secretions must be placed in red plastic bags, sealed, and placed in biohazard storage until removal from premises. - Disposable items soiled with visible blood or feces will be placed in red plastic bags or containers and placed in biohazard storage until removed from the premises. - Biohazard storage will be locked when not in use. Record review of the undated facility Infection Control policy revealed: Policy: The community has an established policy and procedure related to Infection Control and Infection Prevention. Purpose: To assist in preventing the spread of infection. Procedure: - The Wellness Director in coordination with the Executive Director is responsible for infection control and infection prevention. - Associates will be educated related to all infection control procedures including personal hygiene requirements. - The community will follow guidelines for the prevention and control of Nosocomial Infections and standard precautions as provided by the Centers for Disease Control and Prevention in Atlanta Georgia.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. The facility failed to ensure the food was properly stored in the freezer and the pantry. This failure could place residents at risk being served food that could have been crossed-contaminated, frost bitten, and foodborne illness. Finding included: Observation on 03/11/2024 between 9:30 am and 10:30 am revealed an open bag of frozen fish was undated in the walk-in freezer. The box of fish was pulled forward to show the DM the fish was exposed, and he stated the staff was going to cook it that day. Continued observation walking throughout the freezer revealed there was a box of chicken nuggets open and exposed which was 2 boxes down on the same shelf with the fish. There was a box of what appeared to be hamburger patties open and exposed. Observation of the pantry revealed there was an open and exposed bag of crotons. The DM stated that it was wrapped up as there was plastic wrap around the bag. However, the top of the bag was open and exposed. Observation on 03/13/2024 between 11:00 am and 12:00 pm revealed cake served from the previous day was in the refrigerator exposed on a rack. In an interview with CK 1 on 03/13/2024 at 11:45 AM, CK 1 stated once the food was opened it should be wrapped and labeled. He stated once he opened the boxes and he does not use all the food, he wrapped and labeled the food. CK 1 stated if the food was not closed or wrapped up, it can be freezer burnt and rodents or anything can get into the pantry food items, then the food will have to be thrown away; which will become costly. In an interview with CK 2 on 03/13/2024 at 12:00 PM, CK 2 stated if the food was exposed in the freezer, it will get frost bitten but it should not be wrapped up. CK 2 stated once a box or bag was opened, it should be closed, wrapped, and dated. CK 2 stated if the food is exposed it can be at risk of cross contamination. CK 2 stated he did not open any food and leave it exposed. CK 2 stated he properly closed the food, labeled, and dated it, and placed it in the designated area within the kitchen. In an interview with DM on 03/13/2024 at 2:30 PM, DM stated his expectations of his employees regarding their kitchen duties was to keep everything safe and compliant, provide high quality food and services, and to respect everyone. DM stated that food left exposed in the refrigerator could be spilled onto other food items, cross-contaminate foods. DM stated foods left exposed in the freezer could cause cross-contamination and freezer burn. DM stated foods left exposed in the pantry could spill onto other items or get contaminated by pests. DM stated all of this could cause food-borne illness. DM stated staff is trained on food preparation, handling, and pathogens. DM stated the administration is responsible for ensuring annual training is completed. DM stated that it is his responsibility to ensure staff had updated food handlers licenses. In an interview with the DM on 03/13/2024 at 3:30 PM, DON stated her expectations for the kitchen staff is to provide high quality food and service, attention to detail, and do it in a safely manner. DON stated if food is left exposed in the refrigerator/freezer, it can be crossed contaminated with spillage from other foods, and end in product loss. DON stated if food is left exposed in the pantry, it can possibly be contaminated by pests and spillage from other foods, and end in product loss. DON stated the kitchen staff is trained on food borne illness and pathogens on in the computer-based training system. DON stated it is the Administrator's responsibility to ensure the staff completed their training. DON stated the staff has food handling license. DON stated it is responsibility of the DM to make sure the licenses are current. A record review of the facility's undated policy titled Storage - Refrigerator and Freezer reflected the following: All foods used in the dietary departments are received, stored, and issued in a timely fashion to reduce deterioration, contamination, and loss. A record review of the facility's undated policy titled Storage - Supplies reflected the following: To provide for safe and sanitary storage of dietary food and non-food supplies. A record review of the facility's undated policy titled Storage - Dry Goods reflected the following: All foods used in the dietary department are received, stored, used in a timely fashion to reduce deterioration, contamination, and loss.

Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents needs' as identified through resident assessments, and described in the plan of care for one of one resident (Resident #1) and 2 of 2 nurses reviewed for competent nursing staff. The facility failed to ensure nursing staff were properly trained and nursing staff failed to reported to management when they were unable to obtain the medication from the Omnicell Automated Medication Dispensing Systems. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. While the IJ was removed on 10/04/23, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings include: R1 is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), diabetes, cognitive communication deficit, and difficulty in walking. Record review of Resident #1's MDS assessment, dated 07/13/23, revealed a BIMS score of five suggesting severe cognitive impairment, used a walker and a wheelchair, had a medically complex condition, had an active diagnoses of seizure disorder or epilepsy, and had a fall in the last month and a fracture related to a fall in the last six months. Resident #1's care plan focus initiated on 01/06/23 reflected that she is on anticoagulant (having the effect of retarding or inhibiting the coagulation of the blood) therapy, care plan focus on 01/10/23 revealed she has a diagnosis of a seizure disorder and had a fall post seizure activity on 09/20/23 with intervention ensure Keppra in Omnicell (ADMS) for back up. Review of MAR reflects medication order for Keppra Oral Tablet 1000 milligram (Levetiracetam) give 1.5 tablet by mouth two times a day for seizure disorder total dosage 1500 milligram. Review of medical record dated 09/20/34 revealed Resident #1 was at the hospital on 09/20/23 seen for seizure and head injury. Interview on 10/02/23 with LVN A at 12:38 pm revealed on Tuesday, 09/19/23 at approximately 8:00 am when LVN A tried to administer Resident #1 her medications, LVN A noticed Resident #1 did not have her Keppra (Levetiracetam) medication in the facility medication cart. When asked if the facility had an e-kit, LVN A revealed that the ADMS was the facility e-kit but when she went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser the computer screen for the ADMS said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the surveyor told her the DOW said that Keppra (Levetiracetam) was available at the facility in the ADMS LVN A revealed she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know how to get Resident #1's medication. When asked what could happen if a resident did not receive their dose of Keppra (Levetiracetam), she said that someone could die. LVN A administered Resident #1 her remaining prescribed medication and used the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam). LVN A revealed that she knew that the facility policy was to notify the NP or the DOW if a residents' medication was not available or something was missing. LVN A revealed it was a hectic morning and she just did not do it. LVN A revealed she knew Resident #1 was taking Keppra (Levetiracetam) for a seizure disorder and she learned the next day, on Wednesday 09/20/23, Resident #1 had a seizure. LVN A said she did not enter a note in the electronic medication administration record about Resident #1 not getting her am 1500 milligram dose of Keppra (Levetiracetam) but she said she did report it to the nurse who took over her shift, but she could not remember that person's name. Interview on 10/02/23 with LVN B at 2:55 pm revealed she worked 6:00 pm to 6:00 am and when she began administering Resident #1 her medication at approximately 8:00 pm, she realized Resident #1 was out of Keppra (Levetiracetam) and she ordered the medication using the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam) and saw that it was previously ordered earlier that day, but she reordered again. LVN B revealed she was unaware that Resident #1 did not receive her first dose of Keppra (Levetiracetam). LVN B went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser the computer screen for the ADMS said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the surveyor told her the DOW said that Keppra (Levetiracetam) was available at the facility in the ADMS LVN B revealed she received training on how to use the ADMS e-kit but she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know that Resident #1's medication was available at the facility. When asked what could happen if a resident did not receive Keppra (Levetiracetam), LVN B revealed the resident could possibly have a seizure, injury, and hospitalization . LVN B revealed that sometimes there are some mix-ups with getting medications from the pharmacy. LVN B revealed she knew that Keppra (Levetiracetam) was for seizures. LVN B said she had had a conversation with Resident #1 who told LVN B she has had seizures. LVN B revealed it is the facility policy to call the NP or the DOW if a resident is out of medication. LVN B revealed that she would be concerned that Resident #1 would have a seizure if she did not receive her Keppra (Levetiracetam) and she missed a step by not calling the NP or DOW. Interview on 10/02/2023 with the NP at 12:56 pm revealed that on 09/20/23 in the am she was speaking with a staff member in the hallway of the facility and heard a loud bang from Resident #1's room. She observed Resident #1 on the ground having a seizure. NP revealed Resident seized for 60 seconds afterwards was lethargic and had a contusion on her head (a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise). EMS was called and Resident #1 was taken to the hospital. NP revealed that Resident #1 was taking Plavix (an antiplatelet medication that stops platelets from clumping up together and forming blood clots) and it was important to watch Resident #1 for bleeding issues. NP revealed that, after the incident, she looked at Resident #1's medication administration record and found that on 09/19/23, the day prior to the seizure and fall, Resident #1 did not receive the two of her two daily doses of Keppra (Levetiracetam) 1500 milligrams each dose. NP revealed that Resident #1 had a history of falls, a stoke, is on a blood thinner and had other medical issues and she cannot attribute the lack of Keppra (Levetiracetam) to her seizure. NP revealed that Resident #1 was administered Keppra (Levetiracetam) for a seizure disorder. NP revealed she was not notified that Resident #1 did not receive either of her two Keppra (Levetiracetam) 1500 milligram doses for 09/19/23. Interview on 10/10/23 at 12:07 pm with the hospitial physician who treated Resident #1 revealed that he believed the missing doses of Keppra (Levetiracetam) were the most likely culprit for Resident #1's seizures and the lack of her receiving the Keppra (Levetiracetam) was his biggest concern. He revealed it is hard for him to say definitively that Resident #1 and a seizure then fell or fell and then had a seizure but the reisent should have been getting her Keppra (Levetiracetam) at the facility and thought that the Keppra could have prevented other issues had it been in her system. Interview on 10/02/23 with the DOW at 11:46 am who revealed that ADMS did contain Keppra (Levetiracetam) but neither LVN A nor LVN B knew to use the house stock medication order tab that listed all the medications stored in the ADMS. The ADMS had an override that was used when a nurse could not find an item on the scheduled medications or active medication order tab for a specific resident. The DOW revealed that the ADMS did not have Keppra (Levetiracetam) in Resident #1's 1500 milligram dose tablet size but the ADMS did have Keppra (Levetiracetam) stocked in other tablet quantities that could be requested from the ADMS to fulfill Resident #1's 1500 milligram dose. The DOW revealed that neither LVN A nor LVN B knew how to use this feature. The DOW revealed that the staff was trained on how to use the ADMS by the pharmacy staff who owned the ADMS. If the pharmacy staff was not available to train new staff when a new nurse was hired, facility staff trained the new staff. The DOW did not have any documents that reflected who or when the training occurred. She revealed that when the pharmacy staff who owned the ADMS trained the nurses, they went over the information very quickly . The DOW revealed that LVN A should have done a follow up call to the pharmacy when the pharmacy did not deliver the medication after LNVA requested it by electronic medication administration. The DOW confirmed Resident #1 missed two doses' of 1500 milligrams of Keppra (Levetiracetam), both her morning and her evening doses. The DOW revealed that Resident #1 had a seizure on 09/20/23 and in addition to the seizure, she fell and had a contusion on her head. The DOW revealed that Resident #1 has not had a seizure since she has resumed her Keppra (Levetiracetam). The DOW revealed that the calls to the NP and the DOW to alert them that Resident #1 was missing medication were not made and the DOW did not know Resident #1 missed two Keppra (Levetiracetam) until Resident #1 had the seizure and fell . The DOW revealed that she can't really state that not having the Keppra caused the seizure, but that the situation of Resident #1 missing 2 doses could have caused a seizure, could have been a lot worse and could have caused death. Review of nursing description in medication administration record dated 09/20/23 revealed Resident #1 was seen sitting on side of bed approximately 2-3 minutes prior to the incident. CNA heard a loud crashing sound and entered Residents #1's room. Resident was seen on floor, laying down in between bed and table with the table against her face. Resident was tense, non-responsive and shaking (less than one minute). NP entered the room and helped move Resident #1 away from objects. Lips noted to be blue, 15L 02 via non-rebreather mask given. 911 was called and Resident #1 started to respond with one work responses when the Emergency Medical Technicians arrived. Resident #1 was unaware of what happened when started to become more alert. Resident #1 unable to give description. Injuries observed at time of incident abrasion to top of scalp and face. Predisposing Physiological Factions recent change in medications/new Review of Resident #1's hospital records dated 09/20/23 revealed patient with prior history of seizures and a history of dementia which limited her ability to provide history but is assumed that she had a seizure as she was mildly postictal (lethargic). Patient's facility reports she was out of her Keppra (Levetiracetam) and had missed several doses, she typically takes 1500 milligrams twice a day. The patient (Resident #1) was provided with IV dose of Keppra (Levetiracetam) at patient's home dose rate. Patients had head injury, suspected seizure, and history of seizures, noncompliant with medication and ran out of them. Diagnoses seizure and head injury. CT maxillofacial impression small midline forehead contusion. Review of LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual last updated 01/04/23 reflected the facility may use an ADMD to access emergency medications, or medically necessary medications or routine orders and medications removed from the AMDS must have a corresponding Physician/Prescriber's order. The pharmacy will provide staff training and train-the-trainer programs as necessary. Facility should document staff training competencies on the use of the AMD S including: Content of the AMDS Accessing medications Facility should generate a refill report to identify those medications that require restocking and provide such refill report to the pharmacy. Review of facility Administering Medications policy revised date 07/01/12 reflected Policy: Medications will be administered in a timely manner and as prescribed [NAME] the residents' attending physician or the community's medical director. Purpose: To provide quality services regarding administering medications. The Director or Wellness (DOW) is responsible for the supervision and direction of all personnel with medication administration duties and functions. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal ordered. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administrating the medication must initial and circle the medication administration record space provided for that drug. Any explanatory note on the reverse side of the medication administration record must be entered when drugs are withheld, refused, or given other than at scheduled time. (Note: the attending physician must be notified when a medication is refused or withheld per physician's order). Review of facility Medication Errors and Drug Reactions revision date 07/01/23 revealed Purpose: The purpose of this procedure is to establish uniform guidelines in the reporting and recording of medication errors and drug reactions. Procedure: All medications errors and drug reactions must be promptly reported to the Director of Wellness (DOW) attending physician, resident/or family/POA and the pharmacist if applicable. An account of the incident must be recorded in the resident's medical record, such documentation must include, but is not limited to: a. The name, strength, and dosage of medication administered date and time. b. The date and time the physician was notified and his/her instructions. c. Date and time resident and/or party were notified. Residents receiving incorrection medication or having a drug reaction must be closely monitored. Any change in the resident's condition must be immediately reported to the Director of Wellness (DOW) and attending physician. The nurse discovering the error will be responsible for completing an incident report and submitting a copy to the Director of Wellness (DOW) and a copy to the administrator. All incidents reported related to medication errors and drug reactions will be reviewed by the QA community and pharmacy consultant. On 10/02/2023 at 6:10 pm, the ADM and the DOW were notified of the Immediate Jeopardy (IJ) due to the above failures and the IJ template was provided at that date and time. The following Plan of Removal was submitted by the facility and was accepted on 10/03/2023 at 3:17 pm: Plan of Removal Immediate Jeopardy On 10/02/23 an abbreviated survey was initiated at[The facility] . On 10/02/23 the surveyor provided an Immediate Jeopardy (IJ) template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F726- The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required. Action: All licensed nurses will be in-serviced, by end of day 10-03-23, with return demonstration, using a checkoff list, on the Omnicell operations. The Omnicell is a facility medication dispensing machine. The training will be completed by the DOW/ADOW and will be on-going for all current and newly hired staff. This will be an annual training for facility nurses. The facility does not use agency staff but if this occurs in the future, they will also be trained on this process by the DOW/ADOW, on hire. Each nurse was provided with a quick reference guide to access the Omnicell, which was provided during this in-service. The pharmacy and the Regional Director of Wellness has in-serviced the DOW/ADOW on this issue prior to them in-servicing facility staff. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Action: All licensed nurses will be in-serviced , by end of day 10-03-23, on the refill process when a medication becomes low or is about to run out and who is to be notified (i.e. pharmacy, physician, DOW). This process will be monitored by the DOW/ADOW. All licensed nurses were also instructed to check the list of medications on the side of the Omnicell for availability in the Omnicell. The training will be completed by the DOW/ADOW and will be on-going for all current and newly hired staff. This will be an annual training for facility nurses. The facility does not use agency staff but if this occurs in the future, they will also be trained on this process by the DOW/ADOW, on hire. The Regional Director of Wellness has in-serviced the DOW/ADOW on this issue. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Monitoring of the plan of removal from 10/04/23 through 10/04/23 included the following: Reviewed that all licensed nurses (with the exception of one LVN who was unavailable to attend because of a family emergency and would be in-serviced upon her return) were in-serviced by 10/03/23 demonstrated, using a checkoff list, the ADMS operations including refill process when medication runs low and instructed to check the list of medications on the side of the ADMS for availability of medication in the ADMS. The in-service for the nurses was completed by the ADOW. Reviewed the in-service conducted by The Regional Director of Wellness to the DOW/ADOW on these same issues prior to the DOW/ADOW in-servicing their nursing staff. Interviewed four LVNs between 10:52 am and 11:14 am 0n 10/04/23 who confirmed that they received the were in-serviced on and understood where to locate the list of available medications in the ADMS, the process of obtaining medications from the ADMS if a resident medication was low and the ADMS refill process. The ADM and DOW were informed the Immediate Jeopardy was removed on 10/04/23 at 12:05 pm, however the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for one of one resident (Resident #1) reviewed for medications. The facility failed to ensure nursing staff were properly trained and nursing staff failed to reported to management when they were unable to obtain the medication from the Omnicell Automated Medication Dispensing Systems. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. While the IJ was removed on 10/04/23, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), diabetes, cognitive communication deficit , and difficulty in walking. Record review of Resident #1's MDS assessment, dated 07/13/23, revealed a BIMS score of 5, which indicated severe cognitive impairment. Resident #1 used a walker and a wheelchair, had a medically complex condition, had an active diagnoses of seizure disorder or epilepsy, and had a fall in the last month and a fracture related to a fall in the last six months. Record review of Resident #1's care plan focus, initiated on 01/06/23, reflected she was on anticoagulant (having the effect of retarding or inhibiting the coagulation of the blood) therapy, care plan focus on 01/10/23 revealed she had a diagnosis of a seizure disorder and had a fall post seizure activity on 09/20/23 with intervention ensure Keppra in Omnicell (ADMS) for back up. Record review of Resident #1's MAR reflected medication order for Keppra Oral Tablet 1000 milligram (Levetiracetam) give 1.5 tablet by mouth two times a day for seizure disorder total dosage 1500 milligram. Record review of Resident #1's hospital medical record , dated 09/20/34, revealed Resident #1 was at the hospital on 09/20/23 seen for seizure and head injury. Interview on 10/02/23 with LVN A at 12:38 PM revealed on Tuesday, 09/19/23 at approximately 8:00 AM when she tried to administer Resident #1 her medications, LVN A noticed Resident #1 did not have her Keppra (Levetiracetam) medication in the facility medication cart. LVN A revealed the ADMS was the facility e-kit but when she went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser, the computer screen for the ADMS, said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the State Surveyor told LVN A the DOW said Keppra (Levetiracetam) was available at the facility in the ADMS, LVN A revealed she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know how to get Resident #1's medication. LVN A stated if a resident did not receive their dose of Keppra (Levetiracetam), they could die. LVN A administered Resident #1 her remaining prescribed medication and used the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam). LVN A revealed she knew the facility policy was to notify the NP or the DOW if a residents' medication was not available or something was missing. LVN A revealed it was a hectic morning and she just did not do it. LVN A revealed she knew Resident #1 was taking Keppra (Levetiracetam) for a seizure disorder and she learned the next day, on Wednesday 09/20/23, Resident #1 had a seizure. LVN A said she did not enter a note in the electronic medication administration record about Resident #1 not getting her AM 1500 milligram dose of Keppra (Levetiracetam) but she said she did report it to the nurse who took over her shift, but she could not remember that person's name. Interview on 10/02/23 with LVN B at 2:55 PM revealed she worked 6:00 PM to 6:00 AM and when she began administering Resident #1 her medication at approximately 8:00 PM, she realized Resident #1 was out of Keppra (Levetiracetam) and she ordered the medication using the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam) and saw it was previously ordered earlier that day, but she reordered it again. LVN B revealed she was unaware Resident #1 did not receive her first dose of Keppra (Levetiracetam). LVN B went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser the computer screen for the ADMS said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the State Surveyor told LVN B the DOW said Keppra (Levetiracetam) was available at the facility in the ADMS, LVN B revealed she received training on how to use the ADMS e-kit but she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know Resident #1's medication was available at the facility. LVN B revealed if a resident did not receive Keppra, the resident could possibly have a seizure, injury, and hospitalization . LVN B revealed sometimes there were some mix-ups with getting medications from the pharmacy. LVN B revealed she knew Keppra (Levetiracetam) was for seizures. LVN B said she had had a conversation with Resident #1 who told LVN B she had seizures. LVN B revealed it was the facility policy to call the NP or the DOW if a resident was out of medication. LVN B revealed she would be concerned Resident #1 would have a seizure if she did not receive her Keppra (Levetiracetam) and she missed a step by not calling the NP or DOW. Interview on 10/202/23 with the NP at 12:56 PM revealed on 09/20/23 in the am she was speaking with a staff member in the hallway of the facility and heard a loud bang from Resident #1's room. She observed Resident #1 on the ground having a seizure. The NP revealed Resident seized for 60 seconds afterwards was lethargic and had a contusion on her head (a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise). EMS was called and Resident #1 was taken to the hospital. The NP revealed Resident #1 took Plavix (an antiplatelet medication that stops platelets from clumping up together and forming blood clots) and it was important to watch Resident #1 for bleeding issues. The NP revealed after the incident, she looked at Resident #1's medication administration record and found on 09/19/23, the day prior to the seizure and fall, Resident #1 did not receive two of her two daily doses of Keppra (Levetiracetam) 1500 milligrams each dose. The NP revealed Resident #1 had a history of falls, a stoke, is on a blood thinner and had other medical issues and she could not attribute the lack of Keppra (Levetiracetam) to her seizure. The NP revealed Resident #1 was administered Keppra (Levetiracetam) for a seizure disorder. The NP revealed she was not notified Resident #1 did not receive either of her two Keppra (Levetiracetam) 1500 milligram doses for 09/19/23. Interview on 10/10/23 at 12:07 pm with the hospitial physician who treated Resident #1 revealed that he believed the missing doses of Keppra (Levetiracetam) were the most likely culprit for Resident #1's seizures and the lack of her receiving the Keppra (Levetiracetam) was his biggest concern. He revealed it is hard for him to say definitively that Resident #1 and a seizure then fell or fell and then had a seizure but the reisent should have been getting her Keppra (Levetiracetam) at the facility and thought that the Keppra could have prevented other issues had it been in her system. Interview on 10/02/23 with the DOW at 11:46 AM revealed the ADMS did contain Keppra (Levetiracetam) but neither LVN A nor LVN B knew to use the house stock medication order tab that listed all the medications stored in the ADMS. The ADMS had an override that was used when a nurse could not find an item on the scheduled medications or active medication order tab for a specific resident. The DOW revealed the ADMS did not have Keppra (Levetiracetam) in Resident #1's 1500 milligram dose tablet size but the ADMS did have Keppra (Levetiracetam) stocked in other tablet quantities that could be requested from the ADMS to fulfill Resident #1's 1500 milligram dose. The DOW revealed neither LVN A nor LVN B knew how to use this feature. The DOW revealed the staff were trained on how to use the ADMS by the pharmacy staff who owned the ADMS. If the pharmacy staff were not available to train new staff when a new nurse was hired, the facility staff trained the new staff. The DOW did not have any documents that reflected who or when the training occurred. She revealed when the pharmacy staff who owned the ADMS trained the nurses, they went over the information very quickly. The DOW revealed LVN A should have done a follow up call to the pharmacy when the pharmacy did not deliver the medication after LNVA requested it by electronic medication administration. The DOW stated Resident #1 missed two doses of 1500 milligrams of Keppra (Levetiracetam), both her morning and her evening doses. The DOW revealed Resident #1 had a seizure on 09/20/23 and in addition to the seizure, she fell and had a contusion on her head. The DOW revealed Resident #1 had not had a seizure since she had resumed her Keppra (Levetiracetam). The DOW revealed the calls to the NP and the DOW to alert them Resident #1 was missing medication were not made and the DOW did not know Resident #1 missed two Keppra (Levetiracetam) until Resident #1 had the seizure and fell . The DOW revealed she couldn't really state that not having the Keppra caused the seizure, but the situation of Resident #1 missing 2 doses could have caused a seizure, could have been a lot worse and could have caused death. Record review of the nursing description in the medication administration record, dated 09/20/23, reflected Resident #1 was seen sitting on the side of bed approximately 2-3 minutes prior to the incident. CNA heard a loud crashing sound and entered Residents #1's room. The resident was seen on floor, laying down in between the bed and table with the table against her face. The resident was tense, non-responsive and shaking (less than one minute). The NP entered the room and helped move Resident #1 away from objects. Lips noted to be blue, 15L 02 via non-rebreather mask given. 911 was called and Resident #1 started to respond with one work responses when the Emergency Medical Technicians arrived. Resident #1 was unaware of what happened when she started to become more alert. Resident #1 was unable to give a description. Injuries observed at time of incident abrasion to top of scalp and face. Predisposing Physiological Factions recent change in medications/new. Record review of Resident #1's hospital records, dated 09/20/23, revealed patient with prior history of seizures and a history of dementia which limited her ability to provide history but is assumed that she had a seizure as she was mildly postictal (lethargic). Patient's facility reports she was out of her Keppra (Levetiracetam) and had missed several doses, she typically took 1500 milligrams twice a day. The patient (Resident #1) was provided with IV dose of Keppra (Levetiracetam) at patient's home dose rate. Patients had head injury, suspected seizure, and history of seizures, noncompliant with medication and ran out of them. Diagnoses seizure and head injury. CT maxillofacial impression small midline forehead contusion. Record review of the LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual, last updated 01/04/23, reflected the facility may use an ADMD to access emergency medications, or medically necessary medications or routine orders and medications removed from the AMDS must have a corresponding Physician/Prescriber's order. The pharmacy will provide staff training and train-the-trainer programs as necessary. Facility should document staff training competencies on the use of the AMDS which include: Content of the AMDS Accessing medications Facility should generate a refill report to identify those medications that require restocking and provide such refill report to the pharmacy. Record review of the facility Administering Medications policy, revised date 07/01/12, reflected Policy: Medications will be administered in a timely manner and as prescribed by the residents' attending physician or the community's medical director. Purpose: To provide quality services regarding administering medications. The Director or Wellness (DOW) is responsible for the supervision and direction of all personnel with medication administration duties and functions. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal ordered. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administrating the medication must initial and circle the medication administration record space provided for that drug. Any explanatory note on the reverse side of the medication administration record must be entered when drugs are withheld, refused, or given other than at scheduled time. (Note: the attending physician must be notified when a medication is refused or withheld per physician's order). Review of facility Medication Errors and Drug Reactions revision date 07/01/23 revealed Purpose: The purpose of this procedure is to establish uniform guidelines in the reporting and recording of medication errors and drug reactions. Procedure: All medications errors and drug reactions must be promptly reported to the Director of Wellness (DOW) attending physician, resident/or family/POA and the pharmacist if applicable. An account of the incident must be recorded in the resident's medical record, such documentation must include, but is not limited to: a. The name, strength, and dosage of medication administered date and time. b. The date and time the physician was notified and his/her instructions. c. Date and time resident and/or party were notified. Residents receiving incorrection medication or having a drug reaction must be closely monitored. Any change in the resident's condition must be immediately reported to the Director of Wellness (DOW) and attending physician. The nurse discovering the error will be responsible for completing an incident report and submitting a copy to the Director of Wellness (DOW) and a copy to the administrator. All incidents reported related to medication errors and drug reactions will be reviewed by the QA community and pharmacy consultant. This was determined to be an Immediate Jeopardy (IJ) on 10/02/2023 at 6:10 PM. The ADM and the DOW were notified. The ADM as provided with the IJ template on 10/02/2023 at 6:10 pm. The following Plan of Removal was submitted by the facility and was accepted on 10/03/2023 at 3:17 PM: Accepted 3:17 pm Plan of Removal Immediate Jeopardy On 10/02/23 an abbreviated survey was initiated at [the facility]. On 10/02/23 the surveyor provided an Immediate Jeopardy (IJ) template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F760- The facility failed to ensure residents are free of any significant medication errors. Action: 100% audit was completed to determine the number of residents on anticonvulsant medication. The medication is available, both on the med cart and in the Omnicell. The audit was completed by the Regional Director of Wellness. The audit will be completed bi-weekly by the DOW/ADOW and will be an on-going process. One resident was found to be on this type of medication and the medication is in stock and available in the med cart and the Omnicell. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Action: All licensed nurse nurses will be in-serviced, by end of day 10-03-23, that if any resident missed a dose of an anticonvulsant medication, or any medication, the nurse is to immediately notify the physician, DOW and pharmacy. The nurses are also to check the quick reference guide on the side of the Omnicell for medication availability. The training will be completed by the DOW/ADOW and will be on-going for all current and newly hired staff. This will be an annual training for facility nurses. The facility does not use agency staff but if this occurs in the future, they will also be trained on this process by the DOW/ADOW, on hire. The DOW/ADOW were in-serviced by the Regional Director of Wellness prior to the facility staff being in-serviced. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Monitoring of the plan of removal from 10/04/23 through 10/04/23 included the following: An audit was completed by Regional Director of Wellness, and it was determined Resident #1 was the only current resident in the facility on anticonvulsant medication. The medication was available, both on the med cart and in the ADMS Omnicell. Interviewed four LVNs between 10:52 AM and 11:14 AM on 10/04/23 revealed they received the in-serviced and understood where to locate the list of available medications in the ADMS and who and when to notify if anticonvulsant medication, or any medications, is missing . Record review of in-service taken by licensed nurses, by end of day on 10/03/23, (with the exception of one LVN who was unavailable to attend because of a family emergency and would be in-serviced upon her return) for any resident who missed a dose of an anticonvulsant medication, or any medication the MD/NP, pharmacist, and DOW would be notified. If the medication was missing the MD/NP, and family needed to be called and an incident report/medication error would need to be completed. The in-services included information for all nurses to check the quick reference guide on the side of the ADMS Omnicell for medication availability. The ADM and DOW were informed the Immediate Jeopardy was removed on 10/04/23 at 12:05 PM. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #12) reviewed for dignity. CNA D referred to an adult brief as diaper in the presence of Resident #12. This failure placed resident at risk of embarrassment, dignity, and diminished quality of life. The findings included: Review of Resident #12's Face Sheet dated 01/20/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of HTN (high blood pressure), CKD, heart failure, difficulty in walking, cognitive communication deficit (difficulty in thinking and using language), need for assistance with personal care, muscle weakness and anxiety disorder. Review of Resident #12's MDS dated [DATE] reflected a BIMS score of 12, indicating moderate cognition impairment. MDS reflected Resident #12 has indwelling catheter and frequent bowel incontinent. Review of Resident #12's Care Plan dated 01/09/23 reflected Resident #12 had an indwelling catheter related to obstructive and reflux uropathy (condition in which the kidneys are damaged by the backward flow of the urine into the kidney) with intervention to provide catheter care per policy. Observation on 01/19/23 at 1:40PM revealed CNA D was providing Foley catheter care to Resident #12 along with CNA A for assistance. During care CNA D asked CNA A to get the pad and diaper while in the presence of Resident #12. CNA D communicated to Resident #12 with a statement I am going to put the cream on the front and then will close the diaper. Interview on 01/19/23 at 2:21PM, CNA D stated she did not realized she was referring to the brief as a diaper. CNA D stated the word should not been used because it could make the resident felt they were babies. CNA D stated she had received in-service once a month from the ADON, DON, ADM, and/or HR. Review of CNA D's personal file reflected she did not complete resident rights training since year 2021. Certification of completion for understanding resident rights was completed on 01/20/23. Interview on 01/20/23 at 1:47PM, the ADON stated staff should not referred brief as a diaper because it was a dignity issue and residents were not babies, therefore, it was referred as adult briefs. The ADON stated the impact of staff referred brief as diaper could affect the residents' self-esteem and their thought of treated as babies. Interview on 01/20/23 at 2:25PM, the BOM/HR stated CNA D has not completed resident rights training for a year referred to the transcript of the employee training. The BOM/HR stated each department head/managers was responsible to ensure their employees had completed their training. The BOM/HR stated she sends a report to each department head by the 20th of each month to inform employees needed training to be completed. The BOM/HR stated she conducts the report following month and provides the report to the department head . The BOM/HR stated the importance of training on resident rights was for better interaction with the residents and also helps towards renew the employee licensure. Interview on 01/20/23 at 2:36PM, the RN stated staff should not referred adult brief as diaper because of dignity issue. The RN stated the impact of referring brief as diaper was a dignity issue and could had a negative impact and cannot state the exact negative impact. The RN stated during on-boarding or orientation upon hire the employees were mandated to had an in-service on resident rights. The RN stated each department head was responsible to ensure staff were in-serviced on resident rights as well as the ADM. Interview on 01/20/23 at 3:11PM, the ADM stated employees should not use the word diaper in the presence of a resident due to dignity issue. The ADM stated the impact of the used word diaper could had a psycho-social effect on the resident. The ADM stated the staff are in-serviced and had verbal communications on the topic. The ADM stated the in-service was through Relias (software used for training) which contained training that included dignity and rights. The ADM stated the direct supervisor of each department was responsible for ensuring their staff had completed the training. The ADM stated the importance of training on resident rights was to refresh their knowledge and how to treat their residents. The ADM stated the staff may not followed the residents rights and they may not treat them properly per residents rights guidelines if the training is not completed. Review of facility's policy titled Resident Rights dated 07/01/2014 reflected: The goal of the facility is to provide residents with a holistic program that assures respect, dignity, and compassion. The right to be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to provide residents respiratory care consistent with professional standards of practice for 2 or 8 residents (Resident #16 and Resident #4) reviewed for oxygen therapy. The oxygen tubing on Resident #16 was not labeled with a date. The humidifier bottle for Resident #4 on the oxygen concentrator was empty for an unknown time. This failure placed residents at risk of nose and throat discomfort, skin breakdown, inadequate respiratory care and infection control. The findings included: Review of Resident #16's Face Sheet dated 01/20/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of heart failure with presence of cardiac pacemaker, dementia, HTN (high blood pressure), CKD, and muscle weakness. Review of Resident #16's MDS dated [DATE] reflected a BIMs score of 13, indicating intact cognition. MDS indicated Resident #16 requires oxygen therapy. Review of Resident #16's Care Plan dated 08/07/22 reflected Resident #16 received oxygen therapy related to diagnosis of CHF with an intervention of oxygen via nasal prongs at 2 liters PRN and humidified. Observation and interview on 01/18/23 at 10:35AM revealed Resident #16 was lying down in bed receiving oxygen via nasal cannula (oxygen tube). The nasal cannula tubing did not have a date on it. Resident #16 did not know when the nasal cannula was changed. Interview on 01/18/23 at 10:38AM, LVN C after oxygen tube was checked stated there was no date, and it should been dated. LVN C stated the purpose of dated oxygen tube were to knew when the oxygen tubing was last changed. LVN C stated the oxygen tubing were changed weekly or PRN. Review of Resident #4's Face Sheet dated 01/20/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of HTN (high blood pressure), CKD, and muscle weakness. Review of Resident #4's MDS dated [DATE] reflected a BIMs score of 3, indicating severe cognition impairment. Observation on 01/19/23 at 2:24 PM revealed Resident #4 was in bed and was not wearing a nasal cannula. The nasal cannula was observed with no date and the humidifier connected to the oxygen concentrator did not have a date on it. Interview on 01/19/23 at 2:25 PM, after LVN S checked the oxygen tubing and the humidifier stated there was no dates on either of the items and both should had a date on them. LVN S stated the date identifies when the items was last changed. LVN S stated both items was changed weekly on Sunday's. LVN S stated the adverse effect of not labeling the items with the date could get residents had bacteria or infection from not having the items changed as it should. Interview on 01/20/23 at 1:47PM, the ADON stated the nasal cannula tubing should been dated for the importance of knowing when it was changed. The ADON stated the impact of not dating the items would been not knowing when it was last changed or how long the water had been in the humidifier. ADON stated the nurses was responsible to check every day for the function of the humidifier and the tubing was dated. The ADON stated staff were given in-services and were constantly reminded. Interview on 01/20/23 at 2:36PM, the RN stated if the oxygen tubing were opened and no longer in the original bag then it should had been dated as well as the humidifier. The RN stated the date on the item indicated when the item were used on the resident. The RN stated the prolonged use of oxygen tubing could lead to infection and the impact of an undated humidifier could result in water running out which could cause upper nasal passages to dry out. Interview on 01/20/23 at 3:11PM, the ADM stated the oxygen tubing and humidifier should had been labeled due to infection control reasons. The ADM stated the impact of an undated item could be unsanitary items being used on the resident. The ADM stated the nurses are responsible for ensuring the items were dated when used on residents. The ADM stated nurses was in-serviced by the ADON/DON. Review of the facility policy titled Oxygen Administration dated 07/01/15 reflected: 15. At regular intervals, check and clean oxygen equipment, masks, tubing and cannula. Change masks tubing and cannulas every 7 days and as needed. Humidifier should be labeled with the date and time changed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of one medication room and one of one crash cart reviewed for pharmacy services, in that: The facility failed to: - date a multi-dose vial of a medication when opened. - dispose of expired pre-filled syringes, wound vac dressings, and catheters in the medication/medical supply room. - dispose of expired bottles of saline on the crash cart. These failures placed residents at risk of adverse therapeutic effects from expired medication and medical supplies. Findings included: Observation on 10/12/21 at 8:02 AM revealed a multidose vial of [MEDICATION(S)], a solution to perform TB skin test, opened and undated in the refrigerator in the medication/medical supply room. Upon further observation, the following expired supplies were found: - One wound vac dressing, expired 1/21/21 - Three syringes of [CONDITION(S)] vaccine, expired 9/4/21 - A box of pre-filled saline syringes, expired 7/31/21 - Five foley catheters, expired 1/30/21 Observation of the crash cart on 10/12/21 at 9:12 AM revealed three expired (expired 1/8/21) bottles of saline. During an interview on 10/14/21 at 12:55 PM with the DON, she stated all multidose vials should be dated when opened. She stated having an open and undated vial could compromise the integrity of the medication and increase the chance of contamination. She stated it was her expectations that all expired medication and medical supplies were to be disposed of. She stated it was not best practice to have expired medications or supplies stored in the medication/supply room. She stated using expired medical supplies could be unsafe because they could potentially be unsterile or not work properly. Review of the facility's Storage of Medications Policy, revised 2/22/16, reflected the following: The purpose of this procedure is to ensure that medications are stored in a safe, secure, and orderly manner. . 3. No discontinued, outdated, or deteriorated medications are available for us in this community. All such medications are destroyed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to: Label or date food items in the refrigerator. Dispose of expired food items with marked expiration dates. This failure could place residents who eat from the kitchen at risk for foodborne illness. Findings: Observation of the kitchen on [DATE] at 7:20 a.m., revealed the following: In the walk-in refrigerator -a plastic bag of parsnips with expiration date of [DATE]; bagged cauliflower without labels or dates of expiration, -an open box of tomatoes without a label or date of expiration - a large open bag of carrots without a label or expiration date -a large box of eggs was observed without a label bearing received or expiration date, and the producer's label was observed with a date of [DATE],. -a large mixing bowl was observed with what appears to be egg salad, covered with plastic wrap, without a label or date of expiration. In the dry food pantry: - two Ziploc-style bags; one with dried beans with a label stating, expiration date: [DATE] and one with walnuts with a label stating expiration date [DATE]. In an interview with the DSD on [DATE] at 9:50 a.m., he stated that all kitchen staff are responsible for ensuring food items are dated and labeled. He stated they are supposed to do an am walkthrough and a pm walkthrough. In an interview with DSD on [DATE] at 11:35 a.m., he stated dates and labels should be on all stored foods that have been opened or are outside of their original packaging. The DSD stated there is a morning worker and evening worker who are supposed to conduct a walkthrough to inspect for dates, labels, and expirations, and to dispose of any foods that are not within policy. The DSD stated all kitchen staff are trained on safe food handling and storage. The DSD acknowledged that expired or unlabeled foods can result in foodborne illness among residents. A review of the facility's policy titled Community Life Policy and Procedures Dining Section, Storage dated [DATE], revision date [DATE], Policy item #18 indicated: All food items in refrigerators are properly dated, labeled, and placed in containers with lids. The Storage-Dry Goods section of the same policy indicated All foods used in the dietary department are received, stored, and used in a timely fashion to reduce deterioration, contamination and loss.

Based on interview, observation, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infection for the residents in the facility for 7 of 8 staff members (CNA A, CNA B, LVN C, LVN D, DSDS, and ALD) and one of one visitor, in that: The facility failed to: A.) ensure staff (LVN D, DSD, and ALD) and visitor wore the required N95 masks appropriately while in the facility. B.) to properly dispose of two sharps containers on the medication carts when the containers were overflowing, and the contaminated items were easily accessible. C.) ensure LVN C changed her gloves in-between cleaning and applying medication to the wound during wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] D.) CNA A and CNA B folded wipes in half to reuse during peri care for Resident #14 and Resident #79. These failures placed residents at risk for cross contamination that could result in infections or illness. Findings included: A.) Observation and interview on 10/12/21 at 8:50 AM, revealed the ALD wearing her N95 mask upside down. She acknowledged the mask being on upside down., She stated all staff were required to wear N95 masks since there was a COVID-positive resident in the facility. Observations throughout the day on 10/12/21 revealed LVN D wearing a KN-95 face mask. During an observation and interview on 10/13/21 at 9:44 AM revealed LVN D wearing an N95 face mask. He stated he was wearing a KN-95 mask the day prior (10/12/21) because he was unable to find an N95 mask. He stated that he had been in-serviced on wearing a KN95 mask when there was a COVID-positive resident in the facility. Observation of the service kitchen on 10/12/2021 at 7:35 AM, revealed the DSD wearing a KN-95 mask rather than the facility-required N95 mask. Observation on 10/12/2021 at 12:40 PM, the DSD was observed wearing a KN-95 mask during lunch service. Observation on 10/13/2021, the DSD was observed wearing a KN-95 mask in the service kitchen shortly following breakfast service, again during lunch service, and at the nurse's station following lunch service. In an interview at 10/14/21 at 11:35 AM with the DSD, he stated that current policy is that kitchen and food staff should use an N95 mask on the skilled care side of the facility. He stated infection control and PPE use policy is communicated to them through training and by the front desk. He stated this policy should be known since the COVID-positive case in the building. He acknowledged that failure by staff to wear N95 masks can result in spread of infection or a COVID outbreak. Observation on 10/14/21 at 9:42 AM, revealed a visitor of a resident in the communal dining room wearing a surgical mask. During an observation and interview on 10/14/21 at 9:45 AM with the HIC, she stated all staff and visitors were required to wear an N95 in the facility. She went and gave the visitor an N95 mask, she did not educate him on how to don the mask, and the visitor put the mask on upside down. During an interview on 10/14/21 at 9:53 AM with the ICP, she stated all staff and visitors are required to wear an N95 mask at this time. She stated most of the time visitors entered through the ALF entrance and walked over to the SNF. She stated the Receptionist was responsible for ensuring visitors going to the SNF had an N95. If they did not, she was to provide them with one. When asked how a visitor who entered through the SNF entrance to know an N95 was required, she stated she had a basket of them on the table in the foyer of the entrance. She stated there was not a sign indicating that an N95 was required. During an interview on 10/14/21 at 10:AM with the Recep F at the entrance of the ALF, she stated she was responsible for giving masks to visitors who would be going to the SNF. She stated management kept her well-informed regarding any COVID-positive cases at the SNF. When asked how she knew which visitors would be going to the SNF, she stated she was familiar with all visitors and knew if they would be visiting a resident at the ALF or at the SNF. Observation on 10/14/21 at 10:09 AM revealed signage at the doors separating the ALF from the SNF that reflected, N95 must be worn beyond these doors. Review of the facility's COVID-19 policy, reflected CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic reflected the following: Facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. B.) Observation on 10/12/21 at 7:30 AM revealed a sharps container on the treatment cart over ¾ full, well over the fill line. There were no staff seen on the hall. During an interview on 10/12/21 at 7:40 AM with LVN D, he stated sharps containers should be emptied when they were at least ¾ full. He stated that was important to ensure no staff or resident got poked or injured should they try and put their hand in it. Observation on 10/12/21 at 12:44 PM revealed the sharps container on the medication cart to be filled to the brim. There were no staff seen on the hall. During an observation and interview on 10/12/21 at 12:48 PM with MA E, she acknowledged the full sharps container. She stated it should be emptied once it was past the fill line but was unsure of who was supposed to empty the container. Observation on 10/13/21 at 9 AM revealed both sharps containers, one from the treatment cart and one on a medication cart, to still be full with sharps. Observation on 10/14/21 at 8:14 AM revealed both sharps containers, one from the treatment cart and one on a medication cart, to still be full with sharps. During an interview on 10/14/21 at 10:26 AM with the NP, she stated sharps containers should never be full and should be emptied regularly and definitely when past the fill line. She stated if it was not done it created an opportunity for someone to get hurt. The Surveyor stated her concern was the full sharp containers had been pointed out to staff on the first day of the Survey, and still nothing had been done. She stated that was unacceptable and would go ensure they were taken care of immediately. Review of the facility's Sharps Injury Prevention and Engineering Controls Policy, revised 8/1/14, reflected the following: Purpose: To assist in the risk of workplace injury of associates. Procedure: . 6. The Wellness Director will inspect, maintain, and replace sharps disposal containers to prevent overfilling. C.) Review of Resident #3's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's care plan, revised 6/10/21, reflected she had actual impairment to skin integrity, stage 4, to coccyx. Observation on 10/14/21 at 11:11 AM revealed LNV C performing wound care on Resident #3. After removing the old dressing, LVN C performed hand hygiene and applied clean gloves. She used a piece of gauze moistened with wound cleanser to clean the wound. She then used corners of the same gauze to pat dry the wound. She applied skin prep to the skin around the wound area then applied some granules to the wound. Wearing the same gloves, she reached into her pant pocket for her scissors. Without cleaning the scissors, she cut a piece of a medicated dressing and applied to the wound and covered it with a bordered foam dressing. Still wearing the same gloves, she assisted MA E to reposition the resident and adjust the bedding. LVN C then removed her gloves, and without hand hygiene, put on a new pair of gloves. She disposed of her trash and then proceeded to wash her hands for 12 seconds. She gathered her used supplies and went to the storage room where the treatment cart was located. She returned the bottle of wound cleanser and the open package of medicated dressing into the cart without first sanitizing the supplies. During an interview on 10/14/21 at 11:28 AM with LVN C, she stated she just started working at the facility and had not had any training on infection control since starting. She stated she usually would put the resident's name on the dressing package, so it would not be used for other residents, but she failed that time. She stated putting potentially contaminated objects in the treatment cart could spread infections. During an interview on 10/14/21 at 12:55 PM with the DOW, she stated items going in different resident rooms should be sanitized between residents to prevent the spread of germs or infection. Review of in-service on Handwashing was dated 8/12/21. Attached to the sign in sheet was the facility Policy titled Handwashing/Hand Hygiene that was revised 4/9/21. The policy reflected in part Associates will wash their hands . when moving from a contaminated body site to a clean body site. The policy also reflected Associates will wash their hands by doing the following . Rub vigorously for at least 20 seconds. D.) Review of Resident #14's undated face sheet reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's most recent MDS, dated [DATE], reflected she required extensive assistance for peri care. Review of Resident #14's care plan, revised 9/13/21, reflected she had intermittent catheter care every shift related to [CONDITION(S)], now transitioned to indwelling foley catheter [CONDITION(S)] ([CONDITION(S)] bladder). Observation on 10/14/21 at 9:59 AM revealed CNA A and CNA B performing peri care on Resident #14. CNA B used disposable wipes to clean the indwelling urinary catheter and the perineum, three times folding and reusing the same wipe multiple times going back and forth between clean to dirty areas. Review of Resident #79's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #79's most recent MDS, dated [DATE], reflected he required one-person physical assistance with peri care. Review of Resident #79's care plan, dated 10/21/21, reflected he had functional/mixed bladder incontinence secondary to activity intolerance. Observation on 10/14/21 at 10:20 AM revealed CNA A and CNA B performing peri care on Resident #79. CNA A used a disposable wipe to clean the head of the penis, wiped his leg with the wipe and used the same wipe to again clean the head of the penis. The aides repositioned the resident on his side and CNA A proceeded to use a new disposable wipe to clean the resident's rectum, the wipe contained a brown smear. She folded the wipe and used it two more times before getting a clean wipe to continue cleaning. During an interview on 10/14/21 at 10:33 AM with CNA B, she stated she had training on peri care and she was supposed to use each disposable wipe only one time. She stated she had folded the wipes multiple times and reused them. She stated this could cause the spread of infection. During an interview on 10/14/21 at 12:45 with the DOW and REGN, they stated catheter care should be performed per the facility policy. They stated competency checks were done regarding peri care. They stated that not following the proper techniques could increase the risk of infection, especially UTIs. They stated that a wipe should be used once and disposed of. Review of the facility's Perineal Care and Incontinence Care Policy, revised 7/1/15, do not address anything regarding hand sanitization between clean and dirty or the procedure on the use of wipes.

Based on interview and record review, the facility failed to implement facility Resident Rights policy related to respecting resident's choice to receive or not receive cardiopulmonary resuscitation determined by advanced directives for 1 of 4 residents (Resident #1) reviewed for advanced directives, in that: Upon finding Resident #1 unresponsive, the facility conducted CPR (cardiopulmonary resuscitation) on Resident #1 when Resident #1 had an out of hospital advanced directive -DNR (Do Not Resuscitate) in place. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated. This failure could place residents at risk of not having their wishes known, respected and implemented in an emergency. Findings: Review of medical records for Resident #1 revealed an 89 yo male admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan last revised [DATE] revealed Resident #1's code status as DNR and DNR documentation was verified to be available in the medical record. Intervention included honor the resident choice of code status, date initiated [DATE]. Review of an MDS dated [DATE] revealed a BIMS of 9 of 15 indicative of moderative cognitive dysfunction. Review of out of hospital advanced directives revealed a DNR dated [DATE] signed by Resident #1's POA, physician, and notary. Review of uploaded documents in the electronic medical record revealed the same out of hospital DNR dated [DATE]. Review of the electronic medical record face sheet revealed a code status of DNR. Review of the electronic orders revealed a DNR order dated [DATE]. Review of Resident #1's hard chart revealed a code status of DNR. In an Interview on [DATE] at 9:48 a.m. the Administrator stated Resident #1 had been a full code but had recently switched to DNR status. The Administrator had not yet arrived to the facility on Monday ([DATE]) morning when Resident #1 was found unresponsive, 911 was called and CPR was initiated. In a phone interview on [DATE] at 10:15 a.m. RN D stated staff had initiated CPR in response to finding Resident #1 unresponsive. RN D stated he would have expected nursing staff to check the hard chart or electronic medical record for code status before initiating CPR. In an interview on [DATE] at 10:30 am., LVN A stated he had arrived early for Monday ([DATE]) morning 6 a.m. to 2 p.m. shift. As soon as he walked in, CNA B, the 10 p.m.-6 a.m. aide, called him over to notify him that Resident #1 did not look good. LVN A stated he immediately went to resident #1's room to check on him. LVN A stated he found Resident #1 unresponsive and could not get a pulse. LVN A called for LVN B, the 10 p.m. - 6 a.m. nurse, to stay with Resident #1 while LVN A went back to the nurses station to call 911. LVN A stated EMS arrived very quickly, while he was still at the nurses station on the phone with 911. LVN A reported he stayed at the nurses station once EMS arrived to Resident #1's room because LVN B and LVN C were also in Resident #1's room with EMS personnel and EMS personnel had taken over CPR anyway. LVN A stated he knows he should have checked the chart for code status but did not check Resident #1's chart for code status because he knew Resident #1 was a full code. LVN A stated he was unaware of the change in code status because he had not worked the weekend and when he arrived Monday, he had not had a chance to do shift change report with LVN B because CNA B had called for him so urgently upon his arrival. In an interview on [DATE] at 10:45 a.m., the NP stated she had been off the previous week ([DATE]-[DATE]) but was aware of the change in code status because she had met with Resident #1's POA about Resident #1's outlook following his most recent hospitalization and they had discussed changing him from full code to DNR. The NP stated the POA had signed the DNR paperwork on Friday ([DATE]). The NP reported that when she arrived to the facility Monday ([DATE]) morning she saw the ambulance out front of the facility and asked LVN A what was going on. When she learned Resident #1 had coded and EMS was called for a full code, she grabbed Resident #1's hard chart and took it down to Resident #1's room. The NP informed EMS personnel that Resident #1 was a DNR but by then they had given him [MEDICATION(S)] and intubated him. EMS personnel were by this time able to regain Resident #1's pulse so Resident #1 remained intubated while Resident #1's POA discussed with ER doctor over the phone and EMS personnel whether to maintain or revoke the DNR in the event Resident #1 coded again. The POA decided to maintain the DNR. Resident #1 coded again, no further measures were taken, and Resident #1 expired. The NP stated she would expect staff to check the resident chart for code status. In an interview on [DATE] at 10:42 a.m., the SW stated she had worked with Resident #1's POA on the advanced directives, placed a copy in the hard chart, electronic chart and notified nursing staff of the change on Friday ([DATE]). In an interview on [DATE], LVN C stated that the process for communicating a change in code status is to write it down in the 24 hour report. She stated they do not have a 24 hour book, but they have sheets for each shift, and if something changes, they write on the shift sheet so that the next shift can see it. They do not save these sheets, and she has no access to anything going back further than this shift. Review of the facility CPR policy last revised ,d+[DATE] revealed In the event a resident is found to have no pulse and/or is not breathing, an associate should: 1) Call 911 immediately, 2) Verify DNR status of the resident and notify the 911 operator of the resident's current known DNR status. Review of the facility Resident Rights policy last revised ,d+[DATE] revealed Associates shall adhere to and respect resident's rights as applicable to state and federal regulations. Residents are entitled to exercise their rights and privileges to the fullest extent possible. The community will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. Review of the facility policy titled PL.,d+[DATE] Advance Directives Section VI- Client Records last revised ,d+[DATE] reflected the following: DNR identification. The physician signed advanced directive should be noted in the client record and part of the agency folder to be kept in the clients home. The Administrator was notified on [DATE] at 7:26 p.m. an Immediate Jeopardy situation had been identified due to above failure. The IJ template was provided to the Administrator on [DATE] at 7:49 p.m. The following Plan of Removal was submitted by the administrator on [DATE] at 11:40 p.m. and accepted at 11:55 p.m. Actions Taken/Planned included: -In-service nursing staff on Advanced Directives When to verify out of hospital do not resuscitate Instructions for correct completion of the out of hospital do not resuscitate Location in paper and electronic medical record Review of Advanced Directives policy Review of process - when a change of code status occurs, social service provides the hard copy of the out of hospital do not resuscitate to the nurse, who changes the code status in point click care and places the copy of the out of hospital do not resuscitate in the medical record. In a code situation, nurses are to verify the code status in the hard copy medical record. -Initiate Change of Condition/24 hour report Night shift nurse to initiate the change of condition/24 hour report for the up coming day Each shift nurse is to complete the change of condition/24 hour report prior to the completion of shift Write in comments section any code status change Nurses are to review the Change of Conditions/24 hour report for the last 72 hours For code status needs, the nurse is to verify with the chart to ensure the residents rights are followed -Audit advanced directives for all current residents and reconcile to medical records. The survey team monitored the plan of removal as followed: Review of facility in-servicing dated [DATE] reflected the following: When to verify the Out-of-Hospital Do-Not-Resuscitate order (OOH-DNR): -prior to entering the resident's room to administer medication -At the time that a resident is observed with absent vital signs Verify in the resident's paper medical record. Verify in the resident's electronic health record. Send Out-of-Hospital Do-Not-Resuscitate when the resident is transferred to another setting. This in-service had been signed by 16 staff members. Reviewed documentation for in-services conducted on advanced directives, Abuse/Neglect, Resident Rights, Change of Condition on 24 hour report, Policy on Advanced Directives (including how to complete an advanced directive, where to find in the records, hard chart, etc). Review of the 24 hour report for the last ~4 days on [DATE] reflected one resident with a change of status to their advanced directive in the last week and it was documented on 24 hour report. Review of the advanced directive audit documentation on [DATE] reflected that it had been completed. In interviews on [DATE], staff members reported they had undergone related in-services, indicated the process of executing an advanced directive, where to locate advanced directives, verification of advanced directives in the case a resident is found unresponsive and the process of documenting/reporting a change in advanced directive in the 24 hour report In an interview on [DATE] at 10:16 a.m., the DON stated she will be auditing the advanced directive list weekly but did add that their admissions/discharges are so fluid that status of advanced directives can change at any time. She stated she will continue to monitor the 24-hour reports and order reconciliation. The administrator was informed on [DATE] at 12:35 p.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm and a scope identified as isolated.

Based on interviews, record reviews, and observations the facility failed to accurately make a comprehensive assessment for 1 of 2 (Resident #1) residents in that: The facility failed to accurately assess the resident's corneal transplant upon admission. The facility discontinued a critical medication when staff entered the physician orders [REDACTED].#1's antibiotic and steroid eye drops prescribed to prevent an infection to the resident's right eye corneal transplant. The Resident missed 32 doses of his [MEDICATION NAME] (used to treat eye infection such as [MEDICAL CONDITION] and 19 does of his [MEDICATION NAME] Acetate (Steroid used to treat eye swelling by allergy, infections, injury, and surgery). Resident #1 was admitted to the hospital with [REDACTED]. These failures resulted in an Immediate Jeopardy situation on 2/7/19. While the IJ was removed on 2/8/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This failure has the potential to put other residents at risk of eye infection, complete transplant failure, or loss of vision, and places all residents at risk for improper assessment. Findings: Review of Resident #1's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet reflected a discharge date of [DATE]. Review of Hospital Discharge Medications (Dated 9/7/2018 ) provided to the facility for Resident #1 reflects that resident had a 30 -day order for [MEDICATION NAME] Acetate and [MEDICATION NAME]. During an interview on 2/6/2019 at 9:00 am, OPT A stated that she performed an emergency corneal transplant on Resident #1 about three years ago. OPT A stated that she prescribed [MEDICATION NAME] and [MEDICATION NAME] to help fight off infection which is especially important in a nursing home setting. OPT A stated that the eye drop medications for Resident #1 help fight infections, keep eyes moisturized, and help the body accept the transplant. OPT A stated that she expected Resident #1 to have a reoccurring order for the medications and that the resident could expect to be taking the medication for the rest of his life. OPT A stated that the risk of rejection for the corneal transplant never goes away, which is why there is a reoccurring order for the eye drop medications. OPT A stated that discontinuing the resident's [MEDICATION NAME] and [MEDICATION NAME] would cause the body to reject the transplant. OPT A stated that a medical person that does not specialize ophthalmology should not discontinue [MEDICATION NAME] and [MEDICATION NAME] for a resident who has had a corneal transplant. Review of Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. No documentation of new orders for Resident #1's eye drop medications were documented or entered into PCC. Resident #1's [MEDICATION NAME] was ordered to be given once a day at bed time for infection of the eye. Review of the MAR indicated [REDACTED]. Resident #1's [MEDICATION NAME] Acetate was ordered for 1 drop in the morning. Review of MAR indicated [REDACTED]. Review of Resident #1 care plan (dated: 9/8/2018) a focus for an eye infection for the right eye and to administer antibiotic as per MD orders. The care plan also included a focus on activities of daily living (ADLs) for self-care and listed an intervention to monitor/document/report to the medical director any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The care plan did not include any focus areas dedicated to care of Resident #1's cornea transplant. Resident #1's care plan did not reflect focus areas for identifying eye infections for resident's corneal transplant. Review of Resident #1's physician exam (History and Physical) dated 9/10/2018 reflected that the resident had a medical history of [REDACTED]. Review of Resident #1's MDS assessment dated [DATE] reflected, Section B (Hearing, Speech, and Vision), sub section B1000. Vision states that resident #1 has adequate vision meaning he can see fine details, such as regular print in newspapers/books. Section I (Active Diagnosis) does not document resident's corneal surgery as stated on the H&P. MDS also reflected a BIMS score of 15/15, cognitively intact. MDS reflects that Resident #1 was not assessed for his corneal transplant. Review of the emergency provider report dated 10/17/2018 revealed that Resident #1 had discontinued medication prescriptions from the facility, including [MEDICATION NAME] Acetate 1% Ophthalmic (econopred plus 1% ophth susp) 1 drops right eye qam and [MEDICATION NAME] 0.5% ophth oint 1 applic right eye bedtime. The emergency provider report states in the Free Text MDM Notes that Resident #1 had evidence of failed outpatient antibiotic treatments. Review of hospital Admitting Form reflects that Resident #1 was admitted to the hospital on [DATE] at 4:28 pm, with a [DIAGNOSES REDACTED]. The hospital MD who is also Resident #1's physician at the facility did know about Resident #1's right eye infection until he was admitted to the hospital on [DATE]. Review of hospital discharge notes from Resident #1's hospital stay beginning 10/17/2018 reflected medication records dated 10/31/2018 and noted in Resident #1's general appearance that he had an abnormal cornea, (R eye ulcer). Review of hospital consultation report dated 10/18/2018 revealed that MD was the attending physician and a corneal infection was suspected. MD sent Resident #1 to see an eye specialist. A corneal ulcer approximately 4mm in diameter was located in the inferior central portion of the corneal transplant. Corneal transplant ulcer in the right corneal transplant, clinically, was deemed likely to be pseudomonas bacterial infection. The recommendation was to administer [MEDICATION NAME] and [MEDICATION NAME] 1 drop of each medication in the right eye every hour. The [MEDICATION NAME] and [MEDICATION NAME] were ordered to treat Resident#1's corneal transplant infection. Review of hospital coding summary record dated 11/5/2018 referring to his stay on 10/17/2018-10/31/2018 reflected that the admitting physician was MD A. The record revealed that the primary [DIAGNOSES REDACTED]. Review of Resident #1's nursing progress notes reflected there was no documentation of Resident #1 having an eye infection, or treatment of [REDACTED]. During an interview on 2/5/2019 at 4:38 pm, Resident #1's POA stated the she was not aware that the facility stopped giving Resident #1 his [MEDICATION NAME] Ointment and [MEDICATION NAME] Acetate suspension for his cornea transplant in his right eye. POA stated that OPT A performed the corneal transplant in resident's right eye and that she ordered the eye drops for Resident #1 and that the eye drops were not supposed to be stopped. POA stated that she did not find out until Resident #1 was admitted to the hospital on [DATE] with pneumonia, when the hospital identified that the resident had an infection in the right eye. POA stated that the resident's eye infection was so bad that the hospital was worried it would perforate the cornea. POA stated that the hospital had OPT B care for Resident #1's eye and she ordered [MEDICATION NAME] hourly for several days. POA stated that she was told by DR that the [MEDICATION NAME] Ointment and [MEDICATION NAME] Acetate suspension eye drops were discontinued at two different times. POA stated that DR told her that [MEDICATION NAME] was manually entered incorrectly with a discontinue date and the [MEDICATION NAME] Acetate suspension was discontinued, but she doesn't know by whom. POA stated that the OPT B stated that the infection could cause the transplant to fail. POA stated that when Resident #1 was at the hospital he had pus coming out of his eye. Stated that when she talked to OPT B she told her that Resident #1's transplant is going to fail due to the infection. POA stated that OPT B told her that Resident #1 could do one of two things: 1 - Nothing and keep the amount of vision he has now or 2 - Get another corneal transplant. POA stated that once the OPT B told her that she felt the need to make a complaint because the facility's error is causing the transplant to fail. During an interview on 2/6/2019 at 1:15 pm, Resident #1 stated he recalls being without eye drops for about a week at the facility. He stated he wasn't sure why the drops were stopped, and nobody explained to him why. He stated he assumed the doctor had discontinued them. He stated he is most upset that no one explained why he wasn't getting the drops anymore. He stated he didn't ask anyone about it at the time. He stated that when he first had the transplant, he was seeing an ophthalmologist almost weekly and would apply drops himself (when living on his own). He stated the ophthalmologist had told him he needed to use the drops regularly or he could get an infection in the eye. He stated the transplant was about 3 years ago. During an interview on 2/6/2019 at 3:13 pm, DON stated that a doctor must sign the prescription order before any change. DON acknowledged that the order was created by LVN A and that MD must have given her the order to discontinue the use of the eyedrop medication. He said that nurses know that they are not allowed to discontinue or change any order without doctor's authorization. He said that the medication was prescribed by the cornea surgeon. When asked about the process they follow to discontinue medications, DON stated that nurses may receive the order to discontinue medication verbally. He stated that if a medication is discontinued by error/mistake, it is considered a medication error, and an incident report should be completed. DON stated that if there is a verbal order the medication will be discontinued. The DON stated that he was not aware of any infection on or in Resident #1's right eye and does not recall any symptom of infection in resident's eye. The DON stated that he and MD had a conversation about how the prescription was signed but they do not know how the order came out. During an interview on 2/6/2019 at 3:47 pm, MD stated that the [MEDICATION NAME] and [MEDICATION NAME] orders for Resident #1 were entered by the admitting floor nurse upon resident admission. MD stated that the floor nurse should have called the NP or physician to review the medications orders and give a verbal or electronic signature for the orders to be administered. MD stated that he does not recall reviewing the order to discontinue or to give an end date for the [MEDICATION NAME] and [MEDICATION NAME]. MD stated that he would not have stopped or discontinued these medications for a resident with a corneal transplant without consulting ophthalmology. MD confirmed that he did talk to Resident #1's POA and that he told her he is not sure how they were discontinued or stopped but that he would talk the DON about it. MD stated that a nurse entered the order wrong at the facility and that the DON told him he would talk to the nurse and provide training in the facility's online documentation system for her if needed and determine what the correct follow up is. MD stated that he was not alerted by the facility about the discontinued eye drops and only found out about the erroneous medication orders because he was the attending physician at the hospital where Resident #1 was admitted . MD stated that when he spoke to the DON, he informed the DON that Resident #1 was diagnosed with [REDACTED]. During an interview on 2/6/2019 at 4:22 pm, MDSN stated that she utilizes an admitting resident's History and Physical sheet (H&P) to identify resident [DIAGNOSES REDACTED]. MDSN stated that she does not recall much about resident's admission but that the floor nurses would look at the resident's medication orders and compare it to the H&P to make sure the medication ordered has a [DIAGNOSES REDACTED]. During an interview on 2/6/2019 at 4:52 pm, the RN B stated that she has worked for the facility for four years. RN B stated that the process for entering new resident medication into the facility's online documentation system is to get the MEDICATION ORDERS FOR [REDACTED]. RN B stated that the Nurse Practitioner (NP) reviews the orders before the floor nurse ever puts the medications into the documentation system. RN B stated, after the NP reviews the medications the FN would then put the new orders into documentation system. RN has the ability to enter or change a medication order in the PCC system. During an interview on 2/7/2019 at 11:18 am, LVN A stated that her job duties as a Floor Nurse include entering medical information for the resident into the online documentation system and admitting new residents. LVN A stated that part of the process for entering the medication for new residents is to consult the NP or Dr. to verify orders then enter them into PCC. LVN A verified that her name was on the MD orders for Resident #1's eye drops. LVN A stated that she does not recall anything else about Resident #1 because she was not the admitting nurse, LVN A stated that she was helping another nurse by entering the medications for her. LVN A stated the other nurse was doing a physical assessment and the NP that she consulted with at the time no longer works at the facility. LVN A stated that she did not see the resident because he was not in her hall. LVN A was not certain how she received the end dates for the medications. During an interview on 2/7/2019 at 12:50 pm, RN A stated that she remembered that Resident #1 was on eye drops but did not ever administer them. She stated that she remembers he was taking the eye drops because of a surgery, and she remembered this because he talked a lot about his medications. When asked if Resident #1 asked about his eye drop medication, RN A stated that she does not recall the resident ever complaining about his eye drops. RN A stated that a Dr. would enter the medication orders, all the orders are on the MAR, and if it is discontinued, it will drop off of the eMAR so the CMAs won't give it. RN A stated that she does not remember the eye drops. RN A stated that the night nurse does a night audit every night to look at medications and the hard chart. RN A stated that she does not recall if he did go out for an ophthalmalogical appointment. She stated that she does not remember the resident not getting his medication, stated that he did complain about one of his medications but not sure what medication it was. RN A stated that the charge nurse is the floor nurse and stated that she was not sure if that nurse did the physical assessment or put medications in. RN A stated that she does remember Resident #1 being admitted but not putting him into the documentation system. Observation on 2/7/2019 and interview at 5:53pm revealed RN C reviewing new resident medication order and H&P with NP over the phone. RN C was asked if a floor nurse has the ability to go into an order and change the end date to a medication. RN C clicked on the [MEDICATION NAME] order and went to the schedule tab within the electronic order then clicked on the end date tab. RN C was able to change the end date of the medication after the order was entered. Observation of the process revealed that a RN C was able to enter a doctor medication order change such as changing end date, dosage change, time change, or discontinuing a medication with or without a NP or Dr. order. During an interview on 2/7/2019 at 8:07 pm, the Administrator stated that the expectation is that the nurses follow the facility policy specific to skilled nursing. Administrator stated that if there is a known medication error the facility will make an incident report and notify the family and the physician if it is known. Administrator stated that if a nurse is going to make a change to a medication order there must be an order or if there is a verbal, it must be written down. Administrator stated that she would expect the DON to handle the oversight of nurses and ensuring they are compliant with medication order policies. She stated that she would expect the staff would notice a change in condition through visible signs and report to an aide or a nurse. She stated that if there is a change in resident condition, the notice will go to the charge nurse then ADON and DON depending on the severity. Record review of facility's Physician order [REDACTED].#: PL.6-011.1) states that verbal orders should be read back to the physician/healthcare practitioner to verify the accuracy of the orders and to decrease errors in documentation of verbal orders. Physician orders [REDACTED]. If a medication is discontinued the medication is documented by highlighting the medication and discontinued date is recorded on the medication list. The nurse making the change should sign and date the medication list. Record review of Reconciliation of Medication Admission/Re-Admission and Monthly orders - MED 3 Policy (revised: 12/2010) states that the charge nurse will perform medication reconciliation upon admission, readmission, or transition of care, for the purpose of providing an accurate and current medication regimen. The admission team should upload the discharging entities orders, history and physical, discharge summary, and labs into Point Click Care (PCC). Medication reconciliation reduces errors and enhances resident safety during the administration/transfer process by identifying the medications the resident needs and administering without interruption, the correct dosages and routes. Review the list carefully to determine if there are any discrepancies/conflicts/severe drug to drug interactions. If there is a discrepancy or conflict in the medications, dose, route or frequency, or severe drug to drug interaction, determine the most appropriate action to solve the discrepancy. For Example: Contact resident's primary physician from the referring community, discuss with resident or legal representative. Record review of facility Medication Reconciliation Competency check list (revisions:12/2017, 1/2019) states: 1. Obtain a copy of the most current medication list at the time of discharge from two (2) prior settings i.e. hospital, SNF, home, AL, etc. 4. Review/compare for an medication variances in the past two (2) transitions/discharge points with current physician/HCP medication orders. 8. Notify physician/HCP of any variances to verify if they want to reorder any medications that were discontinued in the hospital/prior setting or continue with all prior setting meds. 9. Ensure the physician/HCP signature accompanies medications and not just discharge nurse. 10. Inform the resident/POA of any changes/medication orders. Record review of facility medication error report revealed that the DON did not submit a medication error for Resident #1. Record review of the facility's infection control log revealed that the DON did not report that Resident #1 [MEDICAL CONDITION]. The Administrator was notified on 2/7/2019 at 3:29 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator on 2/7/2019 at 8:04 pm and was accepted by the Program Manager at 8:31 pm. Quality of Care: 1.To ensure residents receive their eye medications in accordance to physician order, the DON will perform a 100% audit of residents currently receiving antimicrobial and steroidal eye medication to ensure accuracy of transcription of physician's orders [REDACTED]. 2.To ensure licensed associates are proficient in transcription od physician orders, the DON or designee will perform in servicing on order transcription for licensed nurses. DON or designee to request associates to report to the community within the next 24 hours to complete in servicing. Associates unable to attend within the next 2 hours will not be permitted to report to work until in servicing is completed. 3. To ensure licensed associates are proficient in transcriptions of physician orders, the DON or designee will complete a Medication Reconciliation Competency on licensed associates. DON or designee to request associates report to the community within the next 24 hours to complete competency evaluation. Associates unable to attend within the next 24 hours will not be permitted to report to work until competency evaluation is completed. 4. To ensure accurate order transcription, DON or designee will complete an audit of medication order transcription for new admissions and new orders during the Interdisciplinary Team Huddle daily. 5. To ensure licensed associates are competent in identifying signs and symptoms of infection, DON or designee will perform in servicing on signs and symptoms for licensed associates. DON or designee to request associates to report to the community within the next 24 hours to complete in servicing. Any associates unable to attend within the next 24 hours will not be permitted to report to work until in servicing is completed. 6. Identification of residents with active signs of symptoms of infection, DON or designee will perform assessment of residents currently receiving antibiotic medication. 7. Identification and correction of order discrepancies, upon receipt of new physician orders [REDACTED]. Monitoring for the Plan of Removal began on 2/8/19 at 1:00p.m. Staff were interviewed for understanding regarding the new procedure regarding transcribing doctor's orders, medication administration, competency in identifying signs and symptoms of infection, identification of signs and symptoms of infection, and the correction of order discrepancies and addressing those issues. All staff interviewed had a good understanding of the training. Approximately 90% of the staff had received their training. On 2/8/19 at 3:45 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.

Based on interviews, record reviews, and observations the facility failed to ensure one of two residents reviewed for quality of care (Residents #1) received treatment and care for a corneal transplant, in accordance with professional standards of practice in that: The facility discontinued a critical medication when staff entered the physician orders [REDACTED].#1's antibiotic and steroid eye drops prescribed to prevent an infection to the resident's right eye corneal transplant. The Resident missed 32 doses of his [MEDICATION NAME] (used to treat eye infection such as [MEDICAL CONDITION]) and 19 does of his [MEDICATION NAME] Acetate (Steroid used to treat eye swelling by allergy, infections, injury, and surgery). Resident #1 was admitted to the hospital with [REDACTED]. These failures resulted in an Immediate Jeopardy situation on 2/7/19. While the IJ was removed on 2/8/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This failure has the potential to put other residents at risk of eye infection, complete transplant failure, or loss of vision, and improper assessment. Findings: Review of Resident #1's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet reflected a discharge date of [DATE]. Review of Hospital Discharge Medications (Dated 9/7/2018 ) provided to the facility for Resident #1 reflects that resident had a 30 -day order for [MEDICATION NAME] Acetate and [MEDICATION NAME]. Review of Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. No documentation of new orders for Resident #1's eye drop medications were documented or entered into PCC. Resident #1's [MEDICATION NAME] was ordered to be given once a day at bed time for infection of the eye. Review of the MAR indicated [REDACTED]. Resident #1's [MEDICATION NAME] Acetate was ordered for 1 drop in the morning. Review of MAR indicated [REDACTED]. During an interview on 2/6/2019 at 9:00 am, OPT A stated that she performed an emergency corneal transplant on Resident #1 about three years ago. OPT A stated that she prescribed [MEDICATION NAME] and [MEDICATION NAME] to help fight off infection which is especially important in a nursing home setting. OPT A stated that the eye drop medications for Resident #1 help fight infections, keep eyes moisturized, and help the body accept the transplant. OPT A stated that she expected Resident #1 to have a reoccurring order for the medications and that the resident could expect to be taking the medication for the rest of his life. OPT A stated that the risk of rejection for the corneal transplant never goes away, which is why there is a reoccurring order for the eye drop medications. OPT A stated that discontinuing the resident's [MEDICATION NAME] and [MEDICATION NAME] would cause the body to reject the transplant. OPT A stated that a medical person that does not specialize ophthalmology should not discontinue [MEDICATION NAME] and [MEDICATION NAME] for a resident who has had a corneal transplant. Review of Resident #1 care plan (dated: 9/8/2018) reflected a focus for an eye infection for the right eye and to administer antibiotic as per MD orders. The care plan also included a focus on activities of daily living (ADLs) for self-care and listed an intervention to monitor/document/report to the medical director any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The care plan did not include any focus areas dedicated to care of Resident #1's cornea transplant. Resident #1's care plan did not reflect focus areas for identifying eye infections for resident's corneal transplant. Review of Resident #1's physician exam (History and Physical) dated 9/10/2018 reflected that the resident had a medical history of [REDACTED]. Review of Resident #1's MDS assessment dated [DATE] reflected, Section B (Hearing, Speech, and Vision), sub section B1000. Vision states that resident #1 has adequate vision meaning he can see fine details, such as regular print in newspapers/books. Section I (Active Diagnosis) does not document resident's corneal surgery as stated on the H&P. MDS also reflected a BIMS score of 15/15, cognitively intact. MDS reflects that Resident #1 was not assessed for his corneal transplant. Review of the emergency provider report dated 10/17/2018 revealed that Resident #1 had discontinued medication prescriptions from the facility, including [MEDICATION NAME] Acetate 1% Ophthalmic (econopred plus 1% ophth susp) 1 drops right eye qam and [MEDICATION NAME] 0.5% ophth oint 1 applic right eye bedtime. The emergency provider report states in the Free Text MDM Notes that Resident #1 had evidence of failed outpatient antibiotic treatments. Review of hospital Admitting Form reflects that Resident #1 was admitted to the hospital on [DATE] at 4:28 pm, with a [DIAGNOSES REDACTED]. The hospital MD who is also Resident #1's physician at the facility did not know about Resident #1's right eye infection until he was admitted to the hospital on [DATE]. Review of hospital discharge notes from Resident #1's hospital stay beginning 10/17/2018 reflected medication records dated 10/31/2018 and noted in Resident #1's general appearance that he had an abnormal cornea, (R eye ulcer). Review of hospital consultation report dated 10/18/2018 revealed that MD was the attending physician and a corneal infection was suspected. MD sent Resident #1 to see an eye specialist. A corneal ulcer approximately 4mm in diameter was located in the inferior central portion of the corneal transplant. Corneal transplant ulcer in the right corneal transplant, clinically, was deemed likely to be pseudomonas bacterial infection. The recommendation was to administer [MEDICATION NAME] and [MEDICATION NAME] 1 drop of each medication in the right eye every hour. The [MEDICATION NAME] and [MEDICATION NAME] were ordered to treat Resident#1's corneal transplant infection. Review of hospital coding summary record dated 11/5/2018 referring to his stay on 10/17/2018-10/31/2018 reflected that the admitting physician was MD. The record revealed that the primary [DIAGNOSES REDACTED]. Review of Resident #1's nursing progress notes reflected there was no documentation of Resident #1 having an eye infection, or treatment of [REDACTED]. During an interview on 2/5/2019 at 4:38 pm, Resident #1's POA stated the she was not aware that the facility stopped giving Resident #1 his [MEDICATION NAME] Ointment and [MEDICATION NAME] Acetate suspension for his cornea transplant in his right eye. POA stated that OPT A performed the corneal transplant in resident's right eye and that she ordered the eye drops for Resident #1 and that the eye drops were not supposed to be stopped. POA stated that she did not find out until Resident #1 was admitted to the hospital on [DATE] with pneumonia, when the hospital identified that the resident had an infection in the right eye. POA stated that the resident's eye infection was so bad that the hospital was worried it would perforate the cornea. POA stated that the hospital had OPT B care for Resident #1's eye and she ordered [MEDICATION NAME] hourly for several days. POA stated that she was told by MD that the [MEDICATION NAME] and [MEDICATION NAME] Acetate suspension eye drops were discontinued at two different times. POA stated that DR told her that [MEDICATION NAME] was manually entered incorrectly with a discontinue date and the [MEDICATION NAME] Acetate suspension was discontinued, but she doesn't know by whom. POA stated that the OPT B stated that the infection could cause the transplant to fail. POA stated that when Resident #1 was at the hospital he had pus coming out of his eye. Stated that when she talked to OPT B she told her that Resident #1's transplant is going to fail due to the infection. POA stated that OPT B told her that Resident #1 could do one of two things: 1 - Nothing and keep the amount of vision he has now or 2 - Get another corneal transplant. POA stated that once the OPT B told her that she felt the need to make a complaint because the facility's error is causing the transplant to fail. During an interview on 2/6/2019 at 1:15 pm, Resident #1 stated he recalls being without eye drops for about a week at the facility. He stated he wasn't sure why the drops were stopped, and nobody explained to him why. He stated he assumed the doctor had discontinued them. He stated he is most upset that no one explained why he wasn't getting the drops anymore. He stated he didn't ask anyone about it at the time. He stated that when he first had the transplant, he was seeing an ophthalmologist almost weekly and would apply drops himself (when living on his own). He stated the ophthalmologist had told him he needed to use the drops regularly or he could get an infection in the eye. He stated the transplant was about 3 years ago. During an interview on 2/6/2019 at 3:13 pm, DON stated that a doctor must sign the prescription order before any change. DON acknowledged that the order was created by LVN A and that MD must have given her the order to discontinue the use of the eyedrop medication. He said that nurses know that they are not allowed to discontinue or change any order without doctor's authorization. He said that the medication was prescribed by the cornea surgeon. When asked about the process they follow to discontinue medications, DON stated that nurses may receive the order to discontinue medication verbally. He stated that if a medication is discontinued by error/mistake, it is considered a medication error, and an incident report should be completed. DON stated that if there is a verbal order the medication will be discontinued. The DON stated that he was not aware of any infection on or in Resident #1's right eye and does not recall any symptom of infection in resident's eye. The DON stated that he and MD had a conversation about how the prescription was signed but they do not know how the order came out. During an interview on 2/6/2019 at 3:47 pm, MD stated that the [MEDICATION NAME] and [MEDICATION NAME] orders for Resident #1 were entered by the admitting floor nurse upon resident admission. MD stated that the floor nurse should have called the NP or physician to review the medications orders and give a verbal or electronic signature for the orders to be administered. MD stated that he does not recall reviewing the order to discontinue or to give an end date for the [MEDICATION NAME] and [MEDICATION NAME]. MD stated that he would not have stopped or discontinued these medications for a resident with a corneal transplant without consulting ophthalmology. MD confirmed that he did talk to Resident #1's POA and that he told her he is not sure how they were discontinued or stopped but that he would talk the DON about it. MD stated that a nurse entered the order wrong at the facility and that the DON told him he would talk to the nurse and provide training in the facility's online documentation system for her if needed and determine what the correct follow up is. MD stated that he was not alerted by the facility about the discontinued eye drops and only found out about the erroneous medication orders because he was the attending physician at the hospital where Resident #1 was admitted . MD stated that when he spoke to the DON, he informed the DON that Resident #1 was diagnosed with [REDACTED]. During an interview on 2/6/2019 at 4:22 pm, MDSN stated that she utilizes an admitting resident's History and Physical sheet (H&P) to identify resident [DIAGNOSES REDACTED]. MDSN stated that she does not recall much about resident's admission but that the floor nurses would look at the resident's medication orders and compare it to the H&P to make sure the medication ordered has a [DIAGNOSES REDACTED]. During an interview on 2/6/2019 at 4:52 pm, the RN B stated that she has worked for the facility for four years. RN B stated that the process for entering new resident medication into the facility's online documentation system is to get the MEDICATION ORDERS FOR [REDACTED]. RN B stated that the Nurse Practitioner (NP) reviews the orders before the floor nurse ever puts the medications into the documentation system. RN B stated, after the NP reviews the medications the floor nurse would then put the new orders into documentation system. RN has the ability to enter or change a medication order in the PCC system. During an interview on 2/7/2019 at 11:18 am, LVN A stated that her job duties as a floor nurse include entering medical information for the resident into the online documentation system and admitting new residents. LVN A stated that part of the process for entering the medication for new residents is to consult the NP or Dr. to verify orders then enter them into PCC. LVN A verified that her name was on the MD orders for Resident #1's eye drops. LVN A stated that she does not recall anything else about Resident #1 because she was not the admitting nurse, LVN A stated that she was helping another nurse by entering the medications for her. LVN A stated the other nurse was doing a physical assessment and the NP that she consulted with at the time no longer works at the facility. LVN A stated that she did not see the resident because he was not in her hall. LVN A was not certain how she received the end dates for the medications. During an interview on 2/7/2019 at 12:50 pm, RN A stated that she remembered that Resident #1 was on eye drops but did not ever administer them. She stated that she remembers he was taking the eye drops because of a surgery, and she remembered this because he talked a lot about his medications. When asked if Resident #1 asked about his eye drop medication, RN A stated that she does not recall the resident ever complaining about his eye drops. RN A stated that a Dr. would enter the medication orders, all the orders are on the MAR, and if it is discontinued, it will drop off of the eMAR so the CMAs won't give it. RN A stated that she does not remember the eye drops. RN A stated that the night nurse does a night audit every night to look at medications and the hard chart. RN A stated that she does not recall if he did go out for an ophthalmalogical appointment. She stated that she does not remember the resident not getting his medication, stated that he did complain about one of his medications but not sure what medication it was. RN A stated that the charge nurse is the floor nurse and stated that she was not sure if that nurse did the physical assessment or put medications in. RN A stated that she does remember Resident #1 being admitted but not putting him into the documentation system. Observation on 2/7/2019 and interview at 5:53pm revealed RN C reviewing new resident medication order and H&P with NP over the phone. RN C was asked if a floor nurse has the ability to go into an order and change the end date to a medication. RN C clicked on the [MEDICATION NAME] order and went to the schedule tab within the electronic order then clicked on the end date tab. RN C was able to change the end date of the medication after the order was entered. Observation of the process revealed that a RN C was able to enter a doctor medication order change such as changing end date, dosage change, time change, or discontinuing a medication with or without a NP or doctor's order. During an interview on 2/7/2019 at 8:07 pm, the Administrator stated that the expectation is that the nurses follow the facility policy specific to skilled nursing. Administrator stated that if there is a known medication error the facility will make an incident report and notify the family and the physician if it is known. Administrator stated that if a nurse is going to make a change to a medication order there must be an order or if there is a verbal, it must be written down. Administrator stated that she would expect the DON to handle the oversight of nurses and ensuring they are compliant with medication order policies. She stated that she would expect the staff would notice a change in condition through visible signs and report to an aide or a nurse. She stated that if there is a change in resident condition, the notice will go to the charge nurse then ADON and DON depending on the severity. Record review of facility's Physician order [REDACTED].#: PL.6-011.1) states that verbal orders should be read back to the physician/healthcare practitioner to verify the accuracy of the orders and to decrease errors in documentation of verbal orders. Physician orders [REDACTED]. If a medication is discontinued the medication is documented by highlighting the medication and discontinued date is recorded on the medication list. The nurse making the change should sign and date the medication list. Record review of Reconciliation of Medication Admission/Re-Admission and Monthly orders - MED 3 Policy (revised: 12/2010) states that the charge nurse will perform medication reconciliation upon admission, readmission, or transition of care, for the purpose of providing an accurate and current medication regimen. The admission team should upload the discharging entities orders, history and physical, discharge summary, and labs into Point Click Care (PCC). Medication reconciliation reduces errors and enhances resident safety during the administration/transfer process by identifying the medications the resident needs and administering without interruption, the correct dosages and routes. Review the list carefully to determine if there are any discrepancies/conflicts/severe drug to drug interactions. If there is a discrepancy or conflict in the medications, dose, route or frequency, or severe drug to drug interaction, determine the most appropriate action to solve the discrepancy. For Example: Contact resident's primary physician from the referring community, discuss with resident or legal representative. Record review of facility Medication Reconciliation Competency check list (revisions:12/2017, 1/2019) states: 1. Obtain a copy of the most current medication list at the time of discharge from two (2) prior settings i.e. hospital, SNF, home, AL, etc. 4. Review/compare for an medication variances in the past two (2) transitions/discharge points with current physician/HCP medication orders. 8. Notify physician/HCP of any variances to verify if they want to reorder any medications that were discontinued in the hospital/prior setting or continue with all prior setting meds. 9. Ensure the physician/HCP signature accompanies medications and not just discharge nurse. 10. Inform the resident/POA of any changes/medication orders. Record review of facility medication error report revealed that the DON did not submit a medication error for Resident #1. Record review of the facility's infection control log revealed that the DON did not report that Resident #1 [MEDICAL CONDITION]. The Administrator was notified on 2/7/2019 at 3:29 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator on 2/7/2019 at 8:04 pm and was accepted by the Program Manager at 8:31 pm. Quality of Care: 1.To ensure residents receive their eye medications in accordance to physician order, the DON will perform a 100% audit of residents currently receiving antimicrobial and steroidal eye medication to ensure accuracy of transcription of physician's orders [REDACTED]. 2.To ensure licensed associates are proficient in transcription od physician orders, the DON or designee will perform in servicing on order transcription for licensed nurses. DON or designee to request associates to report to the community within the next 24 hours to complete in servicing. Associates unable to attend within the next 2 hours will not be permitted to report to work until in servicing is completed. 3. To ensure licensed associates are proficient in transcriptions of physician orders, the DON or designee will complete a Medication Reconciliation Competency on licensed associates. DON or designee to request associates report to the community within the next 24 hours to complete competency evaluation. Associates unable to attend within the next 24 hours will not be permitted to report to work until competency evaluation is completed. 4. To ensure accurate order transcription, DON or designee will complete an audit of medication order transcription for new admissions and new orders during the Interdisciplinary Team Huddle daily. 5. To ensure licensed associates are competent in identifying signs and symptoms of infection, DON or designee will perform in servicing on signs and symptoms for licensed associates. DON or designee to request associates to report to the community within the next 24 hours to complete in servicing. Any associates unable to attend within the next 24 hours will not be permitted to report to work until in servicing is completed. 6. Identification of residents with active signs of symptoms of infection, DON or designee will perform assessment of residents currently receiving antibiotic medication. 7. Identification and correction of order discrepancies, upon receipt of new physician orders [REDACTED]. Monitoring for the Plan of Removal began on 2/8/19 at 1:00p.m. Staff were interviewed for understanding regarding the new procedure regarding transcribing doctor's orders, medication administration, competency in identifying signs and symptoms of infection, identification of signs and symptoms of infection, and the correction of order discrepancies and addressing those issues. All staff interviewed had a good understanding of the training. Approximately 90% of the staff had received their training. On 2/8/19 at 3:45 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.