Every finding on record at Signature Healthcare of Kinston

Based on observations, record review, and interviews with staff, the facility failed to provide 1 of 3 meals observed at the regular scheduled times (lunch 12/01/25). The lunch meal was served 2 hours after the posted mealtimes to the dining room and all 5 halls. The findings included: The posted mealtimes documented lunch service in the dining room was to begin at 12:00 PM, the 500 hall at 12:15 PM, the 400 Hall at 12:30 PM, the 300 Hall at 12:45 PM, the 200 Hall at 1:00 PM, and the 100 Hall at 1:15 PM. Observation of the lunch meal service on 12/01/25 revealed the lunch meal trays arrived at 2:15 PM in the dining room, at 2:20 on the 500 Hall, at 2:23 PM on the 400 Hall, at 2:25 PM on the 300 Hall, at 2:32 PM on the 200 Hall, and at 2:40 PM on the 100 Hall. In an interview on 12/01/25 at 2:21 PM, the Regional Dietary Manager (acting as the interim dietary manager) confirmed the lunch trays were still being plated in the kitchen and had not been served to the 300, 200, and 100 Halls. She stated the lunch meal was being served late due to staffing issues in the kitchen. The dishes from the dinner meal on 11/20/25 had not been washed because the dietary aides who were working that night had quit without notice, so the dishes had to be washed the morning of 12/01/25. As a result, breakfast was served 2 hours late at approximately 10:00 AM, which affected when the dishes would be ready to use to serve lunch. In an interview on 12/3/25 at 10:30 AM, the Administrator stated he was aware of dining service being late in the past and the facility had been trying to address the concern, but staffing had not been identified as the reason for late meals.

Based on record review, observations, and resident, staff and Medical Director interviews, the facility failed to protect a resident's right to be free from misappropriation property and exploitation for 2 of 6 residents (Resident #103 and Resident #4) reviewed for abuse, neglect and/or misappropriation of property/exploitation. (1) In November 2024, Resident #103 reported her debit card account had been depleted to $9.34 after giving Nurse Aide (NA) #3 her debit card to pay her (NA #3's) light bill. The unauthorized spending to Resident #103's debit card totaled $2265.15. (2) In July 2025, NA #2 told Resident #4 she needed money to feed her children and Resident #4 gave NA #2 $65 dollars and was not reimbursed by the facility. Findings included: 1. Resident #103 was admitted to the facility on [DATE] with diagnoses that included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #103 was moderately cognitively impaired. An initial report dated 11/24/2024 alleging misappropriation of property for Resident #103 was completed by the former Director of Nursing #1 and faxed to the State Agency. The initial report recorded the facility became aware of the allegation of misappropriation of property on 11/24/2024 at 5:00pm when Resident #103 stated an employee, Nurse Aide (NA) #3 , had borrowed money from Resident #103. The facility's initial report indicated the local law enforcement was notified of Resident #103's allegation on 11/24/2024 at 5:30pm. Resident #103's written statement dated 11/24/2024 at 5:05pm when interviewed by the former Director of Nursing #1 stated NA #3 had told Resident #103 that her (NA#3) light bill was a little over $100.00 and Resident #103 had given NA #3 her (Resident #103) debit card to pay the light bill. Resident #103 stated there was a balance of $1900.00 on the debit card when she loaned NA #3 the debit card (date not recorded) and stated NA#3 brought the debit card back to Resident #103 the next day(date not recorded). Resident #103 stated on Friday (date unknown) when checking the balance on the debit card, there was a balance of only $9.34. Resident #103 stated she asked NA #3 why she spent all of Resident#103's money and NA #3 did not have an explanation. Attempts to interview Resident #103 were unsuccessful. In NA #3's written statement taken by the former Director of Nursing #1 on 11/24/2024, NA #3 reported Resident #103 asked NA #3 to take the debit card to Walmart to get Resident #103 some drinks, snacks and fruit. NA #3 stated Resident #103 told her to get her (NA#3) something as well and a gift for NA #3's kids since it was the holidays and stated she (NA#3) got the items and some meat for herself from Walmart that totaled to a couple hundred dollars. NA #3 stated she gave Resident #103 a hundred-dollar bill for the items bought at Walmart because Resident #103 was going home for Thanksgiving and needed some cash. The former Director of Nursing wrote in NA #3 statement that NA #3 was explained she was suspended pending the investigation of Resident #103's allegation for misappropriation of property. Attempts to interview NA #3 were unsuccessful. A written statement from NA #4 on 11/24/2024 stated Resident #103 approached and pulled her to the side to ask if she was still friends with NA #3. When NA #4 answered yes, Resident #103 asked NA #4 to call NA #3 and ask NA#3 when she planned to give Resident #103 back her money. When NA #4 asked Resident #103 what she meant, Resident #103 told NA #4 she gave NA #3 a debit card because NA #3 told Resident #103 that she needed help paying the rent. Resident #103 stated she was trying to be nice and told NA #3 that NA #3 could use some of the money on the debit card but would not say how much money was allowed. NA #4 stated the amount used was way over $1900.00 and informed Resident #103 that this needed to be reported to someone in Administration. NA #4 stated she contacted and informed NA #3 Resident #103 wanted to see her about Resident #103's money. NA #4 stated NA #3 did say she used Resident #103's debit card and never confirmed or denied taking extra money from Resident #103. NA #4 stated when Resident #103 asked who she should report the incident to if Resident #103 did not get her money back on Monday (11/25/24), NA #4 told her to see the former Director of Nursing #1. NA #4 reported that she informed Nurse #2 of the conversation with Resident #103 and contacted the former Director of Nursing #1 of the conversation with Resident #103 on 11/24/2024. In a phone interview with NA #4 on 12/5/2025 at 8:12 am, she recalled how Resident #103 coming to her on 11/24/2024 stating she didn't know what supervisor to go to tell that she had loaned her (Resident #103) debit card to NA #3 for a certain amount of money (amount unknown). She stated Resident #103 told her NA #3 brought back Resident #103's debit card and NA #3 had spent more than the amount of money (unknown amount) she had loaned NA #3 on the debit card. NA #4 stated Resident #103 wanted to talk with NA #3 to try to get the money back. NA #4 stated NA #3 did not answer the phone when she called NA #3. She explained although Resident #103 was upset her money was gone from the debit card account, Resident #103 didn't want to get NA #3 into any trouble. NA #4 stated she informed Nurse #2 of Resident #103's allegation of money spent with her debit card and notified the former Director of Nursing #1 via phone. NA #4 recalled receiving educational in-services after reporting the incident for abuse, neglect and misappropriation of property and receiving gifts from residents. In a written statement by Nurse #2 dated 11/25/2024, Nurse #2 stated Resident #103 informed Nurse #2 on 11/24/2024 that she let NA #3 use her (Resident #103) debit card to pay for NA #3's electric bill that was due because NA #3 was pitiful. Resident #103 informed Nurse #2 that initially the debit card had $1900.00 and NA #3 returned the debit card on Thursday night (date unknown). Nurse #2 stated Resident #103 reported calling her bank to inquire of the debit card balance on Friday morning (date unknown) and was shocked and mad there was only $9.34. Nurse #2 reported Resident #103 stated when she (Resident #103) confronted NA #3 (date unknown) about the money spent on the debit card, NA #3 told Resident #103 she would give $50.00 back to Resident #103 and Resident #103 got mad because Resident #103 knew NA #3 had spent more than $50.00 from Resident #103's debit card. In a phone interview with Nurse #2 on 12/3/2025 at 7:21 pm, she stated Resident #103 was alert and oriented and told her on 11/24/2024 that the reason Resident #103 gave NA #3 her debit card was because NA#3's family needed the money and NA #3 was to pay her back the money. Nurse #2 stated the Administrator, Director of Nursing and the Assistant Director of Nursing were notified upon learning Resident #103 was upset because her money had been drained (spent) from the debit card. She explained NA #3 was notified by the Administration team not to report to work on 11/24/2024, and Resident #103 was reimbursed for the lost money on the debit card. She stated Resident #103 was observed interacting with staff and residents with no changes in behaviors and staff received educational in-services on abuse, neglect and misappropriation of property and receiving gifts. A police report for debit card fraud dated 11/24/2025 at 6:56 pm recorded Resident #103 reported NA #3 had used Resident #103's debit card and took $1900.00. The police officer recorded NA #3 stated Resident #103 had given her permission to use the debit card months ago to purchase food for herself and Resident #103. NA #3 reported after purchasing the groceries at Walmart, she returned the debit card to Resident #103. The police report stated Resident #103 was unable to provide any statements and/or proof money was missing from the debit card account. A review of the expenditures reported by the debit card's bank on 11/25/2024 included the following: On 10/23/2024, $442.45 spent at Piggly Wiggly (a grocery store) On 11/2/2024, $506.50 spent at Walmart (retail store) On 11/2/2024. $49.69 spent at Walmart On 11/2/24, $87.06 spent at Dollar General (retail store) On 11/3/24, $107.61 spent at Wal-Mart On 11/3/2024, $60.00 spent at Cricket Wireless (mobile phone store) On 11/4/2024, $5.09 spent at Piggy Wiggly On 11/16/24, $887.85 spent at Real Estate Agent-Managers (rental company) On 11/18/24, $118.90 spent at Real Estate- 530 Nunn Road (rental company) The facility's investigation report dated 11/26/2024 and signed by former Director of Nursing #1 recorded Resident #103 reported on 11/24/2024 at 5:00 pm she had given a debit card to NA #3 to pay for her (NA #3) light bill that NA #3 had told her was a little over $100.00. Resident #103 reported NA #3 took her debit card and brought the debit card back the next day (date unknown). Resident #103 stated there was a $1900.00 balance on the debit card when Resident #103 loaned the debit card to NA #3. Resident #103 stated on Friday (date unknown) when she called the bank to check the balance of the debit card, there was a balance of $9.34 on the debit card. Resident #103 reported she asked NA #3 why she spent all of her (Resident #103) money and NA #3 did not have an explanation. NA #3 was suspended pending the investigation on 11/24/2024. On 11/25/2024, Resident #103 and Administrator contacted the bank of the debit card and was provided a list of unauthorized transactions that totaled $2264.85 that the facility reimbursed Resident #103. Resident #103 was issued a new debit card and educated by the former Director of Nursing #1 not to give or loan her debit card to any staff member or resident. The investigation report recorded no physical injury or harm and no mental anguish to Resident #103 and the former Director of Nursing #1 monitored the social well-being of Resident #103 for 72 hours with no negative findings. Resident #103's requested the local police department filed charges against NA #3. NA #3 was terminated on 11/26/2024. The investigation report reported Resident #103's allegation of misappropriation or property was substantiated and the investigation report was faxed to the State Agency on 11/27/2024. A psychiatric provider note dated 12/5/2024 recorded Resident #103 had mild dementia and was alert, oriented and in good spirits. Resident #103 had adjusted well to the facility with no acute psychiatric complaints noted or reported recently. A review of check invoice dated 12/5/2024 for misappropriated funds due to employee theft in the amount of $2265.15 was requested by the Administrator for Resident #103. A copy of a corporate check to Resident #103 dated 12/12/2024 was in the amount for $2265.15. In a phone interview with the former Director of Nursing #1 on 12/5/2025 at 3:00pm, she stated Resident #103 had given her debit card to NA #3 to purchase some groceries for Resident #103 and NA #3 had returned the debit card to Resident #103. She recalled when Resident #103 checked the balance on the debit card, there was unexplained money missing off the debit card. She stated it appeared NA #3 had used the debit card over a period of time in November 2024 without the permission of Resident #103 to use. She stated NA #3 was suspending pending investigation and was terminated at the end of the investigation. She stated the local police and state agency were notified and facility reimbursed Resident #103 money. She reported skin assessments were conducted on residents with BIMS less than 8 and resident interviews were conducted on a BIMS greater than 8 with no further issue identified with misappropriation of property and/or exploitation. She stated education on receiving gifts and misappropriation of property was provided to the staff. In a phone interview with the previous Administrator on 12/3/2025 at 3:31 pm, he stated Resident #103 gave NA #3 the debit card to buy her (Resident #103) groceries and NA #3 was not given permission to purchase items for herself (NA #3). He explained NA #3 was not given permission by Resident #103 to spend the amount of money not related for Resident #103's needs on the debit card. He stated the employee was suspended during the investigation of the allegation for misappropriation of property and terminated immediately upon completion of the investigation. He stated the facility refunded Resident #103 with a check in the amount of money identified as unauthorized use and Resident #103 was satisfied with the resolution of refunding her money. The facility provided a plan of correction that was not acceptable to the State Agency as the facility did not conduct a systemic approach to prevent future incidents of misappropriation of residents' property. 2. A review of the facility's policy titled Abuse, Neglect, and Misappropriation of Property dated 5/27/16 and last reviewed on 1/31/25 revealed in part the definition of exploitation as taking advantage of a resident for personal gain. Resident #4 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, seizure disorder, depression, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. An initial allegation report dated 7/29/25 was sent from the facility to the State Agency alleging misappropriation of Resident #4's property. Details of the allegation stated NA #2 asked Resident #4 for money to feed her children. The facility's investigation report dated 8/4/25 was sent from the facility to the State Agency. The investigation report recorded that Resident #4 did give NA #2 money to feed her children. NA #2 was suspended pending the investigation, her employment was terminated on 8/1/25. The allegation was substantiated by facility staff. An interview was conducted with Resident #4 on 12/3/25 at 10:10 AM. Resident #4 stated she did remember the incident when NA #2 came into her room and asked her for $20.00 to feed her children. Resident #4 said she did not feel $20.00 would be enough to feed her children so she gave her $65.00. She went on to say NA #2 stated she would pay Resident #4 back, but she did not. The facility did not reimburse Resident #4 or offer to reimburse her. Resident #4 indicated NA #2 told Resident #4 to tell the staff she was picking up food for Resident #4 so she would not get fired. Resident #4 never saw NA #2 again. Resident #4 stated this incident made her feel angry. In an interview with the Social Services Director on 12/3/25 at 9:45 AM, she stated she could not remember the staff member that made her aware of the incident when NA #2 asked Resident #4 for money. She did not know if the funds were reimbursed to Resident #4. An interview with the Assistant Director of Nursing was conducted on 12/3/25 at 10:20 AM, she stated she could not recall the name of the staff member that reported to her that a staff member had borrowed $20.00 to $30.00 from Resident #4 and did not repay the resident. She added she reported it to the Administrator and the Director of Nursing immediately after learning of the incident. An interview was conducted with the Administrator on 12/3/25 at 10:30 AM, he stated the incident was reported to the Administrator and the Director of Nursing. The Director of Nursing and the Assistant Director of Nursing then went to interview Resident #4. Resident #4 reported that NA #2 asked Resident #4 for money to feed her children. The Administrator added it was the facility policy to replace missing items or money. He added the facility did not replace the money that was taken as he felt Resident #4 gave it freely. In a follow-up interview with the Administrator on 12/3/25 at 3:45 PM, he stated he was not sure if the facility offered to replace the money that was taken. In this case he felt Resident #4 gave NA #2 the money voluntarily and that was why it would not have been reimbursed. An interview with the Medical Director was held on 12/3/25 at 11:20 AM. She remembered that this incident was reported to her. She did not feel this incident caused any harm to the resident. The facility provided a plan of correction for past non-compliance. The plan could not be accepted by the State Agency.

Based on record review and staff interviews, the facility failed to report allegations of abuse and misappropriation of property/exploitation to Adult Protective Services (APS) for 3 of 6 residents reviewed for abuse, neglect, misappropriation of property and/or exploitation (Resident #103, Resident #101 and Resident #74). Findings included: The facility's Abuse, Neglect and Misappropriation of Property policy statement last reviewed 1/31/2025 indicated the facility Administrator was responsible for reporting all investigation results of abuse, neglect and misappropriation of property to applicable State agencies as required by Federal and State law. 1. Resident #103 was admitted to the facility on [DATE]. An initial report dated 11/24/2024 for misappropriation of property was completed by the former Director of Nursing #1 and faxed to the State Agency. The initial report recorded the facility became aware on 11/24/2024 at 5:00 pm that Resident #108 alleged an employee, Nurse Aide (NA) #3 had borrowed money from Resident #103. The facility's initial report indicated the local law enforcement was notified of Resident #103's allegation on 11/24/2024 at 5:30 pm. There was no documentation that APS was notified of the allegation of misappropriation of property and/or exploitation. The facility's investigation report dated 11/26/2024 and signed by former Director of Nursing #1 recorded Resident #103 had given a debit card to NA #3 to pay for her (NA#3) light bill that NA #3 had told her was a little over $100.00. Resident #103 stated there was a $1900.00 balance on the debit card when Resident #103 loaned the debit card to NA #3. Resident #103 stated NA #3 brought the debit card back and when Resident #103 checked the balance on the debit card days later, there was a balance of $9.34 on the debit card. The investigation report recorded the allegation was substantiated, and the facility reimbursed Resident #103 a total of $2264.85 for documented unauthorized use of Resident #103's debit card. The investigation report was faxed to the State Agency on 11/27/2024, and there was no documentation that APS was notified of the allegation of misappropriation of property and/or exploitation on the investigation report. In a phone interview with the former Director of Nursing #1 on 12/5/2025 at 3:00pm, she stated she remembered the investigation into the allegation of misappropriation of property and/or exploitation for Resident #103. She stated the State Agency and local law enforcement were notified and she could not recall if the APS was notified. She stated APS should have been notified of the allegation of misappropriation of property and stated the Administration at the time would have been responsible for notifying APS. In a phone interview with the previous Administrator on 12/3/2025 at 3:31 pm, he explained he did not know what the facility's policy was for notifying APS when Resident #103 reported the allegation of misappropriation of property and/or exploitation on 11/24/2024. He stated he could not say that APS was not notified or notified if it was not recorded on the investigation report. The previous Administrator stated APS should have been notified of the allegation. In an interview with the State Signature Clinical Coordinator on 12/6/2025 at 9:55am she stated APS should have been notified of Resident #103's allegation of misappropriation of property and/or exploitation and was unable to recall if APS was notified. An attempt to interview APS was unsuccessful. 2. Resident # 101 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (stroke). He was discharged from the facility on 9/19/25. A facility Investigation Report dated 4/08/25 documented that on 4/05/25 at 1:40 PM, Housekeeper #1 started cursing at him because he wasn't moving his wheelchair down the hallway and had blocked her cart. Housekeeper #1 was witnessed cursing at the resident, and was escorted out of the building during the investigation. The facility investigation found two other employees heard the interaction and confirmed Housekeeper #1 did curse at the resident. The facility substantiated verbal abuse. The report documented that Adult Protective Services (APS) had not been notified. Nurse Aide (NA) #5's written witness statement dated 4/05/25 documented that when Resident #101 was coming down the hallway in his wheelchair, Housekeeper #1 came behind him and stated for him to Move out of the way m******f*****, move b**** and then proceeded to push her housekeeping cart to his wheelchair to move him out of the way. In a phone interview on 12/08/25 at 1:33 PM NA #5 stated Resident #101 had been propelling his wheelchair independently down the hallway. The hallway was crowded because other residents were on the other side of the hallway waiting to go outside to smoke. Housekeeper #1 got upset because Resident #101 was in her way. She started cussing at him in a threatening tone for him to move, which then made the resident angry. She then pushed her housekeeping cart into the back of his wheelchair. The other aide who witnessed the incident, NA #2, helped her to separate Housekeeper #1 and Resident #101. Once he was taken to his room, he calmed down and was back to baseline. NA #2's written witness statement dated 4/05/25 documented that when NA #2 was passing out trays for lunch, Resident #101 was coming down the hall. Housekeeper #1 was behind him. She told him to move out of her way but Resident #101 did not hear her. Housekeeper #1 then shouted that y'all need to learn how to get the f*** out the d*** way and pushed her cart to the side. She yanked the resident's wheelchair, which upset the resident. Resident #101 got up out of his wheelchair and stated he would knock her out. Housekeeper #1 stated he wasn't going to do s*** m*****f*****, grabbed her housekeeping cart again and said what the f*** you going to do and then pushed her housekeeping cart into the resident. She then stated you need to get your black a** back to your room and get out of the way. In a phone interview on 12/09/25 at 3:34 PM NA #2 stated she was passing out meal trays and Housekeeper #1 wanted to get past Resident #101, who was propelling himself in the wheelchair. Housekeeper #1 began cussing at him, telling him to get out of her way. Housekeeper #1 threatened Resident #101, stating if he didn't get out of the way, she would run into him with her cart and make him. She then pushed her cart into the back of the wheelchair. NA #2 and NA #5 separated the housekeeper from the Resident and NA #2 took Resident #101 back to his room. She stated once he calmed down, he was back to his baseline. Resident #101 was unable to be interviewed. Attempts to contact Housekeeper #1 were unsuccessful. In a phone interview on 12/08/25 at 11:31 AM the facility Clinical Consultant stated the facility substantiated that Housekeeper #1 verbally abused and threatened Resident #101 with harm. She stated Housekeeper #1 was let go from the facility. In a phone interview on 12/09/25 at 4:09 PM the Administrator stated the facility had substantiated verbal abuse. In a phone interview on 12/09/25 at 4:05 PM, the Administrator stated former Director of Nursing #2 had been responsible for notifying APS and he wasn't sure if it was done. He stated he relied on her documentation that APS had not been notified and stated they should have been. Attempts to contact former Director of Nursing #2 were unsuccessful. 3. Resident #74 was admitted to the facility on [DATE] with diagnoses including bipolar disorder and anxiety disorder. A Facility Investigation Report dated 2/07/25 documented Resident #74 alleged Nurse Aide (NA) #5 had taken a 4-carat diamond gold and platinum ring that she had purchased online approximately one year prior. She stated she had shown the ring to NA #5 and the next morning the ring was gone. The investigation noted Resident #74 did see or know who took the ring but said NA #5 was the only person that knew it where it was located. The investigation report documented Adult Protective Services (APS) was not notified of the allegation. In a phone interview with the previous Administrator on 12/3/2025 at 3:31 pm, he explained he did not know what the facility's policy was for notifying APS for the allegation of misappropriation of property and/or exploitation. He stated he could not say that APS was not notified or notified if it was not recorded on the investigation report. The previous Administrator stated APS should have been notified of the allegation.

Based on observations, record review, and staff and Medical Director interview, the (a) facility failed to ensure that required emergency tracheostomy (trach) equipment, including an Ambu bag (self-inflating bag that pushes air into lungs), was kept at the bedside as ordered and as required by facility policy and (b) failed to ensure infection-control practices were followed during tracheostomy care for 1 of 2 residents reviewed for tracheostomy care (Resident #8).Findings included:(a) A review of the facility's Tracheostomy Policy revealed that, for emergency management, an emergency tracheostomy tube and an Ambu bag were required to be kept at the resident's bedside.A review of standing admission orders included maintain trach equipment at the bedside at all times, including the obturator (An obturator is a curved rod that fits inside the tracheal cannula, which is a tube inserted into the trachea during tracheostomy), a spare trach tube, and an Ambu bag.On 10/13/2025 Resident #8 was admitted with diagnoses including respiratory failure and tracheostomy status. A tracheostomy is a surgically created opening (stoma) in the windpipe (trachea).A review of the admission Minimum Data Set (MDS) dated [DATE], showed that trach care, suctioning, and oxygen therapy had been recorded under respiratory treatments at the time of admission.A review of Care Plan dated 10/13/2025 revealed resident at risk for adverse outcomes related to trach including increased oral secretions and dislodgement. Interventions included ensuring trach straps secure and suction per medical doctor orders.On 12/01/2025 at 11:15 am, Resident #8 was observed lying in bed with a trach in place. Four spare trach tubes and an obturator were present in the bedside table; however, no Ambu bag was at the bedside or in the bedside table. On 12/03/2025 at 11:41 am, another observation showed that no Ambu bag was present in Resident #8's room, bedside table or in bathroom. During an interview on 12/03/2025 at 11:52 am, Nurse #1 acknowledged that there had not been an Ambu bag at the bedside and stated the Ambu bag may be on the crash cart. When asked to locate it on the crash cart, Nurse #1 was unable to locate an Ambu bag. During an interview with the Director of Nursing (DON) on 12/03/2025 at 12:20 pm, the DON stated she had not known the facility's trach policy. At 12:23 pm, the DON accompanied the surveyor to the resident's room and confirmed that there was not an Ambu bag at the bedside. The DON looked at bedside, in bedside table, in closet, in bathroom and in roommate's closet. The DON stated that there should be an Ambu bag on the crash cart. The DON agreed that the Ambu bag was not immediately visible to a person approaching the crash cart. The DON then cut the crash cart's red tag and located an Ambu bag inside the cart. DON stated she was not sure why Nurse #1 was unable to locate the Ambu bag.On 12/03/2025 at 4:30 pm, maintenance staff provided a measurement showing that the distance between the crash cart and the resident's room had been 143 feet one way.An interview on 12/04/2025 at 11:28 am with the Medical Director revealed that the admission order for the Ambu bag was a standing order for a trach. Medical Director felt it would be okay if Ambu bag was kept on crash cart if nursing staff knew where to locate it. The Medical Director found it concerning nursing staff unable to locate Ambu bag on crash cart. (b) On 12/4/2025 at 11:00 am, an observation of tracheostomy care for Resident #8 showed Nurse #1 brought supplies into the room, placing them on the bedside table, and performing hand hygiene. Nurse #1 opened the trach kit on the bedside table and requested a Nursing Assistant (NA) #3 to hand her a cup, which NA #3 retrieved from a cart outside the room. Nurse #1 placed the cup on the bedside table, opened normal saline, and poured it into the cup. Nurse #1 put on sterile gloves from the trach kit and placed the sterile drape on the resident's lap. When the resident attempted to touch the drape, Nurse #1 held the resident's hands down while wearing sterile gloves, contaminating the sterile gloves. Without changing gloves or reestablishing sterility, Nurse #1 moved the cup of saline from the bedside table to the resident's lap, placing it onto the drape and continuing the procedure. While continuing to wear the contaminated sterile gloves, Nurse #1 lifted the resident's head and removed the old Velcro trach ties, applied new ties, removed the old dressing, cleaned the stoma site with normal saline and long cotton-tipped applicators, removed the inner cannula, inserted a new cannula, and disposed of supplies. After discarding gloves and supplies, Nurse #1 obtained a suctioning kit, put on sterile gloves from the package, and performed suctioning. At no time during the observation did Nurse #1 stop the procedure, change gloves, or re-establish sterility after contaminating the sterile gloves by touching the resident's hands and moving non-sterile items. Nurse #1 stated she was trained by another nurse on the floor on how to do tracheostomy care. She stated that she shadowed another nurse for about four days prior to doing tracheostomy care and working on the floor.An interview on 12/04/2025 at 11:28 AM with the Medical Director revealed that it would be concerning if nursing staff did not use sterile techniques performing trach care.On 12/4/2025 at 2:26 pm an interview with Staff Development Coordinator revealed that staff received three to four days of training for tracheostomy care. She revealed that new nurses are trained by the more experienced floor nurses. All nurses receive annual refresher training. Staff Development Coordinator stated that she did not follow up to ensure staff were trained correctly and that she only intervened if a deficiency came to her attention. She stated that Nurse #1 observed doing the trach care was a new nurse and had tracheostomy care training on 11/11/2025. The training consisted of the nurses being signed off for competency. She provided a copy of the Tracheostomy Care Competency which says that the nurse is to establish a sterile field. She agreed that the nurse broke the sterile field and did not follow the steps outlined in the competency while doing Resident #8's tracheostomy care. An interview 12/4/2025 at 3:01 pm with the DON revealed that it was important for nurses to follow proper protocol when doing tracheostomy care. She stated she did not know the exact policy for that facility as she was new to the facility but agreed establishing a sterile field was an important step.

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for a resident who was admitted to the facility with serious mental health diagnoses for 1 of 1 resident reviewed for PASRR (Resident #18).Findings included:A PASRR Level 1 Determination Notification Letter dated 8/11/25 indicated Resident #18 had a Level I PASRR with no expiration date and no mental or behavioral health restrictions. The hospital's Discharge summary dated [DATE] included bipolar disorder as a secondary diagnosis for Resident #18 and recorded Resident #18's psychiatric history consisted of bipolar disorder, post-traumatic stress disorder (PTSD) and depression that included significant anxiety and trauma history.Resident #18 was admitted to the facility on [DATE] with diagnoses including a bipolar disorder, an anxiety disorder, depression, PTSD and tremors.Physician progress notes dated 8/27/25 recorded Resident #18 had an history of bipolar disorder.Psychiatric physician notes dated 8/28/25 recorded Resident #18 had a history of depression, anxiety and PTSD, and Resident #18 reported a history of a bipolar disorder. Resident #18 was receiving scheduled Fluoxetine (antidepressant), Mirtazapine (antidepressant), Bupropion (antidepressant), Buspirone (antianxiety medication) and Primidone (anticonvulsant). The resident also had an as needed (PRN) order for Lorazepam (antianxiety medication) and Hydroxyzine (an antihistamine medication effective in treating anxiety) . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was not currently considered by the state level II PASRR process to have a serious mental illness or intellectual disability. The MDS indicated Resident #18 was cognitively intact and Resident #18's active psychiatric /mood disorders included a bipolar disorder, anxiety, depression and PTSD. Resident #18 had received anticonvulsive medications, antianxiety medication and antidepressant medications during the MDS assessment period. Resident #18's care plan dated 9/2/25 included a focus for the alteration in Resident #18's mood as evidenced by a bipolar disorder, anxiety, depression. The care plan was updated on 10/22/25 to include Resident #18 complained of seeing and hearing things that were not present. Interventions included consulting with psychiatry, reporting changes in mood to the physician and providing non-pharmacological interventions prior to initiation or increasing of psychotropic medications. The care plan included a focus for PTSD and the interventions included observing and reporting for signs and symptoms of re-traumatization that included anxiety, avoidance, depression, sleep disturbance and new or worsening behaviors. The care plan also indicated Resident #18 was a risk for drug related side effects due to the use of psychotropic medications that included antianxiety, anticonvulsants and antidepressants. Interventions included assessing and recording the effectiveness of drug treatment and monitoring and reporting signs of sedation, anticholinergic (reduced involuntary muscle movements) and /or extrapyramidal (drug-induced movement disorders primarily associated with antipsychotic medications) symptoms. There was no care plan that referenced a PASRR Level II.A medical provider note dated 10/23/25 recorded Resident #18 was having mild hallucinations and was receiving multiple psychiatric medications and pain medications. A routine order for Quetiapine (antipsychotic used to treat depression in patients with a bipolar disorder) was ordered on 9/5/25 and the dosage was increased from 25 milligrams (mg) to 50mg daily.A psychiatric progress note dated 11/20/25 recorded Resident #18's had increased hallucinations at night. Melatonin (medication for insomnia/difficulty sleeping) and Mirtazapine for bipolar disorder were discontinued as possible contributors to the hallucinations and Quetiapine was increased to 100mg at night for PTSD and nightmare disorder. The psychiatric progress notes also recorded Lorazepam prn had been changed to a scheduled dose of Clonazepam (antianxiety medication) three times a day on 8/28/25.There was no Level II PASRR evaluation found in Resident #18's electronical medical record (EMR).On 12/3/2025 at 10:24 am, the Social Worker was unable to provide documentation that a request for an evaluation for a Level II PASRR had been submitted for Resident #18. An interview was conducted with the Social Worker on 12/4/25 at 2:52 pm. She explained that Resident #18 had a PASRR Level I screening at the hospital that indicated he did not have a serious mental illness. She stated she assumed the hospital entered all of Resident #18's diagnoses including anxiety, depression, PTSD and bipolar disorder into the Medicaid Uniform Screening Tool (MUST) that would have triggered a PASRR Level ll evaluation if necessary to be completed at that time. She further explained that she thought if a PASRR Level II determination evaluation was necessary, then it would have been completed at that time. She stated she was unable to see the information entered into MUST by the hospital for Resident #18's PASRR Level I determination. The Social Worker revealed she had not submitted a request for a Level II PASRR determination evaluation for Resident #18 since admission to the facility based on Resident #18's diagnoses, medications changes or report of hallucinations. During an interview with the Administrator on 12/4/25 at 3:03 pm, when asked if Resident #18 needed a PASRR Level II determination screening based on diagnoses of bipolar disorder, anxiety, depression and PTSD he stated he would have to defer answering the question to the Social Worker because he did not know. An interview with the State Signature Clinical Coordinator was conducted on 12/4/25 at 3:45 pm. She stated Resident #18 was admitted with the prior diagnoses of a bipolar disorder, anxiety, depression and PTSD. She explained since the PASRR Level I determination letter did not identify Resident #18 to have a serious mental illness and Resident #18 did not meet the criteria for significant change; the facility had not submitted a PASRR Level II determination evaluation.

Based on observations, record reviews, and interviews with staff, the facility failed to follow the approved menu for 1 of 7 residents on a pureed diet (Residents #80). The findings included: The Week 2 dietitian approved menu indicated residents on a pureed diet were to receive pureed cornbread. Resident #80 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing). Resident #80's physician orders dated [DATE] documented he was to receive a pureed diet. During an observation of tray line on [DATE] at 12:07 PM, [NAME] #1 plated Resident #80's meal which included pureed chicken, pureed broccoli, and pureed candied yams. There was no pureed cornbread or pureed bread product available to serve and none was observed on his tray. Resident #80's tray was then covered and put into the dining room cart for service. In an interview on [DATE] at 12:08 PM, [NAME] #1 stated she forgot to make a pureed bread item to serve. In an interview on [DATE] at 12:09 PM, the Corporate Dietary Manager (DM) confirmed [NAME] #1 did not serve a pureed bread option and after surveyor intervention, asked the Regional Dietary Manager to make some for service. Attempts to reach the Registered Dietitian were unsuccessful.

Based on record review and interviews with staff, the facility failed to protect a resident's right to be free from verbal abuse by staff for 1 of 5 residents reviewed for abuse (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (stroke). He was discharged from the facility to the community on 9/19/25. Resident #101's annual Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact, had no behaviors or signs of depression, and propelled himself in his wheelchair independently. A facility Investigation Report dated 4/08/25 documented that on 4/05/25 at 1:40 PM, Housekeeper #1 started cursing at him because he wasn't moving his wheelchair down the hallway and had blocked her cart. Housekeeper #1 was witnessed cursing at the resident and was escorted out of the building during the investigation. The facility investigation found two other employees heard the interaction and confirmed Housekeeper #1 did curse at the resident. The facility substantiated verbal abuse. Nurse Aide (NA) #5's written witness statement dated 4/05/25 documented that when Resident #101 was coming down the hallway in his wheelchair, Housekeeper #1 came behind him and stated for him to Move out of the way m******f*****, move b**** and then proceeded to push her housekeeping cart to his wheelchair to move him out of the way. In a phone interview on 12/08/25 at 1:33 PM NA #5 stated Resident #101 had been propelling his wheelchair independently down the hallway. The hallway was crowded because other residents were on the other side of the hallway waiting to go outside to smoke. Housekeeper #1 got upset because Resident #101 was in her way. She started cussing at him in a threatening tone for him to move, which then made the resident angry. She then pushed her housekeeping cart into the back of his wheelchair. The other aide who witnessed the incident, NA #2, helped her to separate Housekeeper #1 and Resident #101. Once he was taken to his room, he calmed down and was back to baseline. NA #2's written witness statement dated 4/05/25 documented that when NA #2 was passing out trays for lunch, Resident #101 was coming down the hall. Housekeeper #1 was behind him. She told him to move out of her way but Resident #101 did not hear her. Housekeeper #1 then shouted that y'all need to learn how to get the f*** out the d*** way and pushed her cart to the side. She yanked the resident's wheelchair, which upset the resident. Resident #101 got up out of his wheelchair and stated he would knock her out. Housekeeper #1 stated he wasn't going to do s*** m*****f*****, grabbed her housekeeping cart again and said, what the f*** you going to do and then pushed her housekeeping cart into the resident. She then stated, you need to get your black a** back to your room and get out of the way. In a phone interview on 12/09/25 at 3:34 PM NA #2 stated she was passing out meal trays and Housekeeper #1 wanted to get past Resident #101, who was propelling himself in the wheelchair. Housekeeper #1 began cussing at him, telling him to get out of her way. Housekeeper #1 threatened Resident #101, stating if he didn't get out of the way, she would run into him with her cart and make him. She then pushed her cart into the back of the wheelchair. NA #2 and NA #5 separated the housekeeper from the Resident and NA #2 took Resident #101 back to his room. She stated once he calmed down, he was back to his baseline. Resident #101 was unable to be interviewed. Attempts to contact Housekeeper #1 were unsuccessful. In a phone interview on 12/08/25 at 11:31 AM the facility Clinical Consultant stated the facility substantiated that Housekeeper #1 verbally abused and threatened Resident #101 with harm. She stated Housekeeper #1 was let go from the facility. In a phone interview on 12/09/25 at 4:09 PM the Administrator stated the facility had substantiated verbal abuse and formulated a Corrective Action Plan. The facility submitted a corrective action plan that was not acceptable to the State Agency. The plan did not include sufficient systemic changes and monitoring.

Based on record review and staff interviews, the facility failed to accurately code the physician's documented gradual dose reduction (GDR) as clinically contraindicated on the Minimum Data Set (MDS) assessment for 1 of 31 residents reviewed for MDS assessment accuracy (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE].A review of the psychiatric provider note dated 9/5/25 revealed an attempted dosage reduction to the psychotropic regiment was likely to impair the resident's function and exacerbate underlying psychiatric condition. confirmed she had completed that section of the MDS for the 9/17/25 assessment.The annual MDS dated [DATE] for Resident #4 indicated a GDR had not been documented by the physician as clinically contraindicated.An interview was conducted with MDS Nurse #1 on 12/5/25 at 10:55 AM who confirmed she had completed the Medication section of the MDS for Resident #4's 9/17/25 assessment. She stated the physician documented GDR as clinically contraindicated was marked no which was an error on her part and should have been marked yes. An interview with Administrator was held on 12/5/25 at 11:05 AM. He stated his expectation was for MDS assessments to be accurate.

Based on record review, observations, resident Interview and staff interviews, the facility failed to accurately code the Minimum data Set (MDS) assessment in the areas of medications, smoking, elimination and behaviors for 4 of 28 residents whose MDS assessments were reviewed (Resident #14, #17, #13, and #33). Findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus. There was a physician order for the following hypoglycemic medications on Resident #14's electronic medical record (EMR): * On 11/23/2023, Novolin Regular flex pen insulin 100 units per milliliter, give 11 units subcutaneous three times a day * On 11/23/2023, Novolin Regular flex pen insulin 100 units per milliliter per sliding scale before meals and at bedtime. * For blood glucose reading 200-250, give 3 units subcutaneous. * For blood glucose reading 251 -300, give 5 units subcutaneous. * For blood glucose reading 301-350, give 7 units subcutaneous. * For blood glucose reading 351-400, give 10 units subcutaneous. * For blood glucose reading 401-450, give 12 units subcutaneous. * For blood glucose reading 451-500, give 14 units subcutaneous. * For blood glucose reading 501-550, give 16 units subcutaneous. * For blood glucose reading 551-600, give 18 units subcutaneous. * On 3/10/22024, Empagliflozin (medication used to treat Diabetes Mellitus) 25 milligrams tablet once a day. * On 3/20/2024, Insulin Glargine solution 100 units per milliliter, give 65 units subcutaneous once a day in the morning. * On 3/20/2024, Insulin Glargine solution 100 units per milliliter, give 60 units subcutaneous once a day at bedtime. A review of the September 2024 Medication Administration Record recorded the hypoglycemic medications were given as ordered. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 was not coded for Resident #14 receiving hypoglycemic medications. Resident #14's care plan last reviewed 9/6/2024 included a focus for Diabetes Mellitus. Interventions included to administer medication as ordered by the physician. In an interview with MDS Nurse #1 on 10/17/24 at 10:32 pm, she stated Resident #14's annual MDS dated [DATE] should have been coded for the use of hypoglycemic medications. She explained the MDS worksheet used in the MDS department noted Resident #14 was receiving insulin and hypoglycemic medications. She stated it was human error in not coding Resident #14's annual MDS for hypoglycemic medications. In an interview with the Interim Director of Nursing on 10/17/24 at 12:34 pm, she stated Resident #14's annual MDS should have been coded accurately for the use of hypoglycemic medications based on Resident #14's assessment for the use of insulin. In an interview with the Administrator on 10/17/2024 at 1:05 pm, he stated Resident #14's MDS assessment should be an accurate assessment for the use of hypoglycemic medications. 2. Resident #17 was admitted to the facility on [DATE] with diagnoses including a stroke. Resident #17 care plan initiated on 1/28/2020 indicated Resident #17 was a smoker. A quarterly smoking assessment dated [DATE] reported Resident #17 was a smoker. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact and did not use tobacco products. On 10/15/2024 at 8:30 am in an interview with Resident #17, she stated she was a smoker and used the facility's designated smoking area during the facility's designated times. On 10/15/2024 at 1:24 pm, Resident #17 was observed in the facility's designated smoking area supervised by the Activities Assistant #1 smoking a cigarette. On 10/17/2024 at 10:24 am in an interview with MDS Nurse #1, she stated she was aware Resident #17 was a smoker, and the annual MDS dated [DATE] should have been coded to reflect Resident #17 used tobacco products. She said she clicked the wrong answer on the MDS screen for the use of tobacco products and could not provide a specific reason why the MDS was coded incorrectly for the use of tobacco products for Resident #17. On 10/17/2024 at 12:34 pm in an interview with the Interim Director of Nursing, she stated the MDS assessment should have been coded accurately based on the smoking assessments for Resident #17. On 10/17/2024 at 1:05 pm in an interview with the Administrator, he stated Resident #17's annual MDS assessment should have been coded accurately for smoking. 49502 3. Resident #2 was admitted to the facility on [DATE] with diagnoses that included colostomy. Resident #2's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment and was not coded for an ostomy. Resident #2's care plan dated 9/27/24 revealed a focus for a colostomy for elimination. During an interview on 10/17/24 at 10:35 am with the MDS Coordinator, she stated the ostomy section for Resident #2 should have been coded for her colostomy and it was an error. In an interview with the Interim Director of Nursing (DON) on 10/17/24 at 10:51 am, she stated Resident #2's MDS assessment should have been coded correctly for her colostomy. 39731 4. Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #13's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a gradual dose reduction for antipsychotic medication had not been attempted. Resident #13's care plan dated 10/4/24 revealed a gradual dose reduction of antipsychotic medication was attempted on 6/27/24. Review of a Pharmacy Consultant Report dated 7/5/24 revealed a contraindication for a gradual dosage reduction of antipsychotic medication signed by the physician. An interview was conducted with MDS (Minimum Data Set) Nurse #1 on 10/16/24 at 10:36 AM who stated it was an oversight and should have coded Resident #13's assessment to reflect the gradual dose reduction attempt for antipsychotic medication. During an interview on 10/17/24 at 10:30 AM the Interim Administrator stated Resident #13's assessment dated [DATE] should have been coded to reflect a gradual dosage reduction attempt for antipsychotic medication.

Based on record review and staff interviews, the facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) (form 10123) and the and failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for 1 of 3 residents reviewed for beneficiary protection notification review (Resident #75). The findings included: Resident #75 was admitted to the facility on [DATE] with Medicare Part A skilled services. Resident #75's admission Minimum Data Set assessment dated [DATE] revealed she had moderate cognitive impairment. Resident #75's Medicare Part A skilled services ended on 4/12/24 and her Medicare Part A Skilled Nursing Facility benefit was not exhausted. She remained in the facility. Record review revealed no evidence that Resident #75 or the resident's responsible party were provided the NOMNC notice or the ABN. During an interview with the Business Office Manager on 10/16/24 at 11:24 AM she stated she had trained the former weekday Receptionist to do the required forms. She stated the Receptionist was no longer employed by the facility. The Business Office Manager stated the forms were not uploaded to the facility system and when she searched Resident #75's folder there were blank forms in the folder. The former Receptionist was unable to be contacted. An interview was conducted with the Administrator on 10/18/24 at 9:45 AM who indicated Resident #24 should have received the CMS-10123-NOMNC and the CMS-ABN as required by federal guidelines.

Based on record review, observations, resident interview and staff interviews, the facility failed to assess the ability of a resident to self-administer medications prior to leaving the resident's medications on the overbed table in the resident's room for 1 of 1 resident reviewed for pharmacy services (Resident #18). Resident #18 indicated she could not take a lot of medications together at one time and the medications were left on her overbed table to take when she wanted to. Findings included: Resident #18 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact. Physician orders included the following medication orders for Resident #18 that were active on 10/14/24: - Acetaminophen 325 milligram (mg) tablets give two tablets for pain or fever every six hours as needed. - Augmentin 875-125 mg tablet give twice a day ending 10/15/2024. - Ciprofloxacin HCL 500 mg tablet give one tablet twice daily for seven days. There was no documentation in the Electronic Medical Record (EMR) that Resident #18 had been assessed to self-administer her medications, there was no physician's order for self-administration, and there was no care plan that addressed self-administration of medication. On 10/14/2024 at 10:48 am, two medication cups were observed on Resident #18's overbed table located between the Resident #18's open door and the right side of Resident #18's bed. There were two round white tablets in one medication cup and two white broken oblong tablets in the other medication cup. Residents were observed outside Resident #18's open door in the hallway self-propelling their wheelchairs. On 10/14/2024 at 10:48 am in an interview with Resident #18, she stated the two white, broken oblong tablets in the medication cup were her antibiotic, and the two white round tablets in the other medication cup were her pain medication. She said she could not take a lot of medications together at one time and the medications were left on her overbed tablet to take when she wanted to. An observation and an interview were conducted on 10/14/2024 at 10:50 am with Nurse #1. He was observed at a medication cart in the hallway and walked into Resident #18's room. Nurse #1 explained the two round tablets in one medication cup located on Resident #18's overbed table were Acetaminophen tablets, and the two broken white tablets in the other medication cup located on Resident #18's overbed table were an antibiotic. Nurse #1 explained he saw Resident #18 with the medication cup up at her mouth when he was in room to administer Resident #18 her medications before exiting the room. He stated he should have stayed in Resident #18's room and watched her swallow the medications. Nurse #1 was observed removing the two medications cups from the overbed table when exiting Resident #18's room. On 10/17/2024 at 10:15 am in a follow up phone interview with Nurse #1, he clarified the medications observed on the overbed table were Ciprofloxacin and Acetaminophen. He explained Resident #18 requested to visualize her antibiotic and pain medication separately in medication cups and her other morning medications were crushed in pudding and administered. Nurse #1 stated he observed Resident #18 take the medications administered in the pudding, and the Ciprofloxacin was at her mouth when he walked out of the Resident's room. On 10/17/2024 at 11:47 am in an interview with the Assistant Director of Nursing, she stated Resident #18's medications should not have been left on the overbed table, and Nurse #1 should have stayed with Resident #18 when administering her medications to ensure Resident #18 had taken her medications. On 10/17/2024 at 12:34 pm in an interview with the Interim Director of Nursing, she explained Resident #18 had not been assessed to perform self-administration of her medication. She stated Nurse #1 should have watched Resident #18 take her medication before leaving Resident #18's room when administering medications to Resident #18.

Based on record review and resident and staff interviews the facility failed to refer a resident with a new diagnosis of mental illness for a Preadmission Screening and Resident Review (PASARR) evaluation for 1 of 1 resident reviewed for PASARR (Resident #33). Findings included: Resident #33 was admitted to the facility on [DATE] with diagnosis that included adjustment disorder. A physician progress note revealed Resident #33 was newly diagnosed with post-traumatic stress disorder on 6/27/24. Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed she was cognitively intact. She was not coded as being screened for a PASARR evaluation. A review of Resident #33's care plan last reviewed 7/29/24 revealed she was care planned for behaviors such as nervousness, fears, and a general feeling of uneasiness related to history of a traumatic event. The interventions included encouraging the resident to voice fears and referral to a physician. During an interview with Resident #33 on 10/16/24 at 12:41 PM she stated she had not previously been diagnosed with post-traumatic stress disorder. She was assaulted in the past by a family member. Resident #33 stated she began having nightmares after the family member began calling her at the facility in July 2024. An interview with the facility Social Worker on 10/16/24 at 11:29 PM was conducted. She stated she did not refer Resident #33 to NC MUST (North Carolina Medical Uniform Screening Tool, a tool used to complete PASARR applications) because she felt Resident #33 was doing well. The Social Worker stated she was unaware that Resident #33 was having nightmares. During an interview on 10/17/24 at 11:00 AM the Administrator indicated if a new psychiatric diagnosis required a new referral to NC MUST for a PASARR application the Social Worker should have followed the correct referral process.

Based on record review, observation and staff interviews, the facility failed to complete an accurate medical record in documenting the administration of medication for 1 of 29 residents whose medical records were reviewed (Resident #18). Findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease. Physician orders dated 2/14/2024 included Acetaminophen 325 milligram (mg) tablets give two tablets for pain or fever every six hours as needed for Resident #18. On 10/14/2024 at 10:52 am, Nurse #1 was observed administering Resident #18 Acetaminophen 650 mg in applesauce to Resident #18. There was no record of Resident #18 receiving Acetaminophen 650 mg on 10/14/2024 on Resident #18's October 2024 Medication Administration Record (MAR). There was no nursing documentation in Resident #18's medical record that Acetaminophen 650 mg was administered by Nurse #1 on 10/14/2024. On 10/17/2024 at 10:15 am in a phone interview with Nurse #1, he stated pain medications ordered as needed were to be documented on Resident #18's MAR after administration of the medication to the resident. He explained he thought he had documented the dose of Acetaminophen administered to Resident #18 on 10/14/2024 on Resident #18's MAR. On 10/17/2024 at 12:34 pm in an interview with the Interim Director of Nursing, she stated Nurse #1 should have documented the administration of Acetaminophen on Resident #18's MAR after administering the medication to the resident.

Based on observation, resident and staff interviews, the facility failed to provide maintenance to the bathroom door and keep the grout on the floor at the base of the bathroom doorway clean from buildup of debris for 1 of 2 resident rooms (Resident #63's room) reviewed for environment. The findings included: a. Observation of Resident #63's room on 10/14/24 at 10:40 AM revealed the surface of the bathroom door approximately three quarters from the top of the doorframe, and as well as the sides of the doorway were scuffed. A large area, approximately 3 inches in height, and across the length of the bathroom door revealed peeling paint which exposed what appeared to be a wood-like color underneath. b. Observation of Resident #63's room on 10/14/24 at 10:40 AM revealed the bathroom doorway had what appeared to be a buildup of debris, black in color, on the grout in the right and left spaces at the base of the bathroom doorway. An interview was conducted on 10/14/24 at 10:40 AM and on 10/15/24 at 8:59 AM with Resident #63. During both interviews Resident #63 expressed how unhappy she felt about the condition of her bathroom door and doorway. She stated in each interview she reported the issues with her bathroom door and doorway to staff several times, however, she could not remember the names of the staff members or when she noticed the damaged door or dirty areas at the base of the bathroom doorway. An interview with the Assistant Maintenance Director was conducted on 10/16/24 at 8:46 AM. He stated room inspections were done monthly; random resident rooms were selected. He stated there was a maintenance logbook that was kept at the nurse's station for maintenance issues that needed to be addressed. He added this logbook was checked weekly. He also utilized an electronic work order system. This system was checked weekly. He was unable to find a pending or completed work order for Resident #63's room. He stated he was not aware of any issues with the bathroom door or bathroom doorway in Resident #63's room. On 10/16/24 at 9:24 AM the Assistant Maintenance Director conducted an observation of the areas of concern in Resident #63 room in conjunction with an interview with Resident #63 who resided in the room. Resident #63 showed the Assistant Maintenance Director the issues with her bathroom door, doorway, and floor area. Resident #63 informed the Assistant Maintenance Director she reported her concerns to staff many times, however, she could not remember the names of the staff members. A review of the maintenance logbook at nurses' station was conducted on 10/16/24. There was no work order request for Resident #63's room found. An interview was conducted with the Housekeeping Supervisor on 10/16/24 at 9:31 AM. He stated he was not aware of the blackened discoloration on both sides of the floor in Resident #63's room bathroom doorway. He added Resident #63's room was last deep cleaned on 10/8/24 and he was not notified of discoloration on the floor in the bathroom doorway. An interview was conducted with the Maintenance Director on 10/17/24 at 9:36 AM. He stated the facility conducted ambassador rounds where resident rooms were assessed. He added the Administrator was responsible for ambassador rounds for Resident #63's room. In an interview with the Administrator on 10/17/24 at 9:47 AM he stated he conducted ambassador rounds daily for Resident #63's room. He stated he did not notice any issues with the bathroom door or discoloration on the bathroom doorway floor. He added Resident #63 did not tell him about any concerns. An interview was conducted with the interim Director of Nursing (DON) on 10/17/24 at 10:38 AM. She stated nursing staff were expected to notify housekeeping if a resident's room needed cleaning, as well as notify maintenance for anything in need of repair. The DON further stated the facility also conducted ambassador rounds daily.

Based on record review, resident interview, and staff interviews, the facility failed to treat a resident (Resident #40) in a dignified manner as evidenced by searching her room without permission on 6/24/23. Staff removed money found in her room and this caused Resident #40 to cry and to feel helpless and powerless. The money was later returned to the resident. This was for 1 of 2 residents reviewed for dignity. The findings included: Resident #40 was admitted to the facility on [DATE] with diagnoses that included depression and anxiety. Resident #40's admission Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment. She had no mood symptoms and no indication of psychosis. The assessment indicated she had rejection of care daily. An interview was conducted with Resident #40 on 7/11/23 at 9:51 AM. She was oriented to person, place, time and situation. Resident #40 stated she was watching television while sitting in her wheelchair when two staff members came in and started going through her room on Saturday 6/24/23 after supper while she was watching television. She reported she believed it was two nurse aides but she was not sure. She reported they located cigarettes in a blue bag in her closet. The resident stated she is an occasional smoker and forgot the cigarettes were in her bag. She stated she did not care if the cigarettes were returned and had no issue with the facility keeping the cigarettes locked up. Resident #40 stated they discovered approximately $7,000 in her makeup bag which was in a drawer of her bedside table. Resident #40 stated she tried to get her makeup bag back but was unsuccessful. Resident #40 stated the staff member counted the money while on the phone with the Administrator. She further stated she became very upset and cried because the money in question was her life savings. Resident #40 stated she went out in the hall and begged staff who were in the hall to give her the money back. She was unable to recall the specific staff members. She reported one of the staff members stated if she did not get back in her room and stop crying, she would be sent to a psychiatric ward. Resident #40 stated she could not remember which staff member threatened to send her to a psychiatric ward. Resident #40 stated she was scared due to this threat and returned to her room. She reported the staff told her they were taking her money to ensure it was not stolen. Resident #40 expressed frustration because she stated it was her money and it should be her decision if she kept the money in her room. Resident #40 reported the staff reminded her she was not allowed to have the cigarettes and lighter. She stated she felt very depressed at the thought of losing her money. Resident #40 stated she had this money so when she discharged , she would be able to have remodifications done to her home and pay for assistance as she just had a leg amputation. She stated she felt very hopeless and powerless in this situation. Resident #40 further stated she did not think it was right they (the staff) went into her room and began going through her things. She stated they did not ask her permission. She stated her money was returned to her by the Administrator on 6/26/23 and she was given a lockbox by Nurse #7 on 6/24/23. She pointed out the key to the lockbox on a stretchy cord on her wrist. Resident #40 stated she was her own Responsible Party. During a phone interview with Resident #40's family member on 7/11/23 at 4:30 PM she stated she spoke with Resident #40 on 6/26/23, and she told her staff went in to check for drugs in her room. She stated Resident #40 reported two staff members took money from her. The family member further stated the resident reported she was told to stop crying or she would be sent to a psychiatric hospital. The family member stated she spoke with the Administrator on 6/29/23 and the Administrator admitted they should not have taken Resident #40's money. She stated she was not aware Resident #40 had $6400 in the facility. During an interview with Nurse Aide (NA) #20 on 7/11/23 at 12:00 PM she reported on 6/24/23 a cup with zinc oxide (a cream utilized by staff when changing resident briefs) was found at Resident #12's bedside. It was inadvertently left at the resident's bedside. She reported staff completed room searches for all residents and were looking for medications and/or lotions at bedside. She stated Nurse #5 went in Resident #40's room. NA #20 stated Nurse #5 called her in Resident #40's room because she had found 6 lighters and 3 packs of cigarettes. Residents were not allowed to have lighters and cigarettes in their possession. She further stated Resident #40 had a wad of cash in her room which was in a pencil case. NA #20 stated Nurse #5 called the Administrator and the Administrator stated to remove the cash from her room. She further stated Nurse #5 counted the money out loud with the Administrator on the phone. NA #20 stated Nurse #5 tried to explain to Resident #40 they were taking the money and locking it up her money to ensure nothing happened to it. She stated Resident #40 did not seem to understand. She stated Resident #40 became upset and was screaming and crying. She stated they attempted to calm Resident #40 down without success. She further stated the Unit Coordinator was not scheduled to work that evening but she came in after the search was completed. She stated she witnessed the Unit Coordinator lock the money in her desk drawer. NA #20 stated the weekend charge nurse got a lock box and gave it to Resident #40. She reported she did not hear anyone threaten Resident #40 with psychiatric hospitalization . An interview was conducted with Nurse #5 on 7/11/23 at 5:42 PM. She stated she came in to work on 6/24/23 and was told to search rooms by the Administrator and remove items residents were not supposed to have such as medications, illicit drugs and other contraband. Nurse #5 reported she and the two medication aides were instructed to perform the search. She stated they searched 100% of resident rooms and consent was not secured from residents or their responsible parties. Nurse #5 stated she was working based on the instructions given by the Administrator. Nurse #5 stated she found cigarettes and lighters in Resident #40's room. Nurse #5 reported residents were not allowed to have cigarettes and lighters in their room. She further stated she found a pouch in Resident #40's bedside table and looked in it when searching for medications. Nurse #5 stated she found $6400 in the pouch and contacted the Administrator. The Administrator instructed her to remove any contraband and the money from Resident #40's room. She reported she counted the money while the Administrator remained on the phone. Nurse #5 stated Resident #40 hit her and tried to run her over with her wheelchair. She stated Resident #40 was very upset and crying. Nurse #5 stated she was no knowledge of anyone threatening her with psychiatric hospitalization . An interview was conducted with Nurse Aide (NA) #19 on 7/11/23 at 11:55 AM who stated she recalled the night of the search of resident rooms on 6/24/23. She stated she witnessed Nurse Aide #20, and a nurse (Nurse #5) go into Resident #40's room and was searching for cream. She explained Resident #12 had a cream inadvertently left at his bedside and they wanted to ensure no other residents had medications at bedside. An interview was conducted with the Unit Coordinator on 7/11/23 at 1:00 PM. She stated she was not in the building when the search happened on 6/24/23. She reported she was called in afterwards by the Administrator to help count Resident #40's money. She further stated she believed the money was counted over the phone with the Administrator. The Unit Coordinator stated she placed $6400 in her desk drawer. The Unit Coordinator stated she was in the building from approximately 10:01 PM until 10:45 PM. She reported Resident #40 was very upset and was calling staff derogatory names. The Unit Coordinator stated she did not hear anyone threaten Resident #40 with psychiatric hospitalization . She indicated the cigarettes and lighters were locked in the nurses' station because residents were not allowed to keep smoking materials. An interview was conducted with Nurse #7 on 7/11/23 at 2:45 PM who stated he was not involved with the searching of resident rooms on 6/24/23. He stated Resident #40 was very upset when he entered the building after 9:00 PM on 6/24/23. Nurse #7 reported he spoke with her and she stated staff forcibly took her money. He stated he took Resident #40 outside to smoke to calm down. Nurse #7 stated he provided her with a lockbox and showed her how to use it. During an interview with the Administrator on 7/11/23 at 2:15 PM she reported on 6/24/23 she instructed staff were to search resident rooms for medications at residents' bedside and other contraband. She explained she was notified on 6/24/23 a resident had become ill and they located a zinc oxide cream at his bedside. The Administrator stated she instructed Nurse #5 and two medication aides to search 100% of resident rooms. She stated no consents were obtained. She stated any actions taken by staff members were at her instruction. The Administrator stated when she spoke with the Regional Nurse Consultant after the search on 6/24/23, she was told it should have not been a full search but just to check on room surfaces that no medications were at bedside. An interview was conducted with the Regional Nurse Consultant on 7/11/23 at 3:15 PM who stated she spoke with the Administrator by phone on the evening of 6/24/23 and was told about staff confiscating Resident #40's money. She indicated she told the Administrator the money had to be returned. She reported earlier in the day on 6/24/23 when she was informed of a resident possibly ingesting zinc oxide cream she instructed the Administrator for staff to check resident rooms for medications. The Regional Nurse Consultant stated it was her expectation staff would check surfaces for similar medications, not search closets and drawers. She indicated that the staff should not have conducted full room searches without consent unless there was reasonable suspicion of contraband or property belonging to another person. She further indicated it is a resident rights' issue to enter a resident's room and begin a search without permission. During an interview with the [NAME] President of Clinical Operations on 7/11/23 at 3:30 PM she reported Resident #40's money should not have been taken from her without her permission. She indicated she believed the Administrator did not understand the facility policy. The [NAME] President of Clinical Operations indicated the situation of medications at a resident's bedside did not warrant a 100% search for contraband in resident rooms according to facility protocol. She indicated residents have the right to possessions and the facility cannot search without a reasonable suspicion of contraband or another resident's property. The [NAME] President of Clinical Operations reported Resident #40's money should not have been removed from her possession.

Based on observations, record review and staff interviews, the facility failed to maintain a medication storage refrigerator within the recommended temperature range and failed to discard outdated ophthalmic solution bottles for 2 of 3 medication storage areas reviewed (#1 Medication Room and Medication Cart #2). Findings included: 1. An observation of the medication storage refrigerator located in the #1 Medication Room was made on 7/11/23 at 3:00 PM with Nurse #1. The refrigerator thermometer was observed at 32 degrees Fahrenheit ( F). Nurse #1 viewed the refrigerator thermometer and indicated it appeared to read between 32 F and 34 F. The July 2023 temperature monitoring log for the medication storage refrigerator had been noted daily. Temperatures recorded included: 7/4/23 was 34 F, 7/5/23 was 32 F, 7/6/23 was 32 F, 7/8/23 was 34 F, 7/9/23 was 34 F, and 7/10/23 was 30 F. The instructions on the monitoring log indicated Temperature of refrigerator must be between 36-41 degree F, Freezer must be at or below freezing, If not contact maintenance immediately! Only maintenance is authorized to adjust refrigerator settings! The refrigerator contained: 15- Insulin glargine pens 100 units. The package instructions noted store 36-46 degrees, avoid freezing, discard if frozen. 8- Insulin glargine pens 100 units. The package instructions noted unopened [insulin glargine] devices should be stored in a refrigerator 36-46 degrees. Do not freeze, discard if frozen. 1- Insulin aspart 100 unit vial with package instructions to store between 36-46 degrees. 1- Insulin detemir 100 unit vial with package instructions store 36-46 degrees, do not freeze. 27- Dronabinol 5 mg capsules. No storage instructions were observed on the package. An interview with Nurse #1 was conducted on 7/11/23 at 3:09 PM. She explained she was unsure who checked the refrigerator temperature daily, but the temps should be within range or reported to maintenance. 2. An observation of Medication Cart #2 was made on 7/11/23 at 3:37 PM with Nurse #2. Two bottles of latanoprost ophthalmic solution were noted as opened on 4/11/23. Package instructions indicate to discard 6 weeks after opening. An interview with Nurse #2 was conducted on 7/11/23 at 3:45 PM. She explained the evening nurse administered this medication and she had not noticed the dates on the bottles. An interview with Medication Aide #1 was conducted on 7/11/23 at 3:54 PM. She stated she occasionally stayed over to help the evening shift administer medications. She explained she had checked the expiration date of the eye drops but did not realize they should be discarded 6 weeks after opening. An interview was conducted with the Director of Nursing (DON) on 7/11/23 at 5:19 PM. The DON indicated the nurse who checked the medication refrigerator should have contacted maintenance when the out of range temperatures had been discovered. The DON explained the outdated eye drops had an opened on date and the discard by date should have also been noted.

Based on record review, resident interviews and staff interviews, the facility failed to implement their abuse policy and procedure in the following areas: administration reporting allegations of abuse within two hours to the state agency from the time of notification of the alleged abuse incident (Resident #76 and Resident #40) and completing a thorough investigation that included assessments of all residents for abuse and statements from all residents and involved staff for an allegation of abuse (Resident #40, Resident #7, and Resident #15) for 4 of 7 residents reviewed for abuse. Findings included: The facility's Abuse, Neglect and Misappropriation of Property policy dated 10/17/2022 stated any abuse allegation must be reported to state within 2 hours from the time the allegation was received, and any reasonable suspicion of a crime plus serious bodily injury must be reported to the state and police. The investigation guidelines stated the facility's administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse and may delegate some or all of the investigation as appropriate but retains the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident. The investigation should include interviews of involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations and to the extent possible and applicable, provide complete and thorough documentation of the investigation. The facility administrator will make reasonable efforts to determine the root cause of the alleged violation and will implement corrective action consistent with the investigation findings and take steps to eliminate any ongoing danger to the resident or residents. c substantiated allegation of abuse will be reviewed by the facility's quality assurance and performance improvement committee to detect potential patterns or trends and for consideration of further interventions or training opportunities. 1. Resident #76 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 was moderately impaired cognitively and required assistance with toileting and bathing. Nursing documentation dated 7/6/2023 at 7:42 a.m. by Nurse #4 stated around 5:00 a.m. Resident #76 reported Nurse Aide (NA) #2 had assaulted her and closed the door when Resident #76 confronted her about not answering her call light. Nurse #4 assessed Resident #76 for injuries and recorded Resident #76 stated she was okay. Nurse #4 recorded she informed NA #2, she would answer Resident #76's call lights and provide care as needed. A review of the initial report alleging employee to resident abuse dated 7/7/2023 stated the facility became aware of the incident on 7/7/2023 at 8:35 a.m. and the local law enforcement agency was notified on 7/7/2023 at 8:35 a.m. The initial report was signed by the interim Director of Nursing, and there was a handwritten notation that the initial report was refaxed to the state agency on 7/7/2023 at 4:45 p.m. In an interview with Resident #76 on 7/10/2023 at 12:05 p.m. she stated she made a police report after NA #2 pushed her back onto the bed, turned off the light and shut the door last week. She stated someone got NA #2 out of the facility, and she had not spoken to anyone in Administration. In a follow up interview with Resident #76 on 7/12/2023 at 8:27 a.m., she stated the incident with NA #2 occurred last at night around 8:00 p.m. to 9:00 p.m. She explained she needed someone to come help her change the adult brief. The NA #2 and her were started fussing to each other, and NA #2 with her fingers extended pushed her right shoulder and pushed her down onto the bed into a sitting position. She stated NA #2 turned off the lights and shut the door. She explained when Nurse #4 entered and assisted her with changing her adult brief, she informed Nurse #4 what had happen between Resident #76 and NA #2. In an interview with [NAME] President of Operations #1 and [NAME] President of Operations #2 on 7/10/2023 at 1:00 p.m., they stated the Administration office was informed of the alleged employee to resident abuse on 7/7/2023 with Resident #76, and an initial report was submitted to the state agency and local law enforcement had been notified. In a phone interview with NA #2 on 7/10/2023 at 8:36 p.m., she stated at the beginning of the 7p.m.-7a.m. shift dinner meal trays were still out in residents' rooms. When entering Resident #76's room, she found Resident #76 naked waist down. She stated she provided Resident #76 perineal care and changed her bed linens. She stated Resident #76 sat on the side of the bed and didn't fall backwards on the bed after linens were changed. She stated after exiting the room Resident #76's call light was on. When asked if she was okay, Resident #76 asked why she came into her room and closed the door. She explained Resident #76 became combative, and she went and got Nurse #4. When they returned to Resident #76's room, she told Nurse #4 I had pushed her, and she had called the police. She stated this incident happened within the first hour of the 7:00 p.m. to 7:00 a.m. shift and Nurse #4 informed her she would answer Resident #76's call light and provided care as needed. In a phone interview with Nurse #4 on 7/11/2023 at 9:58 p.m., she stated at the beginning of the 7:00 p.m. to 7:00 a.m. shift on 7/6/2023, Resident #76 was yelling out, and nurse aides were busy with other residents. She explained when she entered Resident #76's room, Resident #76 asked for other staff member, NA #2 that she had seen walking up and down the hall. Nurse #4 stated she explained to Resident #76 that NA #2 was busy with another resident and she was there to assist her. Nurse #4 stated she assisted Resident #76 in changing her adult brief and provided a gown and blanket to Resident #76. bed linens. Nurse #4 stated Resident #76's door was closed around 5:00 a.m. when she entered Resident #76's room during medication pass, and that was when Resident #76 informed her NA #2 had hit her and pushed Resident #76 onto the bed, turned light off and closed her door to the room. She explained she completed an assessment on Resident #76 with no injury observed. Nurse #4 stated she informed NA #2 to write a statement and not to go back into Resident #76's room. She stated she didn't not see NA #2 in the building the remaining of the shift. Nurse #4 stated she called could not recall the name of the person she called to report the incident of alleged abuse on 7/7/2023. She stated she called the number in the information book and left a voice message. She explained at the change of shift on 7/7/2023 7:00 a.m. she informed Nurse #6 of Resident #76's allegation of abuse and Nurse #6 called the Staff Development Coordinator (SDC). She explained since the incident, the SDC had provided abuse training with her because Administration did not receive a report of abuse from me on 7/7/2023. She stated the number for the interim Director of Nursing was posted at the nursing station now and stated it was not the number she called on 7/7/2023. In an interview with Nurse #6 on 7/11/2023 at 1:12 p.m., she stated about 7:30 a.m. on 7/7/2023 Nurse #4 inform her Resident #76 had alleged during the night shift that NA #2 called the police because NA #2 had hit her. She stated she immediately called the interim Director of Nursing (DON), who returned her call at 7:32 a.m. on 7/7/2023 and went to speak with Resident #76. In an interview with the Staff Development Coordinator (SDC) on 7/11/2023 at 12:46 p.m., she stated the interim DON called her at 6:50 a.m. on 7/7/2023 to report Resident #76 had alleged NA #2 had hit her. She explained she lived the closest to the facility and reported to the facility and began the abuse protocol for alleged abuse. She stated Nurse #4 working the 7 p.m.- 7 a.m. shift should had been the nurse to notify the interim DON of the incident. In an interview with the interim Director of Nursing (DON) on 7/11/2023 at 12:13 p.m., she stated she had been acting as interim for the last two weeks and could not recall receiving a phone call before 7:33 a.m. of the morning of 7/7/2023 to report an alleged employee to resident abuse for Resident #76. She explained Nurse #6 notified her of Resident #76's allegation, and she informed the SDC so she could start the abuse protocol until she arrived. The interim DON stated Nurse #4 should had reported the incident upon learning of the alleged abuse at 5:00 a.m. so the facility could send the initial report to the state agency within two hours of learning of an alleged abuse incident. She further explained the initial report was completed incorrectly as the reason for resubmitting the initial report to the state agency at 4:45 p.m. on 7/7/2023. The In an interview with the Regional Nurse Consultant on 7/12/2023 at 10:06 a.m., she stated the interim DON's name and number to contact after the departure of the Administrator from the facility on 7/7/2023 was placed throughout the facility but did not list her as the abuse coordinator. She stated Nurse #4 should had immediately reported the alleged abuse incident to the abuse coordinator so the initial report can be sent to the state agency within two hours. In a follow up interview on 7/13/2023 at 5:47 p.m., she stated contact information for all administration staff was available to the nursing staff, and Nurse #4 should had continued to call up the administrative chain of command if no response was received from leaving a voice mail to report an alleged abuse incident. In an interview with [NAME] President of Operations #1 and [NAME] President (VP) of Operations #2 on 7/13/2023 at 6:00 p.m., VP of Operations #2 stated the facility had a 24-hours care line and an administrative chain of command for Nurse #4 to call to report alleged abuse incidents if notification of the abuse coordinator went to voice mail. He stated the facility was to report the initial report to the state agency within 2 hours of Resident #76 alleging abuse. 2. a. Resident #7 was admitted to the facility on [DATE] and discharged on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was moderately impaired cognitively with inattention and disorganized thinking was continuously present. The MDS also indicated Resident #7 experienced hallucinations and delusions and had displayed physical and verbal behaviors toward others in 1-3 days of the seven-day look back period. b. Resident #15 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was moderately impaired cognitively. Nursing documentation dated 5/17/2023 at 2:41 a.m. by Nurse #5 revealed Resident #7 exhibited aggressive and combative behavior towards her roommate, Resident #15, and NA #4 witnessed Resident #7 walking away from Resident #15 who was lying in the bed. Resident #7 informed Nurse #5 she slept with my man, and Resident #15 informed Nurse #5, she hit me on my arm and hand. Nurse #5's assessment of Resident #15 found no injuries and moved Resident #15 to room [ROOM NUMBER]B for her safety. The facility's Initial Allegation Report to the state agency dated 5/17/2023 at 8:45 a.m. written by the Administrator documented staff reported that a resident hit another resident on her arm and hand. The facility's reported the census on 5/17/2023 was 77 residents. A review of the documented resident questionnaire for abuse dated 5/17/2023 revealed 19 residents in the facility were interviewed. There were 15 documented resident skin care assessments reviewed related to the resident- to-resident abuse investigation for 5/17/2023. Resident #7's skin assessment was documented completed on 5/17/2023. The remaining 14 skin assessments were dated prior to the resident-to-resident abuse incident on 5/17/2023: 12 residents skin assessment dated [DATE], 1 resident skin assessment dated [DATE] and on 1 resident skin assessment dated [DATE]. There was no documented skin assessment for Resident #15, and there were no other skin assessment documents provided by the facility to review. Review of written statements related to the resident-to-resident abuse incident on 5/17/2023 included one by Nurse #5. Nurse #5's statement dated 5/18/2023 stated at approximately 2:00 a.m. Resident #7 was exhibiting aggression and combative behaviors toward her roommate, Resident #15, while she was lying in bed. She wrote NA #4 heard yelling and screaming and witnessed Resident #7 walking away from Resident #15's bed when entering the room. She wrote Resident #7 was yelling out angrily, She slept with my man when she entered the room, and Resident #15 stated, She hit me on my arm and hand. Resident #15 was assessed with no injury identified and Resident #7 continued to show aggressive behaviors and refusing medications. Resident #15 was moved to room [ROOM NUMBER]-B for safety reasons. There were no written statements from nursing staff, Resident #15 and Resident #7 provided for review. The timeline for the resident-to-resident abuse incident on 5/17/2023 written by the Administrator on 5/22/2023 stated the resident-to-resident abuse incident between Resident #7 and Resident #15 was reported to the Administrator on 5/17/2023 at 8:45 a.m. The timeline reported Resident #7 was not interviewed due her cognitive and mental status at the time, and Resident #15 stated Resident #7 hit her on her hand and arm. The physician, resident representatives and police were notified. The timeline further stated head to toe skin assessments were completed on all other residents with a Brief Interview for Mental Status (BIMS) of 7 or less and interviews with done on residents with BIMS of 8 or greater. There were witnesses agreeing with Resident #15, and the allegation of physical abuse by Resident #7 against Resident #15 was substantiated. The timeline further stated the facility's staff was and would continue to be educated on abuse and neglect and the importance of timely notification for abuse and neglect. The facility's 5-day Investigation report dated 5/22/2023 by the Administrator indicated the allegation of abuse between Resident #7 and Resident #15 was substantiated. In an interview with Resident #15 on 7/13/2023 at 1:00 p.m., she stated she didn't know why Resident #7 hit her on 5/17/2023. She said the nursing staff came into the room and stopped Resident #7 from hitting her and she wasn't hurt. She stated she was moved to another room and felt safe at the facility. In an interview with NA #4 on 7/11/2023 at 6:59 p.m., she stated on 5/17/2023 she heard someone hollering and when she got to Resident #15's room, she observed Resident #7 standing over Resident #15's bed and hitting her with a fist hand. She stated she could not see where she was sitting her and Resident #7 returned to her bed when instructed by the staff. She explained she went to get Nurse #5 when another nurse aide, who she was unable to recall by name, came into the room and moved Resident #15 to room [ROOM NUMBER]-B. She recalled it was late in the night when the abuse incident occurred. In a phone interview with Nurse #5 on 7/11/2023 at 5:42 p.m., she stated on 5/17/2023, Nurse Aide #4 reported Resident #15 was screaming and yelling, and Resident #7 was observed standing over Resident #15. Upon enter Resident #15 and Resident #7 's room, Resident #7 stated Resident #15 had slept with her man. NA #4 stated Resident #7 had hit Resident #15 and when asked, Resident #15 stated, Yes, on my arm. Nurse #5 stated she assessed Resident #15 and found no redness or bruising to the hand and arm area. She stated for the safety of Resident #15, she moved the resident to room [ROOM NUMBER]B. She explained the resident-to-resident incident occurred after the night medication pass between 11:00 p.m. and 12:00 a.m., and she called the Administrator right after the incident occurred after transferring Resident #15 to another room and to inform the Administrator of the incident. In a phone interview with the former Administrator on 7/11/2023 at 6:13 p.m., she stated the time on the initial report (5/17/2023 at 8:45 a.m.) was the time she was notified of the resident-to resident abuse between Resident #7 and Resident #15. She stated the nursing staff didn't always report abuse immediately and sometimes she was not notified. She explained an investigation of abuse incidents included interviewing the nursing staff and residents and conducting resident skin assessments or resident interviews based on the BIMS of the resident for all residents. She stated the resident skin assessments dated prior to 5/17/2023 was not right and resident skin assessments should have been conducted after the resident-to resident abuse incident. In an interview with Regional Nurse Consultant on 7/12/2023 at 10:26 a.m., she explained that investigations of abuse should include statements from the residents involved, all staff involved, the initial report, the 5-day report, assessments of abuse for all residents (resident skin assessments and interviews). She stated based on the information provided on the resident-to-resident abuse incident on 5/17/2023, a complete investigation was not completed. In another interview on 7/13/2023 at 5:47 p.m., she stated there was no other information to provide for the resident-to-resident investigation between Resident #7 and Resident #15. She stated all residents did not receive a skin assessment or interview. In an interview with [NAME] President of Operations #1 and [NAME] President (VP) of Operations #2 on 7/13/2023 at 6:00 p.m., VP of Operations #1 stated after an allegation of abuse staff and residents involved were interviewed and all residents were to be assessed by an interview or skin assessments. 39731 3. Resident #40 was admitted to the facility on [DATE]. Resident #40's admission Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment. An interview was conducted with Resident #40 on 7/11/23 at 9:51 AM. She was alert to person, place, time and situation. Resident #40 stated that on 6/24/23 she informed staff held her wrists and caused her bruises when they removed money from her room after a room search was completed that she didn't consent to. She stated her wrist was bruised during the altercation. An interview was conducted with Nurse #7 on 7/11/23 at 2:45 PM who stated on 6/24/23 Resident #40 stated staff forcibly removed money from her room and there was a struggle. Nurse #7 stated Resident #40 indicated staff were pulling on her and she was shaken up a bit. He stated Resident #40 initially stated staff struck her but when he further questioned Resident #40, she stated she struck herself during the altercation. He did not report this allegation to the Administrator on 6/24/23 because Resident #40 stated she had struck herself. During a phone interview with Resident #40's family member on 7/11/23 at 4:30 PM she stated she spoke with the Administrator on 6/29/23 about Resident #40's bruises she saw on 6/29/23. She stated she informed the Administrator that Resident #40 stated staff were aggressive and injured her when they removed her money from her room. She stated the Administrator got Nurse #7 to check Resident #40 for bruises. During an interview with the Administrator on 7/11/23 at 2:15 PM she reported she heard Resident #40 state she was being held down and hit by staff on 6/24/23 while she was on the phone with Nurse #5 as Resident #40's money was being counted following the room search. She recalled on 6/26/23 she spoke with Resident #40 and the resident stated staff had struck her on 6/24/23 and she had a bruise. The Administrator stated she was informed by Nurse #7 on 6/26/23 that when he spoke with Resident #40 on 6/24/23 about the incident her story changed a and she stated she struck herself. She stated Resident #40 never mentioned it to her again. The Administrator stated she met with Resident #40's family member on 6/29/23 and the family mentioned Resident #40 stated that she had been abused and had a bruise on her wrist. She stated she initially did not do a report to the State because she was unaware it needed to be reported. She explained when subsequent allegations were made on 6/26/23 by Resident #40 and her family member she had followed up with Nurse #7 who stated she recanted when he spoke with her on 6/24/23. She stated there was no investigation of Resident #40's allegations of abuse. An interview was conducted with Regional [NAME] President of Operations #1, Regional [NAME] President of Operations #2, and the Regional Nurse Consultant on 7/11/23 at 4:00 PM who stated they were not aware a report to the State was not made regarding Resident #40's allegations of abuse. Review of an initial report to the State dated 7/11/23 revealed an initial report was made related to Resident #40's allegation of abuse that occurred on 6/24/23.

Based on observations and staff interviews, the facility failed to discard expired chocolate milk cartons from the walk-in refrigerator. On [DATE], expired chocolate milk cartons dated [DATE] were observed on 2 of 2 resident's breakfast meal trays (Resident #56 and Resident #22) when breakfast meal trays were returned to the kitchen. This practice had the potential to cause food borne illness. Findings included: On [DATE] at 9:52 a.m. during an observation of the walk-in refrigerator in the kitchen with the Dietary Manager and Regional Dietary Manager, six chocolate milk cartons with an expiration date of [DATE] were observed in the milk crate in the walk-in refrigerator. The Dietary Manager and Regional Dietary Manager were observed discarding the six cartons of expired chocolate milk into the trash. On [DATE] at 9:52 a.m., the Regional Dietary Manager stated she was watched the breakfast serving line the morning of [DATE], and none of the residents received chocolate milk at breakfast. The Dietary Manager stated the expiration date on the chocolate milk cartons was to be checked every morning before going out on the meal trays. On [DATE] at 10:13 a.m. two chocolate milk cartons with expiration date of [DATE] were observed on Resident #56's and Resident #22's breakfast tray on the meal cart returned to the kitchen. Resident #56's chocolate milk was observed opened and half emptied. Resident #22's chocolate milk was observed sealed and returned to the kitchen unopened. On [DATE] at 10:13 a.m., the Regional Dietary Manager stated she did not think any residents got chocolate milk on the serving line that morning. On [DATE] at 2:32 p.m. in an interview with Resident #56, she stated the chocolate milk she drank at breakfast on [DATE] tasted good. On [DATE] at 2:50 p.m. in an interview with Nurse Aide #3, she stated she delivered Resident #56 her breakfast tray on [DATE] and helped set up the breakfast tray by opening the chocolate milk carton. She stated she did not look at the expiration date on the chocolate milk carton. On [DATE] at 12:10 p.m. in an interview with Dietary Aide #1, she explained she was not assigned the beverages on the serving line on [DATE]. She stated expiration dates on milk products were to be checked before using and placing on the meal trays. On [DATE] at 6:17 p.m. in an interview with Regional [NAME] President #1, he stated always check expirations on milk products before use and discard the milk item if expired.

Based on record review and staff interviews, the facility failed to follow a physician's order to call the physician for a blood glucose reading greater than 550 for two incidents of a high blood glucose reading on 6/25/2023 and to obtain physician orders to administration insulin coverage for the high glucose readings for 1 of 2 residents reviewed for the use of insulin. (Resident #82) Findings included: Resident #82 was admitted to the facility on [DATE], and diagnoses included Diabetes Mellitus. There was a physician order dated 6/20/2023 to check Resident #82's blood glucose four times a day before meals and at bedtime and to administer Tresiba 100 units per milliliter (mL) 6 units once a day at night. On 6/21/2023, Humalog sliding scale insulin 100 units per milliliter was ordered as the following: * Blood glucose reading less than 60; call the physician. * Blood glucose reading between 200-250; give 3 units Humalog insulin. * Blood glucose reading between 251-300; give 5units Humalog insulin. * Blood glucose reading between 301-350; give 7 units Humalog insulin. * Blood glucose reading between 351-400; give 10 units Humalog insulin. * Blood glucose reading between 401-500; give 14units Humalog insulin. * Blood glucose reading between 501-550; give 16 units Humalog insulin. * Blood glucose reading greater than 550; call physician. A review of the June 2023 Medication Administration Record (MAR) for Resident #82 recorded the blood glucose reading as high on 6/25/2023 at 12:00 p.m., 4:00 p.m. and 8: 00 p.m. Under comments on the June 2023 MAR, Nurse #7 documented late on 6/25/2023 at 6:31 p.m. Resident #82 was given 8 units of Humalog insulin at 12:00 p.m. and 4:00 p.m. Nurse #5 documented on 6/25/2023 at 8:00 p.m., Resident #82 refused 16 units of Humalog insulin and only wanted 6 units Humalog insulin. Resident #82's next blood glucose reading recorded was 176 at 12:00 p.m. on 6/26/2023. There was no nursing documentation reporting the physician was notified of the high blood glucose readings on 6/25/2023 at 12:00 p.m., 4:00 p.m. and 8:00 p.m. found in Resident #82's medical record. Nurse #7 created a physician telephone order for Humalog 100units per milliliter 8 units subcutaneous immediately on 6/25/2023 at 6:07 p.m. There were no other new physician orders for insulin coverage found on Resident #82's chart for 6/25/2023. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #82 was cognitively intact and had received seven injections of insulin in the seven-day look back period. Resident #82's care plan dated 7/1/2023 included a focus for the risk of unstable blood glucose. Interventions included monitoring the blood glucose as physician ordered, providing meals as ordered and encouraging diet compliance and notifying the physician with significant changes in sign and symptoms of hyperglycemia. In a phone interview with Nurse #7 on 7/13/2023 at 10:27 a.m., she stated she recalled Resident #82 would refuse his insulin and wanted to tell the nursing staff the amount of insulin to administer. She stated she did not recall Resident #82's blood glucose reading being high. She explained when a blood glucose level read high, the physician was called for orders, and new orders were placed in the computer. She said documentation of a high blood glucose reading and treatment, if not documented on the MAR, would be documented in the nursing notes or on a situation background assessment recommendation (SBAR) form. In a phone interview with Nurse #5 on 7/13/2023 at 12:30 p.m., she stated when Resident #82's blood glucose readings were high she was to call the physician. She explained when blood glucose readings read high she would give the maximum dose of insulin on the sliding scale while waiting for the physician to call. She stated when she worked the 7:00 p.m. to 7:00 a.m. (night shift), it was difficult to reach the physician. When calling the physician, a nurse answered and asked multiple questions, or you left a message with no return call. She stated on 6/25/2023 she did not call the physician and used her own judgement to administer Resident #82 insulin for the high blood glucose reading. She said Resident #82 refused Humalog 16 units, the highest amount ordered on the Humalog sliding scale, and was given Humalog 6 units as resident requested. In a phone interview with Physician #1 on 7/13/2023 at 2:32 p.m., she stated she was unable to recall receiving a call from Nurse #7 and Nurse #5 on 6/25/2023 due to Resident #82's blood glucose reading being high. She explained there was a physician on-call every night, and there was an advice nurse that gathered information before calling the physician on-call. She stated based on the Humalog sliding scale order, the nursing staff was to call the physician for specific new orders for blood glucose readings greater than the Humalog sliding scale. In an interview with the interim Director of Nursing and Regional Nurse Consultant on 7/13/2023 at 5:30 p.m., the Regional Nurse Consultant stated Nurse #7 and Nurse #5 should had called the physician for each high blood glucose reading as ordered on the Humalog sliding scale order. She stated medications were to be administered as ordered by a physician, and new physician orders were to entered into the Resident #82's electronic medical record.

Based on record review, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 1 resident whose MDS was reviewed for the use of restraints (Resident #61). Findings included: Resident #61 was admitted to the facility on [DATE], and diagnoses included dementia and use of gastrostomy tube. Nursing documentation dated 7/24/2022 recorded Resident #61's representative provided consent for the use of an abdominal binder and was educated on the use of restraints and side effects from the use of the abdominal binder. Physician orders dated 12/1/2022 included an enteral feeding at 60 milliliters an hour from 6 p.m. to 6 a.m. twice a day, and phsyican orders dated 3/23/2023 included abdominal binder release and assess skin every two hours. If any change of condition, notify physician. Surgical progress notes for percutaneous endoscopic gastrostomy (PEG) placement date 3/21/2023 due to self-removal of gastrostomy tube stated it was essential that the abdominal binder remain in place. An observation assessment dated [DATE] indicated implementation use of an abdominal binder, a restrictive device, for Resident #61 as an enabler and consent for use from Resident #61's representative. The June 2023 Medication Administration Record recorded the abdominal binder was released every 2 hours and skin was assessed daily. The quarterly MDS dated [DATE] indicated Resident #61 was severely cognitively impaired with no limitations in upper body movements. The MDS also indicated Resident #61 required total assistance with eating and received greater than 51% of dietary calories and greater than 501 milliliters of fluids through tube feedings. The MDS was not marked for the use of a restraint. On 7/12/2023 at 8:18 a.m., when Nurse Aide (NA) #1 uncovered Resident #61's abdominal (stomach) area, a white abdominal binder was observed wrapped front and back and closed by Velcro (hoop and loop fastener used to adhere and secure items) around the abdominal area. NA #1 stated the abdominal binder was used to prevent Resident #61 from pulling the gastrostomy tube. In an interview with the MDS Nurse #2 on 7/13/2023 at 4:54 p.m., she stated the abdominal binder was being used for medical reasons. She said it was a medical device, not a restraint, used to keep Resident #61 from self-pulling out the gastrostomy tube ordered by the physician. She stated the use of the abdominal binder had never been coded as a restraint in the MDS assessment. In an interview with the Regional Nurse Consultant on 7/13/2023 at 5:47 p.m., she stated an abdominal binder was a restraint, and when Resident #61 was assessed for the use of the abdominal binder, it was determined to be an enabler and not a restraint. In an interview with Regional [NAME] President (VP) #1 and Regional [NAME] President #2 on 7/13/2023 at 6:14 p.m., VP #1 stated the abdominal binder was not a restraint if Resident #61 could remove the abdominal binder, and he wasn't aware a medical device used to prevent Resident #61 from pulling the gastrostomy tube was a restraint. Regional [NAME] President #2 stated the MDS assessment should be coded accurately, and he did not think the abdominal binder was a restraint.

Based on record review, staff and Physician interviews the facility failed to provide supervision to prevent accidents when residents (Resident #369 and Resident #61) who were ordered to have nothing by mouth (NPO) and enteral feeding (nutrition delivered by a tube into the digestive system as a liquid) were served regular textured meals by Nursing Assistant (NA) #1. NA #1 fed Resident #369 a regular textured meal. Resident #369 aspirated (breathed food/liquid into the lungs) and was hospitalized for 5 days. NA #1 provided a regular textured meal tray to Resident #61. There was a high likelihood of serious harm for Resident #61. The facility also failed to maintain safe water temperatures for residents who performed activities of daily living (ADLs) independently. This was for 8 of 10 residents reviewed for supervision to prevent accident/hazards (Residents #369, #61, #47, #12, #35, #31, #171 and #32). Immediate Jeopardy for example #1 began on 5-11-22 when NA #1 fed Resident #369, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy for example #2 began on 5-11-22 when NA #1 provided Resident #61, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy was removed on 5-20-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education, ensure monitoring systems put into place are effective, and to implement a plan of correction for examples 3 through 10. Findings included 1.Resident #369 was admitted to the facility on [DATE] with multiple diagnoses that included gastrostomy status. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #369 was severely cognitively impaired and required total assistance with one person for feeding. The MDS also coded Resident #369 as receiving 51% or more of her calories from tube feeding and 501cc (cubic centimeters) or more water per day. The May 2022 active physician's orders included an order initiated 7-26-21 for Resident #369 to receive a fortified nutritional supplement at 55cc per hour continuously through enteral feedings. The May 2022 active physician's orders included an order initiated 8-1-21 for Resident #369 to be NPO (Nothing by mouth). Resident #369's active care plan as of 5-10-22 revealed a goal that she would remain free of complications related to the use of a feeding tube. The interventions for the goal were in part keep head of the bed elevated, observe for abdominal distention, lung sounds and check for residual. Resident #369 had a second goal that her weight would remain stable. The interventions for the goal were in part resident is NPO, diet as ordered- fortified nutritional supplement and water flushes per order. A nursing progress note dated 5-11-22 at 9:15am by Nurse #2 documented she was called into Resident #369's room by the Wound Care (WC) nurse. Nurse #2 documented she observed the resident with her eyes open, alert to tactile (physical touch) stimuli and coughing up blood-tinged fluid. The documentation indicated the Physician and family members were notified that Resident #369 was being sent to the emergency room for evaluation. The emergency room hospital records dated 5-11-22 revealed a diagnosis of aspiration of food. A CT scan (series of x-ray images) was ordered which showed Resident #369 also had pneumatosis (increased gastric pressure in the colon due to vomiting) along the right colon. The hospital records dated 5-16-22 indicated Resident #369 received intravenous fluids, intravenous antibiotics and was restarted on her enteral feedings. The resident was discharged back to the facility on [DATE] During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA explained 5-11-22 was her first day working at the facility. She added that it was only her 2nd time working in a long-term care facility. She discussed handing out breakfast trays on 5-11-22 and realizing Resident #369 and another resident (Resident # 61) had not received a meal tray. NA #1 stated she went to the kitchen and requested 2 meal trays (one for Resident #369 and one for Resident #61) from dietary staff. She said the dietary staff provided her 2 regular textured meal trays with eggs, French toast with apples, sausage patty and orange juice and commented the dietary staff had not mentioned to her the residents were NPO. NA #1 stated she went back to the unit, placed Resident #61's tray on the tray table and proceeded to Resident #369 where she began to feed the resident some of the eggs and orange juice. She stated Resident #369 began to turn red in the face and had trouble breathing, so she turned the resident on her side and retrieved help from a nurse that was in a meeting. She explained she did not see any nurses on the unit and had left the resident for approximately 1 minute to get help. NA #1 said she had received no orientation, training or computer access prior starting her shift. She stated she saw the enteral feeding pump for Resident #369 but did not know what it was and since she did not have access to the computer to check the resident's diet, she was unaware the resident was NPO. The WC nurse was interviewed on 5-17-22 at 2:12pm. The WC nurse discussed being in a morning meeting on 5-11-22 when NA #1 entered the meeting requesting help. She stated when she walked into Resident #369's room, she saw dark red mucous on the resident's face and sheets. The WC nurse said the resident was sitting up in the bed and NA #1 told her she had been feeding the resident breakfast when the resident became ill. Nurse #2 was interviewed on 5-17-22 at 12:39pm. The nurse explained she was called down to Resident #369's room on 5-11-22 and observed the resident sitting up in the bed, coughing with blood-tinged fluid coming out of her mouth. She further explained the WC nurse had informed her NA #1 had been trying to feed the resident a meal. She stated she called the Physician, 911 and the resident's family. The nurse stated the resident was sent to the emergency room for further evaluation. Dietary Aide #1 was interviewed on 5-17-22 at 1:20pm. The Dietary Aide stated she was working on 5-11-22 during breakfast but was assigned to the washroom and did not hand NA #1 any meal trays. She explained the Assistant Dietary Manager had spoken with and handed the meal trays to NA #1. A telephone interview occurred with the Dietary Assistant Manager on 5-17-22 at 1:56pm. The Dietary Assistant Manager stated NA #1 had come to the kitchen on 5-11-22 requesting meal trays for Resident #369 and Resident #61. He discussed checking the dietary orders for both residents and saw they were both NPO and received enteral feedings but explained he thought staff was trying to switch the residents back onto solid food, so he provided a regular meal tray for both Resident #369 and Resident #61 to NA #1. The Dietary Assistant Manager stated he could only see a resident's dietary order in the computer. He explained that sometimes the orders were not entered into the electronic medical record before trays were passed out, so he did not know if there had been an actual order to switch the residents back onto solid foods. He revealed he should have asked the Dietary Manager or the nursing staff before providing the trays to NA #1. The Medical Director was interviewed by telephone on 5-19-22 at 3:35pm. The Medical Director stated she was aware of the 5-11-22 incident for Resident #369. She indicated there was high potential for serious harm resulting from a resident aspirating. The Director of Nursing (DON) was interviewed on 5-17-22 at 2:25pm. The DON stated the accident with Resident #369 could have been avoided if NA #1 had been oriented and educated regarding the resident's care prior to receiving her assignment. 2. Resident #61 was admitted to the facility on [DATE] with multiple diagnoses that included gastrostomy status. The May 2022 active physician's orders included an order initiated 7-31-21 for Resident #61 was to be NPO. The May 2022 active physician's orders included an order initiated 1-7-22 for Resident #61 to receive a fortified nutritional supplement at 45cc (cubic centimeters) per hour continuously through enteral feedings. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was severely cognitively impaired and required total assistance with one person for eating. Resident #61 was also coded for tube feeding acquiring 51% or more of her calories per day with 501cc (cubic centimeter) or more of water per day. Resident #61's active care plan as of 5-10-22 revealed a goal that she would not exhibit overt signs and symptoms of complications related to her feeding tube. The interventions for the goal were in part administer feedings as ordered, resident is NPO (nothing by mouth) and elevate the head of the bed 30-35 degrees while feeding. During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA explained 5-11-22 was her first day working at the facility. She added that it was only her 2nd time working in a long-term care facility. She discussed handing out breakfast trays on 5-11-22 and realizing Resident #61 and another resident (Resident # 369) had not received a meal tray. NA #1 stated she went to the kitchen and requested 2 meal trays (one for Resident #61 and one for Resident #369) from dietary staff. She said the dietary staff provided her 2 regular textured meal trays with eggs, French toast with apples, sausage patty and orange juice and commented the dietary staff had not mentioned to her the residents were NPO. NA #1 stated she went back to the unit, placed Resident #61's tray on the tray table next to the residents bed. She commented Resident #61 would not have been able to reach the tray then stated she proceeded to Resident #369's room. NA #1 stated she had not fed Resident #61 but said another staff could have tried to feed Resident #61 since she left the meal tray in the room. NA #1 said she had received no orientation, training or computer access prior starting her shift. She stated since she did not have access to the computer to check the resident's diet and she was unaware the resident was NPO. A telephone interview occurred with the Dietary Assistant Manager on 5-17-22 at 1:56pm. The Dietary Assistant Manager stated NA #1 had come to the kitchen on 5-11-22 requesting meal trays for Resident #61 and Resident #369. He discussed checking the dietary orders for both residents and saw they were both NPO and received enteral feedings but explained he thought staff was trying to switch the residents back onto solid food, so he provided a regular meal tray for both Resident #61 and Resident #369 to NA #1. The Dietary Assistant Manager stated he could only see a resident's dietary order in the computer. He explained that sometimes the orders were not entered into the electronic medical record before trays were passed out, so he did not know if there had been an actual order to switch the residents back onto solid foods. He revealed he should have asked the Dietary Manager or the nursing staff before providing the trays to NA #1. The Medical Director was interviewed by telephone on 5-19-22 at 3:35pm. The Medical Director stated she was aware of the incident on 5-11-22. She indicated there was high potential for serious harm from a resident who was NPO and fed solid foods to aspirate. The Director of Nursing (DON) was interviewed on 5-17-22 at 2:25pm. The DON stated the potential accident with Resident #61 could have been avoided if NA #1 had been oriented and educated regarding the resident's care prior to receiving her assignment. The Administrator was notified of Immediate Jeopardy on 5-17-22 at 6:05pm. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #369's diet order: NPO Resident #61's diet order: NPO Nurse Aide #1, an agency staff, began working at the facility on 5/11/22 at approximately 7:00 AM. On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room and the breakfast tray was placed on the bedside table of Resident #61 (out of residents' reach). Resident #369's tray consisted of scrambled eggs, sausage patty, French toast, apples, and orange juice. Both residents had the same items on the trays. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. A staff member (unknown) immediately removed the meal tray from Resident #61's room when staff became aware of the concern with Resident #369. Resident #61 was not fed the regular textured tray. Post event: - Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC), Minimum Data Set (MDS) Coordinator, the Medical Director, Regional Nurse Consultant, Special Projects DON, and the Unit Manager. - Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders or care plans to see what the diet orders were. Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system and consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). - Nurse Aide #1 no longer works at the facility. Her last day was 5/11/2022. Nurse Aide #1 did not return to the floor after the incident. - Dietary Assistant Manager was suspended on 5/11/2022. He remains on suspension, but termination was recommended on 5/17/2022. - This event was submitted to the state as a reportable on 5/11/2022. The allegation of neglect was substantiated, and the final investigative summary was submitted on 5/18/2022. All residents are at risk for the current deficient practice. Plan developed: - Diets of all current residents will be reviewed for physician's diet order, diet care plans to match, and dietary tray cards to match; this will be completed by 05/13/2022 by the Interim DON, Unit Managers, or Dietary Director. There were three resident diets corrected. - All resident care plans and CNA care guides will be reviewed for matching level of meal assistance (set-up; supervision; encourage/cue; dependent on staff); this will be completed 05/16/2022 by the Interim DON, Unit Managers, or Minimum Data Set (MDS) Nurse. No discrepancy noted. - Audit of past 30 days of grievances, events, and progress notes will be reviewed by the interim administrator and/or Regional Nurse Consultant by 05/13/2022, for purposes of assessing other events during resident meals and/or residents receiving improper diets/meal trays, to ensure appropriate steps. One grievance was identified related to the way the diet was ordered to ensure the correct meal consistency was provided to the resident. Diet has been corrected and clarified. There was no harm to the resident affected. - Resident council meeting will be held by 5/17/2022 for any additional concerns meal/dietary concerns. Residents had no concerns regarding their food. - Clinical licensed and unlicensed and dietary staff will be reeducated by the DON and/or SDC on (i) locating and verifying resident diet information if in question, (ii)proper set-up of resident meal trays: proper positioning of residents at mealtime (whether in dining room, resident room, wheelchair, and in bed), (ii) proper consistency of diets and liquids (e.g., regular, mechanical soft, pureed, nectar/pudding/honey thickened liquid), and (iii) checking resident tray cards when setting up resident meal tray to ensure matching. Reeducation will be completed by the IDT by 05/18/2022. No staff including agency staff will work on the floor after 5/18/22 until education has been received. Education provided by the DON and/or SDC on the facility's Assistant with Meals policy, ensuring residents are served the correct meal as ordered by validation of residents' diets using the CNA care guides, what NPO means, and how giving a resident the wrong diet could cause choking episodes, aspiration into the lungs, or subsequent death of the resident. - The facility staff development coordinator immediately educated all staff on the need to provide a diet as ordered and the serious adverse outcomes that could result from providing an incorrect diet. This education was initiated on 5/17/2022 and completed on 5/19/2022. Education was also provided by the DON and/or SDC to agency staff and a post-test provided to validate understanding starting on 5/17/2022 and completed on 5/19/2022. All staff will complete and score 100% on the written post-test. This written test was completed on 5/18/2022 and included validation of the diet report, notification of the dietary manager if unsure of a diet request, training on diet textures including NPO diet, and reviewing all diet orders for accuracy in the meal tracking system. No staff including agency staff will work on the floor after 5/17/2022 until education has been received. - The dietary staff were re-educated on the protocol in place to ensure meal trays are not provided to NPO residents unless ordered by the physician. A list of resident diets is printed and posted as a second reference for the dietary staff to validate a residents' diet. This education was provided by the Regional Dietary Manager on 5/18/2022. The list of resident diets was posted on the bulletin board in the kitchen. The dietary manager will keep the posting updated if changes are made. - Additional education was provided to Dietary staff by the Director of Nursing that providing a diet not ordered for a resident could result in serious adverse outcomes. Re-education and a verbal re-test completed on 5/18/2022. Dietary staff required to attain a 100% by 5/18/2022 or they will not be allowed to work. - Facility Staff Development Coordinator, Wound Nurse and/or Regional Nurse Consultant will ensure all staff have access to the electronic medical records system prior to the beginning of their first assigned work shift as of 5/16/2022. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. No nursing staff will work on the floor after 5/16/2022 without access to the electronic medical records system. Orientation on the electronic medical record will be completed with the agency staff by the facility wound nurse, staff development coordinator, and/or the regional nurse consultant. The Agency Orientation Checklist includes education on how to use the medical records system. In addition, the Clinical Team Member or Weekend Manager are responsible to audit agency staff and validating staff are accessing the electronic medical record for resident care needs. The agency staff are also instructed on the use of the care delivery guides for information on each resident's care needs prior to working on the floor. - The facility has provided the staffing agencies a copy of the agency orientation guide on 5/12/22. Agency staff will present to the facility with a signed orientation packet. Agency staff will not be permitted to work until this agency orientation material has been completed. The number to the on-call phone has been posted at each nurse's station for agency staff to receive this education over the phone and complete agency orientation guides have been placed at each nurse's station for reference. A Clinical Team Member rotation, consisting of either the Director of Nursing, Wound Care Nurse, or Staff Development Coordinator, will have the on-call phone on off hours and weekends and will be available to staff to conduct training and other assistance as needed. Should the agency staff arrive to the facility without the orientation packet completed, the agency staff will be directed to contact the on-call phone/Clinical team member for the orientation process to be completed prior to beginning their assignment. The on-call clinical team member will be responsible to be in the facility at the beginning of day shift and available on off hours and will be responsible to collect the agency staff orientation paperwork at the start of the shift or assist with the orientation process. In the afternoon hours of weekend days, approximately 2:45 pm - 7:00 pm, the Manager on Duty will be responsible to collect the agency staff orientation paperwork at the start of the afternoon shift, as previously established, or assist the agency staff in contacting the on-call clinical team member to complete the orientation process. The Clinical Team will be responsible to review the schedule daily, specifically on the weekend days, to determine who will be an agency staff person working at the facility for the first time and who will need to have validation of the orientation packet being completed prior to their arrival, or if it must be done on site prior to beginning their job duties. Education will also include information on residents who are NPO and/or fed by a tube. Additional education was provided by the Director of Nurses and Unit Manager for the nursing staff, going over the list of residents who are NPO, and adding list to the CNA care guide notebook located at each nurse's station. Centralized scheduling has been educated by Clinical Information Technology Nurse Technologist on providing agency staff access to the electronic medical record prior to arrival to the facility. If the access is not obtained prior to arrival, the agency staff will call the on-call phone number and access will be provided along with steps to access the system. Validation will be completed that electronic medical record access is successful prior to the staff working their shift. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. This was implemented on 5/18/2022. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. Alleged date of IJ removal: 5/20/2022. The facility's credible allegation of Immediate Jeopardy was validated onsite on 5-24-22 through interviews with facility staff including nursing staff and dietary staff as well as the Regional Consultant. The nursing staff verbalized receipt of education prior to starting their shift in the facility. The staff education documentation, audits and monitoring were reviewed. Nursing staff education included completing the orientation checklist and obtaining access to the facility's electronic medical record system prior to providing resident care, and the use of the resident care guides to locate resident care information including diets. Nurse aides were observed using resident care guides, located at the nursing station, to confirm resident's diets and stated resident diets were verified with nursing staff before requesting a diet tray from the kitchen. Dietary staff education included use of resident diet list to confirm a resident's diet and to clarify resident diets with the dietary manager or nurse as needed. Dietary staff stated resident dietary list was printed daily and used as a reference when nursing staff requested diet trays for residents, and a list of residents with nothing by mouth (NPO) diets and the resident diet list was posted in the kitchen. All resident diets were audited for accuracy, and daily meal audits indicated no issues with residents receiving the correct diets. Signage with contact information was posted at the time clock and both nursing stations reminding agency nursing staff not to provide resident care until obtaining access to the facility's electronic medical record and receiving the Orientation Checklist. Interviews with the nursing staff and a review of staffing audits revealed new agency staff were receiving access to the facility's electronic medical record and the orientation checklist information prior to or on the first day working in the facility and providing resident care. The facility's date of immediate jeopardy removal of 5-20-22 was validated. 3. A review of the medical record revealed Resident #47 was admitted on [DATE]. The Annual Minimum Data Set (MDS) dated [DATE] noted Resident #47 was cognitively intact and needed extensive to total assistance for all daily care with the help of one person. Resident #47 could feed himself with altered utensils. Resident was in a motorized wheelchair when out of bed and could propel himself throughout the facility. The care plan dated 4/29/22 noted a focus of Activities of Daily Living (ADL) function with interventions of: Resident has preferred routine of bath and out of bed by 7 AM. Provide assistance for toileting and hygiene. On 5/16/22 at 10:30 AM, the Assistant Maintenance Director took hot water temperatures in bathroom sinks available to residents who had the ability to use the sink in the bathroom areas to perform self-care. There were residents in these rooms that were unable to perform self-care. On 5/16/22 at 10:30 AM, accompanied by the Assistant Maintenance Director, the temperature in the bathroom area of Resident #47's room registered 118.9. The Assistant stated that was too high, and the mixing valve needed to be adjusted. Resident #47 was in the room and was asked if he went into the bathroom area to wash his hands and he stated yes, I can take my chair in the bathroom and wash my hands. The Resident was encouraged by the Assistant Maintenance Director to turn on the cold water first with the hot water so he would not burn his hands. At 4:55 PM on 5/16/22, Resident #47's sink hot water temperature was 121.5. The Assistant Director of Maintenance stated the mixing valve had been adjusted, the plumber was in the facility and the temperatures would be monitored throughout the evening. On 5/17/22 at 2:00 PM, the Maintenance Director stated the plumber came, found rings in the mixing valve were flat and broken. The Director stated the mixing valve was repaired but water may require 24 hours to reach even temperatures, and the temperatures were being monitored. On 5/18/22 at 9:20 AM, the temperature of the hot water in the bathroom area of Resident #47's room was 107.2. 4. A review of the medical record revealed Resident #12 was admitted on [DATE] with diagnoses of Diabetes Mellitus, debility, pain. The Annual Minimum Data Set (MDS) dated [DATE] noted Resident #12 was cognitively intact and needed supervision to extensive assistance for all daily care with the help of one person. The MDS indicated Resident #12 could feed herself independently after tray set up. The care plan dated 2/15/22 noted a focus of Activities of Daily Living (ADL) with an intervention of only do what is needed so resident can maintain ability. On 5/16/22 at 10:30 AM, hot water temperatures were taken in bathroom sinks available to residents who had the ability to use the sink in the bathroom areas to perform self-care. On 5/16/22 at 10:35 AM, accompanied by the Assistant Maintenance Director, who took the temperatures, the temperature of the hot water in the bathroom area sink was 119.9. The Assistant Maintenance Director stated the mixing valve needed to be adjusted. On 5/16/22 at 4:55 PM, hot water temperatures were rechecked. Resident #12's bathroom sink registered 120.1 Assistant Director of Maintenance stated the mixing valve had been adjusted, the plumber was in the facility and the temperatures would be monitored throughout the evening. Resident #12 stated she goes into the bathroom area and uses the bathroom and washes her hands. The Maintenance Director was interviewed on 5/17/22 at 2:00 PM and stated the plumber had found rings in the mixing valve were flattened and broken. The Director stated the mixing valve was repaired but water may require 24 hours to reach even temperatures, and the temperatures were being monitored. On 5/18/22 at 9:20 AM, Resident #12's hot water in the bathroom sink registered at 105.1. 5. A review of the medical record revealed Resident #35 was admitted on [DATE]. The Annual Minimum Data Set (MDS) dated [DATE] noted Resident #35 to be cognitively intact and needed only supervision or was independent for all daily care, with the assistance of one person. The care plan dated 5/17/22 noted a focus of Activities of Daily Living (ADL) with interventions of provide assistance for ADLs as needed, consistent approach, and monitor for pain. On 5/16/22 at 10:40 AM, accompanied by the Assistant Director of Maintenance, who took the temperatures, the temperature of the hot water from the sink in the bathroom area was 118.7. The Assistant stated that temperature was too high, and the mixing valve needed to be adjusted. At 5:00 PM on 5/16/22 the hot water was found to be 124.8. the Assistant Director of Maintenance stated the mixing valve had been adjusted, the plumber was in the facility and the temperatures would be monitored throughout the evening. On 5/17/22 at 2:00 PM, the Maintenance Director stated the plumber came, found rings in the mixing valve were flat and broken. The Director stated the mixing valve was repaired but water may require 24 hours to reach even temperatures, and the temperatures were being monitored. Resident #35 was asked on 5/18/22 at 8:45 AM, if he used the bathroom area sink and he stated he did use it to wash his hands. Resident # 35 stated he had not noticed the water being too hot. On 5/18/22 at 9:25 AM, the hot water in Resident #35's bathroom area sink registered at 106.3. 6. A review of medical records revealed Resident #31 was admitted on [DATE] with diagnoses including stroke, dementia, anxiety and [CONDITION(S)]. The annual Minimum Data Set (MDS) dated [DATE] noted Resident #31 was cognitively impaired and needed extensive to total assistance with all daily care with the help of one person. The care plan dated 5/16/22 noted a focus of Activities of Daily Living (ADL) self- care deficit and interventions of allow rest periods, total care for all ADLs, monitor for pain. Resident #31 was interviewed on 5/16/22 at 10:40 AM and stated he could propel himself in his motorized wheelchair without difficulty and was observed moving throughout the facility in his chair, feeding himself and attending activities. Resident #31 stated he did go into the bathroom area and use the sink. On 5/16/22 at 10:40 AM, accompanied by the Ass [TRUNCATED]

Based on record review, staff interviews, and Physician interview, the facility failed to train and orient new agency nursing staff and verify competency to deliver care in accordance with the resident's assessed care needs. Nursing Assistant (NA) #1 was not oriented to the protocol for determining residents' dietary orders resulting in the NA feeding a regular textured meal on 5-11-22 to a resident (Resident #369) who had enteral feedings (nutrition delivered by a tube into the digestive system as a liquid) and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #369 aspirated and was hospitalized for 5 days. NA #1 also provided a regular textured meal tray to another resident (Resident #61) who had enteral feedings and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This occurred for 2 of 2 residents (Resident #369 and Resident #61) reviewed for enteral feedings. Immediate Jeopardy for example #1 began on 5-11-22 when NA #1 fed Resident #369, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy for example #2 began on 5-11-22 when NA #1 provided Resident #61, who was NPO and on enteral feedings, a regular textured meal. Immediate Jeopardy was removed on 5-19-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: a. Resident #369 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #369 was severely cognitively impaired and required total assistance with one person for feeding. The MDS also coded Resident #369 as receiving 51% or more of her calories from tube feeding and 501 cubic centimeters (cc) or more water per day. The May 2022 active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #369's active care plan as of 5-10-22 revealed a goal that she would remain free of complications related to the use of a feeding tube. The interventions for the goal were in part keep head of the bed elevated, observe for abdominal distention, lung sounds and check for residual. Resident #369 had a second goal that her weight would remain stable. The interventions for the goal were in part resident is NPO, diet as ordered- fortified nutritional supplement and water flushes per order. A nursing progress note dated 5-11-22 at 9:15am by Nurse #2 documented she was called into Resident #369's room by the Wound Care (WC) nurse. Nurse #2 documented she observed the resident with her eyes open, alert to tactile (physical touch) stimuli and coughing up blood-tinged fluid. The documentation indicated the Physician and family members were notified that Resident #369 was being sent to the emergency room for evaluation. The emergency room hospital records dated 5-11-22 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital records dated 5-16-22 indicated Resident #369 received intravenous fluids, intravenous antibiotics and was restarted on her enteral feedings. The resident was discharged back to the facility on [DATE]. b. Resident #61 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The May 2022 active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was severely cognitively impaired and required total assistance with one person for eating. Resident #61 was also coded for tube feeding acquiring 51% or more of her calories per day with 501cc or more of water per day. Resident #61's active care plan as of 5-10-22 revealed a goal that she would not exhibit overt signs and symptoms of complications related to her feeding tube. The interventions for the goal were in part administer feedings as ordered, resident is NPO and elevate the head of the bed 30-35 degrees while feeding. During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA explained 5-11-22 was her first day working at the facility. She added that it was only her 2nd time working in a long-term care facility. She discussed handing out breakfast trays on 5-11-22 and realizing Resident #369 and Resident #61 had not received a meal tray. NA #1 stated she went to the kitchen and requested 2 meal trays (one for Resident #369 and one for Resident #61) from dietary staff. She said the dietary staff provided her 2 regular textured meal trays with eggs, French toast with apples, sausage patty and orange juice. NA #1 stated she went back to the unit, placed Resident #61's tray on the tray table and proceeded to Resident #369 where she began to feed Resident #369 some of the eggs and orange juice. She stated Resident #369 began to turn red in the face and had trouble breathing, so she turned the resident on her side and retrieved help from a nurse that was in a meeting. She explained she did not see any nurses on the unit and had left the resident for approximately 1 minute to get help. NA #1 said she had received no orientation, training or computer access prior starting her shift. She stated she saw the enteral feeding pump for Resident #369 but did not know what it was and since she did not have access to the computer to check the resident's diet, she was unaware the resident was NPO. She added that she did not feed Resident #61 but said another staff member could have tried to feed the resident since she left the meal tray in the resident's room. The Director of Nursing (DON) was interviewed on 5-17-22 at 2:25pm. The DON stated she was not aware if NA #1 had received training/orientation prior to accepting her work assignment. The DON explained the Staff Development Coordinator would have provided the education. During an interview with the Staff Development Coordinator (SDC) on 5-18-22 at 9:56am, the SDC confirmed she was responsible for the orientation/training of NA #1 on her first day working at the facility (5-11-22). The SDC revealed she had not provided NA #1 any education/orientation or computer access until after the incident with Resident #369. She explained NA #1 started her shift at 7:00am on 5-11-22 and she did not arrive to work until later and she did not want to pull NA #1 off the floor to provide the orientation/education and computer access. The SDC stated she was unaware NA #1 did not have long term care experience. She indicated NA #1 would not have been able to know what her assigned residents' diet orders were or what their care needs were without having orientation. The SDC also discussed new agency staff scheduled off hours and weekends did not receive training/orientation prior to starting their assignment. She added she was concerned for the residents' well-being but did not know how to correct the problem. She also said this was only a problem for agency staff as facility staff received scheduled orientation prior to beginning their first shift. The Medical Director was interviewed by telephone on 5-19-22 at 3:35pm. The Medical Director stated she was not involved in the training or orientation of staff but expected staff to have the education to care for the residents in the facility. The Administrator was interviewed on 5-19-22 at 5:35pm. The Administrator stated he expected all staff to be educated and oriented in the care needs of the residents. The Administrator was notified of Immediate Jeopardy on 5-18-22 at 12:56pm. Resident #369's diet order: NPO Resident #61's diet order: NPO On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. Resident #61 was provided a meal tray. Resident #61 was not fed, and the meal tray was left on the bedside table. The meal tray was not accessible to Resident #61. The meal tray was removed from Resident #61's room as soon as staff were aware Nurse Aide #1 had placed a tray in the room. Upon review of this event, administrative staff immediately implemented the process of dietary staff not issuing a food tray without the resident name being listed on the census diet report audit sheet to prevent a serious adverse outcome from occurring or recurring. Additionally, dietary staff are to consult with the dietary manager and/or the licensed nurse if additional diet clarification is needed. The licensed nurse will validate the correct diet by using the electronic medical record. The dietary manager will validate the correct diet by using the electronic meal tracking system. Post event: 1) Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, the Medical Director, Director of Nursing (DON), Staff Development Coordinator (SDC), Special Projects DON, Interim Unit Manager, and Regional Nurse Consultant. 2) Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system, and to consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). 3) Nurse Aide #1 was provided agency orientation immediately after the incident by the Staff Development Coordinator. 4) Nurse Aide #1 no longer works at the facility. Nurse Aide #1's last day was 5/11/2022. Nurse Aide #1 did not return to the floor after the incident. 5) This event was submitted to the state as a reportable on 5/11/2022. The allegation of neglect was substantiated, and the final investigative summary was submitted on 5/18/2022. All residents are at risk for the current deficient practice. Plan developed: 1) The facility has provided the staffing agencies a copy of the agency orientation guide on 5/12/22. Agency staff will present to the facility with a signed orientation packet. Agency staff will not be permitted to work until this agency orientation material has been completed. The number to the on-call phone has been posted at each nurse's station for agency staff to receive this education over the phone and complete agency orientation guides have been placed at each nurse's station for reference. A Clinical Team Member rotation, consisting of either the Director of Nursing, Wound Care Nurse, or Staff Development Coordinator, will have the on-call phone on off hours and weekends and will be available to staff to conduct training and other assistance as needed. Should the agency staff arrive to the facility without the orientation packet completed, the agency staff will be directed to contact the on-call phone/Clinical team member for the orientation process to be completed prior to beginning their assignment. The on-call clinical team member will be responsible to be in the facility at the beginning of day shift and available on off hours and will be responsible to collect the agency staff orientation paperwork at the start of the shift or assist with the orientation process. In the afternoon hours of weekend days, approximately 2:45 pm - 7:00 pm, the Manager on Duty will be responsible to collect the agency staff orientation paperwork at the start of the afternoon shift, as previously established, or assist the agency staff in contacting the on-call clinical team member to complete the orientation process. The Clinical Team will be responsible to review the schedule daily, specifically on the weekend days, to determine who will be an agency staff person working at the facility for the first time and who will need to have validation of the orientation packet being completed prior to their arrival, or if it must be done on site prior to beginning their job duties. Education will also include information on residents who are NPO and/or fed by a tube. Additional education was provided by the Director of Nurses and Unit Manager for the nursing staff, going over the list of residents who are NPO, and adding list to the CNA care guide notebook located at each nurse's station. Centralized scheduling has been educated by Clinical Information Technology Nurse Technologist on providing agency staff access to the electronic medical record prior to arrival to the facility. If the access is not obtained prior to arrival, the agency staff will call the on-call phone number and access will be provided along with steps to access the system. Validation will be completed that electronic medical record access is successful prior to the staff working their shift. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. This was implemented on 5/18/2022. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. 2) Facility Staff Development Coordinator, Wound Nurse and/or Regional Nurse Consultant will ensure all staff have access to the electronic medical records system prior to the beginning of their first assigned work shift as of 5/16/2022. The on- call clinical team member or weekend manager will be responsible for the EMR access validation as stated above for the agency orientation process. No nursing staff will work on the floor after 5/16/2022 without access to the electronic medical records system. Orientation on the electronic medical record will be completed with the agency staff by the facility wound nurse, staff development coordinator, and/or the regional nurse consultant. The Agency Orientation Checklist includes education on how to use the medical records system. In addition, the Clinical Team Member or Weekend Manager are responsible to audit agency staff and validating staff are accessing the electronic medical record for resident care needs. The agency staff are also instructed on the use of the care delivery guides for information on each resident's care needs prior to working on the floor. 3) The Agency Orientation Checklist has been reviewed by the Regional Nurse Consultant on 5/18/22 and approved for education purposes for agency staff and is designed to be completed at the start of the shift for new agency staff. The orientation checklist covers nursing processes, as well as emergency preparation for newcomers to the facility. 4) Additional education provided by the Director of Nursing and Unit Manager on the CNA care guide located at each nurse's station which contains resident diet orders. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. 5) Agency orientation guides have been placed at each nurse's station as an additional resource. The guides were placed at the nurses on 5/17/2022. The staff have been re-educated by the Regional Nurse Consultant and Director of Nurse on the placement of the agency orientation guides at each nurses' station as an accessible resource. Any staff, to include agency staff, who were not educated by 5/18/2022 will receive education prior to working on the floor. 6) Agency staff will be educated on the CNA care report cards located at each nurse's station to include the residents' current diet orders and the definition of NPO (nothing by mouth) by the Director of Nursing, Staff Development Coordinator, and the Regional Nurse Consultant beginning 5/17/2022. No staff including agency staff will work on the floor after 5/17/2022 until education has been received. 7) Staff were provided education on the severity of what could happen to a resident if they were provided a diet that was not ordered by the physician and could result in serious adverse outcomes by the Director of Nursing and the Staff Development Coordinator. No staff including agency staff will work on the floor after 5/17/2022 until education has been received. Alleged date of IJ removal: 5/19/2022. The facility's credible allegation of Immediate Jeopardy was validated onsite on 5-24-22 through interviews with facility staff including nursing staff as well as the Regional Consultant. The staff verbalized receipt of education prior to starting their shift in the facility. The staff education documentation, audits and monitoring were reviewed. Nursing staff education included completing the orientation checklist and obtaining access to the facility's electronic medical records system prior to providing resident care, and the use of the resident care guides to locate resident care information including diets. Nurse aides were observed using resident care guides, located at the nursing station, to confirm resident's diets and stated resident diets were verified with nursing staff before requesting a diet tray from the kitchen. Meal audits indicated no issues with residents receiving the correct diets. Signage with contact information was posted at the time clock and both nursing stations reminding nursing staff not to provide resident care until obtaining access to the facility's electronic medical record system and receiving the Orientation Checklist. Interviews with the nursing staff and a review of staffing audits revealed new agency staff were receiving access to the facility's electronic medical records and the orientation checklist information prior to or on the first day working in the facility and providing resident care. The facility's date of immediate jeopardy removal of 5-19-22 was validated.

Based on record review and staff interviews the facility failed ensure that dietary staff were competent to carry out the functions of the food and nutrition service in accordance with residents' dietary orders. The Dietary Assistant Manager provided Nursing Assistant (NA) #1 with a regular textured meal for 2 residents (Resident #369 and #61) who were ordered nothing by mouth (NPO) and on enteral feedings (nutrition delivered by a tube into the digestive system as a liquid) continuously resulting in Resident #369 aspirating and being hospitalized . Immediate Jeopardy began on 5-11-22 when the Dietary Assistant Manager provided regular meal trays for 2 residents (Resident #369 and Resident #61) who were NPO and on continuous enteral feedings. The Immediate jeopardy was removed on 5-19-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope/severity of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to competent dietary staff. Findings included: a. The May 2022 active physician's orders included an order for Resident #369 to be NPO and to receive a fortified nutritional supplement at 55 cubic centimeter (cc) per hour continuously through enteral feedings. b. The May 2022 active physician's orders indicated Resident #61 was to be NPO and was to receive a fortified nutritional supplement at 45 cubic centimeter (cc) per hour continuously through enteral feedings. During a phone interview with NA #1 on 5-17-22 at 1:31pm, the NA discussed handing out breakfast trays on 5-11-22 and realized Resident #369 and Resident # 61 had not received a meal tray. The NA stated she went to the kitchen and requested 2 meal trays for Resident #369 and Resident #61 from dietary staff. She said the dietary staff provided her 2 regular meal trays with eggs, French toast with apples, sausage patty and orange juice and commented the dietary staff had not mentioned to her the residents were NPO. She stated she saw the enteral feeding pump but did not know what it was and since she did not have access to the computer to check the resident's diet, she was unaware the residents were NPO. She added that she did not feed Resident #61 but said another staff member could have tried to feed the resident since she left the meal tray in the resident's room. During the interview, the NA explained on 5-11-22 she fed Resident #369 eggs and orange juice. The NA stated Resident #369 began to turn red in the face and had trouble breathing, so she turned the resident on her side and retrieved help from a nurse that was in a meeting. Resident #369 was sent to the emergency room and hospitalized for 5 days. A telephone interview occurred with the Dietary Assistant Manager on 5-17-22 at 1:56pm. The Dietary Assistant Manager explained he had been working at the facility for a few weeks but had received the new employee training that included the tray card print outs and how to verify orders in the computer. He stated Nursing Assistant (NA) #1 came to the kitchen on 5-11-22 during the breakfast meal and requested meal trays for Resident #369 and Resident #61. He discussed checking the dietary orders in the electronic medical record for both residents and saw they were both NPO and received enteral feedings but thought staff was trying to switch the residents back onto solid food, so he provided a regular meal tray consisting of eggs, French toast with apples, sausage patty and orange juice for both Resident #369 and Resident #61 to the NA. The Dietary Assistant Manager stated he could only see a resident's dietary order in the computer. He explained that sometimes the orders were not entered into the electronic medical record before trays were passed out, so he did not know if there had been an actual order to switch the residents back onto solid foods and should have asked the Dietary Manager or the nursing staff before providing the trays. The Dietary Manager (DM) was interviewed on 5-19-22 at 11:47am. The DM explained he was not in the kitchen when NA #1 requested 2 meal trays for Resident #369 and Resident #61 on 5-11-22. He stated the Dietary Assistant Manager was a new employee but received new employee training/orientation on the tray card print outs and how to verify diet orders in the computer. He said the Dietary Assistant Manager should have found him or clarified the order with the nurse prior to giving the trays to the NA. The Administrator was interviewed on 5-19-22 at 5:35pm. The Administrator stated he expected dietary staff to follow dietary orders and seek clarification from management if there are any questions before providing a meal tray to any resident. The Administrator was notified of Immediate Jeopardy on 5-18-22 at 1:55pm. Resident #369's diet order: NPO Resident #61's diet order: NPO On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. Resident #61 was provided a meal tray. Resident #61 was not fed, and the meal tray was left on the bedside table. The meal tray was not accessible to Resident #61. The meal tray was removed from Resident #61's room as soon as staff were aware Nurse Aide #1 had placed a tray in the room. Post event: - Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, the Medical Director, Director of Nursing (DON), Staff Development Coordinator (SDC), Special Projects DON, Interim Unit Manager, and Regional Nurse Consultant. - Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders or care plans to see what the diet orders were. Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system, and to consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). - Dietary Assistant Manager was suspended on 5/11/2022. He remains on suspension, but termination has been recommended on 5/17/2022. - This event was submitted to the state as a reportable on 5/11/2022. This event was submitted to the state as a reportable on 5/11/2022. The allegation of neglect was substantiated, and the final investigative summary was submitted on 5/18/2022. All residents are at risk for the current deficient practice. Plan developed: - Dietary staff educated that providing a diet not ordered for a resident could result in serious adverse outcomes by the Director of Nursing and the Regional Dietary Manager on 5/18/2022. No dietary staff will work after 5/18/2022 until education has been completed. - Dietary manager reviewed the census diet report (a roster of residents and diet orders) with the dietary staff and re-education provided on the validation process to follow prior to giving out any food/drinks on 5/17/2022. The dietary staff will refer to the census dietary report prior to issuing a meal tray to a resident. No dietary staff will work after 5/18/2022 until education has been completed. - Dietary manager will provide validation with dietary staff to ensure understanding resident diets, texture, and restrictions. Dietary staff will be able to state the process to follow if they are unsure about a residents' diet. A copy of the facility's dietary provider's Diet Cross Walk (dietary conversion list provided a comparable diet or meal plan), and the National Dysphagia diet level and Consistency modified diet control panel will be posted as a dietary staff resource. This validation was started and completed on 5/17/2022. The information was posted on the board in the kitchen for staff review on 5/17/2022. No dietary staff will work after 5/17/2022 until validation has been completed. - Dietary staff will not issue a food tray without the resident name being listed on the census diet report audit sheet. Dietary staff has been educated by the Regional Dietary Manager to consult with the dietary manager and/or the licensed nurse if additional diet clarification is warranted. The licensed nurse will validate the correct diet by using the electronic medical record. The dietary manager will validate the correct diet by using the electronic meal tracking system. This action was completed 5/18/2022. Alleged date of IJ removal: 5/19/2022. The facility's credible allegation of Immediate Jeopardy was validated onsite on 5-24-22 through interviews with facility staff including dietary staff. The dietary staff verbalized receipt of education including the importance of providing resident with the correct diet as ordered. The staff education documentation, audits and monitoring were reviewed. All resident diets were audited for accuracy, and daily meal audits indicated no issues with residents receiving the correct diets. Dietary staff education included the use of resident diet list to confirm a resident's diet and to clarify resident diets with the dietary manager or nurse as needed. Dietary staff stated resident dietary list was printed daily and referenced to when nursing staff requested diet trays for residents, and a list of residents with nothing by mouth (NPO) diets, resident diet list, diet terminology conversion list and national dysphagia diet levels were posted in the kitchen to reference for diet information. Daily meal audits indicated no issues with residents receiving the correct diets. The facility's date of immediate jeopardy removal of 5-19-22 was validated.

Based on record review and staff interviews the facility failed to provide leadership and oversight to ensure effective systems were in place for training, orienting, and verifying competencies for new agency staff which resulted in Nursing Assistant (NA) #1 providing a regular meal tray to two residents (Resident #369 and Resident #61) who were to receive nothing by mouth (NPO) and received continuous enteral feedings (nutrition delivered by a tube into the digestive system as a liquid). Immediate Jeopardy began on 5-11-22 when the facility failed to ensure NA #1 was trained, oriented and competent to care for residents who were NPO and on enteral feedings. Immediate Jeopardy was removed on 5-19-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope/severity of an D (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: This tag is cross referenced to: F726 Based on record review, staff interviews, and Physician interview, the facility failed to train and orient new agency nursing staff and verify competency to deliver care in accordance with the resident's assessed care needs. Nursing Assistant (NA) #1 was not oriented to the protocol for determining residents' dietary orders resulting in the NA feeding a regular textured meal on 5-11-22 to a resident (Resident #369) who had enteral feedings (nutrition delivered by a tube into the digestive system as a liquid) and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #369 aspirated and was hospitalized for 5 days. NA #1 also provided a regular textured meal tray to another resident (Resident #61) who had enteral feedings and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This occurred for 2 of 2 residents (Resident #369 and Resident #61) reviewed for enteral feedings. The Administrator was interviewed on 5-19-22 at 5:35pm. The Administrator discussed it was the Staff Development Coordinators (SDC) position to ensure all agency staff were trained and oriented prior to starting their shift and the Director of Nursing (DON) was to oversee the training and orientation was complete as well as being available for any questions the agency staff may have. The Administrator stated the management in the facility were agency/contract staff which led to a lack of consistency and poor communication. The Administrator was notified of Immediate Jeopardy on 5-18-22 at 2:51pm. Resident #369's diet order: NPO Resident #61's diet order: NPO On 5/11/2022 during breakfast meal tray delivery Nurse Aide #1 recognized that Residents #369 and #61 had not received meal trays. She went to the kitchen and requested meal trays for both residents and was provided trays with regular textured meals from the Dietary Assistant Manager. At approximately 8:40 am, Nurse Aide #1 delivered a breakfast tray to Resident #369's room. Nurse Aide #1 sat down to feed Resident #369. Shortly thereafter, resident appeared to have some difficulty and Nurse Aide #1 gave her orange juice. Resident's color appeared red. Nurse Aide #1 turned resident on her side and called out for nursing assistance. Arriving nurse reported resident began to vomit bloody emesis (vomit). Staff called MD and 911 and the resident was sent to the hospital at approximately 9:40 am, while alert and oriented, for further evaluation and treatment. At no time did Resident #369 stop breathing or lose consciousness during event. Resident #61 was provided a meal tray. Resident #61 was not fed, and the meal tray was left on the bedside table. The meal tray was not accessible to Resident #61. The meal tray was removed from Resident #61's room as soon as staff were aware Nurse Aide #1 had placed a tray in the room. Post event: - Medical director notified, and in-depth ad hoc Quality Assurance & Performance Improvement (QAPI) meeting for this event held 5/11/2022, with the Interdisciplinary Team, Medical Director and Regional Nurse Consultant. The QAPI committee consists of the Administrator, the Medical Director, Director of Nursing (DON), Staff Development Coordinator (SDC), Special Projects DON, Interim Unit Manager, and Regional Nurse Consultant. - Plan developed. Root cause was determined to be the following: Nurse Aide #1's first day working at the facility was 5/11/2022 and she received no orientation or training prior to working on the floor. She had no long-term care experience and the failure to orient prior to working on the floor contributed to the deficiency. In addition, the facility failed to validate Nurse Aide #1's access to the electronic medical record. She had no access to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Aide #1 failed to validate residents' diet with charge nurse prior to requesting a meal tray from dietary. The Dietary Assistant Manager failed to follow the policy to validate the tray card system, and to consult with the dietary manager and/or a licensed nurse to determine if there was a change in the residents' diet order prior to fixing a meal tray for two residents (Residents #369 and #61). All residents are at risk for the current deficient practice. - Administration staff, consisting of the Administrator, Director of Nursing, Staff Development Director, and Regional Nurse Consultant, immediately reviewed the facility's protocol for orienting, training, and verifying competencies of new staff prior to allowing the staff to work on the floor. Root Cause Analysis review completed and determined staff were not consistent in completing new agency staff orientation at the start of their shift, leaving the potential for significant issues to arise with resident care. Based on this review, it was determined additional oversite was required with completing the first-time agency staff orientation to remove the potential for significant issues with resident care. The administrative team is ultimately responsible to attain and maintain the implementation of the revised plan to ensure orientation is completed and competencies verified at the time of agency staff's initial shift in the building prior to the staff working on the floor. The revised plan was fully implemented on 5/18/22. - Education was provided on 5/18/22 by the Regional Nurse Consultant to the administrator reviewing thoroughly F835 at §483.70 Administration from Appendix PP of the State Operations Manual. This education focused on the regulatory requirement that a facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Alleged date of IJ removal: 5/19/2022. The facility's credible allegation of immediate jeopardy removal was validated onsite on 5-24-22 through interviews with facility staff including nursing staff and dietary staff as well as the Regional Consultant. The staff verbalized receipt of education prior to starting their shift in the facility. The staff education documentation, audits and monitoring were reviewed. The dietary manager education dated 5/11/2022 included different types of diets, nothing by mouth (NPO) and the importance of the accuracy of resident diets, and these topics were included in the re-education of the dietary staff. Dietary staff education also included use of resident diet list to validate resident's diet and confirmation with dietary manager or nurse as needed. Assistance with meals education conducted on 5/11/2022 to the nursing staff included checking meal tray card for correct resident and diet and verifying physician diet order with nurse. The administrative team education dated 5/18/2022 included administration regulation, ensuring expected practices were followed and overseeing as necessary on the floor to assist staff in resident care. Nursing education also included providing resident care before receiving access to the facility's electronic resident record and the orientation checklist information. Staffing audits and interviews revealed centralized scheduling or management staff were providing the orientation checklist and access to the facility's electronic medical record prior to the agency staff reporting to work and prior to providing resident care. Nursing staff were using resident care guides for resident care information including diet orders and were verifying resident diets with the assigned nurse before requesting a diet tray from the kitchen, and dietary staff used the daily printed resident diet list, NPO list, dietary manager and nurse to confirm resident's diet. Daily meal audits indicated residents were receiving diets as ordered. The facility's date of immediate jeopardy removal of 5-19-22 was validated.

Based on observation, staff interviews, record review and the facility policy and procedures the facility failed to clean and disinfect glucometers (a device used to test blood sugar) that were shared between residents (Residents#24, #25 and Resident #30) for 3 of 28 diabetics with fingerstick monitoring in the facility; failed to clean and disinfect a glucometer prior to storage in the medication cart on the 300 Hall and failed to maintain surveillance logs, tracking and trending as outlined by the facility's infection control policy and procedure for six months (September 2010 through February 2011). The immediate jeopardy began on 1/19/11 and was removed on 1/20/11. The facility Administrator, Director of Nursing and Corporate Consultant were informed of the immediate jeopardy on 02/24/11 at 4:45 P.M. The facility provided a credible allegation of compliance on 2/25/11 at 6:41 P.M. The facility will remain out of compliance at a scope and severity level D (No actual Harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete employees training and to monitor its corrective action. Findings include: A. Glucometer Cleaning: Page 42 of the owner's manual for (brand name) glucometer stated under Maintenance; "A cloth dampened with water and mild detergent can be used to wipe down the outside of the meter." Under Cleaning the brand name glucometer; "to disinfect" the meter "prepare a disinfectant solution of one part household bleach to 10 parts water. Dampen a cloth with this solution and wipe thoroughly." Instead of preparing bleach solution extemporaneously, the Center has chosen to purchase two brands of cleanser/disinfectant that contain the required strength (1:10) of bleach solution. Record review of the facility policy entitled (brand name) Blood Glucose Monitoring System Calibration and Cleaning, PRO , revised 10/31/10 stated under "Cleaning the (brand name of the blood glucose monitoring system)- Weekly and as needed: 11. Remove the test strip holder by pressing down on the left side and sliding the holder out. 12. Wash inside cover and both sides of the test strip holder base, the lens area and contact points, using a 10% bleach solution moistened wipe. Allow contact with bleach solution for 1 -minutes. Follow with a cloth dampened with water to remove residual bleach. 13. Clean the outside of the meter with 10% bleach solution moistened wipes in-between each resident and as needed. Allow contact with bleach solution for 1-minute. Follow with a cloth dampened with water to remove residual bleach." The Center for Disease Control (CDC) and Prevention Guidelines for Glucose Monitoring read in part, "Any time blood glucose monitoring equipment is shared between individuals there is a risk of transmitting viral hepatitis and other blood borne pathogens. Decontaminate environmental surfaces such as glucometers regularly and any time contamination with blood or body fluids occurs or is suspected. Glucose test meters approved for use with more than one person must be cleaned and disinfected following disinfection guidelines." B. Surveillance Policy Review of the facility infection control policy dated 04/28/10 revealed under Bloodborne Pathogen Exposure Control Plan, Compliance Guidelines; "1. The center Executive Director designates an individual (usually the Infection Preventionist formerly called the Infection Control Nurse) to implement and maintain all components of the exposure control plan." The Infection Control and Prevention Program revised 10/31/09 was designed to identify and reduce the risk of acquiring and transmitting infection among residents, staff volunteers, students and visitors. It is maintained to provide a safe, sanitary and comfortable environment and involves each department. Under Compliance Guidelines the policy stated a) Key surveillance activities c) calculation of infection rates and d) data analysis." 1. An observation of a medication pass on 01/19/11 on the 100 Hall at 8:30 A.M. revealed that the nurse administering medications (Nurse #2) did three consecutive fingersticks for three different diabetic residents (Resident # 24, #25 and #30) and failed to disinfect the glucometer after use for each resident. Record Review of the three residents' medical records revealed Resident #24 had a [DIAGNOSES REDACTED]. During the medication pass observation on 01/19/11 at 8:30 AM, the surveyor approached the cart as the nurse was preparing medications. She prepared medications for Resident # 25. Nurse #2 entered the resident's room, and with gloves on, she did a fingerstick which registered 129, administered the oral medications and left the room. The lancet was discarded in the sharps container and the glucometer was placed on top of the medication cart. No attempt was made to clean or disinfect the glucometer. Nurse #2 then prepared medications for Resident #24. Nurse #2 entered the room, administered the oral medication and donned a fresh set of gloves and did a fingerstick which registered at 36. She then left the room, discarded the lancet in the sharps container and placed the glucometer on the top of the medication cart without cleaning or disinfecting the machine. Nurse #2 then entered Resident #30's room and donned a fresh set of gloves and did a third fingerstick which registered 139. She then returned to the cart discarded the lancet in the sharps container. After she finished with testing the blood sugars of the three residents, nurse #2 returned the glucometer to its position on top of the medication cart without cleaning and disinfecting the machine with the special cleanser and disinfectant provided by the facility. A 1:10 bleach solution was provided for each medication cart in the form of canister with disposable towelettes and boxes of individual towelettes both within reach. The machine was not cleaned and was placed on the medication cart. In an interview with nurse #2 on 01/19/11 at 2:00 PM, she stated she simply forgot to clean the glucometer after use for each resident In an interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 01/20/11 at 2:00 PM, the DON stated that she had just done an inservice for glucometer cleaning the week before but could not produce documentation of that program. The Director stated she would repeat the program and do counseling. Record review of a submitted plan of correction stated that Nurse #2 was re-in serviced on 01/09/11. The Director of Nursing stated that the glucometers (brand A) designated in the policy had been purchased at the direction of the corporate office and were chosen because they could upload data on diabetics into the Center's computer system for tracking. However, the glucometers observed on 01/19/11 were a different brand because the bleach solution had disabled the designated Brand A glucometers. Brand B glucometers were supposed to be wiped down with the bleach towelettes but it was not possible to reach inside the port of the reader since it is a closed system. When asked as to who was the Infection Preventionist (IP) for the facility and who would provide education and training for staff on cleaning and disinfecting glucometers, she stated that she currently held both positions (as a DON and IP) and had since August 2010. The DON stated that the Center had started a new policy of weekly (Monday) walking rounds for administrative nursing on 01/17/11 and she had a number of new initiatives in place. She felt that by doing the walking rounds the administrative nursing staff could observe care and procedures and have the IP/SDC (Staff Development Coordinator) correct any issues with infection control. Another initiative instituted was that all orders for antibiotics and lab orders to be followed up on would be added to the 24 hour report. In an interview on 02/25/11 at 3:05 P.M. the DON presented a copy of the Center's Employee Orientation Checklist and referenced "Nursing staff in-serviced on facility's infection control practices." She stated a new SDC (staff development coordinator) has been hired as of February and is in orientation and she will be responsible for educating staff and new staff on the Center's policy for infection control and will be the IP for the Center. Her duties will include observing staff for glucometer disinfecting, hand hygiene, and tracking and trending for infection control. 2. An observation of the nurse on the 300 Hall on 01/20/11 at 11:45 AM revealed that Nurse #1 took her glucometer out of the cart, walked up the 400 Hall with a lancet and test strip, entered a room, came back to the cart with the glucometer and the used lancet and test strip; discarded the strip and lancet in the sharps container and placed the glucometer in the top drawer of the medication cart without using the special cleanser and disinfectant provided by the facility. Other supplies in the drawer included over the counter stock bottles of medication and clean diabetic supplies such as alcohol wipes, glucometer test strips and a supply of lancets. In an interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 01/20/11 at 2 PM, the DON stated that she had just done the inservice for glucometer cleaning the week before, but the DON was unable to produce any documentation that supported this statement. The Director stated she would repeat the program and do counseling. In an interview with the Director of Nursing and Administrator on 02/23/11 at 2:30 PM. she stated that she had redone the inservice for nurse #1 who did not clean and disinfect the glucometers on 01/20/11. On 02/23/11 at 2:30 PM the Director of Nursing was asked for prior inservice training done by her for cleaning of glucometers. The DON provided a sheet of paper dated 02/03/11 with the attendance record of staff attending. Record review of the attendance for training for the inservice done by the Director of Nursing on 02/03/11 did reveal nurse #1's name. On 02/23/11 at 2:30 PM the DON stated that there was one glucometer on each medication cart and the Center currently did not use dedicated glucometer equipment for patients in isolation. She stated that the glucometers designated in the policy (Brand A) had been purchased at the direction of the corporate office and were chosen because they could upload data on diabetics into the Center computer system for tracking. However, the glucometers observed on 01/19/11 were a different brand (Brand B) because the bleach solution had disabled the Brand A glucometers. Brand B glucometers were supposed to be wiped down with the bleach towelettes but it was not possible to reach inside the port of the reader since it is a closed system. When asked as to who was the Infection Preventionist (IP) for the facility and who would provide education and training for staff on cleaning and disinfecting glucometers, she stated that she currently held both positions (as a DON and IP) and had since August 2010. The DON stated that the Center had started a new policy of weekly (Monday) walking rounds for administrative nursing on 01/17/11 and she had a number of new initiatives in place. She felt that by doing the walking rounds the administrative nursing staff could observe care and procedures and have the IP/SDC (Staff Development Coordinator) correct any issues with infection control. Another initiative instituted was that all orders for antibiotics and lab orders to be followed up on would be added to the 24 hour report. In an interview on 02/25/11 at 3:05 P.M. the DON presented a copy of the Center's Employee Orientation Checklist and referenced "Nursing staff in-serviced on facility's infection control practices." She stated a new SDC (staff development coordinator) has been hired as of February and is in orientation and she will be responsible for educating staff and new staff on the Center's policy for infection control and will be the IP for the Center. Her duties will include observing staff for glucometer disinfecting, hand hygiene, and tracking and trending for infection control. 3. Review of the facility infection control policy dated 04/28/10 revealed under Bloodborne Pathogen Exposure Control Plan, Compliance Guidelines; "1. The center Executive Director designates an individual (usually the Infection Preventionist formerly called the Infection Control Nurse) to implement and maintain all components of the exposure control plan." The Infection Control and Prevention Program revised 10/31/09 was designed to identify and reduce the risk of acquiring and transmitting infection among residents, staff volunteers, students and visitors. It is maintained to provide a safe, sanitary and comfortable environment and involves each department. Under Compliance Guidelines the policy stated a) Key surveillance activities c) calculation of infection rates and d) data analysis." At the entrance conference on 02/23/11 at 10 AM the Director of Nursing and Administrator were asked to provide the infection control surveillance logs for 6 months with tracking and trending of infections. In an interview on 02/23/11 at 2:30 PM, the Director of Nursing and Administrator were asked as to who was the Infection Preventionist (IP) for the facility and who would provide education and training for staff on cleaning and disinfecting glucometers, the DON stated that she currently held both positions and had since August 2010. In an interview with the Director of Nursing on 02/23/11 at 5:00 PM, a second request was made for the infection control surveillance records. In an interview with the Director of Nursing on 02/24/11 at 11:00 AM a third request was made for 6 months of surveillance records. The DON stated that she might not be able to provide the surveyor with all surveillance records for 6 months. On 02/24/11 at 4:45 PM, the DON, Administrator and Corporate Consultant revealed the facility did not keep logs of infections in the last 6 months. The Corporate Consultant stated that the facility pharmacy would be asked to produce a list of antibiotics dispensed in the last six months (September 2010 through February 2011.) In an interview with the Corporate Consultant and DON on 02/25/11 at 10:00 AM, they produced a handwritten "Infection Control Log" for the period of time from September 2010 through February 2011. The logs had the names and room numbers of residents who received antibiotics and the dates of those antibiotics. The organisms' column was frequently blank. The facility did use a map of the facility to indicate where the categories of infection (i.e., UTIs, URIs, eye infections) were located. Without identifying the infecting organisms, the records remained incomplete for tracking and trending. When asked if these records had been constructed solely from the pharmacy dispensing records, the Corporate Consultant stated, "I will not lie to you, we worked on these logs last night." Review of the created infection control log for the month of October 2010 revealed there were 4 cases of urinary tract infections (UTI) with no identifying organisms. Review of the created infection control log for the month of November 2010 revealed there was a questionable case of Clostridium difficile that was treated with [MEDICATION NAME]. There was no documentation of a culture to confirm the organism. Review of the created infection control log for the month of December 2010 revealed there were 7 urinary tract infections. There was one case of UTI with [MEDICATION NAME] Resistant [MEDICATION NAME]. The other 6 cases had no identifying organisms. Review of the created infection control log for the month of January 2011 revealed 3 cases of urinary tract infections and three cases of conjunctivitis. Review of the created infection control log for the month of February 2011 revealed 4 cases of urinary tract infections. One resident had both a urinary tract infection and questionable Clostridium difficile. One resident had MRSA (Methicillin Resistant Staphylococcus aureus) in the urine. The administrator provided a credible allegation of compliance on 02/25/11 at 5:29 PM. The credible allegation included: The following residents have been identified in the annual survey on 1/18/-1/20/2011 as not having the shared glucose monitoring device cleaned prior to their blood sugar being obtained nor was the glucose monitoring device cleaned after their blood sugar was obtained. (Resident name); [DIAGNOSES REDACTED]. (Resident name); [DIAGNOSES REDACTED]. (Resident name); [DIAGNOSES REDACTED]. There are a total of 28 residents in the facility that require blood glucose monitoring. No resident required infectious disease testing because the level of exposure was minimal because the glucometer never came in contact with the resident. Nurse working the 100 hall medication cart on 1/19/2011 7-3 shift is no longer employed by the facility due to an unrelated issue and the nurse working the 300 hall medication cart on 1/20/2011 7-3 shift received individualized training by the Director of Nursing Services on 2/3/2011 regarding cleaning and disinfecting the glucometer between each use. The facility does not plan to provide individual glucometers. However, the facility will continue to clean and disinfect shared glucometer between each resident use per manufacturers' recommendations. The shard glucometers will be cleaned and disinfected prior to each use, and after each use with a 10% bleach solution according to manufacturer's guidelines. Licensed nursing staff inserviced on 02/03/2011 and again with return demonstration on 02/25/2011 by the Director of Nursing Services regarding cleaning and disinfecting of the glucomenter between each resident use. 21 licensed nurses have received inservices, with two licensed nurses remaining who will receive inservice with return demonstration prior to the start of their next shift. New hired nurses will receive training during initial orientation with return demonstration prior to performing resident care. The Director of Nursing Services or Assistant Director of Nursing Services will conduct quality assurance checks on five nurses per week (covering all shifts) during blood sugar monitoring to ensure glucometer is clean and disinfected appropriately between resident use. The Director of Nursing Services or Assistant Director of Nursing Services will observe 5 opportunities daily times one week, then 10 opportunities times one week then 10 opportunities per month for six months. The Director of Nursing Services or Assistant Director of Nursing Services will bring their findings of blood glucose monitoring to the performance improvement committee for review and further recommendations per month x 6 months. The validation of the credible allegation was completed on 2/25/11 at 6:41 PM. Observations and interviews with 6 nurses revealed they properly cleaned and disinfected glucometers after each use. Review of the inservices log revealed nursing staff were inserviced regarding proper cleaning and disinfecting techniques of glucometers.

Based on record review and staff interviews the facility failed to assess and intervene in a change of condition for 1 (Resident #26) of 3 sampled residents reviewed for dehydration. The resident was admitted to the hospital with [REDACTED]. The findings include: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Medical Nutrition Therapy Assessment by Registered Dietician #1 dated 01/07/11 showed that the resident was eating 75-100% of meals and required 1925ccs (cubic centimeters) of fluids per day. The Admission Minimum Data Set (MDS) assessment dated [DATE] showed that the resident had short and long term memory loss and was severely cognitively impaired. The MDS indicated that the resident required setup help only with meals and required total assistance with toileting. The MDS showed that the resident was incontinent of bowel and bladder. The Care Area Assessment (CAA) Summary for Cognitive Loss/Dementia dated 01/18/11 showed that the resident recently had a fall at home and became increasingly confused and had poor decision making skills related to dementia. The CAA for Activities of Daily Living (ADLs)/Functional Status/Rehabilitation Potential dated 01/18/11 indicated that set up help only was provided with meals, incontinent care was provided by staff and that the resident required limited assistance for all other ADLs. Dehydration/Fluid Maintenance was not identified as a concern on the CAA Summary. A nursing progress note dated 01/13/11 indicated that the resident was agitated and more confused and that the on call physician gave an order via fax (facsimile) for [MEDICATION NAME] 0.5mg (milligram) ever 6 hours as needed for agitation. The resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A nursing progress note dated 01/22/11 at 3:00 PM revealed that the resident had a good appetite. The nursing assistant flow sheet dated 01/22/11 revealed that the resident consumed a total of 960ccs of fluids with meals. A nursing progress note dated 01/23/11 at 4:00 PM revealed that the resident was able to feed himself and the nursing assistant flow sheet dated 01/23/11 revealed that the resident consumed a total of 960ccs of fluids with meals. A nursing progress note dated 01/30/11 at 11:00 AM revealed that the resident was in bed and was groggy and confused. The nursing assistant flow sheet dated 01/30/11 revealed that the resident did not drink fluids at breakfast or lunch and consumed 360ccs with the evening meal. A nursing progress note dated 02/01/11 at 10:00 PM read in part: " Noted to pocket lg (large) amt (amount) of cake/food in Lt (left) cheek-yet was able to spit it out in a cup when asked. Observed x (times) 2 by this nurse. MD (medical doctor) faxed to make aware & request possible eval (evaluation). " The progress note was signed by Nurse #7. A fax sheet to the resident ' s physician dated 02/01/11 with the name of Resident #26 read in part: " May we have an order for [REDACTED]. The nursing assistant flow sheet showed that the resident consumed a total of 720ccs of fluids with meals. The nursing assistant flow sheet for 02/02/11 showed that the resident consumed a total of 360ccs of fluids with meals. The nursing assistant flow sheet dated 02/03/11 showed that the resident consumed a total of 840ccs of fluids with meals. The nursing assistant flow sheet dated 02/04/11 indicated that the resident consumed a total of 600ccs of fluids with meals. The nursing assistant flow sheet dated 02/05/11 revealed that the resident consumed a total of 480ccs of fluids with meals. The nursing assistant flow sheet dated 02/06/11 revealed that the resident consumed a total of 480ccs of fluids with meals. The nursing assistant flow sheet dated 02/07/11 showed that the resident consumed a total of 600ccs of fluids with meals. A nursing progress note signed by Nurse #7 dated 02/08/11 at 8:50 PM revealed that the resident remained in bed sleeping throughout the evening and consumed 25% of dinner. The nursing assistant flow sheet revealed that the resident refused breakfast, consumed 25% of lunch and 10% of dinner and consumed a total of 440ccs of fluids with meals. A nursing progress note signed by Nurse #7 and dated 02/09/11 at 11:45 PM indicated that the resident had slept the majority of the shift. The nursing assistant flow sheet dated 02/09/11 showed that the resident consumed a total of 440ccs of fluids with meals. A nursing progress note signed by Nurse #6 dated 02/10/11 at 1:45 PM read in part: " (name of physician) has been faxed & called regarding pt (patient) not eating & sleeps alots. He will just look straight ahead hold food in mouth swallow small amts. Goes to therapy unable to do much with him. " A nursing progress note signed by Nurse #7 dated 02/10/11 at 10:00 PM revealed that the resident had refused dinner and that an order was received from the resident ' s physician for the resident to have a swallowing evaluation. The nursing assistant flow sheet dated 02/10/11 showed that the resident consumed a total of 480ccs of fluids with meals. Nurse #6 stated in an interview on 03/09/11 at 9:42 AM that she was aware of the request made to the physician on 02/01/11 for a swallowing evaluation but does not recall if he was contacted between the time it was requested and the time the order was received on 02/10/11. Nurse #7 stated in an interview on 03/09/11 at 9:48 AM that she could not recall whether or not the physician was contacted between the time the swallowing evaluation was requested and the time the order was received. The Nurse stated that during this time the resident would eat and drink if staff was very patient with him and worked with him. The fax sheet dated 02/01/11 requesting a swallow evaluation for the resident showed that it was faxed back to the facility on [DATE] at 3:29 PM with a note under Physician ' s Remarks that read: " OK " followed by the name of the resident ' s physician. There was an order written [REDACTED]. WO (written order) (name of physician)/name of Nurse #7. " A nursing progress note written by Nurse #6 and dated 02/11/11 at 2:00 PM read in part: " Still holding food in mouth not swallowing well. (Name of physician) was notified and continues to say get a swallowing eval. done. " A nursing progress note written by Nurse #7 and dated 02/11/11 at 3:50 PM read in part: " T.O. (telephone order) (name of resident ' s physician) - 0 IVF (intravenous fluids) @ this time. If pt has a (arrow down) in voiding over weekend send to (name of hospital) ER (emergency room ) for eval. Pts. Swallow eval is scheduled for 2/14/11 @ 9 AM. " The nursing assistant flow sheet dated 02/11/11 showed percent of breakfast eaten " 0, " morning fluid intake " 0, " percent lunch taken " 0, " mid day fluid intake " 0, " percent dinner eaten " 50, " fluid intake " 360. " A nursing progress note written by Nurse #7 dated 02/12/11 at 10:50 PM indicated that the resident ate 50% of dinner, was incontinent of bladder x 2 and temperature 97.6, pulse 72, respirations 20 and blood pressure 152/70. The nursing assistant flow sheet for 02/12/11 was blank for breakfast and lunch and percent of dinner eaten was " 0 " and fluid intake at dinner was " 0. " A nursing progress note written by Nurse #8, dated 02/13/11 at 9:00 AM read: " Resident in bed (sign for with) head (arrow up). Attempted to administer PO (by mouth) meds, resident unable to swallow, holding in mouth. Noted residual from breakfast in mouth as well. Oral cavity cleansed. Unable to safely administer meds. Resident appears lethargic, responds to verbal and tactile stimuli. " There was no documentation to indicate that the physician was notified. Nurse #8 was not available for an interview. There were no entries for fluid intake for breakfast or lunch on the nursing assistant flowsheet for 02/13/11. The percent of dinner eaten read: " 0, " and fluid intake was " 0. " A fax sheet to the resident ' s physician written by Nurse #7, dated and faxed to the physician on 02/13/11 at 6:38 PM read: " Pt. is scheduled for a swallow eval in AM @ (name of hospital). Family would like for him to be seen @ office D/T (arrow down) appetite & lethargy during the day. Also requesting some labs to evaluate res condition & ensure there isn ' t an underlying condition for his (arrow up) lethargy. May we D/C (discontinue) [MEDICATION NAME] 0.5mg BID (twice a day) @ this time? " A nursing progress note signed by Nurse #6 and dated 02/14/11 at 7:30 AM revealed that the resident went to the hospital for a swallowing evaluation. A nursing progress note signed by Nurse #6 dated 02/14/11 at 9:30 AM revealed that the resident returned to the facility and that the swallowing evaluation could not be completed and indicated that there were no additional orders. A nursing progress note signed by Nurse #6 dated 02/14/11 at 10:00 AM read: " (Name of physician) was called by this nurse and talked with (name of nurse) and told her pt needs to be seen in his office today and checked d/t (due to) not eating or drinking well. His nurse said to fax over and she would tell him & see & let us know what to do. I told (name of nurse) that we have to do something d/t him not taking enough food & drink. " A nursing progress note signed by Nurse #6 dated 02/14/11 at 10:15 AM revealed that the family requested that the resident be seen by the physician and the family was informed that the request had been made by fax and telephone. A progress note signed by Nurse #6 dated 02/14/11 at 12:30 PM showed that a Flexible Endoscopic Evaluation of Swallowing (FEES) test was scheduled for 02/15/11. The above fax sheet dated 02/13/11 showed that the physician ' s response was faxed back to the facility on [DATE] at 3:29 PM with an order to D/C [MEDICATION NAME] BID and change to 0.25 q HS (hour of sleep). A nursing progress note written by Nurse #6 dated 02/14/11 at 4:00 PM read: " Called (name of physician) again. (Name of nurse) said he faxed what he wanted to (symbol for change). [MEDICATION NAME] 0.25mg q HS. Waited for answer this is his reply. " Nurse #6 stated in an interview on 03/09/11 at 9:42 AM that when the resident returned from the hospital she was told that they could not do the swallowing evaluation because the resident would not swallow. The Nurse stated that speech therapy told her that a FEES test would be done the next day. A review of the Speech Therapy Bedside Dysphagia assessment dated [DATE] revealed that the Speech Therapy Related [DIAGNOSES REDACTED]. The report indicated that the resident had an impaired left gag reflex and that the right gag reflex was absent. The Bedside Dysphagia Assessment Comments read in part: " Pt attempted to follow commands. He was given thin liquid by cup & straw & puree consistencies. Pt had difficulty getting liquid from straw and took only a minimal amount. When given thin liquid by cup, labial spillage was noted & coughing was heard. All puree was held in mouth or labial spillage was seen. No swallow occurred even when given verbal cues. Due to pt ' s lack of responsiveness & inability to swallow, a modified [MEDICATION NAME] swallow was not given. Recommend: NPO (nothing by mouth) with alternative nutrition. " The Speech Therapist (ST) at the hospital stated in an interview on 03/09/11 at 10:45 AM that the results of the Bedside Dysphagia Assessment was sent to the resident ' s physician. The ST stated that the physician called to ask her why the modified swallowing evaluation was not done and she stated that she told him that the resident would not swallow during the bedside assessment. The ST stated that she makes recommendations based on the swallowing evaluation but that the physician has to give the orders. Speech Therapist (ST) #1 stated in an interview on 03/09/11 at 10:27 AM that she was not aware of the recommendations made by the ST at the hospital. There were no additional orders on the resident ' s chart to reflect the recommendation from the swallowing evaluation attempted on the morning of 02/14/11. A nursing progress note by Nurse #7 dated 02/14/11 at 10:00 PM revealed that the resident was very alert and that the resident consumed less than 25% of dinner. The note indicated that the resident was encouraged to take 1 glass of apple juice and 1 glass of water but refused a snack. The progress note indicated that the resident had been incontinent x 1 on the 3 PM - 11 PM shift. The nursing assistant flow sheet for 02/14/11 showed that the percent of breakfast eaten was " 0, " morning fluid intake, " 0, " percent of lunch intake, " 0, " mid-day fluid intake, " 0, " percent of dinner eaten, " 0, " and fluid intake " 0. " A progress note written by Nurse #6 on 02/15/11 at 2:15 PM read in part: " (Name of physician) nurse was called by this nurse to let her know to tell (name of physician) that Fees swallow eval was not completed. Pt continues to hold food in his mouth. Takes small amt liquids. " The Assistant Director of Nursing stated in an interview on 02/24/11 at 3:02 PM that she was told that the resident was not eating well and that Nurse #6 had tried to contact the physician and was not getting a response. The ADON stated that she told Nurse #6 to call the medical director. A progress note written by Nurse #6 on 02/15/11 at 2:45 PM that read: " (name of physician ' s nurse) was called and msg. (message) related to her that if she didn ' t get an order to have a G tube put in pt that we would have to get (name of medical director) to order it. She said that she couldn ' t do that. " A progress note by Nurse #6 written on 02/15/11 at 2:50 PM read: " (Name of medical director) nurse has been notified to ask (name of medical director) for OK to have a [DEVICE] put in pt for not eating or drinking for past few days. " A progress note written by Nurse #6 on 02/15/11 at 3:10 PM read: " (name of medical director ' s nurse) has already called (name of [MEDICATION NAME]) to be on call for G tube to be activated as soon as someone is given OK and to go with him to sign order. " A progress note written by Nurse #6 on 02/15/11 at 4:00 PM revealed that the resident would be seen by the [MEDICATION NAME] at 02/16/11 at 2:00 PM for an evaluation for a G tube. A nursing progress note dated 02/15/11 at 7:10 PM indicated that the resident had very poor PO intake and that 90ccs of fluid had been given with much encouragement over 45 minutes. The nursing assistant flow sheet for 02/15/11 revealed that the percent of breakfast eaten was " 0, " fluid intake at breakfast was " 0, " the percent of lunch eaten was " 0, " the mid day fluid intake was " 0, " the percent of dinner eaten was " 0, " and the fluid intake at diner was " 0. " Speech Therapist (ST) #1 stated in an interview on 03/09/11 at 10:27 AM that when the FEES test was done she was told that the resident was definitely having a problem swallowing and that it might be due to his dementia and to talk with the family about alternate nutrition. The ST stated that she spoke with the Assistant Director of Nursing (ADON) after the FEES test who stated that they had already talked with the family and the plan was for the resident to go out for a feeding tube. A nursing progress note written by Nurse #6 on 02/16/11 at 8:15 AM read in part: " 120/72 - 99.7 - 84 - 18. Alert - non verbal. Very poor intake food & fluids holds food in mouth. " A progress note dated 02/16/11 at 1:45 PM revealed that the resident had gone to the GI doctor ' s office for an evaluation for a G tube. On 02/16/11 at 3:15 a progress note was written to indicate that the resident had returned to the facility and that the GI doctor would contact the resident ' s nurse to schedule the G tube placement. A progress note dated 02/16/11 at 7:00 PM revealed that the resident had been incontinent of urine x 2. The nursing assistant flow sheet for 02/16/11 revealed that the percent of breakfast eaten was " 0, " fluid intake at breakfast " 0, " percent of lunch eaten was " 0, " fluids taken at lunch was " 0, " percent eaten at dinner was " 0, " fluid intake at dinner was " 0. " A Dietary Progress Note dated 02/17/11 by Dietician #1 revealed that the resident had a very poor intake and was holding food in the mouth. The note indicated that the resident ' s diet was changed to a pureed diet on 02/10/11 by speech therapy. The note indicated that the resident continued to refuse to eat or drink at times and was scheduled to have a G tube placed the next morning. The note indicated that there were no new labs ordered. Dietician #1 stated in an interview on 02/25/11 at 5:00 PM that she reviewed the resident ' s chart on 02/17/11 but did not see the resident. A nursing progress note dated 02/17/11 at 8:20 AM revealed that the resident was scheduled for a G tube placement on 02/18/11 at 11 AM. A progress note dated 02/17/11 at 8:35 PM revealed that a family member visited the resident and requested that the resident be sent to the hospital. The Responsible Party was called who stated to send the resident to the hospital for G tube placement in the morning as scheduled. A progress note dated 02/17/11 at 8:45 PM revealed that the on-call physician was notified that the family member was upset and that the resident had not eaten much that day. Orders were given to have blood drawn for a CBC (complete blood count) and electrolytes. A review of the CBC and electrolytes drawn at the facility and completed by the hospital lab on 02/17/11 at 9:30 PM revealed a white blood count of 23.7 (normal range 4.8-10.8), a hemoglobin of 15.4 (normal range 14.0-18.0) and a hematocrit of 47.6 (normal range 42.0-52.0). The resident ' s blood urea nitrogen (BUN) was 99 (normal range 7-22), creatinine was 3.19 (normal range 0.50-1.20 with resident ' s baseline of 1.6). The sodium was 160 (normal range 137-147), potassium was 4.4 (normal range 3.5-5.0) and the chloride was 122 (normal range 98-106). A progress note dated 02/17/11 at 11:00 PM revealed that the on-call physician was notified of the lab results and the physician gave orders for the resident to be sent to the hospital with dehydration and possible [MEDICAL CONDITION]. A progress note dated 02/17/11 at 11:30 PM revealed that the ambulance had arrived and that the resident ' s vital signs were as follows: " Blood pressure 103/78, temperature 98.1, pulse 95 and respirations 24. A review of the Emergency Department (ED) record dated 02/18/11 at 11:48 PM revealed that the resident had initial vital signs as follows: Blood pressure 136/93, temperature 95.5 orally, pulse 112, respirations 20. Vital signs at 12:31 AM were as follows: Blood pressure 99/74, temperature 101.7 rectally, pulse 112 and respirations 20. Lab tests done in the ED showed a CBC with a white blood count of 23.1, Hemoglobin 15.0 and a Hematocrit of 47.7. The resident ' s electrolytes were as follows: Sodium 161, potassium 5.1, chloride 123, BUN 102 and creatinine 3.30. A urinalysis collected in the ED was suggestive of a urinary tract infection (final urine cultures were negative). Blood cultures were drawn in the ED (final blood cultures were negative). A one view chest x-ray showed a new right lower lobe pneumonia and a computed axial tomography of the head showed no evidence of acute intracranial pathology. The emergency room Note showed that the resident presented to the ED with altered mental status. The note read in part: " Chest x-ray was suggestive of pneumonia and he was dehydrated. The hospitalist was consulted and will admit the resident to the hospital. " The Emergency Department Physician that saw the resident initially in the ED stated in an interview on 02/28/11 at 2:55 PM that the resident was awake but did not answer questions or interact with her. The Physician stated that the resident ' s tongue looked like sandpaper and looked dry. The Physician stated that she could not recall what the resident ' s skin turgor was like but that the resident was severely dehydrated. The History and Physical dictated on 02/18/11 at 6:08 AM by the admitting hospitalist read in part: " Chief Complaint: Change in mental status with fever. History of Present Illness: An elderly male, appearing increasingly frail and ill and noncoherent while in the emergence room. Initial laboratory evaluation showed critically elevated BUN level of 102 with a sodium of 161. Physicial Examination: An elderly male, lying on the hospital stretcher who appears frail and lethargic. Oral mucosa is dry. The Assessment showed 1. Altered mental status, 3. Pneumonia, 6. Severe azotemia, 7. Acute [MEDICAL CONDITION], 8. Dehydration and 9. [MEDICAL CONDITION]. Plan of Care: Admit this patient to hospitalist service to Intensive Care Unit. " Nurse #6 stated in an interview on 02/24/11 at 2:39 PM that she could not get an order from the resident ' s physician for a feeding tube so she called the medical director who gave an order for [REDACTED]. The Nurse stated that the resident was offered food but would only eat a little bit and hold the food in his mouth. The nurse stated that she usually got about 500ccs of fluids in the resident during her shift but that she did not document it anywhere. The Nurse stated that his skin turgor was not that bad and that the resident did not have a fever. The Nurse stated that the resident acted sluggish and just wanted to sleep and prior to going to the hospital the resident would just mumble a word or two. The Nurse stated that she thought that this was because of his medications. The ADON stated in an interview on 02/24/11 at 3:02 PM that the medical director was contacted through his nurse. The ADON stated that an appointment with a [MEDICATION NAME] (GI) was made and the resident went out the next day for evaluation for a feeding tube and the procedure was scheduled. The ADON stated that the medical director stated that as long as the resident was voiding that the resident was OK. The ADON stated that the resident was still eating 25-50% of meals. The ADON stated on the night that the resident went to the hospital, the on-call physician was called who ordered some stat lab work and said to send the resident to the Emergency Department. The Director of Nursing (DON) stated in an interview on 02/25/11 at 10:19 AM that the resident ' s physician did not see the resident during the time the resident was in the facility and that the medical director did not get a chance to see the resident before the resident was sent out to the hospital. The DON stated that one of the dieticians came in once a week to do dietary assessments and that the nurses, rehab or anyone could request that dietary see a resident. Dietician #2 stated in an interview on 02/25/11 at 10:38 AM that there were 3 dieticians that evaluated residents at the facility. Dietician #2 stated that when the dieticians come in they check at the nurse ' s station to see if any residents were having a problem that they needed to see. The Dietician stated that she would check with the other 2 dieticians to see if they were requested to see this resident. Dietician #2 stated in an interview on 02/25/11 at 11:02 AM that she had spoken with the other 2 dieticians and that they did not receive a request to see this resident and that there was not a formal request to evaluate the resident. Nursing Assistant (NA) #5 stated in an interview on 02/25/11 at 11:20 AM that for the last week the resident was less alert and that for the last 4-5 days the resident drank very little fluids. The NA stated that she was unable to remember if the resident ' s mouth looked dry and that she did not notice a change in the color or odor of the resident ' s urine. The resident ' s Physician stated in an interview on 02/25/11 at 3:12 PM that the requests he received from the facility did not seem to be distress calls and that he was not aware that the resident was not drinking. The Physician stated that he did not recall a request from the facility for IV fluids. The Physician stated that he did not see the resident while the resident was in the facility. In an interview with NA #6 on 02/25/11 at 4:05 PM the NA indicated that there was a gradual decline in the resident ' s condition. The NA stated that the resident was sleeping a lot and would not eat much. The NA stated that one day the resident might eat 50% of meals and the next day the resident would not eat anything. The NA stated that the resident would be asleep at supper time and that later in the shift she would reheat his food and try to get him to eat but that the resident was unable to swallow the food. The NA stated that Nurse #7 would go in frequently and offer fluids but could only get 3-5 ounces in the resident at a time. The NA stated that the inside of the resident ' s mouth was dry and that he was mouth breathing but could not remember if the resident ' s lips were dry. The NA stated that the resident ' s urine output was very little at a time. The NA stated that she told Nurse #7 about the decreased urine output and the nurse would ask her to go in and try to get some more fluids in the resident. The NA stated that the resident liked apple juice and could get more of that in him than tea or water. The NA stated that 8 ounces of tea and 8 ounces of water usually came of the resident ' s meal tray and that she usually could get about half of the tea and water in him at a time. The NA stated that some days the resident would take more fluids and the next day would not swallow fluids. Nurse #7 stated in an interview on 02/24/11 at 4:30 PM that the resident began pocketing food on 02/1/11 and that she sent a fax to the physician for a swallowing evaluation. The Nurse stated that the Physician responded to the fax on 02/10/11 and said OK. The Nurse stated that at that time the resident was holding food in his mouth but was swallowing and was sleeping a lot. The Nurse stated that the resident ' s last [MEDICATION NAME] was given on 02/04/11 and that his [MEDICATION NAME] was decreased on 02/14/11 to 0.25mg at bedtime. The Nurse stated that on 02/11/11 she called the physician and asked about IV fluids and was told as long as the resident was voiding adequately the physician did not want to give IV fluids at that time. The Nurse stated that the resident was voiding adequately at that time and the vital signs were good. The Nurse stated that she would ask the NAs about his voiding and they would say that the resident had voided 2 or 3 times but that the NAs did not tell her that the resident was only voiding small amounts. The Nurse stated that the resident ' s intake was steadily declining and that on 02/17/11 a family member told her that he would feel better if the resident went to the hospital. The Nurse stated that she called the RP who stated that the resident was scheduled for a feeding tube the next day and to send the resident for the feeding tube as scheduled. The Nurse stated that the family member was upset so she called the on-call physician who ordered a CBC and Chem (Chemistry) 7. The Nurse stated when the lab results came back the on-call physician was called and the resident sent to the hospital for evaluation. In an interview with the resident ' s physician on 02/25/11 at 5:07 PM the Physician stated that a swallowing evaluation was done at the hospital but the resident would not swallow. The Physician stated that the resident was voiding so he felt that the resident was getting enough fluids. The Physician stated that he had reduced the resident ' s [MEDICATION NAME] thinking that if the resident was more awake that the resident would be able to eat more. The Physician stated that (name of medical director) was not in his group and did not know why that physician was called. The Physician stated that he carried a pager and the facility staff could have paged him. The Director of Nursing (DON) stated in a telephone interview on 03/03/11 at 1:35 PM that they do not monitor intake and output unless ordered by the physician or the resident was on fluid restrictions or tube fed (there was not an order to monitor fluids for Resident #26). The DON stated that if there was a problem with a resident not drinking enough fluids they would force fluids but did not track it. The DON stated that in this setting they could not keep an accurate intake and output on residents. The DON stated that the resident received fluids with meals and with the medication pass. At the conclusion of the survey, Resident #26 was still in the hospital. Laboratory studies completed on 02/23/11 revealed the following: CBC - WBC 10.6 (normal range 4.8-10.8), Hemoglobin 10.0 (14.0-18.0) and Hematocrit 31.8 (42.0-52.0). Laboratory studies completed on 02/24/11 revealed the following: BUN 20 (normal range 7-22), Creatinine 1.14 (0.50-1.20), Sodium 143 (137-147) and Chloride 110 (normal range 98-106).