Every finding on record at Solaris Healthcare Forest Lake

Based on observation, interview, and record review, the facility failed to adhere to proper infection control practices for 1 of 2 residents observed during medication administration, of a total sample of 9 residents, (#6). Findings: On 6/12/25 resident #6 was admitted to the facility with diagnoses of asthma, hyponatremia (low sodium), hypertension, gastro-esophageal reflux, osteoarthritis, and chronic kidney disease. On 7/10/25 at 9:15 AM, Licensed Practical Nurse (LPN) A retrieved resident #6's morning medications from the medication cart. On 7/10/25 at 9:21 AM, during medication preparation LPN A placed several medication cups on top of the medication cart. She then placed Losartan 50 milligrams (mg), Meloxicam 7.5 mg, Omeprazole 20 mg, Ursodiol 300 mg, Pregabalin capsule 100 mg, Sodium Chloride 1 gram (gm), and Fluticasone Salmeterol ACT aerosol 500/50 microgram (mcg) each into the separate medication cups. LPN A then proceeded to stack the medication cups on top of each other in order to carry all of the medications in her hands to resident #6's room. The bottom of each stacked medication cup which had been sitting directly on of the medication cart surface was in direct contact with the tablets in the cups below them. LPN A administered the contaminated tablets to resident #6.On 7/10/25 at 9:40 AM, LPN A explained she stacked the medications cups because she could not carry all the medications in her hands, and she could not leave anything behind on the medication cart. She stated the top of the medication cart was not ideal for sanitation in regard to stacking the medication cups inside each other on top of the tablets. She stated she received in-service education on proper medication administration last month.On 7/11/25 at 10:19 AM, the Director of Nursing (DON) confirmed the top of the medication cart was not considered sanitary. She stated the facility had gray trays that nurses could use to carry medications to the residents' rooms, so they did not have to stack the medication cups inside each other. The DON explained once the medication cup was on the surface of the cart it was no longer sanitary because there was no barrier between the medication tablets and the bottom of the medication cups. Review of the facility policy for Medication Administration General Guidelines dated January 2018, showed medications were administered as prescribed in accordance with good nursing principles and practices. The policy detailed that authorized personnel should administer medications only after the personnel were properly oriented to the facility for administration and an adequate supply of disposable containers, equipment, and supplies should be maintained on the medication cart for administering medications.

Based on observation, interview, and record review, the facility failed to prevent medication errors related to not following physicians' orders for 1 of 2 residents sampled for medication administration, of a total sample of 9 residents, (#6). There were 2 medication errors in 11 opportunities, for a medication error rate of 18.18%.Findings:Resident #6 was admitted to the facility on [DATE] with diagnoses including asthma, hyponatremia (low sodium), hypertension, gastro-esophageal reflux, osteoarthritis, and chronic kidney disease. On 7/10/25 at 9:15 AM, Licensed Practical Nurse (LPN) A prepared resident #6's scheduled morning medications. She removed Losartan 50 milligrams (mg), Meloxicam 7.5 mg, Omeprazole 20 mg, Ursodiol 300 mg, Pregabalin capsule 100 mg, Sodium Chloride 1 gram (gm), and Fluticasone Salmeterol ACT aerosol 500/50 microgram (mcg). On 7/10/25 at 9:21 AM, during medication administration pass LPN A administered Losartan 50 mg to resident #6. The nurse signed off that she administered Fluticasone Salmeterol ACT aerosol 500/50 mcg, one inhalation. LPN A said she had six pills total inside the individual medication cups and was reminded the inhalation of Fluticasone Salmeterol ACT aerosol she was holding in her hand would count as the seventh medication for resident #6. LPN A proceeded to administer resident #6 her morning medications. During the administration, LPN A administered two inhalations of the Fluticasone Salmeterol ACT aerosol 500/50 mcg to resident #6. Review of the physician orders and reconciliation with the Medication Administration Record (MAR) revealed LPN A signed for administration of Losartan 100 mg which was ordered on 7/02/25. A closer review showed the Losartan 50 mg for resident #6 was discontinued on 7/02/25. Further review of the physician orders and MAR reflected that LPN A signed off that she administered one inhalation of Fluticasone Salmeterol ACT aerosol 500/50 mcg during the medication pass, instead of the two she actually administered. On 7/10/25 at 3:44 PM, LPN A pulled up the MAR on her computer which indicated she signed off for administration of Losartan 100 mg tablet. She stated she administered the 100 mg tablet. LPN A was informed she administered Losartan 50mg one tablet instead of the physician ordered Losartan 100 mg tablet. Observation and review of resident #6's medication card/bubble packages with LPN A revealed a bubble package for Losartan 100mg give 1 tablet every day, filled by the pharmacy on 7/02/25 and out of the 30 pills the count showed there were 27 tablets left, which indicated only three tablets had been removed from the bubble package over the last eight days. Further review of other bubble packages revealed one for Losartan 50 mg give one tablet every day, filled by the pharmacy on 6/19/25. Out of the 30 tablets total, it showed 16 tablets were left. LPN A verified both Losartan bubble packages with their corresponding physician orders for start dates, stop dates and the number of tablets that remained in each bubble package. LPN A stated if the medication dosage was changed, nurses would order the new dosage of the medication from the pharmacy. She explained they would keep the Losartan 50 mg medication package and administer two 50 mg tablets until the new 100 mg dosage arrived from the pharmacy. LPN A explained the facility's process for discontinued medications was to take the discontinued medications and put them in the medication room so they could be returned to the pharmacy. LPN A elaborated that nurses must get a new label from the pharmacy which indicated the medication had been discontinued while they continued to use that medication package. LPN A acknowledged during the medication administration observation she administered two inhalations of Fluticasone Salmeterol ACT aerosol rather than one inhalation as ordered. She confirmed she did not follow the physician orders for the Fluticasone Salmeterol ACT aerosol. On 7/11/25 at 10:19 AM, the Director of Nursing (DON) stated nurses were to follow the physician orders. She stated medication information on the bubble pack should match the physician's order. The DON stated nurses were to contact the physician and put the directions on the sticker in place, so other nurses would be informed of the changes before administering the medications. She stated discontinued medications should be removed from the medication cart immediately. Review of the facility policy for Medication Administration General Guidelines revised January 2018 revealed, 5) Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any reason to question the dosage or directions, the physician orders are checked for the correct dosage schedule. The policy indicated when a medication order was changed, and the current supply could continue to be used, the container should be flagged right away and the order change communicated to the pharmacy. The policy detailed that medications would be administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure medications were administered according to acceptable standards of practice for 1 of 2 residents observed during a medication administration pass, of a total sample of 9 residents, (#3).Findings:Resident #3 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, personality disorder, depressive disorder, persistent mood disorder, and hyperlipidemia. Review of the Minimum Data Set admission Assessment with an Assessment Reference date of 6/25/25 revealed resident #3 had a Brief Interview for Mental Status score of 15/15, which indicated the resident was cognitively intact. On 7/10/25 at 8:57 AM, Licensed Practical Nurse (LPN) A prepared resident #3's medications which included Divalproex capsule 125 milligrams (mg), Escitalopram 10mg, Buspirone 10 mg, Cetirizine 10 mg, and Alkums 1250/500 mg. LPN A checked the photograph on the medication administration record (MAR) for identification of resident #3 before entering the resident's room.On 7/10/25 at 9:08 AM, LPN A entered the room and proceeded to resident #3's bedside. LPN A greeted resident #3 and placed five medication cups on the resident's bedside table and informed resident #3 she was going to administer her morning medications. LPN A started to explain the name of each medication in the medication cups to resident #3. During that process, LPN A held one of the medication cups and told resident #3 that it contained her seizure medication. LPN A informed the resident that she could not remember the name of the medication so she informed the resident, and both surveyors that she would be right back. LPN A stated she was returning to the medication cart to check the name of the seizure medication. LPN A walked out of resident #3's room but left all of the medication cups that held the yet to be administered medications on the resident's bedside table. Upon return to resident #3's bedside, LPN A stated the name of the medication she forgot and proceeded to administer all the prepared medications to resident #3. Further observation during the medication pass revealed LPN A did not call resident #3 by her name, did not ask the resident to say her name or her date of birth , and she did not check an armband. LPN A did not use a second identifier to verify the resident's identity before she administrated the medications. On 7/10/25 at 9:35 AM, LPN A stated if there was a new resident who she did not know, she asked for their name or date of birth . She stated she used the picture on the MAR as identification. LPN A stated the five rights for medication administration were right patient, right dose, and right medication, but she could not recall the other two rights for medication administration. LPN A stated the residents at this facility did not wear wristbands for identification, but she knew resident #3 and checked her picture on the MAR. LPN A explained the facility practice was to use a second identifier before administrating medications, and she could have the residents say their name, their birthday or check with a second nurse. She said, I had her say her name. LPN A was informed that the resident that verbalized her name and date of birth was not resident #3, but actually another resident observed earlier for medication pass. LPN A acknowledged she left resident #3's medications unattended on the bedside table which she should not have done. On 7/10/25 at 4:18 PM, the 100 Unit's Manager (UM) stated the process of medication verification included the use of two identifiers which could include the resident's name, date of birth (DOB), or the resident could be verified with another nurse before administering medications. On 7/11/25 at 10:19 AM, the Director of Nursing stated the expectation was that nurses would know the five rights for medication administration. She stated medications were not to be left at the bedside unattended and the nurse should use two forms of resident identification during a medication pass. Review of the facility policy for Medication Administration General Guidelines revised January 2018 showed medications were administered as prescribed in accordance with good nursing principles and practices. Section four of the policy listed the five medication rights which included the, Right resident, right drug, right dose, right route, and right time. The policy indicated the five rights were to be applied for each administration of medications. The policy revealed, 8) Residents are identified before medication is administered using two methods of identification.

Based on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) on admission, and/or failed to make referrals for newly evident or possible mental disorders to evaluate the need for specialized mental health services or alternate placement for 7 of 7 residents reviewed for PASARR, of a total sample of 53 residents, (#17, #199, #136, #19, #185, #9 and #72). Findings: 1. Resident #17's medical record revealed she was admitted to the facility on [DATE] from an acute care hospital with a diagnoses including diverticulitis, fibromyalgia, generalized anxiety disorder, and major depressive disorder. Review of the resident 5-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a diagnosis of anxiety, and depression listed under section active psychiatric and mood disorders. The MDS assessment noted the resident was taking antianxiety and antidepressant medications. The resident's level I PASARR form dated 10/09/24 was completed prior to admission to the facility. The form indicated only the diagnosis of anxiety listed under Section IA, Mental Illness or suspected Mental Illness. A psychiatry consultation dated 10/15/24 revealed the resident had diagnoses of major depressive disorder, generalized anxiety, and dementia without behavioral, psychotic, mood disturbances. Resident's plan of action included continuing Donepezil and Memantine for dementia and Duloxetine for depression. The resident's Clonazepam for anxiety was changed from as needed (PRN) to a scheduled medication at bedtime. Review of resident #17's physician medication orders revealed the resident was ordered Clonazepam 0.5 milligrams (mg) at bedtime for anxiety with a start date of 10/15/24, Gabapentin 100 mg every 8 hours for neuropathy with a start date of 10/11/24, Memantine HCl 10 mg every morning and at bedtime for dementia with a start date of 10/09/24, Donepezil HCl 10 mg daily for dementia with a start date of 10/10/24, and Sertraline HCl 25 mg at bedtime for depression with a start date of 12/17/24. Review of resident #17's care plan revealed a focus initiated 10/10/24 regarding the use of antidepressant medication related to depression. Review of the resident's medical record revealed no updates had been made to the level I PASARR form to include this mental illness, major depressive disorder. 2. Resident #199's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses including metabolic encephalopathy (brain dysfunction), dementia without behavioral, psychotic, or mood disturbances, and cognitive communication deficit. Review of the resident Admission MDS assessment dated [DATE] revealed the resident had no diagnosis listed under section active psychiatric and mood disorders, but the assessment indicated the resident was taking antianxiety and antipsychotic medications. The resident's PASARR form dated 1/29/25 was completed prior to admission to the facility. The form indicated no mental illness or suspected mental illness under Section IA. Review of resident #199's physician medication orders revealed the resident was ordered Rexulti 0.25 mg every day for mood disorder with a start date of 1/29/25 and was discontinued on 2/04/25 and an order for Trazodone 25 mg every 12 hours for diagnosis of depression with a start date of 2/04/25. A Psychiatry consultation dated 2/04/25 under the section 'Plan of Action' revealed the resident's medication Rexulti was discontinued and Trazodone 25mg every 12 hours for depression was started. The resident was started on this medication because non-pharmacological interventions were not sufficient to manage the symptoms of the resident. The consultation described the medication was prescribed because in general it helped with depression, anxiety, panic attacks, post trauma anxiety, irritability, agitation and sleep. Review of resident #199's care plan revealed a focus initiated 2/05/25 about the use antidepressant medications and the resident being at risk for complications from these medications. Review of resident medical record revealed no updates were made to the PASARR form to include this mental illness diagnosis. 50401 3. Resident #136 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia (low oxygen), Parkinson's disease, type 2 diabetes mellitus, stroke, insomnia, bipolar disorder, depressive disorder, and post-traumatic stress disorder. Review of the PASARR level I screening dated 2/19/25 revealed it did not include the diagnoses bipolar disorder, depressive disorder, nor post-traumatic stress disorder. On 3/26/25 at 4:06 PM, in a joint interview the Admissions Clerk and Admissions Director stated they both reviewed admission referrals which included reviews of the hospital transfer form for patient transfers, including the PASARR form, prior to admission. They agreed they looked to see if the PASARR was complete, but stated they didn't check the assessment for accuracy. They added, the Social Services Director reviewed the PASARRs for accuracy. On 3/26/25 at 4:19 PM, the Director of Social Services stated she checked to see if the PASARR was accurate and then she provided the PASARR to the Regional Social Worker or the Director Of Nursing. The Director of Social Services added, during Gradual Dose Reduction (GDR) meetings for medications, she reviewed the PASARR's to ensure their accuracy, especially if any new psychiatric diagnoses were added. She did not say why resident #136's level I PASARR was not accurate. 50875 4. Resident #19 was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Some of her diagnoses included acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, heart failure, generalized anxiety disorder and major depressive disorder. Resident #19's most recent MDS assessment with an assessment reference date of 2/27/25 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated she had no cognitive impairment. The assessment indicated she felt depressed, but had no behaviors nor rejection of care and listed diagnoses of both anxiety disorder and depression. Resident #19's Order Summary Report showed the resident had an order for Sertraline HCl Oral Tablet 50 mg, 3 tablets given by mouth at bedtime for depression. Resident #19 had a Plan of Care initiated on 2/29/24 for the use of antidepressant medication related to the diagnosis of depression. On 3/26/25 at 10:31 AM, a review of resident #19's PASARR Level I Screen for Serious Mental Illness and /or Intellectual Disability or Related Conditions dated 1/04/24 incorrectly revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. 5. Review of the medical record revealed resident #185 was admitted to the facility on [DATE] from the hospital. Some of her diagnoses included nontraumatic intracerebral hemorrhage, displaced intertrochanteric fracture of the right femur, dementia, major depressive disorder, generalized anxiety disorder, and Alzheimer's disease. Resident #185's Admission Minimum Data Set (MDS) with an assessment reference date of 2/24/25 revealed the resident scored 6 out of 15 on the Brief Interview for Mental Status which indicated she was cognitively impaired. The assessment indicated resident #185 felt depressed, exhibited behaviors and rejected care. She had diagnoses of anxiety disorder and depression. Resident #19's Order Summary Report showed the resident had an order for Citalopram Hydrobromide 20 mg and half tablet to be given by mouth one time a day for depression. The resident also had orders for Trazadone HCL tablet 50 mg and half tablet to be given by mouth every twelve hours for depression. Resident #185 had a Plan of Care which was initiated and revised on 3/27/25 related to the diagnosis of depression and another care plan for the use of antidepressants initiated and revised on 2/18/25. On 3/26/25 at 3:47 PM, review of resident #185's PASARR Level I Screen for Serious Mental Illness and /or Intellectual Disability or Related Conditions dated 2/18/25 revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. 6. Resident #9 was initially admitted to the facility on [DATE] and readmitted on [DATE] from a rehabilitation hospital. Some of her diagnoses included chronic respiratory failure with hypoxia, hypotension (low blood pressure), type 2 diabetes mellitus, end stage renal disease, and bipolar disorder. Resident #9's Quarterly MDS assessment with an assessment reference date of 1/3/25 revealed the resident scored 00 out of 15 on the Brief Interview for Mental Status which indicated she was cognitively impaired. The assessment revealed resident #9 had no behaviors nor rejection of care and included bipolar disorder as an active diagnosis. Resident #9 had a Plan of Care initiated on 4/08/21 and revised on 7/09/21 for mood problems related to anxiety. Another focus in the Plan of Care revealed resident #9 had a history of being aggressive with staff, anxiety, depression, anger, and poor impulse control initiated 12/06/20. On 3/26/25 at 4:32 PM, a review of resident #9's PASARR Level I Screen for Serious Mental Illness and /or Intellectual Disability or Related Conditions dated 1/17/22 revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. 7. Resident #72 was admitted to the facility on [DATE] from an acute care hospital. Some of his diagnoses included unspecified fracture of the right femur, partial paralysis following stroke, type 2 diabetes mellitus, chronic kidney disease and major depressive disorder. Resident #72's Admission MDS assessment with a reference date of 12/13/24 revealed the resident scored 6 out of 15 on the Brief Interview for Mental Status which indicated he was cognitively impaired. The assessment indicated the resident felt down, depressed and hopeless, but had no behaviors nor rejection of care and listed depression as an active diagnosis. Resident #72's Order Summary Report showed the resident had an order for Venlafaxine HCL tablet extended release 24 hour, 150 mg to be given with Venlafaxine HCL tablet extended release 75 mg to equal 225 mg given daily for depression. The Plan of care revealed resident #72 had mood problems related to depression initiated on 12/10/24. On 3/26/25 at 4:38 PM, a review of resident #9's PASARR Level 1 Screen for Serious Mental Illness and /or Intellectual Disability or Related Conditions dated 12/06/24 revealed no diagnoses were listed in Section A for Mental Illness or Suspected Mental Illness. On 3/26/25 at 4:06 PM, the Admissions Director and the Admissions Clerk explained they reviewed PASARRs for potential residents prior to admission. They ensured the form was completed, then given to the Social Services Department who further reviewed them and would determine if a Level II PASARR was needed. On 3/26/25 at 4:19 PM, the Social Services Director (SSD) explained she would review the level I PASARR forms and if necessary, would let the Regional Social Worker or the Director of Nursing (DON) know of any updates or discrepancies. She said most times, she would learn of updated PASARRs or add new diagnoses during the Interdisciplinary Team meetings with the Psychiatrist when they addressed Gradual Dose Reductions for residents on psychotropic medications. The SSD and DON acknowledged and confirmed the list of seven residents, (#17, #199, #136, #19, #185, #9 and #72) whose PASARRs were inaccurate and noted the missing diagnoses in Section A of the form. On 3/27/25 at 9:52 AM, the DON stated that her expectation was accurate diagnoses were listed in Section A of the PASARR screening forms. The Facility's Policy on Preadmission Screening and Resident Review reviewed December 2024 stated A complete and accurate PASARR is required upon admission of each resident. Residents who may need Level II will not be admitted until the review has been completed and that the determination has been made to ensure that placement in a nursing facility is appropriate. The admissions department is responsible for assuring that each resident has a complete and accurate PASARR screening upon admission. If new information has been discovered, facility should complete a Level I or review if applicable. Social Services is responsible for any referral of an in-house resident in need of a level II.

Based on interview, and record review, the facility failed to ensure pharmacy reports of irregularities with medication regimens were reviewed, including actions taken to address the discrepancies, and their rationale for 1 of 5 residents reviewed for medication review, (#151). Findings: 1. Resident #151 was admitted on [DATE] with the diagnoses of fibromyalgia, severe obesity, acute respiratory failure, osteoarthritis, polyneuropathy, anxiety, anemia, hypothyroidism, depression, migraine, and chronic kidney failure, unspecified. On 12/08/24, the consulting pharmacist recommended the side effects of the anxiolytic (antianxiety) medication Buspirone be monitored along with the behaviors related to the antidepressant medication Bupropion Extended Release (XL), which included target behaviors, interventions, adverse effects, and effectiveness of the antidepressant. Review of the medical record revealed no evidence the recommendations were reviewed or addressed by the attending physician as no changes to the residents' orders were made and no rationale for not adding them were provided. Review of the medical record revealed on 1/19/25, the pharmacist recommended a change in the order for potassium 10 milliequivalents (mEq) tablet to Potassium Chloride 10% oral solution (20 mEq/15 milliliters (ml)), 7.5 ml daily with at least 120 ml cold water, because the pharmacist noted, solid sources of potassium chloride were contraindicated for patients with delayed gastric emptying. Review of the medical record revealed no evidence that the pharmacy recommendations were reviewed or addressed; no changes to the orders were made and no rationale was provided. Review of the medical record revealed on 2/07/25, the pharmacist repeated the recommendation for side effect monitoring of the anxiolytic (antianxiety) medication Buspirone, along with monitoring behaviors for the antidepressant Bupropion XL. Review of the medical record revealed no evidence these recommendations were ever reviewed or addressed by the attending physician. On 3/11/25, for the third month the recommendations to monitor the side effects for Buspirone and to monitor behaviors related to the antidepressant Bupropion XL were given by the consulting pharmacist. Review of the medical record revealed no evidence the recommendations were reviewed or addressed. On 3/17/25, an order to monitor behaviors for the antidepressant Bupropion XL was added, but did not include to document for target behaviors, interventions, adverse effects, or effectiveness, as was recommended by the pharmacist, nor a rationale for not adding these recommendations. On 3/27/25 at 1:53 PM, the Director of Nursing (DON) stated the pharmacist reviewed resident medications monthly for appropriateness and for irregularities, then emailed their reports with any recommendations to the DON. The DON stated she then distributed the recommendations to the appropriate Unit Managers who then contacted the doctors. She explained the process must be completed before the end of the month. The DON verified there was an 'order set' available for antianxiety medication side effects, but confirmed it was not added to resident #151's orders anytime between December 2024 and March 2025 as recommended. She confirmed the antidepressant behavior monitoring was not added in December 2024 through February of 2025 as recommended, and when added on March 17, 2025, it did not include the specific recommendations of the pharmacist, but just to monitor behaviors. The DON stated it was important to follow up on pharmacist recommendations because the facility must follow physician orders, and address pharmacy recommendations to provide appropriate care for the residents. The DON added, the January recommendation in January for the change from the Potassium tablet to the liquid form was addressed with the physician with the resident refusing. However, she acknowledged there was no evidence of this until a late entry progress note was added after the interview on the afternoon of 3/27/25. The facility policy entitled Medication Regimen Review, dated 2006, with most recent revision of January 2018, indicated pharmacist recommendations were to be acted upon and documented by the facility staff and/or the prescriber. The policy described that the prescriber either accepted and acted upon the recommendations or rejected them with an explanation.

Based on record review and interview, licensed nurses and respiratory therapists failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of physician orders for resuscitation or code status in an emergency and process for following the Do Not Resuscitate Order (DNRO) for 1 of 8 residents reviewed for advance directives (#1). On [DATE] at approximately 4:47 AM, resident #1 was found unresponsive with no heart rate and no respirations. A Respiratory Therapist (RT) initiated CPR without first verifying the resident's physician orders and advance directives (code status) in the medical record. Emergency Medical Services (EMS) arrived at the facility and spoke to the resident's spouse who confirmed the resident had a DNRO. CPR was discontinued and resident #1 was pronounced dead at 4:52 AM. The facility failed to follow their policies and procedures for Cardiopulmonary Resuscitation by not checking the resident's code status prior to initiating CPR. This resulted in failure to honor the resident's wishes and physician order for Do Not Resuscitate. The facility's failure to ensure staff followed procedures related to honoring an advance directive to withhold CPR contributed to resident #1 suffering unwanted, aggressive resuscitation efforts and placed all residents who had valid DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE] and compliance was achieved on [DATE] after verification of corrective actions. Findings: Cross reference F578. Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including respiratory failure, dependence on respiratory [ventilator] status, tracheostomy status and gastrostomy status. Review of the Minimum Data Set (MDS) significant change in status assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. The document indicated the resident was tracheostomy and ventilator dependent and received oxygen and suctioning. Review of resident #1's electronic medical record (EMR) revealed a State of Florida Do Not Resuscitate Order (DNRO) form dated [DATE] that was signed by the resident and his attending physician. The document showed the resident's signature under the statement, Being informed of my right to refuse cardiopulmonary resuscitation (CPR), including artificial ventilation, cardiac compression, endotracheal intubation and defibrillation, I direct that CPR be withheld or withdrawn from me. The physician's statement read, I direct the withholding or withdrawal of CPR from the patient in the event of the patient's cardiac or respiratory arrest. Resident #1's EMR contained a physician order dated [DATE] which read, Do Not Resuscitate. A Nurses Progress Note dated [DATE] at 7:17 AM revealed Registered Nurse (RN) B was called to the room by resident's spouse. Upon entering, he observed resident #1 was pale and unresponsive. RN B immediately called for help and left the room to check on his code status. The note indicated resident #1 had a DNRO. RN B notified RN Supervisor G who came to the nurse station. He was told that CPR had already commenced and CPR had to keep going as per policy until relieved by EMS. EMS arrived at 4:52 AM and called out time of death. A Respiratory Progress Note dated [DATE] at 6:03 AM indicated resident #1's spouse requested the RT to come check on the resident as he was short of breath. The note indicated upon entering the room, RT C noted the resident looked pale, with a weak pulse. Her note read, CPR was initiated with 100% manual resuscitation bag . Suction for scant amount of thick pale/yellow secretions. Review of the facility's policy and procedure 14.1 Emergency Procedure - Cardiopulmonary Resuscitation revised [DATE] read, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing, Verify or instruct a staff member to verify the DNR or code status of the individual. If the resident is a full code begin CPR. The Facility's policy and procedure for Do Not Resuscitate Order revised [DATE] read, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. On [DATE] at 11:15 AM, The Administrator and Interim Director of Nursing (DON) discussed the incident investigation and Root Cause Analysis related to resident #1 receiving CPR despite documentation of a DNRO. The Administrator and DON stated during the investigation, several staff statements were taken and it was discovered RT E entered the room during the code blue and began chest compressions on resident #1 without verifying his code status. The Administrator explained that RT E gave conflicting statements during a couple of interviews. The Administrator stated the facility had identified the root cause as the RT saw the Code Blue alert and provided CPR without verifying the resident's code status. He confirmed that first and foremost, staff have to check the wishes of the resident and honor those wishes. The Administrator acknowledged that once the staff discovered the resident had an order for DNR, they should have stopped CPR. They could not provide CPR if they did not have a physician order to do so. He explained staff were educated on code blue alerts, honoring Advance Directives and where to verify a resident's code status. Training also included if a resident was found to be a DNR, CPR should stop if already initiated in order to honor the resident's wishes., Attempts were made to reach RT E, but he did not answer the phone and did not return phone calls. In a phone interview on [DATE] at 4:08 PM, Registered Nurse (RN) B described the sequence of events on [DATE], the day resident #1 received CPR. He recalled sometime close to 5:00 AM, resident #1's spouse came out of the room and asked for someone to check on the resident The Respiratory Therapist (RT) C assigned to him was busy, so he went to the room. RN B stated when he entered the room, the resident was very pale, unresponsive and did not have a pulse. RN B pushed the code blue button on the wall to get assistance and then went out to check resident #1's code status. He looked in the EMR and saw resident #1 had an order for DNR. He stated RN Supervisor G came to the desk about that time and he informed her of the resident's code status (DNR order). RN B recalled RN Supervisor G informed him CPR was already in progress and had to continue. He stated his first impression was chest compressions should stop since the resident had an order for DNR. She told him they had to keep doing CPR and wait for EMS to arrive. RN B stated he took the emergency cart which contained resuscitation equipment and went to resident #1's room. When he entered the room with the cart, RT C and RT E were taking turns with the manual resuscitation bag and doing chest compressions. He explained EMS arrived shortly after and were informed of the DNR status and EMS instructed staff to cease CPR efforts. In a phone interview on [DATE] at 7:40 AM, RT C confirmed she was the RT assigned to resident #1 the morning of [DATE]. She recalled the resident's spouse came out to the station and stated the resident was having difficulty breathing. RT C explained she started to go to resident #1's room but forgot the keys to the breathing treatment cart and went back to get them from another RT. As she was headed back to the room, she saw the code blue light on outside resident #1's room. RT C stated when she entered the room, she began assisted manual ventilation with a manual resuscitation bag in the event there was a mucous plug that needed to be cleared. She explained RT E was also in the room and started chest compressions when they could not find a pulse. RT C recalled RT F entered the room and asked if resident #1 was a DNR. She stated they did not know and RT F went out to check. RT F returned and informed them he was a DNR, but RN Supervisor G told them they had to keep going since CPR was already started. RT C stated they continued with CPR until EMS arrived. EMS asked resident #1's spouse if she wanted them to continue and she told them to stop. In a phone interview on [DATE] at 7:30 AM, RT F confirmed she was at the respiratory station where they sit to document in the medical record. She recalled the spouse of resident #1 came to the station and called the RT C to come to the room. RT C asked for the keys from RT F and left. RT F observed the Code Blue light flashing and went into the room. Upon entering, she observed RT E doing chest compressions and RT C using the manual resuscitation bag. She asked what resident #1's code status was and did not get a response. She stated she left the room and went to the nurse station to verify code status. RT F spoke with RN B and was informed the resident had an order for a DNR. She explained RN Supervisor G was in the hall and said they had to continue with CPR once started because it was the policy of the facility. RT F returned to the room and shared the information with RT C and RT E. In a phone interview of [DATE] at 1:08 PM, RT D stated he was the lead RT the night of the incident. He recalled seeing the code blue alert went to resident #1's room. He stated as he entered, he observed RT E doing chest compression and RT C was using the manual resuscitation bag. RT D asked if he could help and RT C stated she was trying to see if the resident had a mucous plug in his airway. He stated LPN A entered and assisted RT E and RT C with chest compression. He recalled RT F checked resident #1's code status and informed them the resident had an order for a DNR. RT D reported RN Supervisor G told them they had to continue with CPR once initiated. When EMS came, he exited the room. He acknowledged staff had to verify code status before initiating CPR. In a phone interview on [DATE] at 12:36 PM, RN Supervisor G confirmed she was on the phone when she heard the code blue alert. When she entered the room, she observed two RTs had initiated CPR. She acknowledged she went to the nurse station and RN B informed her resident #1 had an order for a DNR. She explained she was on the phone with the DON (former) and was instructed to continue CPR until EMS arrived which she shared with RN B. In a phone interview on [DATE] at 8:36 AM, Licensed Practical Nurse (LPN) A stated he was the medication cart when resident #1's spouse asked him to go to the resident's room. LPN A explained he directed her to RN B who was resident #1's nurse. He observed RN B enter the room and then saw the code blue light. He stated he locked his cart and went to the room. LPN A recalled he observed RT E doing chest compressions when he arrived. He explained he asked loudly if anyone knew the code status of the resident and no one answered. LPN A stated he asked if they needed help and RT E said they did, so he did one round of CPR and RT E took over again. He recalled RN B entered the room and LPN A asked what the resident's code status was. LPN A stated RN B told him resident #1 had an order for a DNR. LPN A then said they should stop CPR. He explained RN B informed him RN Supervisor G said the policy was to continue CPR once started until EMS arrived. LPN A confirmed EMS asked about resident #1's code statue and were informed he was a DNR. LPN A stated he left the room at that point because it was getting crowded. On [DATE] at 9:37 AM, RN Unit Manager H stated she was not here the day of the incident but was informed the following day. She explained each resident's code status was in the EMR and it was the responsibility of staff to verify code status/orders for DNR prior to initiating CPR. RN Unit Manager H stated she was always told to stop CPR if you found someone had an order for a DNR after it was initiated. She explained, you have to honor their wishes. In a phone interview on [DATE] at 10:28 AM, resident #1's spouse stated she usually visited earlier in the day but on [DATE] she woke up during the night and just wanted to go in and sit with him. She recalled early in the morning, she went to the nurse station and told RT C that the resident needed some attention. RT C told her she would be there in a minute. Resident #1's spouse stated she told her he needed someone now. She heard a code blue being announced and saw the emergency cart. She explained there was a lot going on and she tried to remember if the resident had signed a DNRO. She stated she said something about a DNRO and the EMS crew must have overheard her. The EMS person asked if she wanted them to stop. She told them if he was going to have broken ribs or brain damage, she wanted them to stop. Resident #1's spouse recalled a conversation she had with the resident when he was in the hospital. She stated he expressed to her and her son that he did not want to have his ribs broken or suffer brain damage. She recalled resident #1 said he just wanted to die in peace. She stated it was his decision to have an order for DNR. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On [DATE], the attending physician, Medical Director, Administrator, Director of Nursing and family were notified of the incident and an investigation was initiated. Immediate education done with all in-house staff regarding verification of code status prior to initiating CPR. Advance Directive audit and code blue drills initiated. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. A Performance Improvement Plan on advance directives was started. Education and audits were started which included code blue drills with test and audit of code status for all residents. 100% chart audit completed by [DATE]. *On [DATE], [DATE], [DATE] and [DATE], Ad Hoc QAPI meetings were held with Administrator, Director of Nursing, Medical Director and administrative staff. Education, audits and drills were reviewed and revised as indicated. *From [DATE] to [DATE], the facility educated all clinical staff on the topics of Advance Directives, Code Blue alert and when to start/stop CPR which included a post-test. Education included the instructions, In the event CPR is initiated when there is an order for DNR, CPR is to be discontinued upon confirmation of DNR status, consistent with physician orders for DNR. On [DATE], 100 percent of clinical staff were trained and had participated in a code blue drill. Education continued to include all staff and new employees. *From [DATE] to [DATE], the facility took actions to reduce the risk of future occurrences. All staff were educated on the Policy and Procedure related to Advance Directives with a focus on Code Status and Following the Physician's orders with post-test; New Hire staff orientation to include Code Blue response and verification of code status in EMR; Code status and Advanced Directives confirmed at the time of admission and orders placed in EMR; Code status and Advanced Directives reviewed with all residents at the time of care plan meetings and Code Blue Drills (includes verifying Code Status, Advance Directives and DNRO). Interviews conducted on [DATE] with 15 staff members (4 Certified Nursing Assistants, 3 Licensed Practical Nurses, 1 RN, 1 Maintenance Assistant, 1 Certified Occupational Therapy Assistant, 1 housekeeper, 3 Respiratory Therapists and 1 unit secretary) indicated they were knowledgeable of advance directives and where to verify the code status in the EMR prior to providing CPR. The surveyors validated the education with attendance sheets for code blue drills and in-services. Review of QAPI audits revealed daily code blue drills were conducted per performance improvement plan. The resident sample was expanded to include three additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to advance directives. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on [DATE].

Based on interview and record review, the facility failed to implement procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were followed and failed to honor an advance directive that reflected the decision to withhold cardiopulmonary resuscitation (CPR) for 1 of 8 (#1) sampled residents reviewed for resident rights and CPR. These failures contributed to resident #1 receiving CPR in violation of an explicit wish for a natural and dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 4:47 AM, resident #1 was found unresponsive with no heart rate and no respirations. A Respiratory Therapist (RT) initiated Cardiopulmonary Resuscitation (CPR) without first verifying the resident's wishes regarding CPR (code status) in the medical record. A RN instructed staff to continue CPR after verifying a current order for DNR. Emergency Medical Services (EMS) arrived at the facility and spoke to the resident's spouse who confirmed the resident had a Do Not Resuscitate Order (DNRO). CPR was discontinued and resident #1 was pronounced dead at 4:52 AM. The facility failed to honor the resident's wishes not to be resuscitated and failed to follow physician order for Do Not Resuscitate. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a Do Not Resuscitate Order (DNRO) advance directive at risk for serious psychosocial harm, physical trauma, and a prolonged, undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE] and compliance was achieved on [DATE] after verification of corrective actions. Findings: Cross reference F678. Resident #1 was admitted to the facility on [DATE] with diagnoses including respiratory failure, dependence on respiratory [ventilator] status, tracheostomy status and gastrostomy status. Review of the Minimum Data Set (MDS) significant change in status assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The document indicated the resident was tracheostomy and ventilator dependent and received oxygen and suctioning. A care plan for Advance Directives which indicated resident #1 had selected Do Not Resuscitate (DNR) status was initiated [DATE]. The document read, Advance Directives will be honored and assistance provided with changes as needed. Review of resident #1's electronic medical record (EMR) revealed a State of Florida Do Not Resuscitate Order (DNRO) form signed by resident #1 on [DATE]. The Facility's policy and procedure for Do Not Resuscitate Order revised [DATE] read, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. In a phone interview on [DATE] at 4:08 PM, Registered Nurse (RN) B described the sequence of events on [DATE], the day resident #1 received CPR. He recalled sometime close to 5:00 AM, resident #1's spouse came out of the room and asked for someone to check on the resident. The Respiratory Therapist (RT) C assigned to him was busy, so he went to the room. RN B stated when he entered the room, the resident was very pale, unresponsive and did not have a pulse. RN B pushed the code blue button on the wall to get assistance and then went out to check resident #1's code status. He looked in the EMR and saw resident #1 had an order for DNR. He stated RN Supervisor G came to the desk about that time and he informed her of the resident's code status (DNR order). RN B recalled RN Supervisor G informed him CPR was already in progress and had to continue. He stated his first impression was the chest compressions should stop since the resident had an order for DNR. She told him they had to keep doing CPR and wait for EMS to arrive. RN B stated he took the emergency cart which contained resuscitation equipment and went to resident #1's room. When he entered the room with the cart, RT C and RT E were taking turns with the manual resuscitation bag and doing chest compressions. He explained EMS arrived shortly after and were informed of the DNR status. EMS instructed staff to cease CPR efforts. In a phone interview on [DATE] at 7:40 AM, RT C confirmed she was the RT assigned to resident #1 the morning of [DATE]. She recalled the resident's spouse came out to the station and stated resident #1 was having difficulty breathing. RT C explained she started to go to resident #1's room, but forgot the keys to the breathing treatment cart and went back to get them from another RT. As she was headed back to the room, she saw the code blue light on outside resident #1's room. RT C stated when she entered the room, she began assisted manual ventilation with a manual resuscitation bag in the event there was a mucous plug that needed to be cleared. She explained RT E was in the room and started chest compressions when they could not find a pulse. RT C recalled another RT entered the room and informed them resident #1 had an order for a DNR, but RN Supervisor G told them they had to keep going since CPR was already started. RT C stated they continued with CPR until EMS arrived. EMS asked resident #1's spouse if she wanted them to continue and she told them to stop. In a phone interview on [DATE] at 12:36 PM, RN Supervisor G confirmed she was on the phone when she heard the code blue alert. When she entered the room, she observed two RTs had initiated CPR. She acknowledged she went to the nurse station and RN B informed her resident #1 had an order for DNR. She explained she was on the phone with the DON (former) and was instructed to continue CPR until EMS arrived which she shared with RN B. On [DATE] at 9:37 AM, RN Unit Manager H stated she was not present in the facility the day of the incident, but was informed afterward. She explained each resident's code status was in the EMR and it was the responsibility of staff to verify code status prior to initiating CPR. RN Unit Manager H stated she was always told to stop CPR if you found someone had an order for a DNR after it was initiated. She explained, you have to honor their wishes. In a phone interview on [DATE] at 10:28 AM, resident #1's spouse stated she usually visited earlier in the day, but on [DATE] she woke up during the night and just wanted to go in and sit with the resident. She recalled early in the morning, she went to the nurse station and told RT C that resident #1 needed some attention. RT C told her she would be there in a minute. Resident #1's spouse stated she told her the resident needed someone now. She heard a code blue being announced and saw the emergency cart. She explained there was a lot going on and she tried to remember if her spouse had signed a DNRO. She stated she said something about a DNRO and the EMS crew must have overheard her. The EMS person asked if she wanted them to stop. She told them if the resident was going to have broken ribs or brain damage, she wanted them to stop. Resident #1's spouse recalled a conversation she had with the resident when he was in the hospital. She stated he expressed to her and her son that he did not want to have his ribs broken or suffer brain damage. She recalled resident #1 said he just wanted to die in peace. She stated it was his decision to not be resuscitated if he stopped breathing or his heart stopped. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On [DATE], the attending physician, Medical Director, Administrator, Director of Nursing and family were notified of the incident and an investigation was initiated. Immediate education done with all in-house staff regarding verification of code status prior to initiating CPR. Advance Directive audit and code blue drills initiated. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held and included the following staff: Medical Director, NHA, DON, ADON, RM, Evening Nurse Supervisor, RSSD, CEO, CEO of Consulting Group, RNC, RICP, RT Supervisor, and RT Manager. A Performance Improvement Plan on advance directives was started. Education and audits were started which included code blue drills with test and audit of code status for all residents. 100% chart audit completed by [DATE]. * The Ad Hoc QAPI meeting on [DATE] included the following staff: MD, NHA, DON, ADON, RNC, RM, RN Unit Manager for 400 unit. The content of the QAPI meeting included: Discussion of the process to verify code status, system changes to put into place, and monitoring tools that will be used. Reviewed education and audits completed to date. Updated content of education message. *The Ad Hoc QAPI meeting on [DATE] included the following staff: MD, NHA, DON, Risk Preventionist, ADON, Director of Education, UMs, and other department heads. The content of the QAPI meeting included: Reviewed all the education that had been provided to clinical staff, the education provided to other staff, reviewed mock code drills performed, and audits conducted. Came to consensus that facility was in compliance for education and audits/mock drills. Continued to review the advance directives, code status and CPR. Reviewed audit tools to ensure they were being done correctly. *From [DATE] to [DATE], the facility educated clinical staff on the topics of Advance Directives, Code Blue alert and when to start/stop CPR which included a post-test. Education included the instructions, In the event CPR is initiated when there is an order for DNR, CPR is to be discontinued upon confirmation of DNR status, consistent with physician orders for DNR. *On [DATE] all clinical staff had been received training/in-service education and had participated in a code [NAME] drill. Education for non-clinical staff and any new employees after [DATE] is ongoing. *From [DATE] to [DATE], the facility took actions to reduce the risk of future occurrences. All staff were educated on the Policy and Procedure related to Advance Directives with a focus on Code Status and Following the Physician's orders with post-test; New Hire staff orientation to include Code Blue response and verification of code status in EMR; Code status and Advanced Directives confirmed at the time of admission and orders placed in EMR; Code status and Advanced Directives reviewed with all residents at the time of care plan meetings and Code Blue Drills (includes verifying Code Status, Advance Directives and DNRO). Interviews conducted on [DATE] with 15 staff members (4 Certified Nursing Assistants, 3 Licensed Practical Nurses, 1 RN, 1 Maintenance Assistant, 1 Certified Occupational Therapy Assistant, 1 housekeeper, 3 Respiratory Therapists and 1 unit secretary) indicated they were knowledgeable of advance directives and where to verify the code status in the EMR prior to providing CPR. The surveyors validated the education with attendance sheets for code blue drills and in-services. From [DATE] to [DATE], 427 staff members received in-service/education. Review of QAPI audits revealed daily code blue drills were conducted per performance improvement plan. The resident sample was expanded to include three additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to advance directives. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on [DATE].

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent elopement for 1 of 1 resident reviewed for actual elopement, of a total sample of 3 residents reviewed for elopement, (#1). Findings: Review of the medical record revealed resident #1 was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included metabolic encephalopathy, stroke, chronic lung disease, major depression, and alcohol dependence. The Minimum Data Set Modification of Admission assessment dated [DATE] revealed resident #1 had adequate hearing, clear speech and moderate cognitive impairment. The assessment indicated he needed supervision for bed mobility, transfers, and walking on or off the unit. The document showed the resident had no wandering behaviors and did not use a wander/elopement alarm during the look back period. An Elopement Risk Evaluation dated 12/23/22 revealed resident #1 was deemed at risk for elopement due to his cognitive impairment and ability to ambulate independently. The document indicated resident #1 was easily re-directed, did not express a desire to leave the facility, nor have a history of wandering. The evaluation did not show any interventions were put in place to mitigate his risk for elopement. Review of the medical record revealed resident #1 had a care plan for elopement initiated on 12/23/22. The goal was for the resident to respond to redirection by staff if he wandered or attempted to exit the building. The care plan listed only one intervention, Resident at risk for elopement. A subsequent Elopement Risk Evaluation dated 12/30/23, determined resident #1 was no longer cognitively impaired; therefore, he was not at risk for elopement. As a result, the resident's care plan for risk for elopement was resolved. Review of the medical record revealed resident #1 had a care plan dated 12/29/22 for impaired cognitive function, impulsiveness, and fluctuating cognitive abilities. Interventions included assistance with all decision-making, and cue, re-orient and supervise as needed. The resident had a care plan for risk for falls related to his medical history and potential side effects of medications. The document noted he had an actual fall on 2/05/23. On 3/14/23 at 6:52 AM, resident #1 was seated on his bed and wore street clothes and tennis shoes. He was alert and oriented to himself and place, but confused to time. Resident #1 recalled he left the facility in the early morning on 2/23/23. He explained he had been in the 100 Unit common room watching television because he could not sleep. The resident stated he got up and just walked through the sliding doors, and sat on a chair. He recalled the staff were angry with him, so he left the patio, walked past the white fence and headed up the driveway. Resident #1 explained he walked to a neighborhood grocery/retail store to buy shampoo, but it was not open. He stated he waited in front of the store for a while, until a worker showed up and told him the store would not be open until 6:00 AM. Resident #1 recalled he then went to a nearby fast food restaurant and a discount retail store to check if they were open. He explained he was walking in the dark when the police found him and brought him back to the facility. Review of a Progress Note dated 2/23/23 at 7:47 PM, revealed agency Registered Nurse (RN) A documented that at 4:15 AM that morning, resident #1 unlocked the facility's outer sliding entrance doors and went outside. The note indicated approximately three minutes later, RN B attempted to get resident #1 to return inside, but he refused and insisted he wanted to sit on a chair outside. RN A wrote that RN B came back inside the facility to inform him and RN C that the resident refused to come inside. The progress note showed approximately five minutes later, RNs A, B and C walked outside together to try and convince resident #1 to come back inside, but he was no longer there. RN A documented that staff searched inside and outside the premises and did not find the resident. RN A's documentation showed he called the overnight Nursing Supervisor at approximately 4:28 AM to inform her of the situation. On 3/15/23 at 2:24 PM, in a telephone interview, agency RN B stated he was at the 100-unit nurses' station with RNs A and C when he saw resident #1 approach the exterior exit doors. He explained the inner sliding doors opened automatically, and then resident #1 walked through the atrium, manually unlocked and opened the outer sliding doors, and headed outside. RN B stated he immediately followed resident #1 outside and saw him seated on a chair to the right of the door. He recalled resident #1 refused to come back in, so he went back inside to get help from the other staff, and left resident #1 alone outside on the chair. RN B stated after he discussed possible methods to redirect the resident with RNs A and C, they all went back outside and discovered he was missing. He recalled RN A accompanied him to search the back of the facility's property, and RN C headed up the sloping driveway towards the front of the facility. RN B stated they were unable to locate resident #1 outside, so they initiated a search inside the facility. He recalled while he searched, he saw Certified Nursing Assistant (CNA) E by the nurses' station and CNA D was in the hallway. RN B stated he decided to search the area near the facility by car since resident #1 still had not been found. RN B explained he drove through the assisted living facility's parking lot next door to the facility, crossed the street to check at the gas station / convenience store, and then down the road to a fast food restaurant. RN B confirmed nobody announced the designated code on the overhead paging system to alert all staff of the elopement. RN B stated, in retrospect, he should not have left resident #1 outside without supervision as it was an unsafe situation. He acknowledged he could have rung the doorbell or knocked on the door to get the attention of other staff instead of leaving resident #1 alone. On 3/15/23 at 1:50 PM, in a telephone interview, RN A recalled he was assigned to resident #1 on the night of 2/23/23. He stated he was at the 100-unit nurses' station and observed the resident open the front door and exit the building. He verified RN B immediately followed resident #1 outside but returned by himself a few minutes later. RN A confirmed he joined RNs B and C to search for the resident in the dark outside the facility but they were unable to find him. RN A acknowledged it was not safe for resident #1 to be left outside, unsupervised in the dark, and a staff member should have stayed with him. On 3/14/23 at 11:04 AM, in a telephone interview, CNA E stated she was resident #1's assigned aide on the night he eloped from the facility. She recalled she last saw the resident in bed watching television at approximately 12:00 AM. She recalled on return from her lunch break, she heard a commotion near the nurses' station and RNs A and B told her resident #1 had eloped. CNA E stated while the 100-Unit staff searched for the resident inside the facility, she jumped into her car to comb the streets and drove through several shopping [NAME]. CNA E explained she stopped to ask people if they had seen resident #1 but no one had, and she drove back to the facility as she could not find him anywhere. Review of CNA E's timecard for the morning of 2/23/23 revealed a conflict with the timeline noted in the facility's investigation. The time card showed CNA E returned from her lunch break at the 2:39 AM, almost two hours before the the medical record showed the facility initiated a search for resident #1. In a telephone interview on 3/14/23 at 9:57 AM, the overnight Nursing Supervisor recalled receiving a phone call on the morning of 2/23/23 from the nurses on the 100-Unit who informed her they could not find a resident. She stated the nurses sounded alarmed and they explained resident #1 had been left outside unsupervised when he refused to come inside with RN B. They told her when they went back outside a few minutes later, the resident was gone. She confirmed staff searched for him inside and outside before they notified her, and they did not announce the code for elopement to alert all staff to join the search. The Nursing Supervisor stated she called 911 for assistance, and the Sheriff's office found resident #1 walking a little over a mile away from the facility and brought him back a little after 5:00 AM. The Nursing Supervisor confirmed resident #1 should not have been left outside, alone and unsupervised, even for a short time. She explained residents were allowed to sit outside, but it was the facility's policy to supervise them at all times. On 3/16/23 at 1:01 PM, resident #1's likely elopement route was retraced. He left the 100-Unit common room, exited through the atrium and front door, and turned right to follow the driveway that led away from the facility. The resident walked approximately 1000 feet to the end of the driveway and turned right to walk along the sidewalk adjacent to the 6-lane divided highway in front of the facility. Resident #1 was found by a Sheriff's Deputy approximately one mile away from the facility. On 3/16/23 at 11:09 AM, the Medical Director stated he was notified of resident #1's elopement. He explained resident #1 had been at the facility for almost two months during which he made no previous attempts to elope. The Medical Director described resident #1 as street-smart since he had been homeless at various periods throughout his life, but he acknowledged staff should not have left resident #1 unsupervised as that situation allowed him to elope from the facility. On 3/16/23 at 6:35 PM, the Risk Specialist stated the facility's investigation of the incident identified two root causes. The first was the resident was able to unlock the outer door to exit the facility, and the second was staff allowed the resident to remain outside alone. She confirmed residents should never be left outside unsupervised. Review of the facility's policy Missing Resident/Resident Elopement Prevention & Management with review date of 8/04/22 revealed the definition, Elopement occurs when a resident leaves the premises or a safe area without authorization and or any necessary supervision to do so.

Based on interview and record review, the facility failed to follow the plan of care orders for insulin administration for 1 of 3 residents reviewed for insulin administration of a total sample of 5 residents, (#1). Findings: Resident #1 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed resident #1 was cognitively intact and displayed no physical or verbal behaviors toward himself or others. The assessment indicated he required extensive assistance of 2 staff for bed mobility and toileting, and extensive assistance of one staff for transfers between surfaces. The MDS assessment showed resident #1 had 6 injections of insulin over the 5-day assessment period. Resident #1 had a care plan for diabetes with a goal for the resident to have no complications related to diabetes diagnosis. Interventions included staff monitor, document and report any signs or symptoms of high or low blood sugars. Resident #1 had a related care plan for potential nutritional problems related to diabetes mellitus. Interventions included nurses to administer medications as ordered by the physician and to monitor and document side effects and effectiveness. Review of resident #1's Order Summary Report with active orders from 9/01/22 through 9/30/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order dated 9/23/22 clarified for nurses to inject 42 units of the insulin under the skin twice a day for [CONDITION(S)] with breakfast and dinner. An additional telephone order dated 9/28/22, indicated for nurses to, Only hold insulin if glucose is less than 110 . Review of resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1. A nurse's progress note dated 9/30/22 indicated resident #1 was sitting up eating breakfast when LPN A assessed his vital signs and blood glucose then administered his morning medications including [MEDICATION(S)] 70/30 Kwik Pen Insulin. She documented he denied pain or discomfort and took his medications whole by mouth without difficulty. Another nurse's progress note dated 9/30/22 revealed the nurse entered resident #1's room at approximately 11:45 AM to assess his blood sugar prior to lunch and had difficulty arousing the resident. The nurse took resident #1's blood glucose which read 60 and she followed the physician ordered [CONDITION(S)] protocol and administered [MEDICATION(S)] by injection. She documented she notified the unit manager and the physician who ordered resident #1 be transported to the emergency room for evaluation. The note read emergency personnel arrived and transported resident #1 to the hospital. An eInteract SBAR Summary for Providers dated 9/30/22 at 12:31 PM, indicated the change in condition for resident #1 was unresponsiveness. His oxygen reading was below normal at 80% on room air with altered level of consciousness and labored or rapid breathing. The recommendation from the provider was to send the resident to the hospital by 911. In a telephone interview on 10/12/22 at 10:03 AM, agency LPN A recalled she had given resident #1 his 70/30 insulin on the morning of 9/30/22 after she took his blood glucose reading. She stated she felt it was safe to give resident #1 his ordered insulin because he was eating breakfast, and his blood glucose was okay when she checked it. She stated she did not recall an order to hold resident #1's insulin if the blood glucose was under 110 on the MAR. She stated she usually held insulin if blood glucose was under 100. LPN A explained she would not see an order to hold the insulin if it was not on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She also confirmed she did not receive direction from the facility as to when she was expected to hold insulin and call the physician. On 10/12/22 at 11:06 AM, Registered Nurse (RN) B stated she entered the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . after messaging the doctor on 9/28/22. She explained she had been concerned resident #1 had not been eating well. She confirmed the order she entered was not visible on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/22 at approximately 11:20 AM, the 400 wing Unit Manager (UM) confirmed RN G entered the order to hold the insulin needed to be clarified by the physician then added to the specific medication order as a parameter so other nurses could see it on the MAR. She confirmed RN B did not know how to correctly add the order she received from the physician concerning holding the medication. The UM stated she was not sure if anyone had reviewed the order entered by RN G, but explained new orders were usually reviewed during the morning meetings. In a telephone interview on 10/12/22 at 2:16 PM, the Medical Director acknowledged he had seen resident #1 the morning he was sent to the hospital. He confirmed resident #1 was alert and oriented and told him he was eating well. The Medical Director explained the typical protocol was for nurses to hold the insulin if the blood glucose was less than 110, Unless they were eating and drinking. The Medical Director stated he chose 110 because from there it wouldn't drop to a pathological level versus a parameter of 100. He explained he felt 106 was not sufficiently different from 110 to cause resident #1's hypoglycemic reaction, especially since he was eating breakfast when it was given. He confirmed it was always preferable for medication orders to be clarified in order for the nurses to follow them correctly. He stated the physicians should give the orders with the specific parameters including to hold if blood glucose was less than 110. On 10/12/22 at 3:46 PM, the Director of Nursing (DON) stated she felt RN B had a knowledge deficit regarding how to correctly input physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained that nurses should contact the doctor if unsure about an order and contact someone in management if they were unsure how to enter physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan policy with review date of 10/31/19 indicated residents would have person centered plans of care that addressed their assessed needs. The procedure included the interim base line care plan was initiated and implemented within 48 hours of admission and included but was not limited to physician orders. Additional procedures indicated that care plan approaches would be communicated for staff to use to provide direction for their care.

Based on observation, interview and record review, the facility failed to ensure scheduled medications were administered as ordered and according to accepted professional standards during the 7 AM to 3 PM shift on 1 of 3 units for 4 of 60 residents on the 200 Unit, (#4, #7, #8 & #9). Findings: 1. On 7/18/22 at 10:58 AM, Licensed Practical Nurse (LPN) A was at medication cart preparing medication for administration. Medication observation was conducted with the LPN. It was noted that resident #4 received his 9 AM medications at 11:21 AM. At the completion of medication administration for resident #4, LPN A verbalized she had four to five other residents to administer morning medications. The LPN stated she was aware medications should be given one hour before or one hour after the scheduled time. She added if the medication was scheduled for 9 AM, medication should be given between 8 AM and 10 AM. She did not explain why medications were being administered late. Review of the Medication Administration Audit Report for the day shift on 7/18/22 revealed the following: Resident #4 received his scheduled 9 AM medications between 10:59 AM and 11:11 AM including: [MEDICATION(S)] 3.125 milligram (mg) every 12 hours for high blood pressure, [MEDICATION(S)] 5 mg every 12 hours for [CONDITION(S)], Potassium Chloride 20 milliequivalents (mEq) every 12 hours for low potassium level, and [MEDICATION(S)] 10 mg daily for [CONDITION(S)]. 2. Resident #7 received his scheduled 9 AM medications between 12:22 PM and 12:32 PM including [MEDICATION(S)] 50 mg. daily for depression, [MEDICATION(S)] 12.5 mg every 12 hours for high blood pressure, Insulin [MEDICATION(S)] 12 units daily for diabetes, and Aspirin 81 mg for blood clot prevention. 3. Resident #8 received his scheduled 9 AM medications between 12:26 PM and 12:28 PM including: [MEDICATION(S)] 10 mg daily, [MEDICATION(S)] 6.25 mg every 12 hours for high blood pressure, [MEDICATION(S)] 75 mg daily, Aspirin 81 mg daily for [CONDITION(S)], and [MEDICATION(S)] 5 mg every 12 hours for depression. 4. Resident #9 received his scheduled 9 AM medications between 11:35 AM and 11:48 AM including [MEDICATION(S)] 50 mg, [MEDICATION(S)] 10 mg. for high blood pressure, [MEDICATION(S)] 550 mg. two times daily for alcoholic [CONDITION(S)] of the liver, and [MEDICATION(S)] 10 gram/15 milliliter (ml.) 30 ml two times daily for high ammonia levels. On 7/18/22 at 4:03 PM, LPN A stated she was not aware of the facility's protocol for late medication administration. She acknowledged medications for residents #4, #7, #8, and #9 were given outside of parameters, and the physician was not notified. On 7/18/22 at 4:06 PM, the 200 Unit Manager (UM) stated she told nurses that after receiving report from the off- going nurse, they should place priority on ensuring diabetic and anti-hypertensive medications were given. The UM said medications were considered late if administered greater than one hour after the medication's scheduled time. She verbalized nurses should notify the physician if medications were administered late. The Medication Admin Audit Report for residents #4, #7, #8, and #9 were reviewed with the UM. She confirmed the medications were administered out of parameters. On 7/18/22 at 6:47 PM, the Director of Nursing (DON) stated if nurses were running behind with medications, the process included notification of the UM, and the physician. She noted this was not done for residents #4, #7, #8, and #9. The facility's policy Medication Administration Times ,with effective date of 12/01/07 and revision date of 01/01/22, read, Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed by sixty (60) minutes after the designated times of administration. Example listed were once a day/daily 9 AM, 2 times a day 9 AM and 5 PM, every 12 hours 9 AM and 9 PM. The policy General dose Preparation and Medication Administration, with effective date of 12/01/07 and revision date of 01/01/22, read, Administer medications within timeframes specified by the facility policy.

Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care related to nail care for 1 of 5 residents reviewed for ADL's, (#143). Findings: Resident #143 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #143 had a Brief Interview for Mental Status (BIMS) score of 13 indicating his cognition was intact. He had severely impaired vision, required extensive assistance of 1 staff person for eating and personal hygiene, and was totally dependent on 2 staff person for bathing. His care plan for ADL self-care performance deficit initiated on 09/30/21 revealed staff should check nail length and trim and clean on bath day and as necessary and to report any changes to the nurse. His care plan for potential/actual impairment to skin integrity initiated on 09/30/21, and revised on 10/17/21 noted resident should avoid scratching his skin and keep finger nails short. Review of the Point of Care tasks response history form from 09/30/21 to 10/20/21 revealed resident #143 received a shower on 10/13/21. He was provided bed bath daily from 09/30/21 to 10/19/21. On 10/19/21 at 10:52 AM, resident #143 was alert and in bed. His finger nails to both hands were 1/2 centimeters (cm) long, jagged, and had dark brown debris in nailbeds. He stated he preferred to have his nails trimmed and cleaned as he sometimes used his hands during meals. He also stated that no one had asked him if he wanted his finger nails trimmed and cleaned. On 10/20/21 at 1:58 PM, resident #143 was seated in his wheelchair. His finger nails remained long with dark debris under nailbeds. On 10/20/21 at 2:14 PM, Certified Nursing Assistant (CNA) A stated she had been assigned to the resident's care since he was on the other unit before he was transferred to the current unit. She said he was totally dependent for most of his ADL care as he had vision problems. She added he never refused care and he was given complete bath last Thursday, 10/14/21. She explained when providing bed bath, CNAs were supposed to check the resident from top to bottom, shave facial hair or beard if needed and check finger nails if they needed to be cleaned and trimmed. At 2:25 PM, she acknowledged resident #143's finger nails needed to be cleaned and trimmed. She explained she had 11 assigned residents during her shift and did not have time to clean his nails. She said the residents assigned to her were not confused but they demanded too much. On 10/22/21 at 10:12 AM, the Interim Director of Nursing (DON) stated that during showers, CNAs were expected to wash the resident's hair, shave facial hair/beard, clean and/or trim nails if needed. If residents refuse, the assigned nurse needed to be notified of the refusal. She also stated that sometimes, the activity staff helped in providing nail care for the residents. On 10/22/21 at 10:20 AM, the Activity Director said for dependent residents, the activity staff provided multisensory stimulation which included massaging hands. He said if the resident preferred to have a manicure, it would be provided as part of the activity. Review of activity task form dated 09/30/21 to 10/21/21 indicated resident #143 did not receive any manicure as part of the activities provided to him. The ADL care of fingernails/toenails guideline dated 05/13/21 revealed that under general guidelines, nail care includes daily cleaning of the finger nails and regular trimming of finger nails and toenails.

Based on interview and record review, the facility failed to provide showers as per the resident's preference, and as scheduled for 1 of 5 residents reviewed for choices of a total sample of 57 residents, (#133). Findings: Resident #133 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 9/30/21 revealed the resident's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS) score of 12/15. A question on the assessment, How important is it to you to choose between a tub bath, shower, bed bath , or sponge bath, was answered as very important. Resident #133 required extensive assistance with one person physical assist for dressing, and personal hygiene, and had total dependence on staff for bathing. On 10/18/21 at 1:02 PM, and 10/20/21 at 10:24 AM, resident #133 stated he had not received a shower since his admission to the facility. He explained he had bed baths, but wanted to have showers. On 10/20/21 at 12:15 PM, the Director of Nursing (DON) stated showers were scheduled at least twice weekly, and bathing was based on the resident's preference. She said showers/baths were documented in the resident's electronic record. The DON noted if the resident refused his/her showers/bath it would be documented in the electronic record in Point of Care Response History. Review of the Tasks and the Certified Nursing Assistant's (CNA) Kardex revealed the resident preferred showers, and his preferred days were Wednesday and Saturday. Review of the Point of Care Response History form from 9/24/21 to present revealed the resident received a shower on 9/29/21 and on 10/06/21. There was no documentation to indicate the resident received/refused his showers on his scheduled shower days on 10/02/21, 10/09/21, 10/13/21 and 10/16/21. A review of the Point of Care Response History regarding showers for resident #133 was conducted with the DON. She acknowledged the findings, and verbalized there was no documentation to indicate showers were given on the resident's scheduled shower days. The DON stated the expectation was that showers be given on the resident's scheduled shower days, unless refused by the resident. She explained the Point of Care Response History had a category to document refusal, and no refusals were documented. On 10/20/21 at 1:44 PM, Registered Nurse (RN) C stated showers were scheduled and given per the resident's preference. RN C said if a resident refused his/her showers, the CNA would report to the resident's nurse and the refusal would be documented. RN C stated there were no reports of refusals of showers by resident #133. On 10/20/21 at 2:27 PM, CNA B said there was a list of resident to be showered each day. She said if the resident refused his/her showers, it would documented by the CNA, and the resident's nurse. CNA B did not provide an answer as to why the resident did not receive showers as per his preference. A care plan for Activities of Daily Living (ADL) self-care performance deficit, created on 9/24/21 included, Showers-Extensive Assist x 1. The policy Activities of Daily Living (ADL's), last reviewed on 5/13/21 read, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral care. The policy Resident Rights with effective date 8/15/2017 read, .Our residents have the right to make choices about how they want to live their lives and receive care .Make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, interview, and record review the facility failed to ensure licensed nursing staff were knowledgeable and competent with the disinfection process of blood glucose meters used to test resident's blood glucose levels according to the germicidal bleach wipe's manufacturer guidelines. This failure placed 21 residents requiring blood glucose testing at risk for unnecessary exposure to blood borne pathogens and highly contagious infectious microorganisms and actual or high likelihood of becoming seriously ill or death, (#41, #75, #454, #135, #138, #86, #146, #100, #55, #79, #14, #58, #59, #50, #69, #19, #66, #98, #137, #25, #136). Two of these residents had [DIAGNOSES REDACTED]. On 01/27/20, it was identified that 4 licensed nurses on 3 of 3 nursing units had not received clinical competency for disinfection of blood glucose meters in accordance with manufacturer's directions for use. The failure to clean and disinfect the blood glucose meters according to manufacturer's guidelines for proper contact time placed all 21 residents requiring blood glucose testing at risk for unnecessary exposure to blood-borne disease causing micro-organisms that can cause serious illness, harm, or death. This failure resulted in Immediate Jeopardy starting on 1/27/20. The Immediate Jeopardy was removed on 1/29/20 prior to exit. The scope and severity of the deficiencies was lowered to an E, pattern, no actual harm with potential for more than minimal harm. Findings: Cross reference F880 On 01/27/20 at 12 PM, an observation of resident #138's blood glucose testing was conducted with Registered Nurse (RN) A on the 300 unit. Resident #138 had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. RN A removed a 3-inch by 3-inch germicidal bleach wipe from an individual packet and wiped the surfaces of the blood glucose meter for 15 seconds and placed the meter on the cart to air dry. RN A said that she had disinfected the meter for 15 seconds. RN A then proceeded into resident #135's room to conduct another blood glucose test with the same glucose meter. While in resident #135's room she removed a 3-inch by 3-inch germicidal bleach wipe from an individual packet and wiped the blood glucose meter for 10 seconds after she completed resident #135's blood glucose test. While at the bedside, she wiped the blood glucose meter with another 3-inch by 3-inch germicidal bleach wipe 10 seconds. RN A returned to the medication cart and placed the blood glucose meter on top of a second blood glucose meter located in the top right-hand drawer of the medication cart. She stated that according to the manufacturer's instructions, the minimum continuous wet contact time to kill bacteria [MEDICAL CONDITION] was 30 seconds. RN A stated that she was a new nurse and had worked in the facility as an RN for approximately 10 months. Review of resident #135's medical record revealed a physician's orders [REDACTED]. Review of the facility's resident list with [DIAGNOSES REDACTED]. Resident #69 had [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and had physician orders [REDACTED]. Review of resident #69's Medication Administration Record [REDACTED]#138 and #135. On 01/28/20 at 4:15 PM, Licensed Practical Nurse (LPN) L stated that the nurses worked on different nursing units, different hallway assignments and different medication carts when picking up extra shifts. She said that she had been assigned to different medication carts and had taken care of different residents throughout the facility. On 01/29/20 at 10 AM, LPN K revealed that she was typically assigned to the 300 unit but had worked on different nursing units and different medication carts when the facility needed her to do so. On 01/27/20 at 4:44 PM, an observation of resident #124's blood glucose testing was conducted with LPN D on the 100 unit. LPN D completed the blood glucose test and then returned to her medication cart. She removed one 5-inch by 7-inch alcohol wipe from a purple topped container and wiped the blood glucose meter surface back and forth for 10 seconds. LPN D stated that she had disinfected the blood glucose meter for a total of 10 seconds and placed the meter on the medication cart to dry. She stated that she had just received an in-service earlier that day (01/27/20) by the Assistant Director of Nursing (ADON)/Educator on the process for disinfecting the glucose meters. Review of resident #124's medical record revealed she had physician orders [REDACTED]. At 4:59 PM, LPN D conducted a blood glucose test with resident #454 residing on the 100 unit. After competing resident #454's blood glucose test, LPN D returned to her medication cart and removed a 5-inch by 7-inch alcohol wipe from the purple topped container. LPN D wiped the surface of the glucose meter for 15 seconds and then placed the glucose meter on a plastic tray located on the top of the medication cart to air dry. When LPN D completed wiping the blood glucose meter with the alcohol wipe the 100 unit manager approached LPN D, gave her a handful of the individual germicidal bleach wipe packets and instructed her not to use the wipes from the container with the purple top containing alcohol wipes. Review of resident #454's medical record revealed physician orders [REDACTED]. Review of the facility's resident list with diagnoses, provided by the Director of Nursing (DON) revealed there were 7 residents residing on the 100 unit with physician orders [REDACTED]. On 01/27/20 at 4:37 PM, an interview with LPN [NAME] revealed she did not have any residents who required blood glucose testing. When asked how she disinfected blood glucose meters after use, LPN [NAME] removed the blood glucose meter from her medication cart. She opened a 3-inch by 3-inch germicidal bleach wipe from the packet and proceeded to wipe the front, back and sides of the meter twice. She then placed the blood glucose meter on 2 tissues and wrapped the meter with the tissues. She then picked up the blood glucose meter and dried the front and back of the meter with the 2 tissues. LPN [NAME] stated, We need to follow the germicidal bleach wipe manufacturer's guideline for use. LPN [NAME] reviewed the manufacturer's guidelines and stated, I did not ensure that the glucose meter was wet for 1 minute and I wiped the meter with the tissues instead of allowing the meter to air dry. On 01/27/20 at 5 PM, RN F working on the 200 unit gathered supplies to do blood glucose testing on resident #75. She placed the supplies on the resident's overbed table and as the resident repositioned herself, she hit the table causing the supplies to fall to the floor. RN F picked up the supplies and returned to her medication cart. She removed a 3-inch by 3-inch germicidal bleach wipe from the packet and proceeded to wipe the front, back and sides of the glucose meter for 10 seconds and placed the meter on a tissue to dry. At 5:10 PM RN F re-entered resident #75's room with the new glucose testing supplies. The glucose meter was still wet. Next, RN F completed the blood glucose test. While still at resident #75's bedside, RN F removed a 3-inch by 3- inch germicidal wipe from the packet and wiped the meter for 5 seconds. At 5:17 PM she returned to her medication cart and cleaned the glucose meter incorrectly for the third time by cleaning the meter for 5 seconds and placed it on a plastic tray. RN F attempted to review the manufacturer's instructions for disinfecting the meters but had difficulty reading the instructions. The surveyor reviewed the instructions with RN F. She stated, I did not keep the meter wet for the required time. Review of resident #75's medical record revealed physician orders [REDACTED]. On 01/27/20 at 5:34 PM, the 200 unit manager stated that it was the expectation that the nurses followed the germicidal bleach wipe manufacturer's guidelines for disinfecting the blood glucose meters. We clean and disinfect the blood glucose meters because the meter is exposed to resident's blood during blood glucose testing. Blood carries blood-borne pathogens [MEDICAL CONDITION](Human Immunodeficiency Virus) and [MEDICAL CONDITION] we want to prevent resident to resident cross-contamination. Review of the Manufacturer's Germicidal Bleach Wipes packet revealed Directions for Use: . 3. Apply pre-saturated towelette and wipe desired surface to be disinfected . 5. A 30 second contact time is required to kill all of the bacteria [MEDICAL CONDITION] on the label except a 1 minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] (fungus) and [MEDICATION NAME] Mentagrophytes (fungus) and a 3 minute contact time is required to kill [MEDICAL CONDITION] spores (disrupts normal healthy bacteria in the colon). Reapply as necessary to ensure the surface remains wet for the entire contact time. 6. Allow surface to air dry and discard used wipe and empty packet On 01/27/20 the Director of Nursing (DON) provided the facility's Glucometer Disinfecting Competency (not dated). Review of the form revealed . Current approved disinfecting agent: (Manufacturer Name) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol) . 4. Clean the glucometer after each use, using the approved bleach disinfectant wipe and ensure all external surfaces of the glucometer remain wet for a period of no less than 3 minutes . 6. Wipe meter dry with a clean lint free cloth/paper towel or allow to air dry The Glucometer Disinfecting Competency did not follow the germicidal bleach wipe manufacturer's guidelines for use. Review of RN A, RN F, LPN [NAME] and LPN D Glucometer Disinfecting Competencies revealed the competencies had been completed on 01/27/20 after it had been identified by the survey team that the licensed nurses were not disinfecting the blood glucose meters according the manufacturer's guidelines. RN F scored an 87% on the competency and the form documented that she had not used the approved bleach disinfectant wipe and ensured all external surfaces of the glucometer remained wet for a period of no less than 3 minutes. On 01/27/20 at 6:43 PM, an interview was conducted with the Administrator, Assistant Administrator, DON and Assistant Director of Nursing (ADON)/Educator. The DON said that the Glucometer Disinfecting Competency was the facility's policy. The competency form was reviewed. 1. Current approved disinfectant: (Manufacturer Name) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol). The DON stated that the nurses were to use a bleach wipe from the blue topped container. The ADON/Educator stated that the nurses were to use either the single packet 3-inch by 3-inch or the 6-inch by 5-inch bleach wipes. The nurse was to make sure the bleach wipe was wrapped around the blood glucose meter. When the surveyor asked how a 3 inch by 3 inch wipe would wrap around the meter, the ADON/Educator replied that the single use wipes were too small, and the nurses should be using the larger wipes to ensure they are covering the entire surface of the meter. The DON confirmed that the bleach wipes were to be used for disinfecting for a 3-minute contact time to ensure pathogens were killed including [MEDICAL CONDITIONS]. The Administrator, DON and ADON/Educator verified that the Glucometer Disinfecting Competency was confusing as it instructed to use alcohol-based wipe and further instructed to use a bleach-based wipe. The DON and ADON/Educator did not provide an answer when the surveyor questioned as to why RN A, RN F, LPN [NAME] and LPN D were not following the correct process for disinfection despite having passed the competency test. The ADON/Educator stated that the disinfection process for glucose meters was taught in general orientation. She stated she had been busy working on other things and had not, completed any audits with the nurses to assure they are cleaning and disinfecting the blood glucose meters per manufacture's guidelines. They were informed that the 4 nurses had not used the correct contact time during disinfecting of the blood glucose meters. On 01/29/20 at 11:05 AM, the DON provided an LPN/RN Nurse Orientation Checklist, dated 06/03/2019 but stated she had never seen the form. She said the Assistant Director of Nursing (ADON)/Educator had been at the facility since (MONTH) 2019 and she was also not aware of this form. On 01/30/20 at 12:54 PM, the ADON/Educator stated that she was responsible for the orientation program for the licensed nurses. LPN P assists her with the orientation and Human Resource does a portion of the general orientation. The licensed nurses have a series of trainings including the computer system and then the new nurse is placed on floor orientation with another nurse. The new nurse is oriented to the unit, observes the nurse, accesses the computer, conducts medication administration, charting, lab ordering and results, contacting the physician, and treatments. This clinical orientation lasts for about 3 days and the nurse on the floor signs off on the new nurse. The ADON/Educator stated that she meets again with the new nurse to review communication, resident rights, charting, and other areas that are not covered with the nurse on the unit. We also go over different competencies and there is a checklist for the nurses. Review of RN F's Orientation Checklist dated 08/31/19, 09/01/19 and 09/02/19 revealed no signature of the nurse that provided clinical floor orientation and no signature of the ADON/Educator responsible for the orientation of new staff in the facility. The form documented only check marks and the signature of the nurse receiving orientation. On 01/30/20 at 1:37 PM, the DON stated that she and the ADON/Educator were not aware of the nurse orientation checklist until a few days ago, 01/27/20. The DON stated that as of 01/28/20 the new nurses that were hired since (MONTH) 2019 had been brought back to the facility to complete the checklist. The DON confirmed that since (MONTH) 2019 until 01/27/20, there was no checklist for the licensed nurse's orientation. The DON stated, We have no process in place to establish if the nurses are competent. The DON was asked how they knew if a floor nurse was competent to train a new nurse if there was no process in place to establish competency. The DON replied, We don't. The DON further stated that the cleaning/disinfection of blood glucose meters was not included on the LPN/RN Nurse Checklist form. On 01/30/20 at 3:10 PM, the DON said that she and the ADON/Educator were not aware of the LPN/RN Nurse Orientation Checklist. A review of LPN F's orientation file showed an Orientation Checklist dated 08/29/19 which was her date of hire. The DON did not provide an answer when asked who completed the orientation checklist. The DON then stated that the checklist was completed on 1/29/20, not 8/29/19. The DON was then asked to provide the LPN/RN Nurse Orientation Checklist forms with the actual date completion dates. On 01/30/20 at approximately 5:40 PM, the DON provided 13 LPN/RN Nurse Orientation Checklist forms. Review of the forms revealed: LPN F form dated 08/14/19 was now dated 01/28/20, LPN D form dated 08/18/19 was now dated 01/28/20, LPN M form dated 10/31/19 was now dated 01/28/20, LPN N form dated 11/24/19 was now dated 01/28/20, LPN O form dated 07/17/19 was now dated 01/28/20, LPN P form dated 05/08/20 was now dated 01/29/20, RN Q form dated 12/29/19 was now dated 01/28/20, RN R form dated 01/27/20 was now dated 01/30/20, LPN S form dated 07/02/19 was now dated 01/28/20, RN T form dated 01/13/20 was now dated 01/29/20, LPN U form dated 12/07/19 was now dated 01/28/20, LPN V form dated 07/29/19 was now dated 01/28/20, and LPN W form dated 06/25/19 was now dated 01/28/20. Review of the orientation file for LPN Y, date of hire (DOH) 12/11/17, LPN K, DOH 01/15/17, and LPN Z, DOH 07/28/08 revealed no LPN/RN Nurse Orientation Checklists. Review of the Facility Assessment Tool, dated 08/18/2017, read, . Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies . Part 3 . ensure a sufficient number of qualified staff are available to meet each resident's needs . Staff training/education and competencies 3.4 . which competencies are reviewed at the time the staff member is hired . Infection control - facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies and procedures for the program . Competencies . Specialized care . diabetic blood glucose testing On 01/30/20 at 3:47 PM, a call was placed to the facility's medical director. The medical director did not return the call as of the exit on 01/30/20. Review of the facility's corrective measures in their Immediate Jeopardy removal plan revealed the following: The (Manufacturer Name) Glucometer Disinfectant Competency was corrected on 1/29/20 to include the germicidal bleach wipe manufacturer's guidelines for disinfecting the blood glucose meter. Education was started on 1/27/20 with all current licensed nurses for following the manufacturer's guidelines for disinfecting the blood glucose meters. As of 1/29/20, 56 of 62 licensed nurses were trained. The facility had a process in place to ensure that the nurses who had not worked would receive training before they started working on the nursing units. A new Orientation Checklist was revised on 1/29/20 to include cleaning and disinfecting process for the blood glucose meters. On 01/30/20 observations of the blood glucose meter disinfecting process were conducted with 6 licensed nurses (RN A, LPN C, LPN D, LPN, K, LPN, M and LPN, N) and revealed no issues. On 01/30/20 at 4:21 PM, an observation and interview were conducted with LPN K. She stated that she had received in-service on the proper disinfecting of the blood glucose meters per the manufacturer's guidelines. LPN K wrapped the blood glucose meter with the germicidal bleach wipe for 3 minutes and then allowed the meter to air dry. On 01/30/20 at 4:19 PM, LPN C was observed disinfecting the blood glucose meter. She wiped the meter with a germicidal bleach wipe and then wrapped the meter with a second germicidal bleach wipe for three minutes and allowed the meter to air dry. On 01/30/20 at 4:22 PM, LPN M was observed disinfecting the blood glucose meter. He wrapped the meter with the germicidal bleach wipe for three minutes and then allowed the meter to air dry. The DON developed a Glucometer Cleaning/Disinfection Audit tool for observations of 10 nurses weekly until all nurses had at least 2 successful documented competencies. An emergent Quality Assurance Performance Improvement (QAPI) meeting was held on 01/27/20 with the Medical Director to discuss the Immediate Jeopardy.

Based on observation, interview and record review the facility failed to ensure on-going infection control program focused on nationally accepted standards for infection control, manufacturer's guidelines for disinfection of resident care equipment, and facility policy and procedure for the prevention of resident infections and communicable diseases for 21 of 21 residents requiring blood glucose testing (#41, #75, #454, #135, #138, #86, #146, #100, #55, #79, #14, #58, #59, #50, #69, #19, #66, #98, #137, #25, #136). On 01/27/20, observations showed 4 licensed nurses on 3 of 3 nursing units did not properly disinfect the blood glucose meters according to the manufacturer's guidelines. There were 2 residents in the facility requiring blood glucose testing with highly contagious and serious infections. The facility's failure to ensure proper disinfection of the blood glucose meters according to manufacturer's guidelines for proper contact time and proper drying procedure placed 21 residents requiring blood glucose testing at risk for unnecessary exposure to blood-borne disease causing microorganisms and actual or high likelihood of becoming seriously ill or death. This failure resulted in Immediate Jeopardy starting on 01/27/20. The Immediate Jeopardy was removed prior to exit on 1/29/20. The scope and severity of the deficiencies was lowered to E, pattern, no actual harm with potential for more than minimal harm. Findings: Cross Reference F726. According to the Centers for Disease Control and Prevention (CDC) for Infection Prevention during Blood Glucose Monitoring and Insulin Administration dated (MONTH) 2, 2011, read, The CDC has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration Devices should be cleaned and disinfected after every use, per manufacturer's instruction An underappreciated risk of blood glucose testing is the opportunity for exposure to blood-[MEDICAL CONDITION] (HBV, [MEDICAL CONDITION] virus, and human immunodeficiency virus ,[MEDICAL CONDITION]. through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of HBV infection associated with blood glucose monitoring have been identified with increasingly regularity, particularly in long-term care settings, such as nursing homes . In the past [AGE] years, alone, there have been at least 15 outbreaks of HBV infections associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. The Germicidal Bleach Wipes packet the facility used revealed . 3. Apply pre-saturated towelette and wipe desired surface to be disinfected . 5. A 30 second contact time is required to kill all of the bacteria [MEDICAL CONDITION] on the label except a 1 minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] (Fungus) and [MEDICATION NAME] Mentagrophytes (Fungus) and a 3 minute contact time is required to kill [MEDICAL CONDITION] spores (bacteria that disrupts normal healthy bacteria in the colon). Reapply as necessary to ensure the surface remains wet for the entire contact time. 6. Allow surface to air dry and discard used wipe and empty packet On 01/27/20 at 12 PM, observation of resident #138's blood glucose testing was conducted with Registered Nurse (RN) A on the 300 unit. Resident #138 had physician orders [REDACTED]. RN A removed a 3-inch by 3-inch germicidal bleach wipe from an individual packet. She wiped the surfaces of the blood glucose meter for 15 seconds and placed the meter on the cart to air dry. RN A said that she had disinfected the meter for 15 seconds. She then proceeded to resident #135's room to conduct another blood glucose test with the same glucose meter. While in resident #135's room, she removed a 3-inch by 3-inch germicidal bleach wipe from an individual packet and wiped the blood glucose meter for 10 seconds. She then completed resident #135's blood glucose test. While at the bedside, she wiped the blood glucose meter with another 3-inch by 3-inch germicidal bleach wipe for 10 seconds. RN A returned to the medication cart and placed the blood glucose meter on top of a second blood glucose meter located in the top right-hand drawer of the medication cart. RN A said that according to the manufacturer's instructions, the minimum continuous wet contact time to kill bacteria [MEDICAL CONDITION] was 30 seconds. RN A stated that she was a new nurse and had worked in the facility as an RN for approximately 10 months. Review of resident #135's medical record revealed a [DIAGNOSES REDACTED]. Review of the facility's resident list with diagnoses, provided by the Director of Nursing (DON) revealed there were 9 residents residing on the 300 unit with [DIAGNOSES REDACTED]. Resident #69 had [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and had physician orders [REDACTED]. Review of resident #69's Medication Administration Record [REDACTED]#138 and #135. On 01/28/20 at 4:15 PM, Licensed Practical Nurse (LPN) L stated that the nurses worked on different nursing units, different hallway assignments and different medication carts when picking up extra shifts. She said that she had been assigned to different medication carts and had taken care of different residents throughout the facility. On 01/29/20 at 10 AM, LPN K revealed that she was typically assigned to the 300 unit but had worked on different nursing units and different medication carts when the facility needed her to. On 01/27/20 at 4:44 PM, an observation of resident #124 blood glucose testing was conducted with LPN D on the 100 unit. LPN D completed the blood glucose test and then returned to her medication cart. She removed one 5-inch by 7-inch alcohol wipe from the purple topped container and wiped the blood glucose meter surface back and forth for 10 seconds. LPN D stated that she had disinfected the blood glucose meter for a total of 10 seconds and placed the meter on the medication cart to dry. She stated that she had just received an in-service earlier that day (01/27/20) by the Assistant Director of Nursing (ADON)/Educator on the process for disinfecting the glucose meters. Review of resident #124's medical record revealed she had a [DIAGNOSES REDACTED]. At 4:59 PM, LPN D conducted a blood glucose test with resident #454 residing on the 100 unit. After completing resident #454's blood glucose test, LPN D returned to her medication cart and removed a 5-inch by 7-inch alcohol wipe from the purple topped container. LPN D wiped the surface of the glucose meter for 15 seconds and then placed the glucose meter on a plastic tray located on the top of the medication cart to air dry. When LPN D completed wiping the blood glucose meter with the alcohol wipe, the 100 unit manager approached LPN D, gave her a handful of the individual germicidal bleach wipe packets and instructed her not to use the wipes from the container with the purple top. Review of resident #454's medical record revealed she had a [DIAGNOSES REDACTED]. Review of the facility's resident list with diagnoses, provided by the Director of Nursing (DON) revealed there were 7 residents residing on the 100 unit with physician orders [REDACTED]. On 01/27/20 at 4:37 PM, an interview with LPN [NAME] revealed she did not have any residents who required blood glucose testing. When asked how she disinfected blood glucose meters after use, LPN [NAME] removed the blood glucose meter from her medication cart. She opened a 3-inch by 3-inch germicidal bleach wipe from the packet and proceeded to wipe the front, back and sides of the meter twice. She then placed the blood glucose meter on 2 tissues and wrapped the meter with the tissues. She then picked up the blood glucose meter and dried the front and back of the meter with the 2 tissues. LPN [NAME] stated, We need to follow the germicidal bleach wipe manufacturer's guideline for use. LPN [NAME] reviewed the manufacturer's guidelines and stated, I did not ensure that the glucose meter was wet for 1 minute and I wiped the meter with the tissues instead of allowing the meter to air dry. On 01/27/20 at 5 PM, RN F working on the 200 unit gathered supplies to do blood glucose testing on resident #75. She placed the supplies on the resident's overbed table and as the resident repositioned herself, she hit the table causing the supplies to fall to the floor. RN F picked up the supplies and returned to her medication cart. She removed a 3-inch by 3-inch germicidal bleach wipe from the packet and proceeded to wipe the front, back and sides of the glucose meter for 10 seconds and placed the meter on a tissue to dry. At 5:10 PM RN F re-entered resident #75's room with the new glucose testing supplies. The glucose meter was still wet. Next, RN F completed the blood glucose test. While still at resident #75's bedside, RN F removed a 3-inch by 3- inch germicidal wipe from the packet and wiped the meter for 5 seconds. At 5:17 PM she returned to her medication cart and cleaned the glucose meter incorrectly for the third time by cleaning the meter for 5 seconds and placed it on a plastic tray. RN F attempted to review the manufacturer's instructions for disinfecting the meters but had difficulty reading the instructions. The surveyor reviewed the instructions with RN F. She stated, I did not keep the meter wet for the required time. Review of resident #75's medical record revealed she had a [DIAGNOSES REDACTED]. On 01/27/20 at 5:34 PM, the 200 unit manager stated that it was the expectation that the nurses followed the germicidal bleach wipe manufacturer's guidelines for disinfecting the blood glucose meters. We clean and disinfect the blood glucose meters because the meter is exposed to resident's blood during blood glucose testing. Blood carries blood-borne pathogens [MEDICAL CONDITIONS] we want to prevent resident to resident cross-contamination. Review of the facility's resident list with diagnoses, provided by the Director of Nursing (DON) revealed there were 5 residents residing on the 200 unit with physician orders [REDACTED]. One of the 5 residents #49 had a [DIAGNOSES REDACTED]. Review of resident #49's physician orders [REDACTED]. On 01/27/20 at 5:42 PM, the DON stated that the facility did not have a policy and procedure for the cleaning and disinfecting of the blood glucose meters. We are using the Glucometer Disinfectant Competency. She stated that she was not aware that nurses did not disinfect the meters properly. I didn't know there was a problem. We have not been auditing the process. Review of the facility's (Manufacturer's Name) Glucometer Disinfectant Competency, not dated, read, . Materials Needed: Current approved disinfecting agent: (Manufacturer Name) Bleach Germicidal Wipes . 4. Clean the glucometer after each use, using the approved bleach disinfectant wipe and ensure all external surfaces of the glucometer remain wet for a period of no less than 3 minutes . 6. Wipe meter with a dry clean lint free cloth/paper towel or allow to air dry Review of the facility's Infection Prevention and Control Policy, dated 01/04/18, read, Policy: It is the policy of this facility to provide a safe, sanitary, and comfortable environment. This facility will investigate, control, and attempt to prevent the development and transmission of infections. The Infection prevention and control program will identify, investigate and control infections and communicable diseases for all residents, staff, volunteers, visitors, and other contracted individuals. Procedure: . 4. The Facility will provide precautionary measures to prevent the spread of potential infection, while monitoring resident's progress per CDC recommendations . 6. The infection prevention practices will be monitored and documented as part of the Quality Assurance and Assessment program. Review of the facility's Infection Control Exposure Control-Blood Borne Pathogens Policy and Procedure, dated 10/16/08, read, Policy: It is the policy of this facility to maintain an infection control program designed to provide a safe and sanitary environment for residents and employees: and to help prevent the development and transmission of disease and infection by blood borne pathogens. Procedure: 1. Make every effort to avoid exposure to a resident's blood/body fluids . 3. Work Practice Controls are acts done to prevent chance of exposure Review of the facility Infection Control Equipment Cleaning and Storing Policy and Procedure, dated 07/01/19, read, Policy: The proper cleaning, disinfection, and storage of resident care items and equipment used for both personal needs and medical treatment are essential to promoting health and preventing pathogen transportation. Procedures: . 4. Maintaining Equipment: All equipment used in the facility will be cleaned and disinfected according to manufacturer instructions . Allow disinfectant to be on the equipment for the recommended wet contact time Review of the Facility Assessment Tool, dated 08/18/2017, read, . Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Part 1 Our Resident Profile . 1.3 . Metabolic Disorders: Diabetes . Staff training/education and competencies 3.4 . Specialized care: . diabetic blood glucose testing On 01/30/20 at 3:47 PM, a call was placed to the facility's medical director for interview. The medical director did not return the telephone call before exit on 01/30/20. Review of the facility's corrective measures in their Immediate Jeopardy removal plan revealed the following: The (Manufacturer Name) Glucometer Disinfectant Competency was corrected on 1/29/20 to include the germicidal bleach wipe manufacturer's guidelines for disinfecting the blood glucose meter. Education was started on 1/27/20 with all current licensed nurses for following the manufacturer's guidelines for disinfecting the blood glucose meters. As of 1/29/20, 56 of 62 licensed nurses were trained. The facility had a process in place to ensure that the nurses who had not worked would receive training before they started working on the nursing units. A new Orientation Checklist was revised on 1/29/20 to include cleaning and disinfecting process for the blood glucose meters. On 01/30/20 observations of the blood glucose meter disinfecting process were conducted with 6 licensed nurses (RN A, LPN C, LPN D, LPN, K, LPN, M and LPN, N) and revealed no issues. On 01/30/20 at 4:21 PM, an observation and interview were conducted with LPN K. She stated that she had received in-service on the proper disinfecting of the blood glucose meters per the manufacturer's guidelines. LPN K wrapped the blood glucose meter with the germicidal bleach wipe for 3 minutes and then allowed the meter to air dry. On 01/30/20 at 4:19 PM, LPN C was observed disinfecting the blood glucose meter. She wiped the meter with a germicidal bleach wipe and then wrapped the meter with a second germicidal bleach wipe for three minutes and allowed the meter to air dry. On 01/30/20 at 4:22 PM, LPN M was observed disinfecting the blood glucose meter. He wrapped the meter with the germicidal bleach wipe for three minutes and then allowed the meter to air dry. The DON developed a Glucometer Cleaning/Disinfection Audit tool for observations of 10 nurses weekly until all nurses had at least 2 successful documented competencies. 21 residents/resident responsible party, attending physicians and the medical director were notified on 1/29/20 of the potential blood borne pathogen exposure. Consent forms [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] were requested. On 01/29/20 lab testing was ordered on all residents requiring blood glucose testing for [MEDICAL CONDITION] and [MEDICAL CONDITION] and for those who consented [MEDICAL CONDITION]. Consent forms and physician orders [REDACTED]. An emergent Quality Assurance Performance Improvement (QAPI) meeting was held on 01/27/20 with the Medical Director to discuss the Immediate Jeopardy.

Based on observation, interview, and record review the facility failed to complete a self-administration of medication assessment for a resident's medication at bedside for 1 of 1 resident, (#142). Findings: Resident #142 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 5 day assessment dated [DATE], revealed her Brief Interview for Mental Status (BIMS) score was 10 which indicated moderate cognitive impairment. She required limited to extensive assistance for all Activities of Daily Living (ADL's) except supervision for eating, and needed partial assistance from staff to take medications. On [DATE] at 1:03 PM, resident #142 was observed in bed. Multiple medications were noted to be on the overbed tray table in front of her in an open plastic container which read Please do not remove. The medications included an open bottle of Clear Eyes Complete (used for dry eyes) 0.5 ounce (oz.) with an expiration date of ,[DATE], an open bottle of Natural Balance Tears (used for dry eyes) 0.5 oz. with an expiration date of ,[DATE], 2 open bottles of Travoprost solution (for [MEDICAL CONDITION]) 0.004% 0.5 milliliters (ml) with expiration dates of [DATE] and ,[DATE], and a tube of [MEDICATION NAME] cream 0.5% 15 oz. (used for [MEDICAL CONDITION] and psoriasis) which was half empty with an expiration date of ,[DATE]. At 1:05 PM resident #142 stated, I put the green top eye drops in both my eyes every night, indicating the Travoprost 0.004% bottles. The day and evening nurses gives me eye drops with the blue and purple top bottles. I do the green one myself ever since I've been here. I don't remember signing a paper to take my own medication. I use the cream on my hands when I need it and I put the other eye drops in my eyes when I need them (indicating the refresh tears and natural balance tears). Review of resident #142's current Medication Administration Record [REDACTED]. A review of resident #142's medical records revealed no orders for self-administration, no self-administration assessments or care plans regarding self-administration. Resident #142's comprehensive plan of care dated [DATE] indicated the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. On [DATE] at 1:20 PM, Licensed practical nurse (LPN) C, stated the medications on resident#142's overbed tray table included over the counter expired Clear Eyes Complete and one of the two bottles of Travoprost that were also expired. LPN C stated, I don't know if she has an order to take her own eye drops. I've noticed them at the bedside before, but she won't let us remove them. She does have an order for [REDACTED]. At 1:36 PM the unit manager registered nurse (RN) B stated we usually don't allow anyone to take their own medications. She (resident #142) is not supposed to have any medications at her bedside. She doesn't have a current order or had an assessment to take her own medications. On [DATE] at 12:02 PM, certified nursing assistant (CNA) G stated I've seen the box on her bedside table, but I didn't notice the meds in the box. On [DATE] at 1:13 PM, RN B stated, my staff should have said something if they noticed any medications at the bedside. I did not know she was taking her own eye drops. The nurses have been documenting that they have been giving the resident her Travoprost eye drops in the evenings. At 4:05 PM the Director of Nursing (DON) stated, the nurses should have gotten a self-administration order, and assessment, updated the care plan and provided a lock box if the resident was appropriate to take her own medications. I didn't know she was self-medicating and she shouldn't have been because she is confused. I can't explain how this happened. Review of facility's Clinical Practice Guidelines, Self-Administration of Medication, dated, [DATE], read, . 1. If a resident expresses a desire to self-administer medications to a licensed staff member, they will complete the self-administration analysis form. 2. A staff member is designated to complete the analysis and the findings are then shared with the ICP team members who include: the physician, resident, and family. 3. The findings will be presented to the ICP team within the completion of the analysis. 4. Until such determination is reached, the facility will continue to administer medication

Based on observation, interview and record review, the facility failed to develop a comprehensive individualized care plan with interventions to address administration of oxygen for 1 of 6 residents reviewed for respiratory care of a total sample of 20 residents who received respiratory care, (#347). Findings: Resident #347 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/7/20 he was re-hospitalized on [REDACTED]. He had a physician order [REDACTED]. On 1/27/20 at 1 PM and on 1/28/20 at 10:15 AM, 1:55 PM and 5:30 PM, observations of resident #347 revealed that he was lying in bed receiving oxygen (O2) via nasal cannula at 3 to 3 1/2 liters per minute with oxygen concentrator at the bedside. Review of resident #347's (MONTH) 2020 medication administration records (MAR) revealed orders pre/post hospitalization dated (12/31/19 to 1/8/20 and 1/23/20 to 1/29/20) for oxygen 2 liters per minute via nasal cannula every shift and change tubing every Thursday. Prior to hospitalization he was getting his oxygen saturation checked every shift from 12/31/19 to 1/8/20. Review of the admission Minimum Data Set, (MDS) assessment dated [DATE], revealed that he received oxygen services. Review of the resident's comprehensive care plans showed no documentation of oxygen therapy. On 1/30/20 at 11:23 AM, the MDS director stated that resident #347 did not have a comprehensive care plan for oxygen therapy. She stated that he should have a care plan as he received oxygen and had a history of [REDACTED]. She confirmed that he received oxygen therapy pre and post most recent hospitalization . She said the MDS nurse who completed the MDS assessment and care plans was not available for interview. She added that the unit manager or floor nurse could have also initiated the care plan when they entered the orders for his oxygen therapy.

Based on observation, interview and record review the facility failed to ensure respiratory therapy was provided as per physician orders for 2 of 6 residents (#347 & 141) and failed to ensure monitoring of oxygen for 1 of 6 residents reviewed for respiratory care (#347) out of a total sample of 61 residents. The facility failure to provide oxygen as ordered can result in hypoxemia (oxygen deficiency), which can lead to complications of the tissues and organs. Findings: 1. Resident #347 was readmitted from an acute care hospital on [DATE], with [DIAGNOSES REDACTED]. The AHCA 5000 3008 form (Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form) dated 1/22/20 indicated the resident was hospitalized due to exacerbation of [MEDICAL CONDITION]. The 300 unit manager's (UM) readmission notes dated 1/22/20 read, readmitted from .hospital with Dx (diagnosis) of [MEDICAL CONDITION] exacerbation and PNA (pneumonia) .SPO2 (oxygen saturation) 94% on O2 (oxygen) at 2 L/m (liters/minute) via NC (nasal cannula). A review of the resident's medical record revealed [REDACTED]. On 1/27/20 at 1 PM and 1/28/20 at 10:15 AM and 1:55 PM, resident #347 was observed in bed with oxygen via NC. The oxygen concentrator was set at 3 to 3 ½ LPM. On 1/28/20 at 5:30 PM, licensed practical nurse (LPN) J entered the resident's room and verified the resident's O2 concentrator was set at 3 ½ LPM and was connected to the resident via NC. On 1/28/20 at 5:44 PM, LPN J checked the physician orders for resident #347 and stated his oxygen concentrator should be set at 2 LPM. She said that she had not checked the oxygen concentrator settings today or yesterday while assigned to his care. She stated that too much oxygen could result in CO2 (carbon [MEDICATION NAME]) levels being too high, for residents with [MEDICAL CONDITION]. On 1/28/20 at 5:58 PM, the 100 UM stated that resident #347 was ordered to receive oxygen at 2 LPM via NC and the assigned nurses should have checked the liter flow at the beginning of each shift. She said that since the resident had [MEDICAL CONDITION], too much oxygen could cause him to retain too much CO2. A review of the nursing progress notes dated 1/22/20 to 1/28/20 revealed that facility staff were checking the SpO2 levels sporadically despite no physician orders. The levels showed, 1/22/20- SPO2 94% on O2 2L/m via NC, 1/23/20- Oxygen saturations ranging 94-98%, 1/24/20- Oxygen sats: 98%, 1/25/20- O2 sat: 97%, 1/26/20 3 liters Oxygen via nasal cannula, O2 sats: 97% and 1/27/20- O2 sat: 97% on room air. On 1/29/20 at 11:13 AM, the 300 UM stated that she did the re-admission assessment on resident #347 when he returned from the hospital on [DATE]. She said she reviewed his orders with the physician and should have included orders for Sp02 monitoring since he was on oxygen. On 1/29/20 at 10:14 AM, the Director of Nursing (DON) verified that the nurses did not follow standards of practice for monitoring the SpO2 levels for resident on oxygen and should have obtained physician order to monitor. A policy for pulse oximetry monitoring was requested and the DON said that they did not have one. A review of the facility Oxygen Therapy Concentrator Set-UP policy and procedure dated 1/2007 read, It is the policy of this facility to administer oxygen in a safe manner in accordance with accepted standards of practice .Procedure: Initiate setup of oxygen upon receipt of physician order .Documentation should include route of administration .and flow rate .Adjust flow meter to prescribed rate . 2) Resident #141 was initially admitted on [DATE] with [DIAGNOSES REDACTED]. The physician order dated 1/7/20 read, oxygen at 2 liters per minute (LPM) via nasal cannula (NC) continuous every shift. The Minimum Data Set (MDS) 5-day assessment dated [DATE] revealed that he had a Brief Interview for Mental Status score of 8/15 indicating moderately impaired cognition. He required extensive assistance of 1 person for bed mobility, transfers, dressing and toilet use. He was able to eat his meals with supervision from 1 person. On 01/27/2020 at 10:00 AM, resident #141 was observed in bed. He had oxygen via NC with the concentrator set at 3.5 LPM. At 1:19 PM, the oxygen setting was still at 3.5 LPM. On 01/28/2020 at 12:43 PM, the resident was resting in bed and had oxygen by NC with concentrator set at 3.5 LPM. On 01/28/2020 at 5:30 PM, RN O stated that the oxygen was set at 3.5 LPM. She stated that the nurses should have checked the setting every shift but had not. At 6:10 PM, the 100 Wing unit manager (UM) confirmed that the oxygen order was 2 LPM via NC continuous every shift. She also stated that nurses were supposed to check the settings at the start of each shift and as frequently as possible because the resident tended to increase the setting of the concentrator. Review of the resident's comprehensive care plan dated 12/12/19 revealed that he had [MEDICAL CONDITION] with intervention to administer oxygen via NC as ordered.

Based on observation, interview and record review, the facility failed to ensure the prescribed therapeutic diet of pureed consistency with nectar thick fluids was followed for 1 of 8 sampled residents, (#146). This failure resulted in the resident consuming the wrong consistency snack placing her at risk for aspiration/impairment/death. Resident #146 was the only resident identified as going to a higher level of care due to being given the incorrect diet type at the time of the survey. On 6/18/19 at 8:00 PM, resident #146 who was on a pureed consistency nectar thick liquid diet was given a peanut butter and jelly sandwich by the certified nursing assistant (CNA) as directed by the licensed practical nurse (LPN). After the resident ate some of the sandwich, the nurse noticed the resident had her hand on her throat and was turning blue. The nurse attempted to administer the [MEDICATION NAME] maneuver to the resident in her wheelchair but was unsuccessful. The resident was then lowered to the floor and the [MEDICATION NAME] was attempted again unsuccessfully. The nurse called for assistance and the director of nursing (DON) arrived on the unit. The DON suctioned the resident with a [MEDICATION NAME] suction tip and removed a 1 inch bolus of food from her mouth. She was treated with oxygen at 10 liters per minute via mask until the paramedics arrived. The resident was transported to the hospital with an admitting [DIAGNOSES REDACTED]. The facility's failure to follow the prescribed therapeutic diet resulted in substandard quality of care at the Immediate Jeopardy level, starting on 6/18/19. The facility implemented actions to remove the Immediacy as of 7/23/19. Findings: Cross Reference F726 and F835. Resident #146 was a long-term resident on the Dementia unit since (YEAR). Her [DIAGNOSES REDACTED]. She had a [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 physician orders [REDACTED]. The resident's quarterly minimum data set (MDS) assessment dated [DATE] identified her cognitive patterns with both short and long-term memory problems with severe impairment regarding tasks of daily life. She had unclear speech. She rarely/never made herself understood or understood others. She was assessed as extensive assist with one person for eating. The resident was not identified as having any symptoms of a swallowing disorder. She had a mechanically altered diet-texture (e.g., pureed food thickened liquids). Resident #146's care plan dated 6/10/19 identified that she had nutritional concerns as evidenced by [DIAGNOSES REDACTED]. The approaches included pureed diet with nectar thick liquids. Observe positioning during meals for proper body alignment to increase swallow ability. Offer assistance with meal consumption. Encourage to drink fluids offered especially with meals, snacks and medications. According to the National Institute of Health, . people with dysphagia have difficulty swallowing . Some people may be completely unable to swallow or may have trouble safely swallowing liquids, foods, or saliva. When that happens, eating becomes a challenge. Dysphagia is any condition that weakens or damages the muscles and nerves used for swallowing people with diseases of the nervous system, such as [MEDICAL CONDITION], often have problems swallowing. Food pieces that are too large for swallowing may enter the throat and block the passage of air. In addition, when foods or liquids enter the airway of someone who has dysphagia, coughing or throat clearing sometimes cannot remove it. (www.nidcd.nih.gov) The facility utilized the National Dysphagia Diet Guidelines Pureed/Dysphagia Level 1. This diet consists of pureed homogenous and cohesive foods in pudding-like consistency. Any foods that require bolus formation, controlled manipulation or mastication are excluded. This diet is designed for people who have moderate to severe dysphagia with swallowing phase abilities and reduced ability to protect their airway. Close or complete supervision or alternated feeding methods may be required on an individual basis. Review of the Academy of Nutrition and Dietetics Nutrition Care Manual © 2019, Foods lists are based on the International Dysphagia Diet Standardization Initiative Framework. Foods not recommended: Grains: any item that is not pureed or has lumps. Protein foods: Nut butters, unless pureed into other foods to correct consistency are to be avoided. A nursing progress note written by the DON on 6/19/19 at 7:52 AM noted that she was called to the unit by staff. Resident had been eating a sandwich then started gasping and vomited. Moved resident to room. Applied O2 (oxygen) via mask. Resident was coughing. Suctioned mouth with [MEDICATION NAME] suction and a large piece of sandwich came out of mouth. Vital signs stable (VSS). No [MEDICATION NAME] needed as airway was not occluded. 911 (emergency transport) was activated. Physician and resident representative notified. Resident was alert and talking when left building but still had some wetness noted in throat. 911 took resident to the hospital at 10:40 PM. Review of the nursing progress note dated 6/18/19 at 9:01 PM by LPN A showed that she spoke with the resident's guardian regarding possible aspiration. The physician was notified and gave order to send the resident to the hospital for evaluation. The resident left the building at 10:39 PM. Her vital signs were, blood pressure 155/79, pulse 106 and Oxygen (O2) saturation was 98% on 10 Liters (per minute) O2 by mask. The resident was suctioned with small bolus of food extracted. At the time of departure the resident was talking, with audible gurgling heard without auscultation. A nursing progress note dated 6/23/19 at 5:11 PM, showed that the resident returned to the facility at 4 PM from the hospital with [DIAGNOSES REDACTED]. Resident was alert to self .lungs diminished with mild crackles at bases . A review of the Patient transfer form AHCA Form 5000-3008 completed by the hospital physician on 6/23/19, noted the primary [DIAGNOSES REDACTED]. Review of the hospital computerized tomography (CT) of the chest without contrast on 6/18/19 at 10:07 PM indicated it was for shortness of breath. There was debris within the mid esophagus. The impression noted . 3. Debris within the mid esophagus which places the patient at risk for aspiration. Review of resident #146's minimum data set (MDS) 5-day readmission assessment dated [DATE] identified [DIAGNOSES REDACTED]. On 7/22/19 at 4:17 PM, the DON stated that on the evening of the choking incident, she was just getting ready to leave the facility. She was called to the secured unit and when she arrived, the resident was sitting on the floor coughing. When she got the resident to her room to suction her, the food bolus was already out of her throat. The food was just at the front of her mouth. I used the [MEDICATION NAME] suction to retrieve the food bolus from the back of her mouth. The DON stated that the root cause of the choking incident was the nurse (LPN A) did not know what a pureed diet consisted of. She said that the LPN thought if she gave the peanut butter sandwich with a drink of milk it would become pureed consistency. On 7/24/19 at 8:33 AM, LPN A was interviewed with the DON present. The LPN A had worked on the secure since (MONTH) (YEAR). She was working the 7 PM to 7 AM shift on 6/18/19 when the choking incident occurred. She stated that she was aware that the resident was ordered a pureed nectar thick diet. She recalled that two certified nursing assistants (CNA's) were passing out snacks in the television area by the nurse's station. One of the CNA's commented that resident #146 could not have a sandwich. I told the CNA that the resident could have a sandwich as long as it was given with milk. This was not accurate. A few minutes later, the CNA said that resident #146 did not look right. When I saw the resident, she had one hand on her throat and was turning blue. I attempted the [MEDICATION NAME] maneuver in her wheelchair unsuccessfully. I could not do it, so I asked someone to get the DON. The DON gave directions to take the resident to her room, get the suction machine and call 911. LPN A stated that she had been a nurse for [AGE] years and in her previous practice they would mix a solid food with liquid. She thought that if a peanut butter sandwich was given with milk it would become soft enough to become pureed consistency. She stated, I failed. I thought the peanut butter and jelly sandwich and milk/Ensure, and she drooled and I thought it would make it like a pureed and that was wrong. She stated that she did not know what else to say except it was her error. On 7/24/19 at 7:18 PM, interview with CNA B revealed that she and CNA EE were passing evening snacks at approximately 8:00 PM on 6/18/19. CNA EE had some cheese nips and asked LPN A if it was okay to give the cheese nips to resident #146. CNA B suggested the peanut butter and jelly sandwich. The LPN A said it was better to give the peanut butter and jelly sandwich. I knew the resident was on a pureed diet and we had never given her a sandwich before. We would usually give her puddings. We followed the LPN's direction and we gave her the sandwich then passed water and juice out to the other residents. About 2-3 minutes later, we noticed something was wrong with resident #146. We realized the resident was choking. She had eaten about half the sandwich and appeared as if she was going to vomit. Her face was pale. The LPN A attempted the [MEDICATION NAME] maneuver while the resident was in her wheelchair. We then took the resident out of her wheelchair and sat her on the floor. The nurse again tried the [MEDICATION NAME] but without success. The other nurse called the code and the DON arrived on the unit. The crash cart was taken to the resident's room. The DON kept suctioning the resident until finally a 1 inch ball of food was brought up and the resident coughed a little bit. She stated, As a CNA you are supposed to trust your nurse. I gave the sandwich when the nurse said it was better than the cheese nips. On 7/25/19 at 11:52 AM, the Speech Language Pathologist (SLP) revealed that resident #146 had been slowly declining prior to the choking incident. She needed cueing or assistance to eat. The restorative nurse was responsible for training the restorative aides based on the therapy notes. The SLP stated that she had not worked directly with resident #146. On 7/25/19 at 12:53 PM, the Restorative Registered Nurse stated that resident #146 needed to be cued and monitored while eating. The aides were supposed to monitor her while eating to ensure she took small bites. Review of the Dietary progress dated 6/10/19 at 2:52 PM by the food service director/certified dietary manager, documented that the resident was receiving a pureed texture/ nectar thick liquids diet without complications. On 7/23/19 at 11:00 AM, the food service director stated that prior to the choking incident, prescribed snacks labeled with the residents' names were brought to the unit as ordered by the physician at 8:00 PM every evening. There were additional snacks on the tray such as peanut butter and jelly sandwiches, crackers and chips in case any other resident who was not prescribed a snack, requested it. On 7/23/19 at 12:50 PM, resident #146 was in her bed and had just finished lunch with Restorative CNA T. The CNA stated that she ate 100% of her meal and only cleared her mouth once with little cough. The resident was aware that she was only to eat soft foods but did not know that she could not eat a sandwich. On 7/24/19 at 12:20 PM, the resident took 2 large spoonfuls of pureed vegetable followed by 3 spoons of mashed potato. She coughed after she ate the vegetables. Restorative CNA T suggested a drink and the resident took a sip and again coughed. The resident then resumed eating. She took 4 large sips of nectar thick apple juice and coughed again. The resident still showed signs of difficulty swallowing and clearing her throat completely. On 7/26/19 at 3:31 PM, the medical director stated he was informed of resident 146's choking incident within 24 hours. He stated that diet orders had to be followed as prescribed. A meeting was held with the administrative team on 7/23/2019 at 6:45 PM and they were informed of the Immediate Jeopardy. The administrator provided a plan to remove the Immediacy as of 7/23/19. The corrective measures in their Immediate Jeopardy removal plan revealed the following: * LPN A was suspended pending investigation and was individually educated prior to returning to work on 6/24/19. *An emergency ad hoc Quality Assurance and Performance Improvement meeting (QAPI) was held on 6/19/19 with a plan of action to educate all nursing staff. The follow-up plan was monitored at the regular QAPI meeting on 6/27/19. The plan of action was determined to be appropriate. *On 6/19/19 the facility reviewed and reassessed all residents on the 400 unit for signs and symptoms of aspiration. *All resident diet orders were reviewed for accuracy on 6/19/19. Discrepancies were corrected/clarified. Resident care plans and nursing aide data sheets were verified for accuracy. The facility eliminated unlabeled non-pureed type snacks. * Verbal and telephonic education to the nursing staff began on 6/19/19 to ensure diet orders were followed. Education included what constitutes mechanical soft and pureed diets, procedure for giving foods to residents, tray pass process, diet and fluid consistencies, when to notify the nurse or DON. Education was completed with 96% of nursing staff including new hires on 7/12/19. On 7/22/19, education records were not present from 6/25/19 and 6/28/19. Staff missing were re-educated and signed the confirmation or provided verbal telephonic confirmation that they had received the education. All therapy staff, housekeeping and maintenance staff were educated on 7/23/19. *Unit managers or their designee randomly audited snacks delivered to the unit two times a week for 4 weeks to verify appropriateness of snacks. No errors were identified. *The dietary policy and procedures adopted by the facility were reviewed for appropriateness on 6/19/19. No changes were required. The survey team expanded the sample to include 7 other residents who were on pureed diets. Observations of these residents were conducted with no identified concerns. Observations, record reviews and staff interviews verified sufficient implementation of the plan to remove immediacy as of 7/23/19 and the scope and severity was lowered from J to D.

Based on record review and interview, the facility failed to ensure that a licensed practical nurse (LPN) had the education, skills and competency to provide foods/snacks to residence in accordance with their plan of care and physician orders [REDACTED].#146). This failure resulted in the resident consuming the wrong consistency snack placing her at risk for aspiration/impairment/death. Resident #146 was the only resident identified as going to a higher level of care due to being given the incorrect diet type at the time of the survey. On 6/18/19 at 8:00 PM, resident #146 who was on a pureed consistency nectar thick liquid diet was given a peanut butter and jelly sandwich by the certified nursing assistant (CNA) as directed by the licensed practical nurse (LPN). After the resident ate some of the sandwich, the nurse noticed the resident had her hand on her throat and was turning blue. The nurse attempted to administer the [MEDICATION NAME] maneuver to the resident in her wheelchair but was unsuccessful. The resident was then lowered to the floor and the [MEDICATION NAME] was attempted again unsuccessfully. The nurse called for assistance and the director of nursing (DON) arrived on the unit. The DON suctioned the resident with a [MEDICATION NAME] suction tip and removed a 1 inch bolus of food from her mouth. She was treated with oxygen at 10 liters per minute via mask until the paramedics arrived. The resident was transported to the hospital with an admitting [DIAGNOSES REDACTED]. The facility's failure to ensure all nursing staff had the education and competency related to therapeutic diets resulted in Immediate Jeopardy starting on 6/18/19. The facility implemented actions to remove the immediacy as of 7/23/19. Findings: Cross Reference to F692 and F835. Resident #146 was a long-term resident on the Dementia unit since (YEAR). Her [DIAGNOSES REDACTED]. She had a [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 physician orders [REDACTED]. No further changes in the resident's diet order were noted in the physician orders. Resident #146's care plan dated 6/10/19 identified that she had nutritional concerns as evidenced by [DIAGNOSES REDACTED]. The approaches included pureed diet with nectar thick liquids. The facility utilized the National Dysphagia Diet Guidelines Pureed/Dysphagia Level 1. This diet consists of pureed homogenous and cohesive foods in pudding-like consistency. This diet is designed for people who have moderate to severe dysphagia with swallowing phase abilities and reduced ability to protect their airway. Review of the Academy of nutrition and Dietetics Nutrition Care Manual © 2019, Foods lists are based on the International Dysphagia Diet Standardization Initiative Framework. Foods not recommended: Grains: any item that is not pureed or has lumps. Protein foods: Nut butters, unless pureed into other foods to correct consistency are to be avoided. On 7/24/19 at 7:18 PM, interview with CNA B revealed that she and CNA EE were passing evening snacks at approximately 8:00 PM on 6/18/19. CNA EE had some cheese nips and asked LPN A if it was okay to give the cheese nips to resident #146. CNA B suggested the peanut butter and jelly sandwich. The LPN A said it was better to give the peanut butter and jelly sandwich. I knew the resident was on a pureed diet and we had never given her a sandwich before. We would usually give her puddings. We followed the LPN's direction and we gave her the sandwich then passed water and juice out to the other residents. About 2-3 minutes later, we noticed something was wrong with resident #146. We realized the resident was choking. She had eaten about half the sandwich and appeared as if she was going to vomit. Her face was pale. The LPN A attempted the [MEDICATION NAME] maneuver while the resident was in her wheelchair. We then took the resident out of her wheelchair and sat her on the floor. The nurse again tried the [MEDICATION NAME] but without success. The other nurse called the code and the DON arrived on the unit. The crash cart was taken to the resident's room. The DON kept suctioning the resident until finally a 1 inch ball of food was brought up and the resident coughed a little bit. She stated, As a CNA you are supposed to trust your nurse. I gave the sandwich when the nurse said it was better than the cheese nips. On 7/24/19 at 8:33 AM, LPN A was interviewed with the DON present. The LPN A had worked on the secure since (MONTH) (YEAR). She was working the 7 PM to 7 AM shift on 6/18/19 when the choking incident occurred. She stated that she was aware that the resident was ordered a pureed nectar thick diet. She recalled that two certified nursing assistants (CNA's) were passing out snacks in the television area by the nurse's station. One of the CNA's commented that resident #146 could not have a sandwich. I told the CNA that the resident could have a sandwich as long as it was given with milk. This was not accurate. A few minutes later, the CNA said that resident #146 did not look right. When I saw the resident, she had one hand on her throat and was turning blue. I attempted the [MEDICATION NAME] maneuver in her wheelchair unsuccessfully. I could not do it, so I asked someone to get the DON. The DON gave directions to take the resident to her room, get the suction machine and call 911. LPN A stated that she had been a nurse for [AGE] years and in her previous practice they would mix a solid food with liquid. She thought that if a peanut butter sandwich was given with milk it would become soft enough to become pureed consistency. She stated, I failed. I thought the peanut butter and jelly sandwich and milk/Ensure, and she drooled and I thought it would make it like a pureed and that was wrong. She stated that she did not know what else to say except it was her error. Review of the nursing progress note dated 6/18/19 at 9:01 PM by LPN A showed that she spoke with the resident's guardian regarding possible aspiration. The physician was notified and gave order to send the resident to the hospital for evaluation. The resident left the building at 10:39 PM. Her vital signs were, blood pressure 155/79, pulse 106 and Oxygen (O2) saturation was 98% on 10 Liters (per minute) O2 by mask. The resident was suctioned with small bolus of food extracted. At the time of departure the resident was talking, with audible gurgling heard without auscultation. A nursing progress note dated 6/23/19 at 5:11 PM, showed that the resident returned to the facility at 4 PM from the hospital with [DIAGNOSES REDACTED]. Resident was alert to self .lungs diminished with mild crackles at bases . A review of the Patient Transfer Form AHCA Form 5000-3008 completed by the hospital physician on 6/23/19, noted the primary [DIAGNOSES REDACTED]. Review of the hospital computerized tomography (CT) of the chest without contrast on 6/18/19 at 10:07 PM indicated it was for shortness of breath. There was debris within the mid esophagus. The impression noted . 3. Debris within the mid esophagus which places the patient at risk for aspiration. A review of LPN A's personnel file noted that she was hired on 12/7/16. She had been a [MEDICATION NAME] LPN since 2009. The facility's Job Description Summary noted, Is responsible for the daily management and direction of nursing care of the residents and unit assigned to her/him. The LPN is accountable for ensuring competent care and safety are consistently delivered to all residents. Related principal duties and job responsibilities included; Attends staff education, training and other required meetings. On 7/25/19 at 3:42 PM, the administrative team stated that all staff completed new hire orientation which included diet types. Review of LPN A's facility orientation and education/in-service from the time of hire up until resident #146's choking incident revealed that the education she received from the facility was not specific about therapeutic diets and the minimization of choking risk/hazards. Review of the LPN's education packet revealed a Licensed Practical Nurse Evaluation/competency dated more than 1.5 years ago on 12/30/17. This was her only documented full competency evaluation by the facility. There were no evaluations related to diet modifications or supervision of certified nursing assistants. There were no job specific competency evaluations related to modified consistency therapeutic diets, food textures or implementation of physician diet orders for modified consistencies. On 7/24/19 at 4:17 PM, LPN A stated, I do not remember getting any education for therapeutic diets during my orientation. She did not recall getting any training related to diet consistency or therapeutic diets prior to the choking incident. A Job Specific Orientation for Registered nurse/Licensed Practical nurse was signed by LPN A on 12/30/17. The orientation review included Pharmacy Orders/ Intravenous Orders, Doctors Orders and Tube Feeding. There was no documentation noted for facility protocol for modified consistency diets. On 6/17/2018, education was provided for Feeding Aspiration Education/ Investigative Statements. LPN A had signed the attendance sheet. The objectives were 1) Educating staff on feeding, aspiration precautions, 2) Family or Caregiver must be educated first of proper feeding techniques for Aspiration precautions of resident. 3) only supervisors /managers are allowed to write investigative statements, employee will sign it. The information sheet was not provided to the LPN. LPN A signed that she had participated in the education. A review of the facility's general orientation check list form for all employees dated 1/10/18, topic #18 included Food Service availability. The presenter showed a slide that showed types of diets, including diet textures of Regular, Ground/Mechanical Soft, Pureed, Thickened Fluids, Nectar, Honey and Pudding. There was no documentation provided that LPN A had participated. A review of the Annual Education for Certified Nursing Assistants showed a half hour presentation given by Dietary and Speech Therapy. The topics included Types of Therapeutic Diets, and Diet Textures. The presentation covered Resident Rights regarding nutrition along with appropriate consistency of food and liquids provided, menu substitution of similar nutritional value, receive correct physician ordered therapeutic diets. There was no documentation that this type of education was presented to the licensed nurses including LPN [NAME] A review of the Facility assessment dated (MONTH) 2019 noted that eating is part of the Activities of Daily Living and specialized diets are noted under Nutrition. The Facility Assessment had no specifics, on how choking risks would be mitigated. Part 3 detailed the facility resources needed to provide competent support and care for residents. The document specified staff education and competency requirements . There were no competencies specified for activities of daily living care, diet order/ food texture knowledge. The Facility assessment did not include mandatory staff education, or how the facility would evaluate competencies and validate knowledge and proficiency of nursing staff. A meeting was held with the administrative team on 7/23/2019 at 6:45 PM and they were informed of the Immediate Jeopardy. The administrator provided a plan to remove the Immediacy as of 7/23/19. The corrective measures in their Immediate Jeopardy removal plan revealed the following: * LPN A was suspended pending investigation and was individually educated prior to returning to work on 6/24/19. *An emergency ad hoc Quality Assurance and Performance Improvement meeting (QAPI) was held on 6/19/19 with a plan of action to educate all nursing staff. The follow-up plan was monitored at the regular QAPI meeting on 6/27/19. The plan of action was determined to be appropriate. *On 6/19/19 the facility reviewed and reassessed all residents on the 400 unit for signs and symptoms of aspiration. *All resident diet orders were reviewed for accuracy on 6/19/19. Discrepancies were corrected/clarified. Resident care plans and nursing aide data sheets were verified for accuracy. The facility eliminated unlabeled non-pureed type snacks. * Verbal and telephonic education to the nursing staff began on 6/19/19 to ensure diet orders were followed. Education included what constitutes mechanical soft and pureed diets, procedure for giving foods to residents, tray pass process, diet and fluid consistencies, when to notify the nurse or DON. Education was completed with 96% of nursing staff including new hires on 7/12/19. On 7/22/19, education records were not present from 6/25/19 and 6/28/19. Staff missing were re-educated and signed the confirmation or provided verbal telephonic confirmation that they had received the education. All therapy staff, housekeeping and maintenance staff were educated on 7/23/19. *Unit managers or their designee randomly audited snacks delivered to the unit two times a week for 4 weeks to verify appropriateness of snacks. No errors were identified. *The dietary policy and procedures adopted by the facility were reviewed for appropriateness on 6/19/19. No changes were required. The survey team expanded the sample to include 7 other residents who were on pureed diets. Observations of these residents were conducted with no identified concerns. Observations, record reviews and staff interviews verified sufficient implementation of the plan to remove immediacy as of 7/23/19 and the scope and severity was lowered from J to D.

Based on observation, interview and record review, the facility failed to effectively analyze the facility's food service operations and efficiently implement approaches that would mitigate choking risk for 1 of 8 residents, that were prescribed pureed diets, of a total sample of 64 residents (#146). The facility's failure resulted in the resident consuming the wrong consistency snack placing her at risk for aspiration/death. Resident #146 was the only resident identified as going to a higher level of care due to being given the incorrect diet type at the time of the survey. The facility failed to ensure all nursing staff had received education and demonstrated competency to follow prescribed diets resulted in Immediate Jeopardy starting on 6/18/19. The facility implemented actions to remove the immediacy as of 7/23/19. Findings: Cross Reference F692 and F726. On 7/22/19 at 10:48 AM, resident #146 was observed sleeping in her room. The resident was a vulnerable adult with [DIAGNOSES REDACTED]. The resident was dependent on staff for all activities of daily living (ADL) included eating. On 6/18/19 at 8:00 PM, resident #146 who was on a pureed consistency nectar thick liquid diet, was given a peanut butter and jelly sandwich by the certified nursing assistant (CNA) as directed by the licensed practical nurse (LPN) [NAME] After the resident ate some of the sandwich, the nurse noticed the resident had her hand on her throat and was turning blue. The nurse attempted to administer the [MEDICATION NAME] maneuver twice but was unsuccessful. The nurse called for assistance and the director of nursing (DON) suctioned the resident with a [MEDICATION NAME] suction tip and removed a 1 inch bolus of food from her mouth. The resident was transported to the hospital with an admitting [DIAGNOSES REDACTED]. A review of the Facility Assessment noted that residents with dysphagia were not included as part of the resident population at this facility. As a result, services/treatments for dysphagic residents were not specifically discussed in the Facility Assessment. Part 2 of the Facility assessment noted that eating was a part of the Activities of Daily Living and specialized diets were noted under Nutrition. The Facility Assessment did not specify how choking risks would be mitigated. The Facility Assessment also did not address staff education/competencies in relationship to therapeutic diets and the monitoring of residents with dysphagia during meals and snack times. A review of the facility's investigation and interview with the DON on 7/22/19 at 4:17 PM, confirmed that the resident was given food in a form that was not conducive to the resident's swallowing deficits and not as per physician orders [REDACTED]. On 7/25/19 at 3:42 PM, a meeting was held with the facility's administrative staff and members from the corporate office. Resident #146's choking incident, along with the facility's investigation and corrective actions were discussed. The facility's staff education and orientation, prior to and post choking incident were reviewed. Prior to the choking incident, the education and orientation information was not specific in identifying and monitoring of residents prescribed therapeutic diets. The DON explained that LPN A was aware that resident #146 was prescribed a pureed diet. The LPN however thought that if the resident ate the peanut butter and jelly sandwich along with milk, it would become pureed consistency. The LPN A used to follow this practice at her previous place of employment. There was no indication that this 'past nursing practice' was currently in the facility's education program. A review of the education records revealed that LPN A was hired on 12/7/16. The education she received from the facility was not specific about therapeutic diets and the minimization of choking risk/hazards. Her most recent evaluation/nursing competency was on 12/30/17 and did not include any evaluations related to diet modifications or supervision of certified nursing assistants. The corporate staff stated that the root cause of this incident was the LPN A's lack of knowledge regarding therapeutic diets. However, it was incumbent upon the facility to ensure that all staff were educated with the most recent nursing practices. The facility could not provide any performance improvement audits to determine if facility staff retained the education that they had received on therapeutic diets. The corporate staff stated that the facility did not have any other choking incidents. A review of the facility's food distribution process and how residents received/obtained foods revealed that the facility provided breakfast, lunch and dinner on a daily basis. Snack times were at 10 AM, 2 PM and 8 PM. The facility also, on occasion, had food centered activities. Resident #146 did not have a physician's orders [REDACTED]. Based on the facility's investigation and interview with CNA B on 7/24/19 at 7:18 PM, CNA B revealed that the staff only had cheese nips or a peanut butter and jelly sandwich to offer resident #146 on 6/18/19. The facility's investigation failed to assess if pureed snacks were available on 6/18/19 and, if so, why the staff did not offer them to resident #146. Contrary to the corporate staff's previous statement, that there was no other choking incident, the Administrator/DON/Risk manager provided information that resident #146 had a previous choking incident at the facility. A nurse's progress note dated 1/23/19 read, Resident was in a food centered activity when staff notified nursing that the resident was having trouble breathing, upon assessment, resident coughing, showing signs of shortness of breath and lips began to turn blue, nursing able to provide suctioning alternating with percussion back blows and clear a quarter size piece of Belgium waffle from resident's throat There was no indication that after this first choking incident on 1/23/19, that Administrative staff reviewed the facility's food distribution process and implemented safety precautions to prevent choking. Since resident #146's choking incident on 6/18/19, the facility instituted snack audits. These audits however only identified if snacks were labeled correctly. The audits did not determine if the correct snack was delivered to the right resident. The Administrative staff did not explain any change in their food distribution to prevent any further incidents of choking. A meeting was held with the administrative team on 7/23/2019 at 6:45 PM and they were informed of the Immediate Jeopardy. The administrator provided a plan to remove the Immediacy as of 7/23/19. The corrective measures in their Immediate Jeopardy removal plan revealed the following: * LPN A was suspended pending investigation and was individually educated prior to returning to work on 6/24/19. *An emergency ad hoc Quality Assurance and Performance Improvement meeting (QAPI) was held on 6/19/19 with a plan of action to educate all nursing staff. The follow-up plan was monitored at the regular QAPI meeting on 6/27/19. The plan of action was determined to be appropriate. *On 6/19/19 the facility reviewed and reassessed all residents on the 400 unit for signs and symptoms of aspiration. *All resident diet orders were reviewed for accuracy on 6/19/19. Discrepancies were corrected/clarified. Resident care plans and nursing aide data sheets were verified for accuracy. The facility eliminated unlabeled non-pureed type snacks. * Verbal and telephonic education to the nursing staff began on 6/19/19 to ensure diet orders were followed. Education included what constitutes mechanical soft and pureed diets, procedure for giving foods to residents, tray pass process, diet and fluid consistencies, when to notify the nurse or DON. Education was completed with 96% of nursing staff including new hires on 7/12/19. On 7/22/19, education records were not present from 6/25/19 and 6/28/19. Staff missing were re-educated and signed the confirmation or provided verbal telephonic confirmation that they had received the education. All therapy staff, housekeeping and maintenance staff were educated on 7/23/19. *Unit managers or their designee randomly audited snacks delivered to the unit two times a week for 4 weeks to verify appropriateness of snacks. No errors were identified. *The dietary policy and procedures adopted by the facility were reviewed for appropriateness on 6/19/19. No changes were required. The survey team expanded the sample to include 7 other residents who were on pureed diets. Observations of these residents were conducted with no identified concerns. Observations, record reviews and staff interviews verified sufficient implementation of the plan to remove immediacy as of 7/23/19 and the scope and severity was lowered from J to D.

Based on observation, interview and record review, the facility failed to provide services to maintain and prevent worsening of contractures and further decrease in range of motion for 1 of 2 residents reviewed for mobility of a total of 64 residents (#63). Findings: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his brief interview for mental status (BIMS) score was 14 indicating he was cognitively intact and noted that he had rejection of care. He required supervision for eating, extensive assistance for personal hygiene and was totally dependent on 2 persons for transfers, toileting and bathing. He had functional limitation in upper range of motion (ROM), impairment on one side. No restorative therapy and no physical therapy (PT) or occupational therapy (OT) or speech therapy (ST) was being provided. On 7/22/19 at 11:07 AM, resident #63 was observed lying in bed watching television. The 3rd, 4th and 5th digits to his left hand were contracted into the palm of his hand. His fore finger was bent and hyper extended outward and his thumb moved freely. When asked if he could open his hand, he attempted to pull open the contracted fingers with his right hand but could not. He was not wearing a splint or palm pad protector and stated that he never had a splint. A review of the medical record did not show a [DIAGNOSES REDACTED]. The record revealed a level 2 preadmission screening and resident review (PASSAR) which indicated he had developmental delay-lack of normal development. The resident's plan of care read that he had cognitive loss: the resident has cognitive function/dementia or impaired thought processes related to developmentally delayed, impaired decision making. Physical therapy/occupational therapy/speech therapy to treat as needed. On 7/23/19 at 1:16 PM, the resident was eating lunch in bed using his right hand. His left 3rd, 4th and 5th digits were contracted into the palm of his hand. He did not have any type of splint or palm guard to his left hand. On 7/25/19 at 10:26 AM, the Director of Therapy stated we screen people on admission, after falls, and when we receive referrals from nursing and restorative nursing staff when they notice a change. We rely on referrals that are provided by the certified nursing assistants (CNAs), families and the residents themselves. We do annual screens on all residents in the facility. Referrals come to us when staff notice a decline in range of motion or when residents need strengthening. Depending on the resident's response to therapy, they would receive active or passive strengthening or ROM. After therapy, residents are referred to restorative therapy, which is usually for 3 to 6 months. On 7/25/19 at 10:42 AM, the Restorative Therapy supervisor stated, After discharge from regular therapy sometimes they get referred to restorative therapy if needed. The therapy department will let us know that someone needs to be on a restorative program. We also let therapy know if we see a decline of the residents and refer them to therapy to be screened. I usually do rounds to check on residents. I don't have any documentation on resident #63's refusal of a hand splint but he does refuse care. On 7/25/19 at 11:06 AM, resident #63 was asked about hand splints. He stated, they never offered to put a splint in my hand. He said that some type of cushion in his hand would keep his finger nails from digging into the palm of his hand. On 7/25/19 at 11:34 AM, licensed practical nurse (LPN) X said she had worked at the facility for 2 years. She stated, (Resident #63) sometimes refuses care but you give him a few minutes and then you go back and he will let you take care of him. I take care of him often. He takes his medication for me without problems. His hand has been contracted like that since I've been working here. I have never seen him wear a splint or palm guard or saw an order for [REDACTED].>On 7/25/19 at 12:00 PM, CNA A said she had been with the facility for 6 years. She stated, he will refuse care he doesn't like but when I go back later, he lets me take care of him. His care has to be when he wants to do it. I remember him when he was on the 100 hall. His left hand has gotten worse, he can't even open it now. On 7/25/19 at 11:41 AM, the Director of Therapy and the surveyor met in resident #63's room. Resident #63 agreed to let the Director of Therapy wash his left hand with a warm washcloth. The resident tried to assist by using his other hand to lift his fingers while the Director of Therapy cleaned between his fingers and the palm of his hand. Resident #63 displayed facial signs of pain during the cleaning of his left hand with the washcloth sliding between his fingers and the palm. After the cleaning, the Director of Therapy fitted a soft palm guard into the resident's left hand. On 7/26/19 at 11:28 AM, Occupational Therapist (OT) Y said an OT evaluation was completed on 7/13/16 showing resident #63's grip strength was measured using a dynamometer, and his left-hand grip strength was measured at 10 pounds (lb.) and his right-hand grip strength was measured at 60 lb. OT Y said that the therapy progress notes from 7/16/16 showed that resident #63 had performed active and active assist left upper extremities for all planes on motion of each joint x 10 repetitions, and that included his fingers. OT Y brought the dynamometer and demonstrated its use. The dynamometer hand grip was measured with a tape measure she provided. It measured ½ inch thick and 2 inches wide. During the demonstration, the OT was asked how resident #63 could have fitted the dynamometer in his left hand? OT Y stated he would have had to put the meter into his left hand between his palm and his fingers indicating his fingers would have had to open 2 inches from the palm of his left hand to measure his grip strength. The OT Y indicated that the resident could no longer do this as a result of the contracted left hand fingers. On 7/26/19 at 4:09 PM, during a telephone interview with the resident's brother, who was his Power of Attorney (POA), stated the facility had not educated him that the ROM of his brother's left hand would decline if he refused therapy. He stated his brother was developmentally impaired and had a low intelligence quotient (IQ). He stated he had asked the Director of Therapy in the past if he could use his brother's funds that needed to be spent down to pay for more therapy and the Director of Therapy told him he could not. On 7/26/19 at 4:47 PM, the Director of Therapy confirmed that resident #63's left hand was contracted, and he could benefit from therapy. The Director of Therapy said resident #63 had not been screened by therapy for 3 years, (YEAR), (YEAR) or currently. He could not provide an answer why resident #63 was not screened. He could not provide any therapy documentation on the resident's left hand after (MONTH) (YEAR) when resident #63 refused therapy. He stated (Resident #63's) bother had called me previously and asked me if he could pay extra for therapy and wanted to use his brother's money. I told him he did not need to use his brother money. If his brother (resident #63) was appropriate, we could provide therapy for him, but we did not screen him.