Every finding on record at Spring Gate Rehab & Healthcare Center

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to provide an environment that was free from accident hazards for 1 of 3 (Resident #3) sampled residents reviewed. Resident #3, a cognitively impaired resident with a tracheostomy (a plastic tube inserted into the throat to allow the person to breath), who was a 2 person assistance for bed mobility and dependent on staff for activities of daily living skills (ADLs) including bed mobility and transfers, fell from an elevated bed and sustained a laceration to her forehead and was later pronounced deceased in the Emergency Room. The facility's failure to provide an environment that was free from accident hazards resulted in an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for Resident #3. The Administrator, Director of Nursing (DON), Regional Nurse Consultant, and [NAME] President of Operations were notified of the Immediate Jeopardy for F689 on [DATE] at 5:06 PM, in the conference room. The facility was cited at F-689 with a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy began on [DATE]. A partial extended survey was done on [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE], and was validated onsite by the surveyor on [DATE]-[DATE]. The Immediate Jeopardy for F689 began on [DATE] through [DATE], the IJ was removed on [DATE]. The facility is required to submit a plan of correction. The findings include: 1. Review of the facility policy titled, Incident and Accident Reporting, revised [DATE], revealed .is the policy of this facility to ensure that residents are handled and transferred safely to minimize risk for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them .the resident's mobility needs will be addressed on admission and reviewed quarterly .Staff members are expected to maintain compliance with safe handling/transfer practices .Resident lifting and transferring will be performed according to the resident's individual plan of care . Review of the facility policy titled, Comprehensive Care Plans, dated [DATE], and revised [DATE], revealed .The comprehensive care plan will describe, at a minimum, the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Diabetes, Morbid Obesity, Atrial Fibrillation, Epilepsy, Congestive Heart Failure, Chronic Kidney Disease Stage 3, Tracheostomy Status, Gastrostomy Status, and Dependence on Respirator Ventilator. Review of the Initial Care Plan Report dated [DATE], revealed .Resident has an ADL self-care performance deficit .Bed Mobility .2 Person assist .Transfers .with 2 person assist AND use of mechanical lift .Resident has impaired cognitive function .Resident is at risk for/has impaired communication .Resident has impaired skin integrity .assist with turning and repositioning .pressure redistribution mattress to bed . Resident #3 had an air mattress on her bed. Review of the facility's Nursing admission Evaluation, dated [DATE], revealed .Activities of Daily Living .Most support needed for toileting and bed mobility .2 person assist .transfers 2 person assist with mechanical lift .Is the resident able to follow commands and cooperate .no .Is the resident cognitively impaired with poor decision-making skills .yes .at risk for falls .yes . Review of the facility's investigation witness statement dated [DATE], revealed .Fall from bed .I [Certified Nursing Assistant (CNA) B] went into residents [resident's] room [Resident #3] approximately 310 [3:10 AM] to 320 [3:20 AM] to check resident and get her ready for repositioning .Resident [Resident #3] was lying on her side facing the window .I pulled the covers back, I undone brief and notice BM [bowel movement] coming out of it. I called for an aide to help me, so I took everything into the room and started getting it ready .At no time did I touch resident or try to reposition .The bed was at my hip level .I was standing behind resident [Resident #3] while she was in the bed, and she began to push like she was having another bowel movement and then she did a hard push and rolled off of bed face down. I couldn't grab her as she rolled. I noticed that her vent [ventilator] tubing had become lose and I yelled for the RT [Respiratory Therapist] and blood was on the floor from the resident [resident's] head .I didn't move resident off the floor and when I left the room resident [Resident #3] was still in the floor . Review of the facility's Fall During Staff Assist form revealed .[Respiratory Therapist (RT) A] .date [DATE] .I heard a call for help .as I respond to the room, the vent [mechanical ventilator] was alarming due to disconnect .patient [Resident #3] was face first on the floor .[Certified Nursing Assistant (CNA) B stated] .I was gathering my supplies to provide care .I turned her to the right .She [Resident #3] gave a large push and fell on the floor .Everything happen [happened] fast . CNA B failed to follow the care plan to use 2-person assist with bed mobility. Review of the facility's Situation, Background Assessment and Recommendation (SBAR) Communication Form and progress note dated [DATE], revealed .This nurse [RN C] notified by the CNA [CNA B] to come to room [Resident #3's room] .I noticed resident lying face down in a pool of blood .noticed open area above left brow . Review of the facility's Transfer Form dated [DATE], revealed .Usual Mental Status .Alert, disoriented, but cannot follow simple command .Current Mental Status .Not alert .Usual Functional Status .not ambulatory .Risk Alerts .Falls .ADL's .Bed Mobility, Transferring and Toileting needs assistance . Review of the (Named Fire Department) Record dated [DATE], revealed .Crews [Emergency Medical Services (EMS) crew] were then guided down the hall to the pts [patient's/Resident #3's] room where facility personnel were standing outside of the room as the pt [Resident #3] laid on the floor in her own feces and blood due to a fall from the bed and incontinent [loss of bowel and bladder control] .was down for 4-5 minutes prior to crews arrival .to find her breathing with a ventilator, unresponsive, blinking occasionally, and with a weak radial pulse .On arrival to the patient's [Resident #3] bedside, we [EMS crew] observed an elderly female patient [Resident #3] lying supine on the floor beside her bed. The patient [Resident #3] was unresponsive .The patient [Resident #3] had a 2-3-inch laceration to the occipital region of the scalp .remained unresponsive and had no purposeful movement .Per staff, this was consistent with her [Resident #3] baseline mental status; they reported the patient [Resident #3] is nonverbal and typically only exhibits minimal eye movement as her normal response. They further noted she had not opened her eyes since the fall, which they attributed to possible drowsiness .Neuro [neuromuscular]- Unresponsive [unable to talk or move] .Date/Time: [DATE] 03:37:00 [3:37 AM]; Head .Laceration . Review of the Hospital Emergency Department (ED) note dated [DATE] at 3:50 AM, documented by the ED physician, revealed .Physical Exam .Mottled skin pulseless, no spontaneous respirations, pupils fixed and already dilated .Time of Death 03:51 [3:51 AM] .Upon triage assessment patient is mottled and covered in feces, cold no sign of life .0552 [5:52 AM] call [Named Facility] .spoke to [Named Registered Nurse (RN) C] stated .the CNA was providing care and the patient did a hard push and ended up falling on the floor . Review of the Hospital ED Triage note dated [DATE] at 3:50 AM, documented by the ED RN, revealed .0347 [3:47 AM] [Name of the Nursing Home] called report stating patient [Resident #3] had a fall, nonverbal on trach [tracheostomy] vent, laceration to the L [left] forehead. On blood thinners. 0348 [3:48 AM]- [EMS] arrived with patient to ER [Emergency Room] .Upon triage assessment patient is mottled, patient is covered in feces, cold, no sign of life, checked for a pulse. No pulse felt .CPR [Cardiopulmonary Resuscitation] started .Unknown how long patient [Resident #3] has been without a pulse .ems states initial call came out for cardiac arrest but upon their arrival to [Name of Nursing home] reported to them [EMS] she [Resident #3] had a fall .0414 [4:14 AM] Called [Name of Nursing Home] spoke to staff member .about what happened and she [staff member] states that a staff member [CNA B] was cleaning the patient [Resident #3] when the patient rolled out of the bed falling and hitting her head .she states she [nursing home staff member] no longer wants to talk about this and would have primary nurse call us back .0505 [5:05 AM] called [name of the Nursing Home] to get more history of event states that nurse is still on break .0552 [5:52 AM] called [Name of Nursing Home] again spoke to [Name of Nursing Home Staff] the primary rn [RN] who cared for patient. [Primary Nurse stated] 'The CNA was providing care and .she [Resident #3] ended up falling on the floor .we seen [saw] her [Resident #3] on the floor and we seen [saw] the blood. We did a log roll and she [Resident #3] was still on the vent and still had vitals' . During an interview on [DATE] at 10:00 AM, RN C stated, .I was in another resident's room when [CNA A] yell [yelled] my name from her [Resident #3] room .I rushed to the room, I saw [Named Resident #3] lying face down on the floor beside of the bed by the window .all I could see was a lot of blood, feces and urine around her .the vent was alarming and pulse ox [oximetry (equipment placed on a finger to measure oxygen in the blood)] was alarming .the resident [Resident #3] was turned on the right side with clean linen rolled up lying on the bed against her [Resident #3] when I went in to check the pump .asked her [CNA B] what happened, she [CNA B] said she walked away, and she [Resident #3] rolled off the bed and she [Resident #3] fell on the floor . RN C was asked if she assisted CNA B with repositioning during the shift prior to the incident. RN C stated, .No .she did not ask me to help her with repositioning or to help clean her up . RN C was asked could Resident #3 roll herself from side to side or roll off the bed. RN C stated, No, she [Resident #3] would have to be turned. During an interview on [DATE] at 10:00 AM, the DON confirmed CNA B's statement was typed as CNA B was being interviewed and was not CNA B's written statement. The facility failed to provide a handwritten statement that was signed and dated by CNA B. During an interview on [DATE] at 11:00 AM, Nurse Practitioner (NP) D was asked if Resident #3 was able to turn or reposition her body or make purposeful movements to roll herself. NP D stated, .No, she [Resident #3] could not .she [Resident #3] was total dependent on staff for repositioning. NP D was asked was Resident #3 cognitively aware to answer questions or blink with her eyes appropriately to answer questions. NP D stated, .No, when I assessed her, she did not open her eyes to follow any commands .I could not get her [Resident #3] to respond or follow commands .she [Resident #3] was total dependent with her [Resident #3] care . During a telephone interview on [DATE] at 3:30 PM, RT A stated, .it was around 3:00 AM or 3:30 AM during my rounds I went to the door and saw her [Resident #3] lying on her back [in bed] the last rounding .the CNA yelled for help . I went in the room and the Resident [#3] was lying face down on the floor in blood .the ventilator was disconnected and alarming .the staff help turned her [Resident #3] over so I could connect the ventilator back. I got her [Resident #3] hooked back up and her oxygen saturations went up and she had a pulse .there was a gash on her [Resident #3] forehead and a lot of blood . During an interview on [DATE] at 11:00 AM, the DON confirmed that CNA B should have asked for assistance when providing care for Resident #3 and stated, She was a 2 person assist with bed mobility and CNA B should have asked for help to reposition and to clean her. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE]. The Removal Plan was validated onsite by the surveyor on [DATE]-[DATE] by medical record reviews, review of audits, review of [NAME]/care plans, review of staff education inservices, and interview with staff and Administration. The acceptable facility Removal Plan revealed: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to review and identify residents affected or likely to be affected. (Completion Date: [DATE]) Resident #3 was discharged to the emergency room on [DATE]. Resident #3 was not appropriate for a bariatric bed. The DON, Assistant Director of Nursing (ADON), SDC (Staff Development Coordinator), IP (Infection Preventionist) nurse, Unit Managers, Nurse Supervisors, Wound Care Supervisor, or Minimum Data Set (MDS) Coordinators will review falls within the last 30 days and access resident care plans to ensure bed mobility instructions are accurate for those residents. The DON, ADON, SDC, IP nurse, Unit Managers, Nurse Supervisors, or MDS Coordinators along with a certified nursing assistant and licensed nurse who cares for the resident will review all residents for assistance with bed mobility to ensure the care plan/[NAME] reflects accurate resident requirements for the number of staff needed for bed mobility. New admissions will be reviewed for appropriate sized bed. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE]) The Administrator and Director of Nursing are reviewing the Incident/Accident Reporting policy and will take any recommendation for change to the Quality Assurance Performance Improvement (QAPI) committee. The Administrator or Director of Nursing will provide 1:1 education with the identified certified nurse assistant in regard to following care plan/[NAME] with the correct amount of assistance for turning and repositioning needs of residents. The DON, ADON, SDC, IP Nurse, Unit managers, or Nursing Supervisors will provide education to all licensed nurses and certified nursing assistants on the importance of following the care plan and [NAME] when assisting residents with bed mobility so that the correct number of staff is utilized. There will be a post-test to validate competency with required 100% accuracy. No certified nursing assistant or licensed nurse will be allowed to work after [DATE] until they have completed this training. The facility does not utilize agency staff, and any new certified nursing assistant and licensed nurse will be educated during orientation. Note: The [NAME] is instantly and automatically updated with any change to the Care Plan in the electronic medical record, so that these documents are always in sync and contain the most up to date-care plan interventions as a resource for the licensed nurses and certified nursing assistants. The DON, ADON, SDC, IP nurse, Unit Managers, Nurse Supervisors, or MDS Coordinators will observe CNAs or licensed nurses providing proper turning and repositioning and bed mobility to residents based on their care plan/[NAME] instructions. They will complete 10 observations per week for 12 weeks. An ad hoc QAPI meeting was convened on [DATE] to review the removal plan and immediate jeopardy citations with no further recommendations at this time. In attendance at a minimum were the Administrator, Director of Nursing, IP Nurse, and the Medical Director who participated by phone. The Administrator will present findings to the QAPI committee at least monthly for 3 months and anytime concerns are identified. The QAPI committee will consist of at a minimum the Administrator, Director of Nursing, Assistant Director of Nursing or Nurse Manager, IP Nurse with the Medical Director attending at least quarterly.

Based on policy review, medical record review, fire department record review, and interview, the facility staff failed to document in the medical record or report the resident's tracheostomy (tube in throat to aid in breathing) was not attached when she was found unresponsive and not breathing and continuous Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) was provided for 1 of 3 (Resident #30) sampled residents reviewed for CPR. The findings include: 1. Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR) & [and] Basic Life Support (BLS), revised [DATE], revealed .the purpose of this policy is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest .include the following procedures .Document the event in the patient's medical record . 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Acute Respiratory Failure, Aphasia, Dysphasia, Systemic Inflammatory Response Syndrome, Epilepsy and Aphonia, Diabetes Mellitus, and Tracheostomy. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 was severely cognitive impaired with short and long-term memory problems, received continuous oxygen therapy, suctioning (procedure to remove mucus) as needed, and tracheostomy care. Review of the medical record revealed Resident #30 was found unresponsive in her room without a pulse on [DATE] at approximately 12:41 AM, by Respiratory Therapist (RT) A. Review of a Progress Note for Resident #30 dated [DATE] at 2:06 AM, by Licensed Practical Nurse (LPN) A revealed .At approximately 00:25-30 [12:25-12:30 AM], resident noted to have leg out of bed and covered up part of body .This nurse assisted resident back into position in bed and covered resident back up with blanket .Resident is in seemly [seemingly] pleasant mood upon exiting room .0 [No] s/s [signs and symptoms] of distress, pain, or discomfort . Review of the [Named Company on call Physician Note] dated [DATE] at 2:36 AM, revealed .Date of Service [DATE] at 1:33 AM .Death Notification .Summary: Death was not expected. Review of the Respiratory Therapist (RT) Progress Note for Resident #30 dated [DATE] at 3:01 AM, revealed .around 0041 [12:41 AM] while making visual round this therapist [RT A] notice [noticed] resident not breathing . There was no documentation that Resident #30's tracheostomy tube was out in the progress note documented by RT A. 3. Review of the Fire Department Prehospital Patient record revealed the fire department was called to the facility at 12:49 AM and arrived at 12:56 AM. Paramedics documented Resident #30 was found with no pulse, was not breathing, and her pupils were fixed and not reactive.the time of death was called at 1:00 AM. 4. During an interview on [DATE] at 11:25 AM, RT A stated . I was passing her door, and [she] had kicked her covers off exposing herself .I went by, and she had pulled her trach out .I put the trach back in and noticed she was non-responsive and had no pulse . RT A was asked how long the tracheostomy was out. RT A stated .I can't tell you how long the trach was pulled out .it was out, and I put it back in . RT A was asked was the tracheostomy being out or decannulated (pulled out) documented in the medical record. RT A stated, .Oh .well, it [tracheostomy] was pulled out, and I put it back in and started CPR . RT A was asked if he reported the trach being out to any staff or emergency personnel. RT A stated .No, I did not . RT A confirmed the tracheostomy being pulled was not documented in the medical record or reported to staff. During a telephone interview [DATE] at 8:00 AM, Licensed Practical Nurse (LPN B) was asked about the CPR event with Resident #30. LPN B stated, . 911 [Emergency Medical Services] had been called. LPN B was asked when you got to the room, were you told that Resident #30's tracheostomy was out. LPN B stated .No.I was never told that. During an interview on [DATE] at 11:00 AM, the Director of Nursing (DON) was asked if a tracheostomy is found dislodged or pulled out would you expect the staff to report and document that event. The DON stated, Yes, absolutely.

Based on medical record review, and interview, the facility failed to ensure medications were given as ordered for 1 of 6 (Resident #3) sampled residents reviewed for medication administration. The findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Diabetes, Morbid Obesity, Atrial Fibrillation, Epilepsy, Congestive Heart Failure, Chronic Kidney Disease Stage 3, Tracheostomy Status, Gastrostomy Status, and Dependence on Respirator Ventilator. Review of the Initial Care Plan Report dated 4/16/2025, revealed .Resident has an ADL [activities of daily living] self-care performance deficit .Resident has impaired cognitive function .Administer mediations as ordered . Review of the Physician Orders dated 4/16/2025 revealed .Clonazepam [medication used to treat anxiety] .2 mg [milligrams] via [by way of] PEG [percutaneous endoscopic gastric tube] twice daily . Review of the Medication Administration Record for April 2025 revealed the facility failed to administer Clonazepam 2 mg on 4/17/2025 at 9:00 AM, and 4/18/2025 at 9:00 AM, and 9:00 PM. The facility failed to follow the physician orders for Clonazepam 2 mg to be administered twice daily for 3 doses. During an interview on 4/26/2025 at 1:00 PM, Registered Nurse (RN) D confirmed the Clonazepam was scheduled to be administered but was not in the medication cart and she failed to obtain it from the emergency drug cart, and she did not call the pharmacy to obtain the medication. RN D confirmed she did not administer the medication as ordered. During an interview on 4/30/2025 at 11:00 AM, the Director of Nursing (DON) confirmed Resident #3 did not receive the medication as ordered for 3 doses and the medication was indeed available in the emergency drug cart and should have been administered as ordered.

Based on policy review, medical record review, and interview, the facility failed to provide clinical documentation that continuous Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) was provided for 1 of 3 (Resident #30) sampled residents review for CPR. The findings include: 1. Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR) & [and] Basic Life Support (BLS), revised [DATE], revealed .the purpose of this policy is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest .Procedures for administering CPR shall incorporate the steps covered in the American Heart Association, Basic Life Support training material .Basic life support .is a level of medical care which is used for victims of life threatening Illnesses or injuries until they are given full medical care at a hospital, and may include recognition of sudden cardiac arrest, activation of the emergency response system, early Cardiopulmonary resuscitation, and rapid defibrillation with an automated external defibrillation with an automated external defibrillator if available .'Cardiopulmonary resuscitation (CPR)' refers to any medical intervention used to restore circulatory and/or respiratory function has ceased .If a resident experiences a cardiac arrest or respiratory arrest and the resident does not show obvious clinical signs of irreversible death .rigor mortis, dependent lividity .facility must provide basic life support, including CPR, prior to arrival of emergency medical services .The facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association, Basic Life Support training material .include the following procedures .Document the event in the patient's medical record . 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Acute Respiratory Failure, Aphasia, Dysphasia, Systemic Inflammatory Response Syndrome, Epilepsy and Aphonia, Diabetes Mellitus, and Tracheostomy. Review of the 5-day Minimum Data Set (MDS) dated [DATE], revealed Resident #30 was severely cognitive impaired with short and long-term memory problems, received continuous oxygen therapy, suctioning (procedure to remove mucus) as needed, and tracheostomy care. Review of the medical record revealed Resident #30 was found unresponsive in her room without a pulse on [DATE] at approximately 12:41 AM, by Respiratory Therapist (RT) A. Review of the Respiratory Therapist (RT) Progress Note for Resident #30 dated [DATE] at 3:01AM, revealed .around 0041 [12:41 AM] while making visual round this therapist [RT A] notice [noticed] resident not breathing. Check for pulse and no pulse was obtained. Called code [term used to activate emergency response] to .[Named Resident #30's room]. CPR was started until AED [Automatic External Defibrillator-a portable medical device that can analyze the heart's rhythm and deliver an electrical shock if needed to correct a dangerous heart rhythm] applied which was about 2-3 minutes after cpr [CPR]. 911 [number used to call the police, fire or ambulance services in an emergency] was called and about 4-5 cycles of cpr done before 911 arrived. Leads [attachments used with a heart monitoring device] were placed on resident by emergency responders and code was called [CPR was stopped] shortly thereafter . Review of a Progress Note for Resident #30 dated [DATE] at 2:06 AM, by Licensed Practical Nurse (LPN) A revealed .At approximately 00:25-30 [12:25-12:30 AM], resident noted to have leg out of bed and covered up part of body .This nurse assisted resident back into position in bed and covered resident back up with blanket .Resident is in seemly pleasant mood upon exiting room .0 [No] s/s [signs and symptoms] of distress, pain, or discomfort . Review of the [Named Company on call Physician Note] dated [DATE] at 2:36 AM, revealed .Date of Service [DATE] at 1:33 AM .Death Notification .Summary: Death was not expected. Patient coded. Code blue [CPR] was started at 0041 [12:41 AM] hours; fire service arrived and took over the code blue . Review of the Fire Department Prehospital Patient record revealed the fire department was called to the facility at 12:49 AM and arrived at 12:56 AM. At 12:57 AM, paramedics found resident was unresponsive, skin was cold, and pupils were not reactive. Resident was in cardiac arrest; CPR was in progress by the facility staff. Staff reported resident was seen alive 15 minutes prior to starting CPR. Crew had doubts about accuracy of downtime of [Resident #30]. Paramedics documented Resident #30 was found with no pulse, was not breathing, and her pupils were fixed and not reactive. The facility staff stopped CPR, the paramedics confirmed there was no heartbeat, and the time of death was called at 1:00 AM. The facility was unable to provide a code sheet or documentation to support which facility staff administered CPR for Resident #30, what steps were taken as part of the CPR event, and the times the steps were taken. During an interview on [DATE] at 11:25 AM, RT A stated .I had made rounds, and she [Resident #30] was fine and responsive, I provided trach care around 11:30 PM. It was no more than about 30 minutes after that I was passing her door, and [she] had kicked her covers off exposing herself .I went by and she had pulled her trach out .I put the trach back in and noticed she was non-responsive and had no pulse . RT A was asked how long the tracheostomy was out. RT A stated .I can't tell you how long the trach was pulled out .it was out, and I put it back in . RT A was asked was the tracheostomy being out or decannulated (pulled out) documented in the medical record. RT A stated, .Oh .well, it [tracheostomy] was pulled out and I put it back in and started CPR . RT A was asked if he reported the trach being out to any staff or emergency personnel. RT A stated .No, I did not . During a telephone interview [DATE] at 8:00 AM, Licensed Practical Nurse (LPN B) was asked about the CPR event with Resident #30. LPN B stated, .before going on break, I repositioned her trach [tracheostomy] hose .she pulled at it a lot .and left out to go on break around 11:50 PM. I was outside, got a call around 10 or 15 minutes [later] saying that [Named Resident #30's room number] was coding [experiencing cardiac arrest] and 911 had been called. LPN B was asked when you got to the room were you told that Resident #30's tracheostomy was out. LPN B stated .No .I was never told that during the code .other staff were in the room .I can't recall who was doing what .don't recall if anyone was recording or not [documenting what occurred during the code] .when the paramedics arrived, they took over .put the leads on .never got heart rate back .the paramedics stopped the code . During an interview on [DATE] at 11:00 AM, the Director of Nursing (DON) was asked do you expect your staff to document and record CPR events. The DON stated .yes .someone should be charting the time it started and who responded .I can't find any documentation regarding the CPR except what is in the progress notes .if they recorded anything I can't find it .yes it should be a record . The DON was asked if a tracheostomy is found dislodged or pulled out would you expect the staff to report and document that event. The DON stated, Yes, absolutely. During a telephone interview on [DATE] at 12:38 PM, RT A was asked did you start CPR. RT A stated Yes, I did if that [is] what my charting said that is what I did. RT A was asked who all was in the room with you and who was recording. RT A stated, .it was a nurse supposed to be [recording the code] I don't know if she was or not. RT A was asked did you apply the AED by yourself and how did you keep track with what was going on. RT A stated, .someone usually recording .I wrote what I was doing . RT A was asked were you doing the chest compression or the Ambu-bag (equipment used to provide breaths). RT A stated .what did the note say . RT A confirmed that what was written in his note was what occurred. RT A did not tell the surveyor whether he was performing chest compressions or using the Ambu-bag to breathe for Resident #30 during the code event.

Based on policy review, medical record review, and interview, the facility failed to follow the care plan for Activities of Daily Living (ADL) skills for 1 of 6 (Resident #3) sampled residents reviewed for ADL interventions with 2-person assistance. The findings include: 1. Review of the facility policy titled, .Comprehensive Care Planning, dated 6/30/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives .to meet a resident's medical, nursing, and mental and psychosocial needs that are identified . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Diabetes, Morbid Obesity, Atrial Fibrillation, Epilepsy, Congestive Heart Failure, Chronic Kidney Disease Stage 3, Tracheostomy Status, Gastrostomy Status, and Dependence on Respirator Ventilator. Review of the Initial Care Plan Report dated 4/16/2025, revealed .Resident has an ADL self-care performance deficit .Bed Mobility .2 Person assist .Transfers .with 2 person assist AND use of mechanical lift .Resident has impaired cognitive function .Resident is at risk for/has impaired communication .Resident has impaired skin integrity .assist resident with turning and repositioning . Review of the facility's Nursing admission Evaluation, dated 4/17/2025, revealed .Activities of Daily Living .Most support needed for toileting and bed mobility .2 person assist .transfers 2 person assist with mechanical lift .Is the resident able to follow commands and cooperate .no .Is the resident cognitively impaired with poor decision-making skills .yes .at risk for falls .yes . The facility failed to follow the care plan interventions for ADL interventions related to bed mobility and repositioning with 2-person assistance when Resident #3, a severely cognitively impaired, nonmobile resident fell from the bed to the floor when Certified Nursing Assistant (CNA) B did not provide 2-person assistance with bed mobility and repositioning. During an interview on 4/23/2025 at 12:58 PM, CNA B stated, .She was a total care patient .she couldn't move .I did brief checks .I did not reposition or turn her from 7 PM [7:00 PM] till about 3 AM [3 :00 AM] .I repositioned her [Resident #3] to her right side by myself . CNA B was asked if any staff assisted her to reposition Resident #3 or other residents in her section during the shift from 7:00 PM until 3:00 AM. CNA B stated, .No one helped me with any of my section .I repositioned [Resident #3] myself and got her on her side . CNA B was asked if Resident #3 was a 2-person assist to be repositioned. CNA B stated, .I really don't know .I just did it myself . During an interview on 4/30/2025 at 11:00 AM, the Director of Nursing (DON) confirmed Resident #3 required 2 person assistance with bed mobility and CNA B did not follow the care plan interventions when providing care and repositioning. The DON stated, .she [CNA B] should have asked for help .

Based on policy review, medical record review, observation and interview, the facility failed to provide appropriate care and services for residents with an indwelling catheter (a tube in the bladder that drains urine) for 2 of 3 residents (Resident #30 and #304) reviewed for indwelling catheters. The facility's failure to implement interventions to prevent pressure and/or secure catheter tubing resulted in Actual Harm when Resident #30 developed a pressure ulcer related to the catheter tubing. The findings include: 1. Review of the facility policy titled, Catheter Care Procedure-Urinary, dated 12/28/2023, revealed .It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter .will provide appropriate catheter care in accordance with current clinical standards .Catheters should be secured to prevent pulling and damage . 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Paraplegia and Pressure Ulcer at Left Gluteus Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 Brief Interview for Mental Status (BIMS) score was unable to be obtained due to severe cognitive impairment, was dependent upon staff for toileting, bed mobility, and transfers, had an indwelling urinary catheter, and was always incontinent of bowel. Review of the signed Physician Orders dated 6/27/2024, revealed . secure anchor [device to stabilize urinary catheter tubing to minimize movement and promote patient comfort] d/t [due to] foley [indwelling urinary] catheter every shift .catheter care every shift . Review of the Progress Note dated 8/30/2024, revealed .When resident's [#30] covers pulled back to perform wound care writer noted resident laying on top of catheter. Skin assessed, deep purple area of trauma noted to left labia [fold of skin around the vaginal opening] . Review of a Pertinent Charting-Skin note dated 8/30/2024, revealed .Location of skin area being documented: Left Labia .Deep purple area of trauma noted to left labia r/t [related to] catheter . During an interview on 10/7/2024 at 10:51 AM, Licensed Practical Nurse (LPN O) confirmed she wrote the progress notes dated 8/30/2024 which indicated trauma to Resident #30's left labia. LPN O confirmed she entered Resident #30's room on 8/30/2024 to provide wound care, removed Resident #30's incontinent brief and discovered Resident #30 laying on her foley catheter tubing and confirmed as a result of Resident #30 laying on her foley catheter tubing, at that time, the left labia was deep purple in color and had slough [type of dead tissue that is moist and stringy]. LPN O was asked what caused Resident #30 to be laying on her foley catheter tubing. LPN O stated, .poor positioning, the catheter tubing was not placed correctly, it was placed coming back, toward her bottom and should have been placed with a sticker with clip that holds the foley catheter tubing in place on top of [the] leg. LPN O confirmed that on 8/30/2024 Resident #30 did not have the clip to hold the catheter tubing. LPN was asked the proper positioning of a urinary foley catheter. LPN O stated, .properly clipped [into the clip that holds the catheter tubing], on top of leg, free from any obstruction and clear of pressing up against any part of her body . During an interview on 10/7/2024 at 11:03 AM, LPN O was asked to describe Resident #30's position in bed when she found the resident laying on top of her (indwelling) catheter tubing and the left labia to be purple in color with slough. LPN O stated, .the resident's leg is contracted, she was sitting upright on her bottom with the [indwelling] catheter tubing on that area and the [indwelling] catheter tubing positioned toward the back of the resident, looked like when someone repositioned the resident the catheter tubing got pulled back .the staff should have made sure the catheter was in proper position, appropriately placed, and not under her . During an interview on 10/07/24 at 3:57 PM, the Director of Nursing (DON) confirmed staff should ensure the indwelling catheter tubing was securely anchored to the resident with a clip or any other device. The DON was asked where the indwelling catheter tubing should be anchored. The DON stated, . preferably the thigh area . During an interview on 10/7/2024 at 4:45 PM, the DON was asked if the indwelling catheter tubing was not secured, could it cause injury to the resident. The DON stated, .Yes . The DON was asked could the indwelling catheter tubing cause injury to a resident if the resident was laying on it. The DON stated, .Yes . During an interview on 10/8/2024 at 2:58 PM, the Nurse Practitioner (NP) confirmed Resident #30 should not have been laying on the indwelling catheter tubing. The NP was asked the correct placement of indwelling catheter tubing. The NP stated, .over the thigh .not under the resident . Observation in Resident #30's room on 10/09/2024 at 11:16 AM, revealed the wound to the left labia open, red in color with slight slough around the lower edge of the wound with no drainage. Failure of the facility to ensure the indwelling catheter was properly secured resulted in actual harm to Resident #30. 3. Review of the medical record revealed Resident #304 was admitted to the facility on [DATE] with diagnoses including Respiratory Failure, Hypoxia and Acute Kidney Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 14 indicating Resident #304 was cognitively intact. Review of the Order Review History Report dated 8/26/2024-9/26/2024, revealed .Catheter-Anchor Secured in Place every shift . Observation in the resident's room on 10/10/2024 at 9:32 AM, revealed a catheter anchor clip attached to the indwelling catheter tubing and not secured to Resident #304's leg. During an interview on 10/10/2024 at 9:32 AM, the Infection Control Nurse confirmed that the catheter anchor clip should be attached to the Resident's leg. 48285

Based on facility policy review, facility fall investigation review, medical record review, observation, and interview, the facility failed to ensure the resident environment remained free of accident hazards for 1 of 3 (Resident #77) sampled residents reviewed for accidents. On 8/9/2024, Resident #77, a vulnerable cognitively impaired resident, rolled out of the bed onto the floor and sustained a fracture to the right humerus, resulting in Actual Harm. Certified Nursing Assistant (CNA) W admitted to returning the resident to the bed without notifying the nurse. CNA W was assisted by CNA X, to get Resident #77 back in the bed. The findings include: 1. Review of the facility policy titled, Falls- Clinical Protocol, dated 11/2/2023, revealed .the staff will help identify individuals with a history of falls and risk factors for subsequent falling .Admission Evaluation Data Form, which includes the fall risk evaluation .this form is completed upon admission, quarterly, and with significant change in status .Based on the assessment an initial care plan will be developed and implemented to address identified risk .Goals of the plan of care may include interdisciplinary team, physician, resident and responsible party when possible .Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining .or improving resident abilities and quality of life .Interventions should be developed and implemented per the assessed needs .Resident's abilities and deficits .Balance .Adaptive equipment needs .Proper use of mechanical lifts and transfer devices .interventions for direct care givers should be placed on the CNA [certified nursing assistant] Kardex [CNA care plan] .For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall .Causes refer to factors that are associated with or that directly result in a fall .Once a fall occurs it is important to gather as much information as possible .Provide emergency care and assessments as indicated .The Physician and Responsible party should be notified as soon as the resident is stabilized .Document findings in the resident's medical record .Complete the Fall Re-evaluation .to determine if there are additional risk factors .Document falls on the 24-hour shift report .An accident/[or]incident report will be completed . Review of the facility policy titled, Incidents and Accidents Reporting, dated 8/11/2022, revealed .It is the policy of this facility for staff .to report, investigate, and review any accident or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .'Accident' refers to any unexpected or unintentional incident, which result or may result in injury or illness to a resident .An 'Incident' is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization .The purpose of incident reporting is: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care .Conducting root cause analysis to ascertain .contributing factors .Meet regulatory requirements for analysis and reporting of incidents and accidents .The following incidents/accidents require an incident/accident report .Falls .Unobserved injuries .In the event of an incident or accident, immediate assistance will be provided .Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so .The supervisor or other designee will be notified of the incident/accident .The nurse will notify the resident's practitioner to inform them of the incident/accident .The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital .The nurse/designee will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information .Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions .and orders obtained or follow-up interventions .If an incident/accident was witnessed by other people, the supervisor or designee will obtain the witnesses' account .In the event that an incident must be recorded .the following should occur .Complete the paper form for the incident .Complete all other assessments .paper incident report should be entered electronically . Review of the facility policy titled, Safe Lifting and Movement of Residents, dated 1/1/2022, revealed .Each resident is assessed .to determine lifting and movement assistance needs .Mechanical lifting devices shall be used for heavy lifting .Except during emergency situations or unavoidable circumstances, manual lifting is not permitted . 2. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure with Hypoxia, Cerebral Infarction, Gastrostomy Status, Tracheostomy Status, and Atrial Fibrillation. Review of Resident #77's Care Plan date initiated on 8/30/2023, revealed .Resident has an ADL [Activities of Daily Living] self-care performance deficit related to CVA .BED MOBILITY: 2 person assist . Review of Resident #77's Physician orders dated 6/3/2024, revealed .Hydrocodone-Acetaminophen Tablet 5-325 mg [milligrams] Give 1 tablet by mouth every 8 hours for pain . There was no documentation in the medical record on 8/9/2024, when the incident occurred. Review of the Incident/Accident Report for Resident #77 dated 8/13/2024, revealed .Resident's CNA [CNA V] notified nurse of abnormal discoloration to resident's right upper arm .This nurse observed resident flinched and showed signs of discomfort upon her arm being touched/moved . Review of the Physician Progress Note dated 8/13/2024, revealed .RUE [right upper extremity] swelling .79 y/o [year old] BF [black female] with hx [history of] multiple CVA, [Cerebrovascular Accident], Chronic Respiratory Failure with Hypoxia, Osteoarthritis .is seen today for RUE swelling .RUE upper arm to hand swelling noted, warm to touch with 2 dime size contusions to inner upper arm noted. Will xray due to hx of arthritis and eval for possible pathogenic fx [fracture] . Review of Resident #77's Care Plan dated 8/13/2024, revealed .Resident is at risk for falls/injury related to Cerebral Vascular Accident (CVA) needs assistance with ADL's [activities of daily living] .Reduce the risk of injury .8/13/2024 X-Ray doppler [test used to detect blood flow] .8/13/2024 ER [emergency room ] evaluation and tx [treatment] .8/13/2024 pain meds as ordered .8/13/2024 immobilizer .monitor resident's position to reduce the risk of sliding/falling . Review of the Physician Progress Note dated 8/16/2024, revealed .FU [follow up] readmission .seen today s/p [status post] ER [emergency room ] with RUE [right upper extremity] commuted [comminuted] displaced fracture through the right humeral neck, humeral shaft is displaced medially with respect to the humeral head, soft tissue of density surrounds the humeral head and proximal humerus suggestive of a component of hematoma seen on CT [computed tomography] scan. She was readmitted with dx [diagnosis] of arm reduction deformity. RUE remains swollen with RUE sling in place .stable .FU with [NAME] [orthopedics] . Resident #77 was evaluated in the ER and returned to the facility with an immobilizer to her right upper extremity and an order for an orthopedic consult. Review of the Incident Investigation Witness Statement from terminated CNA W dated 8/16/2024, for Resident #77 revealed .This incident happened on 8/9/2024 around 2 [2:00] PM .I went in to change [Named Resident] Resident #77 .I left her on her side to change her. I turned her facing the window. She had a large bowel movement. I went out of the room to get more linen .I was gone a couple of minutes. When I returned she was in the floor .I tried to get her up by myself with a sheet. The tubing to her trach was still hooked to her. I left her in the room to get some help .[Named staff] CNA X came in to help me get her back in bed .I never told [Named CNA X] that the [Named Resident] Resident #77 had fallen .we got her up from the floor using the sheet that was under her .I did not tell the nurse or anyone about this incident .I never thought she was hurt .I didn't try to hurt her . Review of Resident #77's Care Plan revised on 8/19/2024, revealed .Resident has an ADL self-care performance deficit related to CVA .BED MOBILITY: 2 person assist .TOILETING: 2 person assist .TRANSFERS: with 2 person assist AND use of mechanical lift . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #77 was rarely/never understood. Brief Interview for Mental Status (BIMS) wasn't conducted due to Resident #77 was rarely/ never understood. Functional status was coded as dependent on staff for all activities of daily living (ADL's) care. Observation and interview in Resident #77's room on 10/2/2024 at 10:15 AM, revealed CNA V turned and repositioned Resident #77 by herself without using 2 staff assistance. CNA V was asked should Resident #77 have 2 person assistance with turning and repositioning. CNA V stated, .yes, but I don't have time to try to find someone .we are all so busy . Attempted to call terminated CNA W on 10/2/2024 at 2:00 PM, to verify statement. CNA W did not return phone call. During an interview on 10/15/2024 at 1:40 PM, CNA V was asked if she witnessed a bruise on Resident #77. CNA V stated, .when I worked on Saturday 8/10/2024 I did not see a bruise and she didn't act like she was hurting .when I gave her a bath on Tuesday 8/13/2024 is when I seen the bruise on her upper right arm .I immediately went to get the nurse so she can see what I was talking about . CNA V was asked if she (Resident #77) can turn herself without assistance. CNA V stated, .she is total dependent on staff, she suppose [supposed] to have 2 people for turning, but I turn her by myself if I can't find someone to help me . During an interview on 10/15/2024 at 1:54 PM, CNA X was asked if she assisted Resident #77 off the floor. CNA X stated, .yes, [Named CNA W] asked me to help clean [Named Resident #77] .the resident was sitting up in the floor, her back against the bed .she had sheets under her .we lifted her up and put [her] back in the bed. I left out of the room. I didn't notify anyone she had fallen .I asked [Named CNA W] how she got on the floor, and she stated she didn't know .I was suspended pending the investigation and was re-educated .I thought the nurse had already been in the room . During an interview on 10/15/2024 at 3:10 PM, the Director of Nursing (DON) was asked how many staff should turn [Named] Resident #77, and how long until the fall was discovered. The DON stated, .[Named Resident #77] is a 2 person staff assist for turning, repositioning, and bed mobility .the occurrence was completed when we were made aware of the bruise, and after investigating and interviewing all staff we determined, and was told what exactly happened .I did not report because we realized soon with a matter of hours what had happened . The DON was asked during her investigation if Resident #77 appeared to be in pain. The DON stated, .No one stated she was in pain until the day the bruise was recognized, however the resident does receive pain medication every 8 hours, and has for several months related to her sacral wound .the physician initially thought it could have been a DVT [Deep Vein Thrombosis] due to her previous history .but also ordered an x-ray of her right humerus and it showed fracture of the lower end of the right humerus .we then sent her to the ER she was there for a few hours and she returned with an immobilizer to her right upper extremity and an order for orthopedic consult. The DON was asked what prompted the termed (terminated) CNA (CNA W) to leave the resident in the bed on her side and then after the fall out of the bed, not tell the nurse and then transfer her from the floor to the bed. The DON stated, .she [CNA W] stated to me it was just a bad judgement call. Both CNA's were suspended but [Named] CNA W was terminated for failure to follow company policy .[Named] CNA X returned to work and [was] given a written warning . The DON stated, The staff know they should report each incident including falls .they should never move the resident who has fallen, before the resident is assessed by the nurse .[Named Resident #77] is a 2 person assist for all bed mobility .with all falls, the CNA should get the nurse so she can assess the resident and then give further instruction to the CNA at that time .

Based on review of the Quality Safety Organization (QSO) - 20 -30 - Nursing Home (NH), policy review, medical record review, observation, and interview, the facility failed to maintain a clean, safe, comfortable, and sanitary environment on 4 of 4 (100, 200, 400, and 500) Hallways that included Resident #s 6, 8, 15, 17, 22, 27, 28, 32, 33, 34, 36, 38, 39, 41, 48, 49, 55, 57, 58, 61, 62, 63, 66, 68, 69 70, 71, 74, 75, 77, 79, 80, 83, 84, 87, 88, 90, 93, 97, 99, 105, 113, 116, 117, 120, 123, 129, 131, 144, 133, 139, 304, 348, and 349. The 400 and 500 Hall was the tracheostomy/ventilator units with vulnerable, high risk, and compromised residents. Observations made from 9/23/2024 through 10/2/2024 revealed there were observations of dried dark brown and tan hardened substances on the residents' bed frames and side rails, enteral feeding pumps, poles, walls, window blinds, and floors. The residents' oxygen concentrators were dirty, had dirty filters, and heavy dust build up. The Heating Ventilation Air Conditioning (HVAC) units were dirty and dusty. The housekeeping department failed to have cleaning disinfectant at all times and/or had to use the disinfectant sparingly per interview. There was a hole observed in the wall in a resident's room, and a gap around the HVAC unit at the end of the 100 Hall by the exit door exposing the facility to the outside. The findings include: 1. Review of QSO-20-30-NH Updates and Initiatives to Ensure Safety and Quality in Nursing Homes - Actions to Improve Infection Prevention and Control, .Environmental cleaning and disinfection. Clean and disinfect the resident's care environment and shared equipment with agents effective against the identified organism or products on an EPA [Environment Protection Agency]-registered antimicrobial list recommended by public health authorities. It is important to follow all manufacturer's directions for use for a surface disinfectant including applying the product for the correct contact time. Facilities need to ensure adequate access to supplies and proper instruction for staff (nursing or housekeeping/environmental services) responsible for cleaning pieces of equipment . Review of the facility policy titled, Routine Cleaning and Disinfection dated 2/1/2022, revealed, .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products .Consistent surface cleaning and disinfection will be with a detailed focus on high touch areas to include, but not limited to .bed rails, tray tables, call buttons . resident chairs .IV [intravenous] poles .Cleaning of walls, blinds, and window curtains will be conducted when visibly soiled .Privacy curtains in resident rooms will be changed when visibly dirty . Review of the undated facility policy titled, Daily Cleaning Procedures revealed .empty trash .disinfect the waste basket and insert a can liner .High Dust .work your way clockwise around the room (starting at the door and finishing at the door) and dust all high surfaces .this includes but not limited to pictures/prints, televisions, over the bed lights, blinds, vents and all corners .Disinfect .work your way clockwise around the room .disinfect flat surfaces .high touch items .door knobs, light switches, call lights, TV [television] remotes, bed siderails, bed frame, foot board and headboard, bedside tables, closet handles, window sills, chairs, heating unit, and any flat surfaces .if resident has a fan in his/her room, check and clean routinely to avoid buildup of dust .Spot Clean Walls and Inspect Privacy Curtains .work your way clockwise around the room .spot cleaning walls and vertical surfaces that are visibly soiled .inspect all privacy curtains in room .if dirty notify your supervisor which curtains need to be changed .Clean Restroom .restock all supplies .empty trash .high dust lights, vents .disinfect sink area .disinfect toilet area-including handrails, call lights and tub/shower .Dust Mop .dust mop the perimeter of the room first .then start at back of room and use a figure 8 motion to dust mop entire floor working your way back to the door .don't forget the restroom .Damp Mop .damp mop the perimeter of the room .then start at the back of the room and use a figure 8 motion to damp mop the entire floor while working your way back to the door .don't forget the restroom . Review of the undated facility policy titled, Deep Cleaning Procedures revealed Check the posted deep clean schedule in the morning and inform the Nursing Supervisor of the appropriate room number that will be deep cleaned today Clean the scheduled deep clean room .room should be emptied .if it is not, contact the nursing Supervisor to assist the situation .in a clockwise rotation from .door, clean, polish, scrub, scrape, dust, disinfect, sweep, wipe and mop everything in the room including: waste baskets .remove liner, wipe down can with disinfectant and remove all excess build-up .insert new can liner .Dressers-pull dresser completely away from the wall so that you can mop the floor where the dresser was sitting .spot scrub wall behind dresser and wipe down the rear of the dresser .sweep and damp mop floor and baseboard making sure to remove all build-up from these areas .clean all sides with disinfectant cleaner, including drawers and tracks, and remove bottom drawers to clean interior shelf .Chairs .remove cushions and scrub with brush or pad .scrub and polish frame .Closet .floor and edges around the closet floor, and spot check walls and shelf .Windows .clean window tracks and clean blinds .report any soiled or damaged curtains to your supervisor .Heating Unit .wipe top and all sides, check top vents for any accumulation of dust or other debris .remove build-up from floor under heating unit, sweep and damp mop .Nightstand .follow same procedure as Dressers .Bed .pull bed at least three feet away from wall .spot scrub the wall, remove build-up from floor and baseboards .sweep and damp mop floor and baseboards .thoroughly clean and disinfect all parts of the resident's bed .remove mattress (pay special attention to the bed frame, headboard, footboard, legs and side rails) .disinfect all areas of the mattress and return it to the frame .place bed in original position against the wall .Bed Side Tables .scrub all areas of table .polish if necessary .Privacy Curtains .check and report any soiled or damaged curtains to supervisor .clean lights above bed and all call lights and cords .Check all corners, ceiling and floor for cobwebs .Spot scrub all walls .Entrance of room .scrub both sides of door and door knob .Remove build-up on floor between room and hallway .Dust mop and damp mop entire room .Clean restroom by moving in a clockwise rotation from the restroom door .restock all supplies .Vents .use high duster to clean vents .Light cover .dust and disinfect .Walls .spot scrub all walls .Clean the light switch and cover plate .Sink .disinfect all porcelain on sink, both top and bottom .scrub all fixtures and drains .be sure to scrub wall under sink .Plumbing .clean spray hose and all pipes under sink .Toilet .scrub and disinfect toilet bowl .remove all stains and build-up .Safety bar and toilet paper holder .clean and polish .Call light and plate .clean and polish .Mirror .clean edges of mirror and shelf .clean mirror and use paper towel to dry .Check all corners for cobwebs .high and low .spot scrub door, frame and knob .Remove all build-up from floor around bowl, door frame, corners and edges .Dust mop the entire floor .Damp mop the entire floor . Review of the facility policy titled, Preventive Maintenance Program dated 3/12/2022, revealed A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public .The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner .The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required . 2. Review of the Housekeeping Vendor undated checklist titled DEEP CLEAN CHECKOFF LIST, revealed .Inform the resident you are deep cleaning their room. Let resident (s) know you will be in their room for 30 minutes .you must move the bed, dresser, and any large objects so you can clean behind it. This room must be sanitized, dusted, and dirt-free when you are done .CHECK OFF THE FOLLOWING AREAS AS WHEN COMPLETED: a. Pull out bed (s) and sweep, vacuum under, wipe down bed frames and springs as well b. Pull out dresser (s) and sweep, vacuum under, do not forget to wipe down sides as well c. Dust and wipe down T.V. [television] and underneath d. Clean and dust bed frame, pillows, and springs e. Clean ceilings, vents, and light fixtures f. Clean windowsills and inside of window g. Clean and wipe down heater/radiator units, remove trash from inside of units h. Clean and wipe down pictures / prints on walls i. Clean and wipe down garbage can inside and out j. Clean and wipe down all walls (PAY SPECIAL ATTENTION TO WALLS NEXT TO TRASH CANS AND UNDER SOAP DISPENSERS) k. Check bed linens for rips and tears l. Check skid strips for damage and alert management so they can be replaced m. Clean and wipe down doors, door jams, and door frames n. Clean and wipe down closets and shelves inside and outside o. Clean and wipe down all tables, nightstands, and rolling tables p. Clean and wipe down all chairs q. Clean and wipe down baseboards/edges (Use scraper to remove dirt in corners) r. Clean and disinfect floors s. Clean and disinfect toilet t. Clean and disinfect sink u. Disinfect and wipe down bathroom pull cords v. Clean and disinfect shower stall/tub w. Clean and wipe down vents x. Clean and wipe down ANY wheelchairs in the room y. Inspect curtains for spills or damage and alert management so they get replaced z. Clean and disinfect refrigerators aa. CLEAN AND DISINFECT ANY PHONES, REMOTES, CALL LIGHTS AND ANYTHING ELSE THAT MAY BELONG TO THE ROOM . 3. Review of the medical records revealed Resident #6 and Resident #15 shared a room. a. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Acute Upper Respiratory Disease, and Muscle Weakness. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score was not assessed, and Resident #6 was dependent on staff for Activities of Daily Living (ADLs). b. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Weakness, Contracture Left Hand, Muscle Weakness, Arthritis, and Lack of Coordination. Review of Resident #15's quarterly MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #15 was moderately cognitively impaired and required dependent on staff for ADL care. c. Observation in Resident #6 and #15's shared room on 9/23/2024 at 9:45 AM and 9/30/2024 at 4:27 PM, revealed the following: A dark black build-up around base board of closet door on the floor and in the corner of the door facing of the closet. A dark black build-up behind the entrance door in the corners leading up the wall and leading to the facing of the closet door. A dark black build-up leading out of the room into the hallway. A dark black build-up around the base board of the bathroom entrance and in the corners of the facing of the bathroom door. Missing floor tile around base of the bathroom vanity and dark black build-up around in the tile flooring on the bathroom floor. 4. Review of the medical records revealed Resident #22 and Resident #90 shared a room. a. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, Anoxic Brain Damage, Persistent Vegetative State, Muscle Weakness, Anxiety, and unspecified Convulsions. Resident #22 had a Percutaneous Endoscopic Gastrostomy (PEG) tube. Review of Resident #22's annual MDS assessment dated [DATE], revealed a BIMS score that was unable to be completed, staff assessed the resident as severely cognitively impaired for daily decision making, and totally dependent on staff for ADLs. Review of Resident #22's care plan dated 5/3/2024, revealed .Resident has impaired pulmonary/respiratory status related to respiratory failure, tracheostomy, ventilator use .Resident will have reduced complications related to their altered pulmonary/respiratory status . Review of Resident #22's [Named] Hospital History and Physical Examination dated 9/3/2024, revealed .DATE OF ADMISSION: 8/31/2024 .CHIEF PRESENTING COMPLAINT: Fever with lethargy .The patient was evaluated in the emergency room and subsequently was admitted for severe sepsis with acute respiratory failure. The resident was admitted to the intensive care unit . Review of the facility Progress Note for Resident #22 dated 9/6/2024, revealed .Chronic General Debility, Deterioration .malaise .chronic respiratory failure s/p [status post] tracheostomy, Seizure do [disorder], Myasthenia Gravis [autoimmune disease caused by a breakdown in communication between nerves and muscles] quadriplegia .presented to the hospital with persistent fever .found to be septic [serious condition in which the body responds improperly to an infection] due to pneumonia .finished her course of antibiotics in the hospital . b. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, Gastrostomy tube, and Seizures. Review of Resident #90's quarterly MDS assessment dated [DATE], revealed a BIMS score that was unable to be completed, staff assessed the resident as rarely/never understood for daily decision making, and was dependent on staff for all ADLs. Review of Resident #90's [Named] Hospital History and Physical Examination dated 7/30/2024, revealed .DATE OF ADMISSION: 7/30/2024 .CHIEF PRESENTING COMPLAINT: Wound infection with bleeding from sacral wound .The patient was brought to the emergency room from the nursing home because they stated that she was having fever and also was bleeding from her sacral wound .to be evaluated for possible sepsis .she was subsequently admitted after intravenous antibiotic therapy initiation . c. Observations in Resident #22 and #90's shared room on 9/23/2024 at 10:30 AM, 9/25/2024 at 11:00 AM, 10/1/2024 at 2:20 PM, and 10/2/2024 at 3:00 PM, revealed dark brown marks on the floor at the doorway of room, tan and brown spots under the base of Resident #90's enteral feeding pump pole, and right side of Resident #90's bed frame contained a thin, brown substance smeared from the head of the bed to the foot of the bed. d. During an interview on 9/25/2024 at 11:15 AM, LPN U was asked what was on Resident #90's feeding pump pole and what was on Resident #22's bedframe. LPN U stated, .could be dried feeding on the pole and feces on the bed . LPN U was asked who should clean the pump pole and the bedframe. LPN U stated, .whoever makes the mess . LPN U was asked if that (the feeding pole and bedframe) was supposed to be cleaned. LPN U stated, Yes. 5. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Dementia, Bipolar Disorder, Muscle Weakness, and Depression. Review of the Resident #27's quarterly MDS assessment dated [DATE], revealed Resident #27 was severely cognitively impaired and was dependent on staff for Activities of Daily Living (ADLs). Observation in Resident #27's room on 9/23/2024 at 10:47 AM, and on 10/1/2024 at 7:27 AM, revealed dirty black build-up on the flooring at the threshold entrance of the Resident's room. 6. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, and Gastrostomy tube and received feedings. Review of Resident #28's admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact and needed partial/moderate assist with ADLs. Observations in Resident #28's room on 9/30/2024 at 10:47 AM and 10/2/2024 at 8:50 AM, revealed dark drips and splatters on the wall by the resident's bed and yellowish tan drip stains on the wall by the unoccupied bed in Resident #28's room. 7. Review of the medical records revealed Resident #34 and Resident #116 shared a room. a. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Cerebral Infarction, Tracheostomy Status, Hemiplegia, and Gastrostomy tube. Review of Resident #34's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated the resident was cognitively intact, and dependent on staff for all ADL's. b. Review of the medical record revealed Resident #116 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Subdural Hemorrhage, Muscle Weakness, Diabetes, Congestive Heart Failure, and Gastrostomy tube. Review of Resident #116's significant change MDS assessment dated [DATE], revealed a BIMS score was unable to be completed due to Resident #116 was rarely/never understood. Resident #116 was assessed by staff to be severely cognitively impaired. c. Observations in Resident #34 and Resident #116's shared room on 9/23/2024 at 9:47 AM and 3:45 PM, 9/25/2024 at 10:30 AM, and 10/2/2024 at 2:30 PM, revealed the vanity mirror was cracked and had brown smears under it, the base of both bed frames had brown smears. Resident #34's right quarter side rail had brown scattered smears on the top and on the side of the side rail. Resident #116's suction cannister contained brown slimy mucus and was not covered, a layer of dust was observed on top of the chest in the corner of the room to the left of Resident #116's bed. Resident #116's feeding pole displayed smears of a tan substance, and the base of the feeding pole was rusted with orange residue and a dried tan substance on it. The floor under the base of the pole revealed a dried brown substance on the floor. The privacy curtain between the 2 residents had splattered brown spots on each side of the curtain. The garbage can under the sink was overflowing with trash and incontinent pads. A thick, dark brown smear appeared on the corner of the bathroom door. The top, right, front edge of Resident #116's nightstand was chipped with sharp edges and jagged wood pieces. The HVAC unit's front vent cover displayed a thick layer of white fuzzy substance, a fuzz ball of dirt, grime and hair. The baseboard behind the base of the rusted brown enteral pump pole contained a smeared brown substance. A dried, thick, dark brown substance was observed on the right side of Resident #116's bed frame. During an interview on 9/25/2024 at 10:36 AM, Certified Nursing Assistant (CNA) P was asked what was on Resident #116's bedframe and Resident #34's side rail and what was the black smear on the corner of the wall beside the bathroom. CNA P stated, .looks like stool . CNA P was asked who was responsible for cleaning that. CNA P stated, .if I do it, I clean it .if I don't do it, I don't clean it . CNA P was asked who was responsible for cleaning the resident rooms. CNA P stated, .doesn't look like no one . CNA P was asked should the resident rooms be clean. CNA P stated, Yes. During an interview on 9/25/2024 at 11:05 AM, LPN C was asked who cleans the rooms. LPN C stated, .we [nursing staff] clean the resident equipment, housekeeping cleans the rooms . LPN C was asked if Resident #34 and Resident #116's room was clean. LPN C stated, No. LPN C was asked should the resident rooms be clean. LPN C stated, Yes. 8. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Senile Degeneration of the Brain, Dementia, Muscle Weakness, and Alzheimer's Disease. Review of Resident #36's quarterly MDS assessment dated [DATE], revealed Resident #36 had a BIMS score of 3, which indicated Resident #36 was severely cognitive impaired and was dependent on staff assistance with ADLs. Observation in Resident #36's shared bathroom on 9/23/2024 revealed: A black build-up on the floor at the entrance to the room and around the base board of the entrance to the room leading to the bathroom. A black build-up on base boards and around bathroom door and the base board and entrance to the close. Missing tile around the base of the bathroom vanity exposing cracked tiles and ground, and brown and gray build up. A black build-up around the closet door and behind the entrance door, with black build up on the bottom of the closet door. Cracked tile behind the entrance door. 9. Review of the medical records revealed Resident #39 and Resident #41 shared a room. a. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Dementia, Acute Respiratory Infection, Hemiplegia and Hemiparesis, Difficulty Walking, Absolute Glaucoma Right Eye, and Legal Blindness. Review of Resident #39's quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #39 was cognitively intact and required moderate staff assistance with ADLs. b. Review of the medical record review revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Dementia, Hemiplegia and Hemiparesis, Muscle Weakness, Acquired Absence of Left Leg and Right Leg Below Knee, and Obesity. Review of Resident #41's annual MDS assessment dated [DATE], revealed Resident #41 was severely cognitively impaired and was dependent on staff for ADL care. c. Observation in Resident #39 and #41's shared room on 9/23/2024 at 9:45 AM, and on 9/30/2024 at 4:27 PM, revealed the following: A dark black build-up in the corner of the closet door leading round the base board leading into the resident's room. Missing base board on the corner of the closet door, and the floor in front of the closet door with black substance build-up going up the wall near closet door. A black build-up in the corners of the entrance door leading from the room to the hallway. A dark black build-up in the grout of the bathroom tile floor and around the base board of the bathroom vanity. 10. Review of the medical record revealed Resident #48 and Resident #57 shared a room. a. Review of the medical record review revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dementia, Cognitive Communication Deficit, and Muscle Weakness. Review of Resident #48's quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #48 was severely cognitively impaired, and was dependent on staff for ADLs. b. Review of the medical record review revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including of Parkinson's Disease, Dementia, Schizophrenia, Dysphagia, and Insomnia. Review of Resident #57's quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #57 was moderately cognitively impaired and was dependent on staff for ADLs. c. Observation in Resident #48 and Resident #57 's shared room on 9/23/2024 at 9:45 AM, and on 9/30/2024 at 4:27 PM, revealed the following: A dark black build-up around in the corners of the entrance door leading into the Residents' room and in the corner behind the entrance door. A dark black build-up around the base board of the closet doors and in the corners of the closet doors going up the wall in the corners. A dark black build-up in the grout of the tile floor in the room and in the bathroom around the base of the bathroom vanity. 11. Review of the medical records revealed Resident #49 and Resident #71 shared a room. a. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Chronic Obstructive Pulmonary Disease, Diabetes, Tracheostomy, and Chronic Kidney Disease. Review of the facility infection tracking report dated June 2024, revealed Resident #49 was diagnosed with a Respiratory Infection on 6/4/2024. Review of Resident #49's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the Resident was cognitively intact. Review of the Progress Note dated 10/1/2024, revealed Resident #49 was started on antibiotic therapy due to pneumonia. b. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Anoxic Brain Damage, Intellectual Disabilities, Convulsions, Tracheostomy, and Gastrostomy tube. Review of the facility infection tracking reports dated April 2024 revealed Resident #71 was diagnosed with a Respiratory Infection on 4/17/2024. Review of the facility infection tracking reports dated June 2024 revealed Resident #71 was diagnosed with a Respiratory Infection on 6/14/2024. Review of Resident #71's quarterly MDS assessment dated [DATE], revealed the Resident was not assessed for a BIMS score and had a stage 4 pressure ulcer on the sacrum. c. Observations in Resident #49 and Resident #71's shared room on 9/23/2204 at 10:57 AM and 4:13 PM, and 9/24/2024 at 7:00 AM, revealed the following: A large area on the floor by Resident #71's bed with dried tan liquid, spots of dried tan liquid and dust build up on the enteral feeding pole, dried tan liquid on the right grab bar of the bed and bed frame, a fan on a stand blowing toward Resident #49 with thick dust on the back side of the fan. Observation in Resident #49 and #71's shared room on 10/2/2024 at 8:57 AM, revealed the filter of Resident #71's oxygen concentrator covered with thick whitish dust and a missing wheel. 12. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Depression, Hypertension, and Muscle Weakness. Review of Resident #55's quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #55 was cognitively intact and was dependent on staff to perform ADLs. Observation in Resident #55's room on 9/23/2024 at 10:50 AM and on 10/1/2024 at 7:27 AM, revealed dirty black build-up on the flooring at the threshold entrance of the resident's room. 13. Review of the medical records revealed Resident #62 and Resident #123 shared a room. a. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Dependence on Respirator, Tracheostomy, and Gastrostomy tube. Review of Resident #62's quarterly MDS assessment dated [DATE], revealed Resident #62 was not assessed for a BIMS score and was severely cognitively impaired, and dependent on staff for ADLs. Review of the Tracking and Trending worksheet revealed Resident #62 was started on antibiotic therapy on 7/10/2024 for a Respiratory Infection. b. Review if the medical record revealed Resident #123 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Tracheostomy, and a Peg tube. Review of Resident #123's quarterly MDS assessment dated [DATE], revealed Resident #123 was not assessed for a BIMS score and was dependent on staff for all care. c. Observations in Resident #62 and Resident #123's shared room on 9/23/2204 at 10:42 AM and 3:36 PM, 9/24/2024 at 7:34 AM, 9/25/24 at 4:07 PM, and 10/2/2024 at 9:16 AM, revealed splatters and drips on the bottom of Resident #62 and Resident #123's enteral feeding pump poles and a dried pool of yellowish tan substance on the ground under each resident's feeding pole. 14. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Severe Persistent Asthma. Review of Resident #63's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated the Resident was cognitively intact. Observation in Resident #63's room on 9/23/2024 at 11:08 AM and 10/01/2024 at 8:18 AM, revealed dried tan liquid on the floor and the HVAC unit vents contained a thick build up of dust. 15. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE], with diagnoses including Diabetes, Heart Failure, Hypertension, and Stage 4 Pressure Ulcer. Review of Resident #68's quarterly MDS assessment dated [DATE], revealed BIMS score of 11, which indicated Resident #68 was moderately cognitively impaired. Observation in Resident #68's room on 9/24/2024 at 9:10 AM and on 10/1/2024 at 7:27 AM, revealed a dirty black build-up on the floor at the threshold entrance of the Resident's room. 16. Review of the medical record revealed Resident #70 and #97 shared a room. a. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Muscle Weakness, Visual Loss, and Quadriplegia. Review of Resident #70's admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #70 was cognitively intact, had impaired vision, and required maximal assistance with ADLs. b. Record revealed Resident #97 was admitted to the facility on [DATE], with diagnoses including Dementia, Muscle Weakness, Difficulty Walking, and Altered Mental Status. Review of Resident #97's admission MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #97 was moderately impaired, with impaired vision, and was dependent on staff for ADLs. c. Observation in Resident #70 and #97's shared room on 9/23/2024 at 9:45 AM, and on 9/30/2024 at 4:27 PM, revealed the following: A dark black build-up around corner of the entrance of the door leading into the Residents' room, in the corners going up the wall. A dark black build-up behind the entrance of the room door leading around the corner of the closet door entrance going up the wall. Chipped and hollowed out wall around base of the entrance of the closet facing leading into the resident room on the A side. A dark brown and black build-up around the base of the toilet. A dark brown and black build-up in the grout of the bathroom floor tile. Missing fl [TRUNCATED]

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for residents with percutaneous endoscopic gastrostomy (PEG) tubes (plastic tube inserted into the stomach to administer medications, supplements and liquid food) when staff failed to ensure the enteral feedings and the flush solutions were properly labeled for 3 of 4 sampled residents (Resident #58, #72, and #304) reviewed for enteral feedings and failed to administer site care for 1 of 4 residents (Resident #498) reviewed for PEG tubes. The findings include: 1. Review of the facility policy titled, Feeding Tubes revised 6/30/2022, revealed .Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary to maintain acceptable parameters of nutrition and hydration. Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .Feeding tubes will be utilized according to physician orders .The plan of care will reflect the use of a feeding tube and potential complications . 2. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Nutritional Deficiency, and Dementia. Review of the care plan revised on 10/5/2023, revealed .Administer enteral nutrition per orders. (nocturnal) . Review of Physician's Order dated 11/6/2023, revealed .Change feeding syringe and /or container daily on night shift (label with resident name and date) . Review of the Minimum Data Sets (MDS) dated [DATE], revealed Resident #58's Brief Interview for Mental Status (BIMS) score was not coded, which indicated the resident was severely cognitively impaired, and was assessed as receiving enteral feedings. Review of the Physician's Order dated 8/23/2024, revealed .Two Cal 2.0 [nutritional supplement administered through a PEG tube] @ [at] 45 cc [cubic centimeters] /hr [per hour] x [times] 12 hours 6p [PM]-6a [AM] . Observation in the Resident's room on 9/24/2024 at 7:33 AM, revealed Resident #58's water bottle used for the PEG was not labeled with a date, rate for delivery via PEG, or initials. Observation in the Resident's room on 9/26/2024 at 8:47 AM, revealed Resident #58's enteral feeding was not labeled with a rate of delivery, and the water bottle for the PEG was not labeled with a delivery rate or time. During an observation and interview on 10/7/2024 at 10:40 AM, in Resident #58's room the Assistant Director of Nursing (ADON) was asked what should be on the enteral feeding and water bottle labels. The ADON stated, It should be labeled with the resident's name, rate [of delivery], room number, date, amount and nurse initial. The ADON confirmed there was no rate or nurse initials on the enteral feeding. 3. Review of the medical record revealed Resident #72 was admitted on [DATE], with diagnoses including Adult Failure to Thrive, Dementia, and Dysphagia. Review of Physician's Order dated 5/23/2022, . [for the PEG] Change feeding syringe and/ or container daily on night shift (label with resident name and date) . Review of Physician's Order dated 6/26/2024, .enteral feed every shift Jevity 1.5 [nutritional supplement administered through a PEG tube] @ 60ml [milliliters] /hr x 22 hours . Review of the MDS dated [DATE], revealed Resident #72's BIMS score was not coded, which indicated the resident was severely cognitively impaired. Review of care plan dated 9/16/2024, revealed .Administer enteral nutrition per orders . Observation in the Resident's room on 9/23/2024 at 10:08 AM, revealed no date and rate of delivery on the water bottle for the PEG. Observation in the Resident's room on 9/24/2024 at 7:24 AM, revealed no start date, rate of delivery, or nurse's initials on the enteral feeding, and no date or rate of delivery on the water bottle. During an interview on 9/25/2024 at 10:35 AM, Licensed Practical Nurse (LPN) B confirmed enteral feedings should be labeled with a name, date, and time hung. Observation in the resident's room on 9/26/2024 at 8:27 AM, revealed no nurse initial, rate of delivery, or time on the enteral feeding and no nurse initial on the water bottle. Observation in resident's room on 9/30/2024 at 3:13 PM, revealed no nurse initials on enteral feeding. Observation in resident's room on 10/1/2024 at 9:37 AM, revealed no nurse initials on enteral feeding. Observations in resident's room on 10/2/2024 at 8:56 AM, revealed no date on the enteral feeding. 4. Review of the medical record revealed Resident #304 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Hypoxia and Acute Kidney Failure. Review of the Medication Administration Record (MAR) dated September 2024, revealed .Enteral Feed Order every shift for Gastrostomy Flush tube with (150) ML's H20 [water] every (4) hours .Enteral Feed Order every shift for Gastrostomy Jevity 1.5 @65 ml/hr X 22 hours . Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 14 indicating Resident #304 was cognitively intact. Observation in the resident's room on 9/25/2024 at 11:35 AM, revealed Resident #304's enteral feeding was not labeled with a date or time. During an interview on 9/25/2024 at 11:39 AM, LPN B confirmed feedings and water should be labeled. 5.Review of the medical record revealed Resident #498 was admitted to the facility on [DATE] with diagnoses including Non-Traumatic Intracerebral Hemorrhage, Diabetes, Dysphagia, and Gastrostomy. Review of a Physician's Order dated 9/6/2024 revealed, .Two Cal HNT [high calorie formula] 1 can 5 times a day .via [by way of] gravity administration .start date 9/6/2024 .End date .9/11/2024. Review of a Physician's Order dated 9/11/2024 revealed, .Jevity 1.5 .1 can/carton bolus every 4 hours .via gravity . Review of the admission MDS assessment dated [DATE], revealed Resident #498 with a BIMS score of 14, indicating the resident was cognitively intact, and used a feeding tube. Review of the Care Plan dated 9/24/2024, revealed Resident #498 was care planned for impaired gastrointestinal status related to the use of a feeding tube. Review of the MAR dated September 2024 revealed no documentation the facility administered PEG site care for the use of a PEG tube. Review of the Treatment Administration Record (TAR) dated September 2024, revealed no documentation the facility administered PEG site care for the use of a PEG tube. Review of the Physician's Orders for September 2024 revealed the facility failed to obtain an order for PEG site care for the use of a PEG tube. Observation in the Resident's room on 9/25/2024 at 9:50 AM, the Resident confirmed he received his feedings through a PEG tube and raised his shirt to show the PEG tube site. The PEG site had no dressing. The facility failed to provide PEG tube site care for the use of a PEG tube to mitigate the risk of infection. During an interview on 10/2/2024 at 11:50 AM, the Director of Nursing (DON) confirmed that the facility failed to obtain a Physician Order for the care of the PEG tube site when the resident was admitted on [DATE] and one had been written with an effective date 10/2/2024. The DON confirmed that PEG tube site care should have been written and administered when the resident was admitted to the facility. 46047 48285

Based on facility policy review, medical record review and interview, the facility failed to ensure physician visits were conducted according to facility policy for 9 of 11 residents (#8, #38, #56, #57, #67, #71, #73, #104, #305) reviewed for Physician visits. The findings include: 1. Review of the facility policy titled, Physician Visits and Physician Delegation dated 9/26/2024, revealed .It is the policy of this facility to ensure the physician takes an active role in supervising the care of the residents .The Physician should .see the resident within 30 days of initial admission to the facility .The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by the physician or physician delegate as appropriate by State law .after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist that is acting within scope of practice . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Hepatic Failure, Acute Hepatitis, Hemiplegia and Hemiparesis. Review of the MD Progress Notes revealed the Physician visited Resident #8 on 11/3/2023 and 4/24/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 3. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dementia, and Alzheimer's. Review of the MD Progress Notes revealed Resident #38 had Physician visits on 10/21/2022, 11/3/2023, 5/24/2024, and 9/27/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 4. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Respiratory Failure, Paraplegia, and Cognitive Communication Deficit. Review of the MD Progress notes revealed Resident #56 had Physician visits on 11/10/2023 and 4/5/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 5. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including of Parkinson's Disease, Dementia, Schizophrenia, Dysphagia, and Insomnia. Review of the MD Progress notes revealed Resident #57 had Physician visits on 10/27/2023, and 4/5/2023. There was no documentation Physician visits were conducted every other 60 days per facility policy. 6. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE], with diagnoses including Dementia, Kidney Failure, Diabetes, and Schizophrenia. Review of the MD Progress notes revealed Resident #67 had Physician visits on 10/27/2023, and 4/5/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 7. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Anoxic Brain Damage, Intellectual Disabilities, Convulsions, and Tracheostomy. Review of the MD Progress notes revealed Resident #71 had Physician visits on 11/17/2023, 4/24/2024, and 8/24/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 8. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Atrial Flutter, Convulsions, Hypertension, and Psychosis. Review of the MD Progress notes revealed Resident #73 had Physician visits on 10/23/2023 and 4/24/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 9. Review of medical record revealed Resident #104 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Down's Syndrome, and Peripheral Vascular Disease. Review of the MD Progress notes revealed Resident #104 had Physician visits on 6/16/2023, 11/17/2023, and 8/3/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 10. Review of medical record revealed Resident #305 was admitted to the facility on [DATE], and the most recent readmitted [DATE], with diagnoses including Ventricular Tachycardia, Myoclonus, Cognitive Communication, and Seizures. Review of the MD Progress notes revealed Resident #305 had Physician visits on 11/17/2023 and 4/12/2024. There was no documentation Physician visits were conducted every other 60 days per facility policy. 11. During an interview on 10/16/2024 at 2:14 PM, the Administrator was asked how often the Physician should make visits to residents. The Administrator replied, The regulations say after admission within 90 days .and every 60 days after that. The Administrator was asked if it was appropriate to not have MD visit for 5 months. The Administrator replied, .they should follow the federal guidelines . The facility failed to ensure Physician Visits were alternated with Nurse Practitioner visits therefore failing to ensure Physician visits were conducted every other 60 days per facility policy.

Based on review of the Quality Safety Organization (QSO) - 20 -30 - Nursing Home (NH), review of NursingHomeAbuse.org, policy review, medical record review, observation, and interview, the facility failed to maintain an infection prevention and control program which provided a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 24 of 38 residents (Residents #22, #28, #34, #49, #62, #63, #71, #75, #77, #80, #83, #90, #116, #117, #120, #123, #129, #131, #133, #139, #144, #304, #348, and #349) reviewed for infection. The 400 and 500 Halls was the tracheostomy/ventilator units with vulnerable, high risk, and compromised residents who were exposed to unsanitary conditions. The findings include: 1. Review of QSO-20-30-NH Updates and Initiatives to Ensure Safety and Quality in Nursing Homes - Actions to Improve Infection Prevention and Control, .Environmental cleaning and disinfection. Clean and disinfect the resident's care environment and shared equipment with agents effective against the identified organism or products on an EPA [Environment Protection Agency]-registered antimicrobial list recommended by public health authorities. It is important to follow all manufacturer ' s directions for use for a surface disinfectant including applying the product for the correct contact time. Facilities need to ensure adequate access to supplies and proper instruction for staff (nursing or housekeeping/environmental services) responsible for cleaning pieces of equipment . 2. Review of the facility policy titled, Routine Cleaning and Disinfection, dated 2/1/2022, revealed .ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Cleaning .refers to the removal of visible soil from objects and surfaces .manually or mechanically using water and detergents or enzymatic products .Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas to include .bed rails .tray tables .Sinks and faucets .Staff will ensure cleaning carts are .stocked with necessary supplies at the beginning of each shift .Horizontal surfaces .window sills and hard surface flooring .should be cleaned .on a regular basis .when soiling and spills occur .when a resident is discharged from the facility Cleaning of walls, blinds, and window curtains will be conducted when visibly soiled .Privacy curtains in resident rooms will be changed when visibly dirty . Review of the undated facility policy titled, Daily Cleaning Procedures, revealed .High Dust .work your way clockwise around the room (starting at the door and finishing at the door) and dust all high surfaces .this includes but not limited to pictures/prints, televisions, over the bed lights, blinds, vents and all corners .Disinfect .clockwise around the room disinfect flat surfaces .high touch items .bed siderails, bed frame, foot board and headboard, bedside tables, window sills .heating unit, and any flat surfaces .if resident has a fan in his/her room, check and clean routinely to avoid buildup of dust .Spot Clean Walls and Inspect Privacy Curtains .work your way clockwise around the room .spot cleaning walls and vertical surfaces that are visibly soiled .inspect all privacy curtains in room .if dirty notify your supervisor which curtains need to be changed .Clean Restroom .restock all supplies .empty trash .high dust lights, vents .disinfect sink area .disinfect toilet area-including handrails, call lights and tub/shower .Damp Mop .damp mop the perimeter of the room .then start at the back of the room and use a figure 8 motion to damp mop the entire floor while working your way back to the door . Review of the undated facility policy titled, Deep Cleaning Procedures, revealed .check the posted deep clean schedule in the morning .Clean the scheduled deep clean room .room should be emptied .in a clockwise rotation from .door, clean, polish, scrub, scrape, dust, disinfect, sweep, wipe and mop everything in the room including .sweep and damp mop floor and baseboard making sure to remove all build-up from these areas .floor and edges around the closet floor, and spot check walls and shelf .report any soiled or damaged curtains to your supervisor .Heating Unit .wipe top and all sides, check top vents for any accumulation of dust or other debris .remove build-up from floor under heating unit, sweep and damp mop .Bed .pull bed at least three feet away from wall .spot scrub the wall, remove build-up from floor and baseboards .sweep and damp mop floor and baseboards .thoroughly clean and disinfect all parts of the resident's bed .remove mattress (pay special attention to the bed frame, headboard, footboard, legs and side rails) .disinfect all areas of the mattress and return it to the frame .Bed Side Tables .scrub all areas of table .polish if necessary .Privacy Curtains .check and report any soiled or damaged curtains to supervisor .clean lights above bed and all call lights and cords .Check all corners, ceiling and floor for cobwebs .Spot scrub all walls .Entrance of room .scrub both sides of door and door knob .Remove build-up on floor between room and hallway .Dust mop and damp mop entire room .Sink .disinfect all porcelain on sink, both top and bottom .scrub all fixtures and drains .be sure to scrub wall under sink .Mirror .clean edges of mirror and shelf .clean mirror and use paper towel to dry . Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 1/2/2024, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection .'Cleaning' is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymatic products .'Reusable multiple-resident items' are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators .non-critical items come in contact with intact skin, but not mucous membranes. These items require cleaning followed by low intermediate level disinfection .(use of EPA [Environmental Protection Agency]-registered disinfectants) following manufacturer's instructions .Staff shall follow established infection control principles for cleaning and disinfecting reusable, noncritical equipment .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident .Multiple-resident use equipment shall be cleaned and disinfected before being used on another resident .Wear gloves when cleaning/disinfecting equipment .Use only EPA-registered disinfectants with kill claims for the common organisms found in the facility . 3. Review of the medical records revealed Resident #22 and Resident #90 shared a room. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, Anoxic Brain Damage, Persistent Vegetative State, Muscle Weakness, Anxiety, and unspecified Convulsions. Resident #22 had a Percutaneous Endoscopic Gastrostomy (PEG) tube. Review of Resident #22's annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score that was unable to be completed, staff assessed the resident as severely cognitively impaired for daily decision making, and totally dependent on staff for activities of daily living (ADLs). Review of Resident #22's care plan dated 5/3/2024, revealed .Resident has impaired pulmonary/respiratory status related to respiratory failure, tracheostomy, ventilator use .Resident will have reduced complications related to their altered pulmonary/respiratory status . Review of Resident #22's [Named] Hospital History and Physical Examination dated 9/3/2024, revealed .DATE OF ADMISSION: 8/31/2024 .CHIEF PRESENTING COMPLAINT: Fever with lethargy .The patient was evaluated in the emergency room and subsequently was admitted for severe sepsis with acute respiratory failure. The resident was admitted to the intensive care unit . Review of the facility Progress Note for Resident #22 dated 9/6/2024, revealed .Chronic General Debility, Deterioration .malaise .chronic respiratory failure s/p [status post] tracheostomy, Seizure do [disorder], Myasthenia Gravis [autoimmune disease caused by a breakdown in communication between nerves and muscles] quadriplegia .presented to the hospital with persistent fever .found to be septic [serious condition in which the body responds improperly to an infection] due to pneumonia .finished her course of antibiotics in the hospital . Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, Gastrostomy tube, and Seizures. Review of Resident #90's quarterly MDS assessment dated [DATE], revealed a BIMS score that was unable to be completed, staff assessed the resident as rarely/never understood for daily decision making, and was dependent on staff for all ADLs. Review of Resident #90's [Named] Hospital History and Physical Examination dated 7/30/2024, revealed .DATE OF ADMISSION: 7/30/2024 .CHIEF PRESENTING COMPLAINT: Wound infection with bleeding from sacral wound .The patient was brought to the emergency room from the nursing home because they stated that she was having fever and also was bleeding from her sacral wound .to be evaluated for possible sepsis .she was subsequently admitted after intravenous antibiotic therapy initiation . Observations in Resident #22 and #90's shared room on 9/23/2024 at 10:30 AM, 9/25/2024 at 11:00 AM, 10/1/2024 at 2:20 PM, and 10/2/2024 at 3:00 PM, revealed dark brown marks on the floor at the doorway of room, tan and brown spots under the base of Resident #90's enteral feeding pump pole, and right side of Resident #90's bed frame contained a thin, brown substance smeared from the head of the bed to the foot of the bed. During an interview on 9/25/2024 at 11:15 AM, LPN U was asked what was on Resident #90's feeding pump pole and what was on Resident #22's bedframe. LPN U stated, .could be dried feeding on the pole and feces on the bed . LPN U was asked who should clean the pump pole and the bedframe. LPN U stated, .whoever makes the mess . LPN U was asked if that (the feeding pole and bedframe) was supposed to be cleaned. LPN U stated, Yes. 4. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, and Gastrostomy tube and received feedings. Review of Resident #28's admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact and needed partial/moderate assist with ADLs. Observations in Resident #28's room on 9/30/2024 at 10:47 AM and 10/2/2024 at 8:50 AM, revealed dark drips and splatters on the wall by the resident's bed and yellowish tan drip stains on the wall by the unoccupied bed in Resident #28's room. 5. Review of the medical records revealed Resident #34 and Resident #116 shared a room. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Cerebral Infarction, Tracheostomy Status, Hemiplegia, and Gastrostomy tube. Review of Resident #34's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated the resident was cognitively intact, and dependent on staff for all ADL's. Review of the medical record revealed Resident #116 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Subdural Hemorrhage, Muscle Weakness, Diabetes, Congestive Heart Failure, and Gastrostomy tube. Review of Resident #116's Significant Change MDS assessment dated [DATE], revealed a BIMS score was unable to be completed due to Resident #116 was rarely/never understood. Resident #116 was assessed by staff to be severely cognitively impaired. Observations in Resident #34 and Resident #116's shared room on 9/23/2024 at 9:47 AM and 3:45 PM, 9/25/2024 at 10:30 AM, and 10/2/2024 at 2:30 PM, revealed the vanity mirror was cracked and had brown smears under it, the base of both bed frames had brown smears. Resident #34's right quarter side rail had brown scattered smears on the top and on the side of the side rail. Resident #116's suction cannister contained brown slimy mucus and was not covered, a layer of dust was observed on top of the chest in the corner of the room to the left of Resident #116's bed. Resident #116's feeding pole displayed smears of a tan substance, and the base of the feeding pole was rusted with orange residue and a dried tan substance on it. The floor under the base of the pole revealed a dried brown substance on the floor. The privacy curtain between the 2 residents had splattered brown spots on each side of the curtain. The garbage can under the sink was overflowing with trash and incontinent pads. A thick, dark brown smear appeared on the corner of the bathroom door. The top, right, front edge of Resident #116's nightstand was chipped with sharp edges and jagged wood pieces. The HVAC unit's front vent cover displayed a thick layer of white fuzzy substance, a fuzz ball of dirt, grime and hair. The baseboard behind the base of the rusted brown enteral pump pole contained a smeared brown substance. A dried, thick, dark brown substance was observed on the right side of Resident #116's bed frame. During an interview on 9/25/2024 at 10:36 AM, Certified Nursing Assistant (CNA) P was asked what was on Resident #116's bedframe and Resident #34's side rail and what was the black smear on the corner of the wall beside the bathroom. CNA P stated, .looks like stool . CNA P was asked who was responsible for cleaning that. CNA P stated, .if I do it, I clean it .if I don't do it, I don't clean it . CNA P was asked who was responsible for cleaning the resident rooms. CNA P stated, .doesn't look like no one . CNA P was asked should the resident rooms be clean. CNA P stated, Yes. During an interview on 9/25/2024 at 11:05 AM, LPN C was asked who cleans the rooms. LPN C stated, .we [nursing staff] clean the resident equipment, housekeeping cleans the rooms . LPN C was asked if Resident #34 and Resident #116's room was clean. LPN C stated, No. LPN C was asked should the resident rooms be clean. LPN C stated, Yes. The shared room was not cleaned until 10/3/2024, for the IJ Removal Plan. 6. Review of the medical records revealed Resident #49 and Resident #71 shared a room. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Chronic Obstructive Pulmonary Disease, Diabetes, Tracheostomy, and Chronic Kidney Disease. Review of the facility infection tracking report dated June 2024, revealed Resident #49 was diagnosed with a Respiratory Infection on 6/4/2024. Review of Resident #49's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the Resident was cognitively intact. Review of the Progress Note dated 10/1/2024, revealed Resident #49 was started on antibiotic therapy due to pneumonia. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Anoxic Brain Damage, Intellectual Disabilities, Convulsions, Tracheostomy, and Gastrostomy tube. Review of the facility infection tracking reports dated April 2024 revealed Resident #71 was diagnosed with a Respiratory Infection on 4/17/2024. Review of the facility infection tracking reports dated June 2024 revealed Resident #71 was diagnosed with a Respiratory Infection on 6/14/2024. Review of Resident #71's quarterly MDS assessment dated [DATE], revealed the Resident was not assessed for a BIMS score and had a stage 4 pressure ulcer on the sacrum. Observations in Resident #49 and Resident #71's shared room on 9/23/2204 at 10:57 AM and 4:13 PM, and 9/24/2024 at 7:00 AM, revealed the following: A large area on the floor by Resident #71's bed with dried tan liquid, spots of dried tan liquid and dust build up on the enteral feeding pole, dried tan liquid on the right grab bar of the bed and bed frame, a fan on a stand blowing toward Resident #49 with thick dust on the back side of the fan. Observation in Resident #49 and #71's shared room on 10/2/2024 at 8:57 AM, revealed the filter of Resident #71's oxygen concentrator covered with thick whitish dust and a missing wheel. 7. Review of the medical records revealed Resident #62 and Resident #123 shared a room. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Dependence on Respirator, Tracheostomy, and Gastrostomy tube. Review of Resident #62's quarterly MDS assessment dated [DATE], revealed Resident #62 was not assessed for a BIMS score and was severely cognitively impaired, and dependent on staff for all care. Review of the Tracking and Trending worksheet revealed Resident #62 was started on antibiotic therapy on 7/10/2024 for a Respiratory Infection. Review if the medical record revealed Resident #123 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Tracheostomy, and a Peg tube. Review of Resident #123's quarterly MDS assessment dated [DATE], revealed Resident #123 was not assessed for a BIMS score and was dependent on staff for all care. Observations in Resident #62 and Resident #123's shared room on 9/23/2204 at 10:42 AM and 3:36 PM, 9/24/2024 at 7:34 AM, 9/25/24 at 4:07 PM, and 10/2/2024 at 9:16 AM, revealed splatters and drips on the bottom of Resident #62 and Resident #123's enteral feeding pump poles and a dried pool of yellowish tan substance on the ground under each resident's feeding pole. 8. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Severe Persistent Asthma. Review of Resident #63's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated the Resident was cognitively intact. Observation in Resident #63's room on 9/23/2024 at 11:08 AM and 10/01/2024 at 8:18 AM, revealed dried tan liquid on the floor and the HVAC unit vents contained a thick build up of dust. 9. Review of the medical records revealed Resident #75 and Resident #83 shared a room. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Gastrostomy tube. Review of Resident #75's quarterly MDS assessment dated [DATE], revealed a BIMS score was unable to be completed, staff assessed the resident as rarely/never understood for daily decision making. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Cerebral Infarction, Hemiparesis, and Gastrostomy tube. Review of Resident #83's admission MDS assessment dated [DATE], revealed a BIMS score that was unable to be completed, staff assessed the resident as rarely/never understood for daily decision making. Observation in Resident #83's room on 9/23/2024 at 10:00 AM, revealed tan liquid running down the enteral feeding pump pole. Observation in Resident #83's room on 9/30/2024 at 10:29 AM, revealed tan liquid ran down the feeding pump pole and collected at the base of the pole, and tan liquid ran down onto the nightstand and pooled in the floor. Observation in Resident #75 and Resident #83's shared room on 10/1/2024 at 8:13 AM and 3:18 PM, revealed a tan liquid ran down Resident #75 and Resident #83's enteral feeding poles, pooled in the floor and dried on the floor. 10. Review of the medical records revealed Resident #77 and Resident #117 shared a room. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure with Hypoxia, Cerebral Infarction, Tracheostomy Status, Atrial Fibrillation, and Gastrostomy tube. Review of Resident #77's quarterly MDS assessment dated [DATE], revealed a BIMS score was unable to be completed, staff assessed the resident as moderately impaired for daily decision making, dependent on staff for all ADLs, and was coded for a feeding tube, oxygen therapy, suctioning, and tracheostomy. Review of the medical record revealed Resident #117 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Cerebrovascular Accident, Hemiplegia/Hemiparesis, Chronic Kidney Disease, Tracheostomy, Pressure Ulcer Sacrum Stage 4, Diabetes, and Gastrostomy tube. Review of Resident #117's quarterly MDS assessment dated [DATE], revealed a BIMS assessment was unable to be completed, staff assessed the resident as rarely/never understood for daily decision making. Resident #117 was dependent on staff for all ADLs, and was coded for an indwelling catheter, feeding tube, oxygen therapy, suction, and tracheostomy. Observations in Resident #77 and Resident #177's shared room on 9/23/2024 at 9:53 AM, revealed the vanity sink contained a dried, brown, chunky substance with the appearance of gastric contents. Observations in Resident #77's and #177's room on 9/25/2024 at 10:10 AM and 10/2/2024 at 2:15PM, revealed Resident #77's oxygen concentrator with white dust like residue blowing off the side of the front of the grill between the vents, the HVAC unit front cover with thick, white, fluffy residue on the vent. The base of Resident #77's enteral pump pole contained a thick, dried, tan substance, a black substance was on the floor in the corner beside the window, Resident #77's bed frame contained thick, black smears with a foul odor, and the floor tile at the head of the bed revealed a black, sticky substance. Resident #177's bed frame contained a thick, black smear with a foul odor on the side and the bottom of the bed frame. The floor under Resident #177's bed was covered with a layer of white dust, black tile grout, and debris. The residents' sink contained rust stains and standing water from a clogged sink, and chipped paint with black smears was observed in the right corner of the vanity with black sticky debris observed under the mirror. During an interview on 9/25/2024 at 10:20 AM, CNA P was asked when Resident #77 and Resident #117's sink was reported clogged. CNA P stated, .I'm not sure, it's been that way for a while . CNA P was asked what was under Resident #177's bed and bedframe. CNA P stated, .looks like dirt and feces .someone needs to clean that . During an interview on 9/25/2024 at 10:24 AM, LPN C was asked who was responsible for reporting clogged sinks. LPN C stated, .we tell maintenance .they will get to it . LPN C was asked who was responsible for cleaning the feeding pumps and poles. LPN C stated, .I would say the nurses . LPN C was asked what was on Resident #77's feeding pump. LPN C stated, .dried enteral feedings and dust . LPN C was asked what was on Resident #77's and #117's bedframe. LPN C stated, .could be dried stool . 11. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, and Gastrostomy tube. Review of Resident #80's 5-day MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated the Resident was cognitively intact, and dependent on staff for all ADLs. Observations in Resident #80 's room on 9/23/2024 at 10:06 AM and 9/24/2024 at 9:30 AM, revealed a thick, dried, yellowish-tan stain on the floor next to the bed. 12. Review of the medical records revealed Resident #120 and Resident #129 shared a room. Review of the medical record revealed Resident #120 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, Diabetes, and Gastrostomy tube. Review of Resident #120's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated the resident was cognitively intact. Review of the medical record revealed Resident #129 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure and Tracheostomy. Review of Resident #129's quarterly MDS assessment dated [DATE], revealed Resident had no BIMS score, staff assessed the resident as severely cognitively impaired for daily decision making, and the resident was dependent on staff for all ADLs. Review of the Tracking and Trending, report dated August 2024, revealed Resident #129 was treated with antibiotics for Respiratory Infections on 8/6/2024 and 8/25/2024. Review of the Admission/Discharge Report dated 9/1/2024-10/2/2024, revealed Resident #129 was discharged to the hospital on 8/28/2024 after unsuccessful treatment of antibiotics for a respiratory Infection. Review of the Progress Notes dated 10/10/2024, revealed Resident #129 was readmitted to the facility (on 10/10/2024) after being discharged to the hospital on 10/5/2024 for acute respiratory distress. Observation in Resident #120 and Resident #129's shared room on 9/23/2024 at 11:08 AM and 10/01/2024 at 8:18 AM, revealed the HVAC vents contained a thick build up of dust and a dried tan liquid was observed on Resident #129's enteral feeding pump pole and the floor. 13. Review of the medical records revealed Resident #131 and Resident #144 shared a room. Review of the medical record revealed Resident #131 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Dependence on Ventilator, and Tracheostomy. Review of Resident #131's quarterly MDS assessment dated [DATE], revealed Resident #131 BIMS score was unable to be completed due to Resident #131 was rarely/never understood. Resident #131 was assessed by staff to be severely cognitively impaired and dependent on staff for all care. Review of the medical record revealed Resident #144 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Dependence on Ventilator, Tracheostomy, and Gastrostomy tube. Review of Resident #144's admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact, and dependent on staff for all care. Review of the Admission/Discharge Report dated 8/1/2024-8/31/2024, revealed Resident #144 was discharged to the hospital 8/15/2024 with a Respiratory Infection. Review of the Tracking and Trending report dated September 2024, revealed Resident #144 was treated with antibiotics for a respiratory infection on 9/5/2024 and 9/6/2024. Observations in Resident #131 and Resident #144's shared room on 9/23/2024 at 10:50 AM and 3:48 PM, on 9/24/2024 at 7:34 AM, on 9/25/2024 at 4:10 PM, and on 10/1/24 at 8:10 AM, revealed a pool of a yellowish tan substance dried on the floor under the enteral feeding pole next to Residents #131's bed and yellowish tan dried drip spots on the floor leading toward the door. 14. Review of the medical record revealed Resident #133 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Tracheostomy, Chronic Kidney Disease, and Gastrostomy tube. Review of Resident #133's admission MDS assessment dated [DATE], revealed a BIMS score was not completed and staff assessed the resident as cognitively impaired for daily decision making, received oxygen, required suctioning, and received tracheostomy care. Observations in Resident #133's room on 9/23/2024 at 11:02 AM and 4:15 PM, and 9/24/2024 at 7:15 AM, revealed a dried, tan liquid on the floor in front of the oxygen concentrator. Observation in Resident #133's room on 9/24/2024 at 1:56 PM, revealed a dried tan liquid on the floor by the nightstand, and a dried, tan liquid and dust on the feeding pump pole. Crumbs and dried, brown spots were observed on the floor under the unoccupied bed in Resident #133's room. Observations in Resident #133's room on 9/25/2024 at 10:39 AM and 9/25/2024 at 4:11 PM, revealed dried, brown drops on the floor by the oxygen concentrator, dried tan liquid on the floor in front of the nightstand, dried, tan liquid on the blinds, thick dust and cobwebs on the windows, and crumbs and brown spots remained on the floor under the unoccupied bed in the resident's room. Observation in Resident #133's room on 9/30/2024 at 9:40 AM, revealed a thick build up of dark brown substance by the wall molding, next to the nightstand along with a bottle of enteral feeding on the floor, an unopened Calcium Alginate Dressing, and a jar of odor eliminator between the nightstand and the wall. Observation in Resident #133's room on 10/2/2024 at 8:51 AM, revealed the oxygen concentrator back vent contained white fluffy dust. 15. Review of the medical records revealed Resident #139 and Resident #349 shared a room. Review of the medical record revealed Resident #139 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Quadriplegia, Tracheostomy, and Gastrostomy tube. Review of Resident #139's admission MDS assessment dated [DATE], revealed a BIMS score was unable to be assessed, staff assessed the resident with severe cognitive impairment, and the resident was dependent on staff for all care. Resident #139 was discharged on [DATE] to the hospital with severe sepsis secondary to pneumonia. The resident did not return to the facility during the survey. Review of the medical record revealed Resident #349 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Tracheostomy and Gastrostomy tube. Review of Resident #349's admission MDS assessment dated [DATE], revealed a BIMS assessment was unable to be completed, staff assessed the resident as severely cognitively impaired for daily decision making, resident was rarely/never understood, and dependent on staff for all care. Observations in Resident #139's room on 9/30/2024 at 10:53 AM and 10/1/2024 at 8:04 AM, revealed the enteral feeding pump was covered with a dried, yellowish tan substance which had dripped and dried down the feeding pole, and a dried pool of the same substance was observed under the base of the enteral feeding pole. Resident #139 was discharged to the hospital on 9/25/2024 and no other patient had been admitted to that bed. Observation in Resident #349's room on 10/2/2024 at 8:47 AM, revealed large gray clumps of dust under the HVAC and tan spots on the floor. 16. Review of the medical record revealed Resident #304 was admitted to the facility on [DATE], with Respiratory Failure, Hypoxia, Tracheostomy, Acute Kidney Failure, and Gastrostomy tube. Review of Resident #304's admission MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated the resident was cognitively intact. Observations in Resident #304's room on 9/23/2024 [TRUNCATED]

Based on policy review, facility documentation review, job description review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses. Observations during the survey revealed the kitchen floors were dirty with standing water from leaking pipes, ice machines were broken and/or contained mold. There were no sanitation logs for the 3 compartment sinks. Observations revealed staff didn't know how to use the sanitizer during the survey, and pots and pans were caked with a carbon build-up, dried food particles were observed on the clean utensils, dust was observed on the drying rack for dishes, the warming oven and flat grill were observed with carbon build-up and with food particles, the 2 and 3 compartment sink pipes leaked, and the metal storage carts were dirty. These serious operational processes had the likelihood to result in foodborne illness outbreaks. All nursing home residents who received food from the kitchen were at risk for serious complications from foodborne illnesses as a result of their compromised health status. Unsafe food handling practices were observed when the preparation kitchen staff prepared the macaroni and cheese on the dirty 2 compartment sink, and when the Certified Dietary Manager (CDM) failed to perform hand hygiene during tray line service. The findings include: 1. Review of the facility policy titled, Kitchen Sanitation, revised 1/1/2022, revealed .The food service area shall be maintained in a clean and sanitary manner .Kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair .Seals, hinges and fasteners will be kept in good repair .equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .Sanitizing of environmental surfaces must be performed with one of the following solutions: 50-100 ppm [parts per million] chlorine solution .150-200 ppm quaternary ammonium compound .or 12/5 ppm iodine solution .For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; Removable components will be scraped to remove food particle accumulation and washed and sanitized .Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy .damaged or broken equipment that cannot be repaired shall be discarded .If a sink is used for washing utensils, cooking equipment or dishes, and also used to wash produce or thaw food, it will be cleaned between uses with an approved cleaning and sanitizing agent .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .The food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas .Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment . Review of the facility policy titled, Food Receiving and Storage, revised 1/1/2022, revealed Foods shall be received and stored in a manner that complies with safe food handling practices, as outlined in the FDA [Federal Drug Administration] Food Code .Food items and snacks kept on the nursing units should be maintained as indicated below: .Food items to be .placed in the refrigerator located at the nurses' station and labeled with an opened on and use by date, sealed or covered and labeled .Foods belonging to residents should be labeled with resident's name, the item and the opened on and use by date .Partially eaten food may not be kept in the refrigerator .Medications .may not be stored in the same refrigerator with food . Review of the facility policy titled, Emergency Food Storage, revised 1/1/2022, revealed .It is the policy of this facility to establish procedures to ensure that food is available for residents, staff, and volunteers in the case of emergency .The Dietary Manager shall maintain a 3 day supply of nonperishable foods and supplies of disposable dishes/utensils .The food and supplies are stored in an area which is less likely to be affected by disaster .The emergency food is rotated/replenished as needed .The amount of food needed is estimated based on the facility assessment, and considers census, total staff, and average number of volunteers/visitors . Review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitors, revised 1/1/2022, revealed .It is the right of the residents of the facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident .All food items that are already prepared by the family or visitor brought in must be labeled with content and dated .If not consumed within days, food will be thrown away by facility staff . 2. Review of the Lead Registered Dietitian's job description dated 2/20/2023, revealed .Provides clinical nutrition services that are full compliance with all regulatory statures, company policies and procedures, and performance .Works effectively with others to ensure that quality nutritional services are being provided on a daily basis, and acts as a resource to the Director of Dining Services so that the dining services department is maintained in a clean safe, and sanitary manner. Provides oversight and guidance to the Dining Services Director regarding dining services operations. Inspects food storage room .Recommends to the Director of Dining Services the equipment and supply needs of the department .Assists the Director of Dining Services in placing orders for the equipment and supplies as necessary or as may be required .Makes periodic rounds to inspect equipment and to ensure that equipment is available and working properly .Evaluates inventory levels of food, supplies, equipment, is maintained according to state guidelines . Review of the Dining Services Director's job description dated 7/1/2024, revealed .Manages the dining services program in a single site according to Healthcare Services Group (HCSG) policies and procedures, and federal/state requirements. Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met .Must be able to perform the essential job functions of dietary aide, cook, and dishwasher positions for purposes of training and assisting when there are call-outs .Supervises, coordinates and evaluates work of all dining services employees in preparing and serving food, and cleaning facilities and utensils in a production kitchen .Maintains required records including food production, inventory .Ensures that established sanitation and safety standards are maintained, Oversees and participates in the preparation and serving of food . Review of the Administrator's job description signed and dated 2/13/2023, revealed .Responsible for the efficient and profitable operation of the facility, facility compliance with [Corporate name] policies and State and Federal rules and regulations, and providing the highest quality of care possible .Manages the day-to-day operations of the facility .Implements control systems to ensure accountability of all departments .Monitors performance for achievement of goals and for improvement, and takes corrective action when necessary . 3. During observations on the initial tour of the kitchen with the Certified Dietary Manager (CDM) on 9/23/2024 at 9:33 AM, revealed the following: a. The kitchen floor was observed to be wet with water build up throughout the kitchen. The pipes under the 2 compartment sink were leaking water. b. The 2nd shelf of the drying rack contained four baking trays with dried food particles on all four of them, a large muffin pan with dried food particles on it, a large cooking pot and frying pan with black carbon build up noted on the bottom and inside of pans. c. On the drying rack beside the 3 compartment sink was a large pan with dried food particles on it, that had been processed/washed through the 3 compartment sink d. The 3 compartment sink had a cooking pot soaking in the water. The CDM performed a sanitation test of the 3 compartment sink with result of 10 PPM (sanitizing range 50 - 100 ppm). The CDM confirmed sanitation solution was not added prior to testing, and that staff should have added sanitation solution to the water prior to utilizing the 3 compartment sink for sanitation. e. The ice machine was observed with an out of order sign. The CDM stated the ice machine had not been working for one month with kitchen staff having to utilize am ice machine outside of the kitchen. f. The coffee maker was observed with coffee grounds on top of the coffee pot. g. The tea maker containing brewed tea was observed without a top on it to prevent contaminants from entering the tea maker. h. The stove was observed with a black carbon build up around the stove eyes. The stove only had one knob working for turning the stove eyes on. The staff were observed turning on the stove eyes using the metal stem. The warming oven was missing a handle. i. The flat top grill was observed with dried food particles and dried spilled substance on the top. j. The fryer baskets were observed with old fries and moderate amount of food crumbs and black particles in the baskets. k. The oven was observed with a black build up on the inside and on the oven door. Dietary [NAME] J confirmed that the oven was supposed to be cleaned daily but appeared that it had not been cleaned. l. The three tier metal serving cart storing clean dishes was observed with a moderate amount of dried tan splattered substances and food particles on the shelves, and dirt build up on the wheels of the cart. m. There was 1/2 cut Watermelon dated 9/16/2024, located in the walk-in refrigerator. n. There was one container of cake icing opened and dated 2/10/2024, located on the top shelf in the dry storage area. 4. During observations of the kitchen with the Regional CDM on 9/24/2024 at 10:14 AM, revealed the following: a. The pipe was leaking under the 2 compartment sink. A moderate amount of water was observed on the kitchen floor. There was standing water in areas on the kitchen floor which required the use of a mop. The Regional CDM confirmed that the pipe leak under the 2 compartment sink was related to an ongoing water issue with the pipe. b. The tea maker containing brewed tea was uncovered without a top to prevent contaminants from entering the tea maker. The tea maker was beside the dirty coffee maker with coffee grounds on it c. The three tier metal serving cart continued storing clean dishes with a moderate amount of tan dried splattered substances and food particles on the shelves, and dirt build up on the wheels of the cart. d. There was one bag of frozen french fries opened and undated located in the walk-in freezer. 5. During observations of the kitchen with the CDM on 9/25/2024 from 11:29 AM to 1:00 PM, revealed the CDM assisted on the tray line of the steam table. The CDM was observed leaving the tray line to gather items from the walk-in refrigerator and returning to the tray line on multiple occasions. The CDM was observed removing gloves and placing soiled gloves in her pocket, and then donning gloves on multiple occasions and failing to perform hand hygiene prior to returning to serving. 6. During observations of the kitchen with the CDM on 9/26/2024 at 1:22 PM, revealed the following: a. A water leak under the 3 compartment sink. b. The freestanding metal drying rack, parked between the 2 compartment sink and the 3 compartment sink, contained clean pots and pans and had a thick dust build up on it. c. The tea maker containing brewed tea was observed uncovered without a top to prevent contaminants from entering the tea maker. d. There continued to be missing knobs on the stove and a broken warming oven handle. The CDM stated during the observations that Maintenance had ordered parts and items were on backorder. When requested on multiple occasions for copies of the purchase orders the facility only provided service calls with estimates for the broken ice machine and steamtable. 7. During observations of the 400/500 Hall Nourishment Refrigerator on 9/30/2024 at 10:08 AM, revealed 11 (eleven) Normal Saline vials labeled Respiratory in a zip lock bag. Registered Nurse (RN) K confirmed medications should not be stored in the nourishment refrigerator. 8. During observations of the 200 Hall Nourishment Refrigerator on 9/30/2024 at 9:58 AM, revealed a plastic bag labeled with a resident room number dated 9/21/2024 with 2 plastic containers of food. 9. During observations on 9/30/2024 at 2:31 PM, revealed the ice machine located outside the kitchen contained black mold-like substance on the inside of the ice machine and a black build up on the inside rim of the ice machine. There was a white substance build up on the exterior of the ice machine. The floor under the ice machine was black and dirty. The kitchen utilizes this ice machine for ice. 10. During observations and interview on 9/30/2024 at 4:11 PM, the Administrator was asked to identify the black substance on the inside of the ice machine. The Administrator stated that he did not feel comfortable stating what he thought it looked like but confirmed that it needed to be cleaned. 11. During observations of the kitchen with the CDM on 9/30/2024 at 2:36 PM, revealed the following: a. The kitchen staff were preparing macaroni and cheese on the dirty 3 compartment sink. b. There was a small frying pan with black build up on the bottom of the pan, stored on the drying rack. c. The drying rack was observed with dust on the shelves. d. There was a one ounce (oz) metal serving ladle hanging on the side of the drying rack with dried white food particles on it. e. There was a twelve oz metal ladle hanging on the side of the drying rack with white dried substance on it. f. There was a gray handle serving scoop with food particles observed on the drying rack beside the 3 compartment sink. g. The three tier metal serving cart contained a moderate amount of tan dried substance on the 2nd and 3rd shelves with clean dishes stored on the shelves. 12. During observations of the kitchen with the CDM on 10/02/2024 at 10:28 AM, revealed the following: a. A water leak remained under the 3 compartment sink. b. The build-up of dust remained on the freestanding drying rack. c. There was a medium frying pan and a large cooking pot with thick carbon build up on the drying rack. d. The dishwasher staff placed a tray container of dirty dishes on top of another tray container of dirty dishes and ran them through the hot water sanitizing dishwasher. 13. During an observation and interview on 10/2/2024 at 10:48 AM, the CDM was asked for a copy of the Daily Cleaning Schedules for the current week of 9/29/2024 - 10/5/2024. The CDM stated she had not put out a new schedule and provided a blank Daily Cleaning Schedule dated 9/29-10/5/2024. The prior week's Daily Cleaning Schedule was still on the kitchen door. The CDM provided a total of 7 weeks of Daily Cleaning Schedules dated 7/28/2024 - 10/5/2024. Review of the Daily Cleaning Schedule for the kitchen revealed missing dates on the Daily Cleaning Schedules and multiple blank areas without initials for the schedules provided. The Daily Cleaning Schedules revealed the following: a. Week of 7/28/2024 - 8/3/2024: Sunday AM the kitchen was not mopped and swept. Sunday PM the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the utility carts were not cleaned, the cooler and freezer seals were not cleaned, the beverage carts were not cleaned, the ice machine was not cleaned, the microwave was not cleaned, the three bay sink was not cleaned, the dish window was not cleaned, the dish tray carts were not cleaned, the coffee and tea urns were not cleaned, the oven top was not cleaned, the floor under the dish machine was not cleaned, and the cooler was not swept or mopped. Monday AM the can opener was not cleaned, the drip pans were not cleaned, the stove top/grill/backsplash were not cleaned, the cook's tables and shelves were not cleaned, the plate warmer was not cleaned, the beverage station was not cleaned, the food carts were not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the pantry was not swept or mopped, the tables and shelves were not cleaned, the coffee urns were not cleaned, the lower shelves were not cleaned, the top and sides of the dishwasher were not cleaned, the trash cans were not cleaned, the dish room was not swept or mopped, and the juice area was not cleaned. Monday PM the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the utility carts were not cleaned, the cooler and freezer seals were not cleaned, the beverage carts were not cleaned, the ice machine was not cleaned, the microwave was not cleaned, the three bay sink was not cleaned, the dish window was not cleaned, the dish tray carts were not cleaned, the coffee and tea urns were not cleaned. Monday weekly cleaning of the cook's shelves, the bottom of the oven and the hood vents was not performed. Tuesday AM the hand sink was not cleaned, the beverage station was not cleaned, the inside and outside of the food carts were not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the pantry was not swept or mopped, the tables and shelves were not cleaned, the coffee urns were not cleaned, the lower shelves were not cleaned, the top and sides of the dishwasher were not cleaned, the dish room was not swept or mopped, and the juice area was not cleaned. Tuesday PM the kitchen was not swept or mopped, the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the utility carts were not cleaned, the cooler and freezer seals were not cleaned, the beverage carts were not cleaned, the ice machine was not cleaned, the microwave was not cleaned, the three bay sink was not cleaned, the dish window was not cleaned, the dish tray carts were not cleaned, and the coffee and tea urns were not cleaned. Tuesday weekly cleaning of the utensil drawer and the rack carts was not performed. Wednesday AM the beverage station was not cleaned, the inside and outside of the food carts were not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the pantry was not swept or mopped, the tables and shelves were not cleaned, the coffee urns were not cleaned, the lower shelves were not cleaned, the top and sides of the dish machine were not cleaned, the trash cans were not cleaned, and the dish room was not swept or mopped. Wednesday PM the steam table was not cleaned, the can opener was not cleaned, the plate warmer was not cleaned, the steam table wells was not cleaned, the drip pans were not cleaned, the kitchen was not swept or mopped, the prep sink was not cleaned, the three bay sink was not cleaned, the stove top/grill/backsplash was not cleaned, the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the utility carts were not cleaned, the cooler and freezer seals were not cleaned, the beverage carts were not cleaned, the ice machine was not cleaned, the microwave was not cleaned, the dish window was not cleaned, the dish tray carts were not cleaned, and the coffee and tea urns were not cleaned. Wednesday weekly cleaning of the griddle, the rack carts, and sweeping and mopping of the storeroom was not performed. Thursday AM the hand sink was not cleaned, the beverage station was not cleaned, the inside and outside of the food carts were not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the pantry was not swept or mopped, the tables and shelves were not cleaned, the coffee urns were not cleaned, the lower shelves were not cleaned, the top and sides of the dish machine were not cleaned, the dish room was not swept or mopped, and the juice area was not cleaned. Thursday PM the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the utility carts were not cleaned, the cooler and freezer seals were not cleaned, the beverage carts were not cleaned, the ice machine was not cleaned, the microwave was not cleaned, the three bay sink was not cleaned, the dish machine filters were not cleaned, the top and sides of the dish machine were not cleaned, the dish room was not swept or mopped, the dish window was not cleaned, the dish tray carts were not cleaned, and the coffee and tea urns were not cleaned. Thursday weekly cleaning of the fryer was not performed. Friday AM the three bay sink was not cleaned, the top and sides of the steam table were not cleaned, the can opener was not cleaned, the prep sink was not cleaned, the drip pans were not cleaned, the stove top/grill/backsplash were not cleaned, the cook's tables and shelves were not cleaned, the kitchen was not swept or mopped, the plate warmer was not cleaned, the hand sink was not cleaned, the beverage station was not cleaned, the food carts were not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the dish room walls were not cleaned, the tops and sides of the dish machine were not cleaned, the dish room was not swept or mopped, the juice area was not cleaned. Friday PM the steam table was not cleaned, the can opener was not cleaned, the plate warmer was not cleaned, the steam table wells were not cleaned, the drip pans were not cleaned, the kitchen was not swept or mopped, the prep sink was not cleaned, the three bay sink was not cleaned, the stove top/grill/backsplash was not cleaned, the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the food carts were not cleaned, the utility carts were not cleaned, the pantry was not swept or mopped, the cooler and freezer seals were not cleaned, the beverage carts were not cleaned, the exterior of the ice machine was not cleaned, the microwave was not cleaned, the dish bay filters were not cleaned, the top and sides of the dish machine were not cleaned, the dish room walls were not cleaned, the dish room window was not cleaned, the dish tray carts were not cleaned, and the coffee and tea urns were not cleaned. Friday weekly cleaning of the fryer and the delime dish machine was not performed. Saturday AM the three bay sink was not cleaned, the top and sides of the steam table were not cleaned, the can opener was not cleaned, the prep sink was not cleaned, the drip pans were not cleaned, the stove top/grill/backsplash were not cleaned, the cooks tables and shelves were not cleaned, the kitchen was not swept or mopped, the plate warmer was not cleaned, the hand sink was not cleaned, the beverage station was not cleaned, the inside and outside of the food carts was not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the dish room walls were not cleaned, the tops and sides of the dish machine were not cleaned, the dish room was not swept or mopped, and the juice area was not cleaned. Saturday PM the steam table was not cleaned, the can opener was not cleaned, the plate warmer was not cleaned, the steam table wells were not cleaned, the drip pans were not cleaned, the kitchen was not swept or mopped, the prep sink was not cleaned, the three bay sink was not cleaned, the stove top/grill/backsplash was not cleaned, the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the food carts were not cleaned, the utility carts were not cleaned, the pantry was not swept or mopped, the cooler and freezer seals were not cleaned, the beverage carts were not cleaned, the exterior of the ice machine was not cleaned, the microwave was not cleaned, the three bay sink was not cleaned, the dish window was not cleaned, the dish tray carts were not cleaned, and the coffee and tea urns were not cleaned. Saturday weekly cleaning under the steam table was not performed. b. Week of 8/4/2024-8/10/2024: Sunday AM the hand sink was not cleaned, the beverage station was not cleaned, the inside and outside of the food carts was not cleaned, the utility carts was not cleaned, the shelf under coffee pot was not cleaned, the pantry was not swept or mopped, the tables/shelves were not cleaned, the coffee urns were not cleaned, the lower shelves in dish room were not cleaned, the dish room walls were not cleaned, the top and sides of the dish machine were not cleaned, the dish room was not swept or mopped and the clean juice area was not completed. Sunday PM the steam table was not cleaned, the can opener was not cleaned, the plate warmer was not cleaned, the steam table wells were not cleaned, the drip pans were not cleaned, the kitchen was not swept or mopped, the prep sink was not cleaned, the three bay sink was not cleaned, the stove top/grill and back splash was not cleaned, the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the food carts were not cleaned, the utility carts were not cleaned, the pantry was not swept or mopped, the seals on the cooler and freezer was not cleaned, the beverage carts were not cleaned, the ice machine exterior was not cleaned, the microwave was not cleaned, the three bay sink was not cleaned, the dish window was not cleaned, the dish tray carts were not cleaned and the coffee/tea urns were not cleaned. Sunday weekly cleaning of the top oven, floor under the dish machine, and the cooler was not performed. The cooler was not swept and mopped. Monday AM the hand sink was not cleaned, the beverage station was not cleaned, the inside and outside of the food carts were not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the pantry was not swept and mopped, the tables/shelves were not cleaned, the coffee urns were not cleaned, the lower shelves in dish room were not cleaned, the dish room walls were not cleaned, the top and sides of the dish machine were not cleaned, the inside and outside of the trash cans were not cleaned, the dish room was not swept and mopped and the juice area was not cleaned. Monday PM the steam table was not cleaned, the can opener was not cleaned, the plate warmer was not cleaned, the steam table wells were not cleaned, the drip pans were not cleaned, the kitchen was not swept or mopped, the prep sink was not cleaned, the three bay sink was not cleaned, the stove top/grill and back splash were not cleaned, the pantry was not swept or mopped, the dish window was not cleaned, the dish tray carts were not cleaned and the coffee/tea urns were not cleaned. Monday weekly cleaning of the cook's shelves, the bottom oven, and hood vents were not performed. Tuesday AM the hand sink was not cleaned, the beverage station was not cleaned, the inside and outside of the food carts were not cleaned, the utility carts were not cleaned, the shelf under the coffee pot was not cleaned, the pantry was not swept and mopped, the tables/shelves were not cleaned, the coffee urns were not cleaned, the lower shelves in dish room were not cleaned, the dish room walls were not cleaned, the top and sides of the dish machine were not cleaned, the dish room was not swept and mopped, and the juice area was not cleaned. Tuesday PM the kitchen was not swept and mopped, the three bay sink was not cleaned, the coffee maker and nozzle was not cleaned, the tea maker and nozzle was not cleaned, the utility carts were not cleaned, the pantry was not swept or mopped, the seals on the cooler and freezer were not cleaned, the ice machine exterior was not cleaned, the microwave was not cleaned, the dish room walls were not cleaned, the dish window was not cleaned, the dish tray carts were not cleaned and the coffee/tea urns were not cleaned. Tuesday weekly cleaning of the utensil drawer, and the rack carts was not performed. Wednesday AM the utility carts were not cleaned, the shelf under coffee pot was not cleaned, the pantry was not swept and mopped, the lower shelves in dish room were not cleaned, the dish room walls were not cleaned, the top and sides of the dish machine were not cleaned, inside and outside of trash cans were not cleaned, the dish room was not swept and mopped and the juice area was not cleaned. Wednesday PM the steam table was not cleaned, the can opener was not cleaned, the plate warmer was not cleaned, the steam table wells were not cleaned, the drip pans were not cleaned, the kitchen was not swept or mopped, the prep sink was not cleaned, the three bay sink was not cleaned, the stove top/grill and back splash were not cleaned, the coffee maker and nozzle were not cleaned, the tea maker and nozzle were not cleaned, the inside and outside of the food carts were not cleaned, the utility carts were not cleaned, the pantry was not swept or mopped, the seals on the cooler and freezer were not cleaned, the beverage carts were not cleaned, the ice machine exterior was not cleaned, the microwave was not cleaned, the dish machine filters were not cleaned, the top and sides of the dish machine were not cleaned, the dish window was not cleaned, the dish room was not swept or mopped, the dish tray carts were not cleaned and the coffee/tea urns were not cleaned. Wednesday weekly cleaning of the griddle, delime dish machine, legs and casters was not performed. Thursday AM the hand sink was not cleaned, the beverage station was not cleaned, the inside and outside of the food carts were not cleaned, the utility carts were not cleaned, the shelf under coffee pot was not cleaned , the pantry was not swept and mopped, the tables/shelves were not cleaned, the coffee urns were not cleaned, the lower shelves in dish room were not cleaned, the dish room walls were not cleaned, the top and sides of the dish machine were not cleaned, the dish room was not swept and mopped and the juice area was not cleaned. Thursday PM the coffee maker and nozzle were not cleaned, the tea maker and nozzle were not cleaned, the food carts were not cleaned, the utility carts were not cleaned, the pantry was not swept or mopped, the seals on the cooler and freezer were not cleaned, the beverage carts were not cleaned, the ice machine exterior was not cleaned, the microwave was not cleaned, the three bay sink was not cleaned the dish machine filters were not cleaned, the top/sides of the dish machine were not cleaned, the dish room walls were not cleaned, the dish tray carts were not cleaned and the coffee and tea urns were not cleaned. Thursday weekly cleaning of the fryer was not performed. Friday AM the three bay sink was not cleaned, the top and sides of the steam table were s not cleaned, the can opener was not cleaned, the prep sink was not cleaned, the drip pans were not cleaned, the stove top/grill/backsplash were not cleaned, the cook's tables and shelves were not cleane [TRUNCATED]

Based on policy review, medical record review, facility investigation review and interview, the facility failed to thoroughly investigate an allegation of abuse and failed to report to the government agency the results of the facility investigation within 5 working days for 4 of 13 residents (Resident #58, #248, #298, #300) reviewed for abuse incidents. The findings include: 1. Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 1/10/2024, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation .the facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law . Possible indicators of abuse include .resident, staff or family report of abuse .Physical marks such as bruises or patterned appearances .on resident's body .physical injury of a resident, of unknown source .written procedures for investigations include: identifying staff responsible for the investigation .investigating different types of alleged violations .identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred providing complete and through documentation of the investigation .protection of resident .reporting alleged violations to the administrator, state agency, adult protective service and to all other required agencies within specified timeframes as required by state and federal regulations .the administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the result of the investigation when final . 2. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Dementia, Anxiety, Psychotic Disorder, Insomnia, Hypertension, and Depression. Review of the Other Skin note dated 10/28/2023, revealed .called to Resident #58's room, by CNA (Certified Nursing Assistant) at approximately 06:00 AM, to look at resident's left hand .noted left hand and digits to be bruised and swollen .Upon assessment, resident noted moaning, when touched . Review of Nurses Note dated 10/28/2023, revealed writer called to resident's room, by CNA, at approximately 06:00 AM, to look at resident's left hand .Upon entry, writer noted left hand and digits to be bruised and swollen .Upon assessment, resident noted moaning when area is touched .Writer notified supervisor on duty .NP [Nurse Practitioner] notified .X-ray ordered . DON [Director of Nursing] notified. Resident's guardian notified . Review of the hospital's History and Physical report revealed .ER [emergency room ] 10/28/2023, with some left hand pain swelling-mechanism of injury not known .found to have proximal fourth and fifth digit fractures on her left hand . Review of Progress Note dated 10/30/2023 at 10:58 AM, revealed .SW [Social Worker] contact MPD [Memphis Police Department] non-emergency police number to report allegation of abuse related to resident with bruises all over her body and 2 broken fingers; spoke with .dispatcher . APS [Adult Protective Service] contacted .someone will be out to investigate incident . Review of Nurses Note dated 10/30/2023, revealed bruises noted to left chin, left cheek, left shoulder, left wrist along with a red-looking rash to right buttocks .Wound care nurse notified of rash along with NP notified of all new bruises and new rash to right buttocks. New order from NP for aptt [activated partial thromboplastin time], pt [prothrombin time], inr. [INR - international normalized ratio] .Wound care nurse to evaluate rash on right buttocks . Review of Pertinent Charting-Skin note dated 10/30/2023, revealed Event Date: 10/30/2023 Location of skin area being documented: Bruises noted to left cheek, left chin, left shoulder and left wrist .Rash to right buttocks Description: Rash to right buttocks red raised. No drainage or foul odor noted from rash site. Interventions: Wound care to evaluate area .Physician notification: DR [Doctor], Responsible Party notification .conservator .Referrals: New orders: PT WITH INR APPT. Review of Nurses Note dated 10/30/2023 at 2:28, revealed This residents' conservator here to see resident R/T [related to] bruising noted on resident which was reported to her .conservator spoke to Adon [Assistant Director of Nursing] and DON before leaving facility .New orders for entire left side of upper body plus skull series R/T bruising of unknown origin . Review of the Nurse's Note dated 10/30/2024, revealed Resident #58 resting quietly in bed at this time. NAD [No apparent distress] noted. Lt.[left] hand with splint intact. Will continue to monitor . Review of Pertinent Charting-Skin on 10/31/2023, revealed Location of skin area being documented: bruises to left upper extremity .Brace to left hand r/t finger fractures and broken left wrist .Resident currently sleeping, call light within reach bed in lowest position and locked . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score was not coded. Resident #58 had short-term memory and long-term memory problems and was dependent upon staff for activities of daily living including bed mobility and transfers. Review of quarterly MDS assessment dated [DATE], revealed a BIMS score was not coded. Resident #58 had short-term memory and long-term memory problems and was dependent upon staff for activities of daily living including transfers. The facility reported the incident on 10/28/2023 but failed to submit the 5 day follow up report of the facility investigation within 5 working days of the incident. 3. Review of the medical record revealed Resident #248 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hypertension, Diabetes, Anxiety, and Psychotic Disorder. Review of the Radiology Report dated 3/11/2020, revealed WRIST .Results: Scaphoid [bone in the wrist] irregularity .Scapholunate widening suggests ligamentous injury. Degenerative changes. Possible scaphoid fracture, recommend scaphoid views or CT [computed tomography] .HUMERUS [bone in the arm] MINIMUM 2V [view], LEFT .Results. No acute fracture or dislocation. The osseous [bone] structures appear intact. Joint spaces are narrowed. Soft tissues are unremarkable. Conclusion . No acute osseous abnormality. Degenerative changes . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 2, indicating that Resident #248 was severely cognitively impaired, was dependent on staff for activities of daily living such as toileting, bathing, dressing, and bed mobility, and was always incontinent for bowel and bladder. Review of the Nursing Evaluation Summary dated 3/10/2023, revealed RESIDENT REQUIRE TOTAL CARE WITH ALL ADLS [Activities of Daily Living] X [Times] 1, INCONTINENT OF B/B [Bowel and Bladder], WEAR ADULT DIAPERS, ALERT AND ORIENTED X 1, DISORIENTED TO TIME AND PLACE. APPETITE GOOD PER FEEDING SELF .HAS LEFT SIDED WEAKNESS . Review of the Nurse Note dated 5/26/2023, revealed 15:30 [3:30 PM] Abnormal Xray results received on left scapula and shoulder. Results forwarded to DON [Director of Nursing] . and [named provider] .Orders received to send to [named hospital emergency room (ER)] for further evaluation. 16:18 [4:18 PM] writer called POA [Power of Attorney] .and informed her of results and that she [Resident #248] would be transferred to [Named hospital emergency room ] for further eval. [evaluation] POA agreed with transfer .ambulance service called with estimated ETA [Estimated time of Arrival] of 2 hours. [Named hospital ER] called and report given to nurse .to inform of arrival in approximately 2 hours . Review of nurse's note dated 5/26/2023 revealed .RESIDENT YELLING OUT AGAIN, NOTED TWITCHING TO RT [Right] SIDE OF FACE AND RT. ARM, MENTAL STATUS CHANGE, FNP [Family Nurse Practitioner] NOTIFIED, RECIEVED FOR CBC [Complete blood count], CMP [Complete metabolic panel], MAGNESIUM, NARCO 7.5MG, [used to treat pain], 1 EVERY 6HRS [Hours] PRN [As needed] PAIN, X-RAY LT [Left] SHOULDER AND ARM. RADIOGRAPHICS NOTIFIED . Review of the hospital triage note dated 5/26/2023 at 5:48 PM, revealed .Chief Complaint: left shoulder dislocation .Additional assessment note - triage: pt [patient-Resident #246] is from [named long-term care facility]. Pt is bed bound and nursing home staff states that they think she was possibly turned wrong, and the shoulder was dislocated . Review of the hospital Emergency Department (ED) nurse's note dated 5/26/2023 at 6:44 PM, revealed .Pt [Resident #248] brought by EMS [Emergency Medical Service] and placed in RM [room] .Pt yelling and screaming. RN [Registered Nurse] attempted to reorient pt with no success. EMS reports pt from [named nursing home] and they [nursing home staff] moved her [Resident #248] the wrong way. Deformity noted to left shoulder .Pt taken to xray with RN. call light and personal items within reach. pending scans for further eval . Review of the Radiology Interpretation dated 5/26/2023, revealed .Left Scapula X-Ray complete .Findings .Left scapula . Fontal and scapular Y views .Anterior gleno-humeral [shoulder joint] dislocation . Impression . Anterior dislocation .Left shoulder X-Ray complete .Findings .Left Shoulder .Frontal and scapular Y views .Anterior gleno-humeral dislocation .Anterior dislocation . Review of the facility's investigation dated 5/27/2023, revealed . Resident frequently yells out due to cognitive deficit. The resident began to yell out more frequently the past 24 hours. NP [Nurse Practitioner] was notified. Labs and x-ray ordered due to c/o [complaints of] left arm [pain]. Resident has c/o left arm pain at times with mobility since admission .Resident c/o left arm pain. X-ray obtained that indicated a dislocated shoulder. Resident had a previous injury to this shoulder with a fracture [Resident #248 actually had a previous scaphoid or wrist fracture/injury]. There is no outward s/s [signs or symptoms] of trauma to the left shoulder. Resident is alert and oriented to person. She can make her needs known. She does yell out frequently due to cognitively impairment. Resident yelled out more frequently. No c/o [complaints] anyone hurting her. No change in baseline other than more frequently yelling out. Resident has an old injury to her left shoulder [actually an old injury to the scaphoid/wrist] and does c/o pain at times. Pain relieved with Tylenol. Due to her yelling out more frequently today, NP notified for x-ray. MD notified for follow up treatment and diagnostics at the ER .5/27/2023 at 1:38 AM Resident was yelling out more frequently today. She does yell out due to cognitive deficit. NP notified for x-ray. X-ray indicates a dislocation of the shoulder. Investigation in progress. Resident sent to the hospital for follow up. 5 day follow up dated 6/5/2023 Resident remains in the hospital. Diagnosis unknown. The dislocated left shoulder was an old injury. X-ray comparison and CT scans at the hospital verified the injury with an old fx [fracture] has been present previously [refers to an old scaphoid/wrist injury]. Multiple attempts to reduce the left shoulder dislocation have been unsuccessful. Employees that provide care report no falls or injuries. Resident refuses to get OOB [Out of Bed] Resident is alert and oriented to self. Cognitively impaired r/t [related to] hemorrhagic cva [cerebrovascular accident] . Requires one person for bed mobility. The unknown origin injury is not substantiated. The injury is chronic [the scaphoid/wrist injury] . Review of 3 witness statements provided with the facility investigation revealed one statement was undated and staff reported that she did not work with Resident #248. One statement was dated 5/5/2023 (prior to the incident). One statement was dated 6/5/2023 and staff stated that she did not work with Resident #248. During a telephone interview on 10/15/2024 at 10:49AM, the former DON was asked about the facility's investigation for Resident #248's injury of unknown origin and if she was aware of the difference between a scapular and a scaphoid fracture. The former DON stated that she thought the scapular and scaphoid were the same thing. The former DON stated since the scapular and scaphoid are two different areas of the body then the injuries should not have been related. The former DON confirmed a thorough investigation should include witness statements from staff who were assigned care of Resident #248 and statements should be dated and signed by staff. During an interview on 10/16/2024 at 2:13 PM, the Administrator confirmed a thorough investigation included interviewing and obtaining complete and accurate witness statements of staff who were assigned care of Resident #248 over the last 72 hours. The Administrator verified the witness statements should be signed and dated by staff, and the facility 5 day follow up should be submitted within 5 days of the facility reported incident. 4. Review of the medical record revealed Resident #298 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Anxiety, Chronic Obstructive Pulmonary Disease, Aphonia and Tracheostomy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9 which indicated Resident #298 was moderately cognitively impaired. Review of the progress notes dated 3/5/2023 at 2:16 PM, revealed .Pt [Resident #298] has new skin issues on both breast r/t holding hands tightly up against chest. Interventions include placing a soft barrier between the Pt arm and breast to relieve the pressure. As well as monitoring the skin condition every day . Review of the nurses note dated 3/13/2023 at 8:20 PM, revealed CNA [Certified Nursing Assistant] discovered 2 bruises, one to each breast this evening during HS [bedtime] care and was reported to her nurse and then shown to me [RN E]. I then informed the DON, the RP and the MD . Resident was also medicated for pain . Review of the Incident Report dated 3/13/2023, revealed .Incident Description .CNA brought to [Named Nurse] attention two new bruises one on each breast her [Resident #298] arms held tightly to her chest . Review of the Skin assessment dated [DATE], revealed .Skin Evaluation .Are there any new abnormal skin areas .yes .site .Chest .2 discolored areas with slight excoriation noted to bilateral breasts. Resident noted holding her hand very tightly at her chest area .Area is caused from resident holding her hands so tight right at chest area causing discoloration . Review of the care plan revised 3/13/2023, revealed .Discoloration to bilateral breasts due to resident holding hands/arms tightly to her chest Date initiated .3/13/2023 .pad area between chest area and hands as allowed .Avoid scratching and keep hands and body parts from excessive moisture .educate .causative factors .to prevent skin injury . Review of the facility investigation revealed 3 witness statements dated 3/17/2023. Review of the witness statements revealed 2 statements verifying Resident #298 keeps her hands close to her chest and keeps her arms and fists balled up close to her chest. There was no documentation of further investigation or statements. During an interview on 10/16/2024 at 2:13 PM, the Administrator stated a thorough investigation would include talking with those who found it, looking at the shower schedules and talk with staff that worked with the resident in the last 72 hours. 5. Review of the medical record revealed Resident #300 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Ovary, Anxiety, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #300 was severely cognitively impaired. Review of Nurses' Notes dated 3/18/2023 at 4:40 AM, revealed .Residents daughter escorted out due to her arguing with resident and threatening to hit her [Resident #300] and at residents request, nurse explained to daughter that she could wait in family room for a ride but could not return to residents room causing a disturbance to her mother and the other residents . A facility investigation for family to resident abuse began on 3/18/2023. Review of the facility investigation revealed Resident #300's daughter visited the Resident and had asked for money form the Resident. Resident #300 refused to give the daughter money, and the daughter was heard threatening to hit Resident #300 and was yelling loudly. The staff removed the daughter from the Resident's room and the Police took the daughter away in the police car. A picture of the alleged perpetrator was shared with staff as a safeguard to keep the daughter from returning to her mother's room. There was no documentation the facility obtained witness statements and/or other residents for the investigation. During an interview on 10/16/2024 at 3:48 PM, the DON confirmed a thorough investigation was not done if there were no witness statements. 47835 48285 49269

Based on policy review, facility investigation, medical record review, and interview, the facility failed to follow up and honor a resident's right to request a room change for 1 of 6 residents (Resident #118) sampled for resident rights. The findings include: 1. Review of the facility's undated policy titled, Residents Rights, revealed, .As a company we place a top priority on preserving resident rights, ensuring their rights are not violated . Review of the facility's policy titled, Change of Room or Roommate, dated 10/30/2023, revealed .It is the policy of the facility to conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or resident representative .Requests for changes in room or roommate should be communicated to the Social Service Designee . 2. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE], with diagnoses including Non-Traumatic Intercranial Hemorrhage, Need Assistance with Personal Care, Muscle Wasting and Atrophy, Difficulty Walking, Aphasia, and Cerebral Infarction. Review of a facility's Alleged Abuse Incident Report dated 10/16/2024, revealed .Resident alleged that DON [Director of Nursing] told him he couldn't move to new room . Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #118 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Review of a facility incident reporting system (IRS) report with an investigation completed date of 10/28/2024, revealed .He [Resident #118] informed me [Administrator] that he had spoke with [DON] and requested a private room .later as he was eating breakfast in the dining room he asked her about it and she said, No . During an interview on 12/4/2024 at 11:09 AM, the Administrator confirmed that Resident #118 told him that he had asked the DON to be moved to a private room and the DON told him he could not move. During an interview on 12/2/2024 at 12:57 PM, Resident #118 confirmed that he asked the DON if he could move to another room, and she told him no. During an interview on 12/4/2024 at 2:35 PM, the Social Service Director (SSD) confirmed that the Social Service Department are responsible for correlating with nursing regarding resident room changes. The SSD confirmed that she was made aware of Resident #118's request for the private room on 10/16/2024 and she has never followed up with him regarding the room change. The SSD was asked should you have followed back up with Resident #118 regarding his request for a room change. The SSD stated, Yes .

Based on policy review, facility investigation, medical record review, and interview, the facility failed to follow up and honor a resident's right to request a room change for 1 of 6 residents (Resident #118) sampled for resident rights. The findings include: 1. Review of the facility's undated policy titled, Residents Rights, revealed, .As a company we place a top priority on preserving resident rights, ensuring their rights are not violated . Review of the facility's policy titled, Change of Room or Roommate, dated 10/30/2023, revealed .It is the policy of the facility to conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or resident representative .Requests for changes in room or roommate should be communicated to the Social Service Designee . 2. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE], with diagnoses including Non-Traumatic Intercranial Hemorrhage, Need Assistance with Personal Care, Muscle Wasting and Atrophy, Difficulty Walking, Aphasia, and Cerebral Infarction. Review of a facility's Alleged Abuse Incident Report dated 10/16/2024, revealed .Resident alleged that DON [Director of Nursing] told him he couldn't move to new room . Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #118 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Review of a facility incident reporting system (IRS) report with an investigation completed date of 10/28/2024, revealed .He [Resident #118] informed me [Administrator] that he had spoke with [DON] and requested a private room .later as he was eating breakfast in the dining room he asked her about it and she said, No . During an interview on 12/4/2024 at 11:09 AM, the Administrator confirmed that Resident #118 told him that he had asked the DON to be moved to a private room and the DON told him he could not move. During an interview on 12/2/2024 at 12:57 PM, Resident #118 confirmed that he asked the DON if he could move to another room, and she told him no. During an interview on 12/4/2024 at 2:35 PM, the Social Service Director (SSD) confirmed that the Social Service Department are responsible for correlating with nursing regarding resident room changes. The SSD confirmed that she was made aware of Resident #118's request for the private room on 10/16/2024 and she has never followed up with him regarding the room change. The SSD was asked should you have followed back up with Resident #118 regarding his request for a room change. The SSD stated, Yes .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the residents' right to retain and use their personal possessions for 1 of 1 (Resident #20) sampled residents. The findings include: 1.Review of the facility policy titled, Quality Assistance Procedure revised 10/30/2023, revealed .Residents, their representatives (sponsors), other interested family members, or resident advocates may file a Quality Assistance Form .concerning treatment, medial care, behavior of other residents, staff members, theft of property, etc., without fear or threat or reprisal in any form .Quality Assistance requests may be submitted orally or in writing. The administrator may delegate the responsibility of Quality Assistance investigation to appropriate department manager .Upon receipt .the department manager will investigate the allegations and submit a written report of such findings to the administrator .The resident .will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems . Review of the undated facility policy titled FEDERAL RIGHTS OF NURSING CENTER RESIDENTS REQUIREMENTS FOR NURSING FACILITIES revealed .The resident has a right to be treated with respect and dignity including .The right to retain and use personal possessions .unless to do so would infringe upon the rights or health and safety of other residents . 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Need for Assistance with Personal Care and Muscle Weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #20 was cognitively intact. Review of the facility QUALITY ASSISTANCE FORMS (Grievance Log) for August 2024 and September 2024, revealed there was no documentation the facility had completed a form related to Resident #20 missing perfume. During an interview on 9/24/2024 at 10:13 AM, Resident #20 stated that perfume was missing from a bag she had covered with a towel on her nightstand last week. Resident #20 stated she reported it to Unit Manager S and has not heard anything back. During an interview on 9/26/2024 at 9:21 AM, the Social Services Director was asked if she had replaced Resident #20's perfume. The Social Services Director stated, not yet we are working on it. During an interview on 9/30/2024 at 10:30 AM, the Social Services Director confirmed that missing items should be on the QUALITY ASSISTANCE FORMS when they are reported to staff.

Based on policy review, medical record review, observation and interview, the facility failed to ensure food preferences were acknowledged for 1 of 1 (Resident #70) sampled resident reviewed for choices. The findings include: 1.Review of the facility policy titled, Resident Rights revised on 10/30/2023, revealed The facility will ensure that all staff are educated on the rights of residents and the responsibility of the facility to properly care for its residents . Review of the facility policy titled, Resident Food Preferences revealed, Nutritional assessments will include an evaluation of individual food preferences .Upon the resident's admission Dietary Manager or designee will identify a resident's food preferences .The resident's clinical record .will document the resident' likes and dislikes and special dietary instructions or limitations . Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Diabetes, Visual Loss, Stage 5 End Stage Renal Disease, and Quadriplegia. Review of the admission Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #70 was cognitively intact, required set up for eating, and diagnoses of visual loss and Quadriplegia. During an interview on 9/23/2024 at 10:00 AM, Resident #70 stated, .I am getting pork, and I don't eat pork . Observation in Resident #70's room during dining on 9/23/24 at 12:50 PM, revealed Certified Nursing Assistant (CNA) A removed a tray from the meal cart, knocked and entered Resident #70's room, and placed the tray on the over the bed table. Resident #70 asked, What did they send me. CNA A stated, You have a cut up ham sandwich and then a ham sandwich in a plastic bag, chips, juice, tea, and water. Resident #70 stated, Ma'am I do not eat pork, I have told this to them since I came here, I do not eat pork. CNA A exited the room with the resident's meal ticket and walked down to the kitchen and reported to staff answering the door that Resident #70 said he does not eat pork, and he received ham sandwiches. CNA A walked back down to the Resident's room and told Resident#70 the kitchen was preparing him turkey sandwiches and French fries. Observation in the resident's room on 9/23/2024 at 1:05 PM, revealed CNA A returned to Resident #70's room with 2 turkey sandwiches and French fries. Review of the Resident's meal ticket dated 9/23/2024, confirmed Resident #70 was to be served finger foods only and no pork. Review of the Care plan dated 9/24/2024 revealed Resident #70 was care planned for Activities of Daily Living skills self-care performance deficit, Blindness, and acknowledgement of resident preferences. Observation during dining on 9/24/24 at 8:50 AM, revealed Resident #70 stated, How is this finger food, [looking at] pudding and fruit cocktail in juice, go get the Unit Manager. Unit Manager B entered the room, looked at the tray and stated, I will get this fixed and exited the room. During an interview on 9/24/2024 at 9:02 AM, Unit Manager B confirmed the resident was to have finger food. Unit Manager B confirmed that the pudding and 2 bowls of fruit cocktail in juice was not finger food and Resident #70 should have been served finger foods. During an interview on 9/26/24 at 10:41 AM, the Lead Dietician confirmed that the facility should honor a resident's dietary preferences and allergies. The facility failed to follow dietary preference for Resident #70 when the resident was served pork and did not follow meal ticket preferences for finger foods.

Based on record review, and interview, the facility failed to provide information to the residents regarding their right to formulate an advance directive for 10 of 32 (Residents #34, #57, #71, #72, #73, #79, #92, #104, #140, and #498) residents reviewed for advance directives. The findings include: 1. Review of the facility policy titled, End of Life dated 12/29/2023, revealed .the facility .will inform and educate the resident and or the residents' family about decisions for end-of-life .advance directives will be documented in the medical record . 2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Cerebral Infarction, Tracheostomy, and Hemiplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #34 was cognitively intact. There was no documentation in the medical record if Resident #34 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Schizophrenia, Dysphagia, and Insomnia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 which indicated Resident #57 was moderately cognitively impaired. There was no documentation in the medical record if Resident #57 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 4. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Anoxic Brain Damage, Intellectual Disabilities, Convulsions, and Tracheostomy. Review of the admission MDS assessment dated [DATE], revealed a BIMS score that was not assessed indicating Resident #71 was severely cognitively impaired. There was no documentation in the medical record if Resident #71 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 5. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Adult Failure to Thrive, Dementia, and Dysphagia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #72 was severely cognitively impaired. There was no documentation in the medical record if Resident #72 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 6. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Atrial Flutter, Muscle Weakness, Convulsions, Hypertension, Insomnia, Osteoarthritis, Anxiety, Difficulty Walking and Psychosis. Review of the annual MDS assessment dated [DATE], revealed a BIMS score that was not assessed indicating Resident #73 was severely cognitively impaired. There was no documentation in the medical record if Resident #73 had an Advance Directive or if the Resident would like to formulate and Advance Directive. 7. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE], with diagnoses including End Stage Renal disease, Heart Failure, and Hypotension. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 8 which indicated Resident #79 was moderately cognitively impaired. There was no documentation in the medical record if Resident #79 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 8. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses including Venous Insufficiency, Diabetes Mellitus, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed a score of 15 which indicated Resident #92 was cognitively intact. There was no documentation in the medical record if Resident #92 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 9. Review of the medical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Down's Syndrome, Peripheral Vascular Disease, Muscle Wasting and Atrophy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not conducted since the patient was rarely or never understood. There was no documentation in the medical record if Resident #104 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 10. Review of the medical record revealed Resident #140 was admitted to the facility on [DATE], with diagnoses including Nontraumatic Intracerebral Hemorrhage, Hemiplegia, Hemiparesis, Diabetes, and Epilepsy. Review of the admission MDS assessment dated [DATE], revealed a BIMS score that was not assessed indicating Resident #140 was severely cognitively impaired. There was no documentation in the medical record if Resident #140 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 11. Review of the medical record revealed Resident #498 was admitted to the facility on [DATE], with diagnoses including Non-Traumatic Intracerebral Hemorrhage, Diabetes, Pulmonary Embolism, Sepsis, Dysphagia, and Disorder of Bladder. Review of the admission MDS assessment dated [DATE], revealed a score of 14, which indicated that Resident #498 was cognitively intact. There was no documentation in the medical record if Resident #498 had an Advance Directive or if the Resident would like to formulate and Advance Directive. 12. During an interview on 9/26/2024 at 9:01 AM, the Admissions and Marketing Director confirmed that if the resident has a Living Will or Power of Attorney, a copy is made on admission, and Social Services should follow up regarding Advance Directive. During an interview on 10/01/2024 at 9:45 AM, Social Services Director confirmed that information should be given to residents to formulate an Advance Directive.

Based on policy review, medical record review and interview, the facility failed to notify the resident representative in advance of a change in room for 1 of 1 (Resident #305) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Change of Room or Roommate dated 10/30/2023, revealed .Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible .The Social Service designee or Licensed Nurse should inform the resident's sponsor/family in advance of a change in the resident's room or roommate . 2. Review of the medical record revealed Resident #305 was admitted to the facility on [DATE], with a readmitted [DATE], with diagnoses including Ventricular Tachycardia, Myoclonus, Cognitive Communication, Seizures, Severe Protein- Calorie Malnutrition, and Severe Hypoxic Ischemic Encephalopathy. Review of the census in the medical record revealed Resident #305 was moved from one room number to a different room number on 3/5/2024. Review of Progress Notes dated 3/6/2024 at 6:49 AM, revealed Son notified of room change. Son is in agreement with room change. Resident transferred from [one room number] to [another room number] with all personal belongings. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score was not assessed, indicating severely impaired cognition. During a phone interview on 10/15/2024 at 5:05 PM, Unit Manager N confirmed that she did not notify the family until the resident was in new room. The facility failed to notify the resident representative in advance of a room change.

Based on policy review, medical record review, Facility Reported Incident (FRI) review, and interview the facility failed to report allegations of abuse and neglect related to injury of unknown origin within 2 hours for 1 of 3 (Resident #248) sampled residents. The Findings include: 1.Review of the facility policy titled Abuse, Neglect and Exploitation revised 1/10/2024, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .establish policies and procedures to investigate any such allegations: and include training for new and existing staff on activities that constitute abuse, neglect .reporting procedures .and resident abuse prevention .the facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law .reporting process for abuse, neglect .including injuries of unknown sources .physical injury of a resident, of unknown source .psychological abuse of a resident observed .failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning .an immediate investigation is warranted when suspicion .reporting alleged violations to the administrator, state agency, adult protective service and to all other required agencies within specified timeframes as required by state and federal regulations .immediately but not later than 2 hours after the allegation is made if the allegation involve abuse or result in serious bodily injury .not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury .the administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the result of the investigation when final within 5 working days of the incident, as required by state agencies . 2.Review of the medical record revealed Resident #248 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hypertension, Diabetes, Anxiety, and Psychotic Disorder. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 2 indicating that Resident #248 was severely cognitively impaired, was dependent on staff for activities of daily living activities and required assistance with toileting, bathing, dressing, and bed mobility. Review of the Radiology Interpretation report dated 5/26/2023, revealed .Left Scapula X-Ray complete .Findings .Left scapula .Fontal and scapular Y views [xray taken at an angle] .Anterior gleno-humeral [ball and socket allows for range of motion] dislocation .Impression . Anterior dislocation .Left shoulder X-Ray complete .Findings .Left Shoulder .Frontal and scapular Y views .Anterior gleno-humeral dislocation .Anterior dislocation . Review of the Nurse Note dated 5/26/2023, revealed 15:30 [3:30 PM] Abnormal Xray results received on left scapula and shoulder. Results forwarded to DON [Director of Nursing] .and [named provider] Dr .Orders received to send to [named facility emergency room ] for further evaluation. 16:18 [4:18 PM] writer called POA [Power of Attorney] .and informed her of results and that she would be transferred to [Named facility emergency room ] for further eval. POA agreed with transfer. Lifecare ambulance service called with estimated ETA [Estimated time of Arrival] of 2 hours. [Named facility emergency room (ER)] called and report given to nurse .to inform of arrival in approximately 2 hours . Review of the Facility's Reported Incident dated 5/27/2023 at 1:14 AM, revealed .Resident frequently yells out due to cognitive deficit. The resident began to yell out more frequently the past 24 hours. NP [Nurse Practitioner] was notified. Labs and x-ray ordered due to c/o [complaints of] left arm [pain]. Resident has c/o left arm pain at times with mobility since admission .5 day follow up added 6/5/2023 .Resident remains in the hospital . There was no documentation the injury of unknown origin was reported per facility policy. During an interview on 10/10/2024 at 10:04 AM, the DON confirmed that an injury of unknown origin should be reported within 2 hours.

Based on Named State Medicaid Long Term Care Program requirements, policy review, medical record review, and interview, the facility failed to provide the necessary mechanical ventilator audible alarm, redundant external alarm system, response processes, and monitoring processes of continuous pulse oximetry (a process to measure the oxygen level in the blood) and end tidal carbon [MEDICATION(S)] (ETCO2) (the level of carbon [MEDICATION(S)] that is released at the end of an exhaled breath) or ETCO2 monitoring for 1 of 4 sampled residents (Resident #7) on mechanical ventilation. The facility's failure resulted in Immediate Jeopardy when Resident #7 was found unresponsive and no mechanical ventilator or pulse oximetry alarms sounded. Resident #7 expired at the facility on [DATE]. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The [NAME] President of Operations, the Regional Nurse Consultant, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on [DATE] at 3:16 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-695. The facility was cited at F-695 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from [DATE] through[DATE]. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on [DATE] through [DATE]. The facility was cited for past noncompliance for F-695 and is not required to submit a Plan of Correction. The findings include: Review of the Named State Medicaid Long-Term Care Programs (Rule [DATE]-.03) requirements for Enhanced Respiratory Care (ERC), revealed .End tidal carbon [MEDICATION(S)] (ETCO2) or transcutaneous monitoring of carbon [MEDICATION(S)] and oxygen (tcCO2) and continuous pulse oximetry measurements shall be available for all residents receiving Chronic Ventilator Care and provided based on the needs of each resident .An audible, redundant external alarm system shall be connected to emergency power and/or battery backup and located outside the room of each resident who is ventilator-dependent for the purpose of alerting staff of resident ventilator circuit disconnection or ventilator failure .Pulse oximetry measurements shall be provided at least daily with continuous monitoring available, based on the needs of each resident .end tidal Carbon [MEDICATION(S)] (ETCO2) measurements shall be provided no less than every four (4) hours, and within one (1) hour following all vent [ventilator] parameter changes, or for residents receiving Sub-Acute Tracheal Suctioning . Review of the facility's policy titled, Weaning Assessment/Ventilator Liberation dated [DATE], revealed .Protocol .All assessments will include the documentation of the resident's breath sounds, ventilator settings, oxygen saturation, heart rate, respiratory rate, and ETCO2 (end tidal carbon [MEDICATION(S)]) .All residents weaning must have a continuous pulse oximetry and/or ETCO2 monitoring device in place .The assessment parameters will be documented every (4) hours along with the ventilator parameters . Review of the medical record, revealed Resident #7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .ETCO2 Q4 [every 4 hours] and PRN [as needed] six times a day .Vent settings: AC [assist-control] 14, 450 [spontaneous tidal volume], +5 [positive end expiratory pressure] . Review of a Respiratory Progress Note dated [DATE] at 5:46 AM, revealed .PT [patient] SWITCH VENT [ventilator] MODE TO PCV [pressure controlled ventilation] DUE TO LOW SATS OF 74% [oxygen saturation] AND INCREASE W.O.B [work of breaths] There was no documentation of ETCO2 measurements within 1 hour following the vent mode change. Review of a Respiratory Progress Note dated [DATE] at 12:08 AM, revealed .Notified by CNA at 0008 [12:08 AM] that resident was non responsive. Vitals were unattainable by nurse . Review of a Nurses' Note dated [DATE] at 12:30 AM, revealed .Called to room by CNA [Certified Nursing Assistant] at 12:08 [AM] Resident found unresponsive. No vitals able to be obtained. Weak thready pulse noted to femoral artery .No breaths noted. Code Blue called. CPR [cardiopulmonary resuscitation] immediately started . Review of the Emergency Department document dated [DATE], revealed .History source: EMS [Emergency Medical Services] The patient [Resident #7] presents in respiratory arrest. The onset was at mn [midnight] .Initial cardiac rhythm Asystole .Cardiovascular: no pulse .No regular rate and rhythm .pronounced dead 0050am [12:50 AM] [DATE] [2022] . Review of the Respiratory-Ventilator Evaluations revealed no documented measurement of ETCO2 on the following dates and times: a. [DATE] at 4:30 AM b. [DATE] at 8:40 AM c. [DATE] at 1:15 PM d. [DATE] at 4:00 PM e. [DATE] at 8:00 PM f. [DATE] at 12:00AM g. [DATE] at 4:00 AM h. [DATE] at 7:45 AM i. [DATE] at 1:15 PM j. [DATE] at 4:00 PM k. [DATE]at 12:00 AM During an interview on [DATE] at 1:20 PM, when asked if the ventilator in use on [DATE] by Resident #7 alarmed in the hallway to alert staff, the Respiratory Therapist (RT) Department Manager stated, .The vent malfunctioned; did not ring in the hall .The vent alarm was on, but it wasn't heard. The pulse ox [oximetry] alarm didn't sound in the hall; not wired to call system alarms . When asked when the alarm sound was last checked for proper functioning, the RT Department Manager stated, .I can't say .Didn't check the actual alarm sound before . During an interview on [DATE] at 3:16 PM, when asked if the ETCO2 measurements were documented every 4 hours as ordered and per ERC guidelines, the RT Department Manager reviewed the Respiratory Administration Records and stated, The documentation is not there. Should include more than that. Needs to have the rate measurements not just the check . The RT Department Manager confirmed the ETCO2 measurements should be documented every 4 hours and within 1 hour if a ventilator mode was changed. During an interview on [DATE] at 4:15 PM, when asked to provide details of the incident involving Resident #7 on [DATE], CNA #1 stated, .I went in her [Resident #7] room during a round .She didn't look right .The vent was still on, everything was still connected, but it wasn't sounding. There was [were] no alarm sounds . During an interview on [DATE] at 10:27 AM, when asked if any alarms sounded on [DATE] to alert staff of Resident #7 in distress, RT #3 stated, .There were no disconnections, and no alarms went off. Pulse ox [oximetry] did not alarm through the call system . During an interview on [DATE] at 11:37 AM, when asked if a pulse oximetry alarm could be heard in the hallway from a resident room, Registered Nurse #1 stated, .You could hear the pulse ox if you were maybe 2 doors down or if you were at the Nurses' Station and the room was right in front of the desk .No alarms for pulse ox outside the rooms till [until] they had it added to the call light system . During an interview on [DATE] at 1:15 PM, when asked if the ETCO2 measurements were documented as ordered, the DON stated, I would pull up assessments by the RTs and there would be parts that were blank. Looked like they started an assessment but didn't finish it. When asked if the pulse oximetry alarms could be heard outside the resident rooms at the time of the incident involving Resident #7, the DON stated, A couple or 3 resident rooms down [the hallway] the pulse ox machine could be heard if the door was open. If door was shut it was very hard to hear because it was so low. When asked if a pulse oximetry alarm could be heard from each room at the Nurses' Station on [DATE], the DON stated, No ma'am. During an interview on [DATE] at 1:45 PM, when asked what result was found when the ventilator used by Resident #7 was checked, the Ventilator Service Manager stated, .On the vent end the jack was damaged at the vent from wear and tear. There was a malfunction at the port .I recommended to unplug from the wall and not from the vent when transferring . During an interview on [DATE] at 4:06 PM, when asked if any alarms sounded on [DATE] to alert staff of Resident #7 in distress, Licensed Practical Nurse #1 stated, The vent was not going off. The Pulse ox only alarmed in rooms. It didn't [alarm] or maybe I didn't hear it; not heard in the hall . During an interview on [DATE] at 4:30 PM, when asked if any alarms sounded on [DATE] to alert staff of Resident #7 in distress, RT #2 stated, .There were no alarms . During an interview on [DATE] at 12:30 PM, when asked if he was aware of the incident involving Resident #7 on [DATE], the Medical Director stated, .I was told that particular vent had a malfunction. No alarm sounded. The pulse ox did not alarm in the hallway or at the Nurses' Station . The facility's corrective action plan included the following: 1. On [DATE], the nurse call system was checked by the vendor. The surveyor reviewed the service invoices and audit forms. 2. On [DATE], the alarm board was checked by vendor. The surveyor reviewed the documented room checks to the board, camera footage of the call light board, audits, and made observations. 3. On [DATE], the call light board was replaced. The surveyor observed the call light board and interviewed the Administrator. 4. Nursing staff and RT staff were educated with skill check off demonstration. This was completed on [DATE]. The surveyor reviewed the competency evaluations and interviewed staff on all shifts. 5. On [DATE], two speakers were added in the hallways between rooms ,d+[DATE] to amplify alarm volumes. The surveyor made observations and interviewed staff. 6. Pulse oximeter alarm function audits will be done weekly. The surveyor reviewed the audits and interviewed staff on all shifts. 7. Vent alarm function audits will be done weekly. The surveyor reviewed the weekly audits and interviewed staff on all shifts. 8. On [DATE], the alarms were set to highest volume on vents and pulse oximeters with checks and documentation every shift. Labels were placed on the vents. The surveyor made observations and reviewed the documentation. 9. The panel board will be checked weekly to ensure the board is lighting up during the vent alarms. The surveyor made observations, interviewed staff on all shifts, and reviewed the audits. 10. On [DATE], the vent manufacturer came to the facility to check every vent in the building by serial number for proper functioning. The surveyor interviewed staff and reviewed the service list check off. 11. On [DATE], the vent manufacturer did one-on-one training with the nurse managers on alarm volume and how to set it and check it. The surveyor made observations and interviewed staff on all shifts. 12. On [DATE], all pulse oximeters were checked for proper functioning. The surveyor reviewed the check list of functioning. 13. On [DATE], the pulse ox alarm was wired to sound through the call board. The surveyor made observations, interviewed staff on all shifts, and reviewed the invoice of parts. 14. On [DATE], labels were placed on all vents indicating where to disconnect when mobilizing the patient to decrease wear on the vent port. The surveyor made observations and interviewed staff on all shifts. 15. Staff were re-educated on turning and repositioning [CONDITION(S)]/vent patients. Nursing staff were re-educated by the Unit 4 Manager on pertinent charting. This was completed on [DATE]. The Surveyor interviewed staff on all shifts and reviewed the education sign-in sheets. 16. On [DATE], an Adhoc (impromptu) Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the incident. The surveyor reviewed the QAPI minutes and interviewed QAPI members.

Based on policy review, facility investigation review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 of 8 sampled residents (Resident #1) reviewed for elopement/wandering behaviors. Resident #1, who had severely impaired cognition, exited the front door, walked approximately 396 feet on the sidewalk, went down a steep embankment, crossed a busy 4-lane highway, and was found at a bus stop approximately 0.1 mile from the facility. The facility's failure to ensure residents were adequately supervised resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-689 on 9/2/2022 at 10:55 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and a severity of J, which is Substandard Quality of Care. The IJ existed from 8/20/2022 through 9/1/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 9/2/2022 at 3:00 PM. The corrective actions were validated onsite by the surveyors on 9/2/2022 through policy review, observation, review of education and audit tools, and staff interviews conducted on various shifts. The findings include: Review of the facility's policy titled, Unsafe Wandering & [and] Elopement Prevention, revised 1/1/2022, revealed .Every effort will be made to prevent unsafe wandering and elopement episodes . Review of a closed medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's, Dementia, [CONDITION(S)], and Nutritional Deficiency. Review of the Care Plan initiated on 1/16/2020, revealed Resident #1 was an elopement risk, a wanderer, wanted to go home, and had impaired safety awareness. The interventions to address this concern included to identify patterns of wandering and observe for acute processes that may increase wandering. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was assessed with a Brief Interview for Mental Status (BIMS) of 3, which indicated severe cognitive impairment and he required supervision when walking in his room. Review of a Significant Change Evaluation dated 8/21/2022, revealed .Is the resident cognitively impaired with poor decision-making skills .Yes .Does the resident wander aimlessly or non-goal .Yes .Resident is at risk for elopement/wandering at this time .No . The facility provided a copy of the video camera footage of the incident to the State Agency. The video did not have audio. The video had the date of 8/20/2022 and the times were visible on the footage. Review of the video footage revealed the following on 8/20/2022: a. At 12:00 PM, Resident #1 walked out the front door of the facility, going down the sidewalk along the front of the building holding a blanket. b. At 12:07 PM, Resident #1 walked on the sidewalk along the right side of the facility. c. At 12:12 PM, Resident #1 was observed walking on the sidewalk along a 4-lane highway and then went out of view of the video. d. At 12:34 PM, Resident #1 walked back into the front door of the facility. Review of the Incident Report dated 8/20/2022, revealed .12:00pm [PM] res [resident] [#1] went outside to get fresh air .didn't stop on porch .kept walking .the receptionist went to look for res on porch and didn't see res and page [paged] staff .12:17[PM] res was found and brought back [the video footage shows Resident #1 arrived back at the facility at 12:34 PM] . Review of the facility's investigation dated 8/20/2022, revealed a written statement from Certified Nursing Assistant (CNA) #2. The statement revealed, .spotted resident [Resident #1] across the street at the bus stop .I yelled his named he came to my truck. He stated .glad you found me . Review of World-weather.com, revealed the high temperature on 8/20/2022 was 88 degrees. During an interview on 8/30/2022 at 1:31 PM, the Accounts Payable Manager brought in the camera footage of Resident #1 leaving the facility which confirmed Resident #1 had to walk down a steep hill. She stated, .[Resident #1] walking on the sidewalk .on the main street .hospital behind us .goes and sits down at the bus stop .he went through where the 18 wheelers are .took him a good little bit . During an interview on 8/30/2022 at 1:40 PM, the Director of Nursing (DON) stated, .we assessed him back in July .didn't trigger [for elopement risk] .he rarely came out of his room .he would come up to the front .[Named Receptionist #1] saw him go out .he told the CNA [CNA #2] he about made it .he just wants to go home and live independent .when [Named Receptionist #1] came in she thought he could sit on the front porch and she noticed he was gone .she called the nurse .staff jumping in the cars .[Named CNA #2] found him, asked him to get in her truck .it was a miracle from God . During an interview on 8/30/2022 at 1:52 PM, Receptionist #1 stated, .went on my break .saw him [Resident #1] walking towards the front .seen him walk out the door .thought he was going out with a family member .his family had came [come] in Thursday [8/18/2022] and took him out .I didn't see nobody out there .and I went and looked out the front door and window and I didn't see him .I called back to Station 2 .and spoke with .[Named Staff Member] and she came up here and I asked was he checking out with a family member .and she said not supposed to .we called .supervisor .he called the page for the search .a lot of people went to go look for him .I went in my car and couldn't see him .we searched for him about 15 minutes .he was at the bus station .he cut through those eighteen wheelers and made it all the way down there .he had to cross the street to get to the bus stop .all those cars coming by fast .so glad he didn't get run over . Observation of the surrounding area on 8/30/2022 at 3:42 PM, revealed the [NAME] President of Operations measured the distance from the front door of the facility to the end of the sidewalk and stopped at the steep hill. The distance measured using a walking wheel was approximately 396 feet. From this location Resident #1 then walked down a steep embankment, through a parking lot, walked on the sidewalk and then crossed a busy 4-lane highway to the bus stop. During an interview on 8/31/2022 at 10:04 AM, CNA #2 stated, .we had CNAs across the field .dietary walking down the street .I turned left first seen some men down there .said hadn't seen anyone .turned around office building .there was a bus been there a long time .I pulled behind it and saw [Named Resident #1] .standing by some trees .told him to get in this truck and he said you got me sister . During an interview on 8/31/2022 at 11:00 AM, Licensed Practical Nurse (LPN) #2 confirmed she had just received the in-service on elopement on 8/31/2022 and had worked after the recent elopement on 8/20/2022. During an interview on 9/1/2022 at 3:41 PM, the Staff Development Coordinator (SDC) confirmed she was still currently doing staff in-services related to the previous elopement on 8/20/2022 and stated, .I was out last Thursday and Friday . During an interview on 9/2/2022 at 9:19 AM, the DON confirmed they were still interviewing staff for the elopement this week. The DON was asked if the staff should have already been educated on elopement. The DON stated, .that can be challenging .sometimes takes a few days .or week .we try our best to do it . The DON confirmed that staff should have been educated on elopement before starting to work and stated, .we have a new HR [Human Resources] .she is still getting training . The DON was asked who was responsible when she was not here to ensure staff were educated. The DON stated, .it's our responsibility .I think there was a break down . During an interview on 9/2/2022 at 2:55 PM, the Administrator was asked if all the staff should have been educated on the elopement. The Administrator stated, .made attempt to get them .incident happened on the 20th [8/20/2022] . The surveyors verified the Removal Plan by: 1. On 8/21/2022, all residents were reassessed for the potential risk for elopement, any residents identified as being at risk, the facility validated placement of a wander guard (a monitoring device to alert staff of a resident attempting to exit the facility unattended). The surveyor reviewed the Elopement Risk Assessments and interviewed administration. 2. On 8/20/2022, the Medical Director was notified by the DON of the elopement. The surveyor interviewed the DON and the Medical Director. 3. On 8/20/2022, all the wander guards that were intact to residents were checked for functioning. The surveyor reviewed the medical records and interviewed the DON. 4. On 8/21/2022, the Elopement Risk books were updated with new photos of all residents at risk for elopement and demographic information. The surveyors reviewed the Elopement Risk books and interviewed the nursing staff and the DON. 5. On 8/21/2022, all wander guards were checked for expiration dates. The surveyor reviewed medical records and interviewed the DON. 6. Staff were re-educated on the code yellow page for missing residents and unsafe wandering and elopement prevention. All staff will now be educated before they work their next shift. The surveyor reviewed the education sign-in sheets, and interviewed the Staffing Development Coordinator (SDC), the DON, and staff on various shifts. 7. On 8/20/2020, the receptionist staff were educated on the procedure for residents going out to sit on the porch, they must be accompanied by a family member or staff. The surveyor interviewed the receptionist staff. 8. On 8/20/2022, all the resident Care Plans were reviewed for accuracy in reflecting the potential risk for elopement and wander guards. The surveyor reviewed the Care Plans and interviewed the DON and Assistant Director of Nursing (ADON). 9. The receptionist staff will notify the nursing staff of any resident exiting the facility. The surveyor interviewed the receptionist's staff. 10. The DON and MDS Coordinator will conduct audits on 2 residents weekly x 4 weeks to ensure orders and Care Plans reflect the correct orders and status. The surveyor reviewed the audits and interviewed the MDS Coordinator and DON. 11. A quiz will be administered to all front office staff weekly with questions concerning compliance with desk monitoring. The surveyor reviewed the quiz with the front office staff and interviewed the front office staff, the DON, and Administrator. 12. New employees will be oriented upon hire during orientation by the SDC concerning procedure for residents leaving facility. The surveyor interviewed the SDC and the ADON. 13. All wander guards will be checked for expiration on the 15th of every month. The surveyor interviewed the Maintenance Supervisor. 14. The Receptionist will be provided a list of any resident that can leave the facility unaccompanied. The surveyor reviewed the list of residents at the front desk and interviewed the receptionist staff. 15. On 8/20/2022, an Adhoc (im-promptu) Quality Assurance Performance Improvement (QAPI) meeting was conducted to review the concerns and plan for improvement with the Medical Director. The surveyor reviewed the Adhoc QAPI meeting that was held on 8/20/2022 and interviewed the Medical Director. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the staff failed to conduct an Ad Hoc (as necessary for a particular purpose) committee meeting and corrective action plan after Resident #1's incident occurred when Resident #1 was found with the Peripheral Midline Catheter (a special long Intravenous (IV) catheter that is placed into a large vein and requires safety mechanisms to prevent bleeding from the IV opening. The midline catheter has a clamp on the extension tubing between the catheter labeled junction and the catheter opening. The clamp should always be closed when the catheter is not in use) open without a safety mechanism cap or a safety clamp on the IV catheter and tubing and a steady drip of venous blood from the lumen of the catheter dripping blood (surface area approximately size of a cantaloupe) on saturated linen with some blood pooling in the bed requiring pressure to be applied to the site and a blood test was ordered and drawn that revealed a critical low hemoglobin. Resident #1 was transferred to the emergency room (ER) and required an infusion of one unit of packed red blood cells. The facility failed to ensure the QAPI committee met to determine a corrective action plan, identified and validated systemic problems, and determined a system was in place to monitor the Peripheral Midline Catheter for complications, disconnection, and bleeding and fully investigate underlying causes and develop corrective actions that would prevent recurrence to any residents requiring a Peripheral Midline Catheter and effect change at systems level to prevent quality of care, quality of life, or safety problems; and monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. These failures resulted in Immediate Jeopardy for 1 of 2 sampled residents (Resident #1) with a Peripheral Midline Catheter and placed the two residents requiring an invasive Peripheral Midline Catheter at risk due to the potential of serious harm or injury. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/12/2021 at 4:37 PM, in the Conference room. The facility was cited Immediate Jeopardy at F-600, F-694, F-835, and F-867. The facility was cited F-600 and F-694 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/24/2021 through 10/13/2021. An acceptable Removal Plan for F-867, which removed the immediacy of the jeopardy, was received on 10/13/2021 at 1:58 PM and was validated onsite by the surveyor on 10/14/2021 through observation, review of records, audit reviews and staff interviews. The findings include: Review of the facility's policy Quality Assessment and Performance Improvement Plan, revised 10/3/2017, revealed .The facility shall develop, implement, and maintain an ongoing, effective, comprehensive, facility-wide Quality Assessment and Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. The QAPI program is designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, promote overall building safety, and resolve identified problems. The Plan covers all systems of care and management practices including but not limited to clinical care, quality of life and resident's choices. Scope and Purpose of the Committee and QAPI Plan: Quality Assurance (QA) is the process of meeting quality standards and assuring that resident care reaches an acceptable level. Performance Improvement (PI) is continuously analyzing your performance and developing systematic efforts to improve it; also known as Quality Improvement. The primary purposes of QAPI Program and plan are: To provide a means to identify and resolve present and potential quality deficiencies related to resident care and safety as well as and employee and visitor safety; To provide a means to identify and resolve present and potential opportunities for improvement .Systematic identification, reporting, investigation, analysis and prevention of adverse events, through root cause analysis .Develop, implement and evaluate effectiveness of performance improvement activities; Revise plans as needed. To provide a structure and process to correct identified quality deficiencies; To establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcomes .Authority: The Administrator in conjunction with the governing body of our facility shall be ultimately responsible for the Quality Assessment and Performance Improvement Program .Implementation: The Quality Assurance and Performance Improvement Committee shall oversee implementation of our Quality Assessment and Performance Improvement Plan. A Quality Assurance and Performance Improvement Coordinator shall coordinate Quality Assurance and Performance Improvement Committee activities, including documentation .The Quality Assurance and Performance Improvement Committee shall oversee and authorize Quality Assessment and Performance Improvement activities and tools, including data-collection tools, monitoring tools, training tools and the basis for and appropriateness and effectiveness of Quality Performance Improvement activities. These activities/tools may include: Checklist, Flowcharting/Process Mapping, Root Cause Analysis, Fishbone .Cause and Effect Diagrams, 5 Whys, Pareto Chart, Bar Charts and Pie Charts, Trend or Run Charts, Department Specific Audits [QAD], Process Driven Audit Tools, Performance Improvement Plans [PIP]. The committee shall approve any corrective actions, including changes in policies and/or procedures, employment practices, standards of care, building safety etc., and shall also monitor all corrective activities for appropriateness and/or the need for alternative measures .Evaluation: The Quality Assurance and Performance Improvement Committee, Administrator, and the governing body shall review and approve a summary of problems and corrective measures, and implement any needed changes to policy, training, environment, supplies, staffing and care methods . Review of the facility's policy titled, Administration of Facility, dated 1/1/2021, revealed .This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident .Facility will follow the accepted professional standards and principles of the various practice acts and regulations for the various licensed personnel within the facility. The facility will employ professionals necessary to carry out the provisions of requirements. An appropriately licensed Administrator, in good standing with the state in which the facility resides, will be appointed by the governing body to be responsible for the management and overall operation of the facility. The facility must have a governing body that is legally responsible for establishing and implementing policies regarding management and operation of the facility as well as QAPI . Review of the facility's undated Administrator job description revealed .Responsible for the efficient .operation of the facility, facility compliance with [Named Company] policies and State and Federal rules and regulations, and providing the highest quality of care possible .Essential Functions: Leads planning process to develop goals for quality care, employee retention and financial performance. Manages the day-to-day operations of the facility .Directs and guides the activities of clinical, administrative and service departments. Implements control systems to ensure accountability of all departments .Monitors performance for achievement of goals and for improvement and takes corrective action when necessary .Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .Acts as chairperson of the facility's Performance Improvement Committee .Knowledge/Skills/Abilities: Ability to react decisively and quickly in emergency situations. Ability to organize and prioritize . Review of the facility's policy titled, Investigating and Reporting Accidents and Incidents, dated 1/1/2021, revealed .Policy: All accidents or incidents involving residents .occurring on our premises must be investigated and reported to the Administrator .A Report of Incident/Accident must be completed for all accidents or incidents .Investigative Action on Incident Report: The nurse Supervisor/charge nurse and/or department director or supervisor must conduct an immediate investigation of the accident or incident. The following data, as it may apply, must be included on the Report of Incident/Accident: The date and time the accident or incident took place .The circumstances surrounding the accident or incident [fact reporting only, avoid unsupported assumptions, opinions or conclusions]; Where the accident or incident took place; The name[s] of witnesses and their accounts of the accident or incident; The injured person's account of the accident or incident .The condition of the injured person, to include his or her vital signs; The disposition of the injured person [i.e. transferred to hospital, put to bed, sent home, returned to work, etc.]; Any corrective action taken; Follow-up information; Other pertinent data as necessary or required; and The signature and title of the person completing the report as well as the date and time of completion . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Complete Blood Count (CBC)) lab results collected on 9/21/2021 at 11:55 AM (prior to the incident), revealed the following results: red blood cell (RBC) 3.15 (low) (L) normal range is 4.00 - 5.50 Hemoglobin (Hgb) 8.1 (L) normal range is 12.0 - 16.0 Hematocrit (Hct) 26.3 (L) normal range is 36.0 - 46.0 Review of Resident #1's Nurse's Note dated 9/24/2021 at 2:00 PM, revealed, .When rounding [checking on resident], resident [Resident #1] was found with left midline leaking approx. [approximately] 30 ml - called for assistance, midline subsequently pulled [removed]. Tip of line noted intact, pressure held to site - no bleeding noted [from the site where the catheter was removed] and pressure dressing applied - will remove [dressing] in 24 hours. [Named Doctor (Dr)] and RP [Responsible Party] notified - orders received for labs [blood tests] and reinsertion [of the midline catheter] .Resident vitals wnl [within normal limits] - will continue to closely monitor . Review of Resident #1's CBC lab results collected on 9/24/2021 at 10:26 PM, revealed the following results: RBC 2.52 (L) Hemoglobin 6.4 (CL) (critical low) Hematocrit 20.5 Review of Resident #1's Nurse's Note dated 9/25/2021 at 3:07 PM, revealed, .Obtained alert critical [extremely low] results lab: HCT 19.8 .HBG 6.2 [critical low] .relayed info [information] to [Named Dr] with order to transfer to hospital. RP [Responsible Party] notified, DON notified . Review of Resident #1's Emergency Department Provider Note dated 9/25/2021 at 5:10 PM, revealed .The patient presents .received her normal abx [antibiotic] at [Named Skilled Nursing Facility] however the cap [needleless connector safety mechanism] on her line was inadvertently removed and pt [patient] was found to have blood around her in bed. This occurred yesterday. Today they drew blood and noted low H/H [hematocrit and hemoglobin] .Pt recently [previously] admitted for b/l [bilateral] pneumonia and septic shock [a widespread infection in the body that can cause organ failure] .Lab results 9/25/2021 4:00 PM RBC 2.52, Hemoglobin 6.4, Hematocrit 19.9 .Transfusion one unit PRBC [packed red blood cells] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Lab values post transfusion 9/26/2021 at 5:15 PM RBC 2.76, Hemoglobin 7.2, Hematocrit 21.8 .discharged back to [Named Skilled Nursing Facility] 9/26/2021 . During an interview on 10/11/2021 at 11:00 AM, the Staff Development Coordinator (SDC) stated, .I responded to the page overhead .When I arrived [Named Person] [Registered Nurse (RN) #2] was holding pressure .The end cap broke off end of line .couldn't get another cap on .I held pressure .the other nurse had called the doctor and was told to pull [take out] the line .I pulled the line and applied pressure. No bleeding after I pulled the line. I put a pressure dressing on it and told them to leave it [dressing] for 24 hours .No, we never found the clamp or cap .we cleaned her up, changed her linen and never found them . During an interview on 10/11/2021 at 4:30 PM, the DON and Administrator were asked if an investigation was done after this unusual occurrence. The Administrator stated the State Survey Agency (SSA) was in the building during the recertification survey on 9/24/2021 and did not leave until 9/25/2021, and the incident was not investigated. The Administrator was asked if the incident had been investigated after the SSA exited. The Administrator stated, .No, we did no investigation they just told me the cap broke off .No, there is no I & A [incident/accident] report .No, we did not investigate or have an ad hoc [as needed] QA [Quality Assurance] meeting .There was no I & A report. We would have if had an I & A report . The DON stated, .I'm trying to find out myself .I had no idea the clamp was missing and the cap till [until] you started questioning people .I was just told the cap broke off and you know things happen . The Administrator and the DON were asked how the facility could ensure a similar incident will not recur if there had not been an investigation or corrective actions had not been put into place. The Administrator and DON did not answer. During an interview on 10/13/2021 at 9:06 AM, the Administrator was asked when the facility's last QAPI meeting was. She stated, .We meet monthly, and our last meeting was in August .We can meet more often if a serious event occurs. We can have a quick emergency meeting and discuss QAPI, and establish a root cause . The Administrator was asked did the facility conduct an Ad Hoc (as needed) QAPI meeting after Resident #1's incident. She stated, .No, we did not .No, we did not investigate . During an interview on 10/13/2021 at 1:00 PM, the Medical Director stated, .I was not notified by the facility till [until] yesterday [10/12/2021] of the incident with Ms. [Resident #1]. However, I did read about it in the notes from the Nurse Practitioner. My Nurse Practitioner was notified but I was not notified as Medical Director until yesterday .After they [facility] told me I thought not a problem about the lab but now since you explained about no investigation and the actual findings, I see the problem . Refer to F-600, F-694, and F-835 The Surveyor verified the Removal Plan by: 1. Resident #1 had their midline access device removed on 10/8/2021. The surveyor confirmed this through record review and staff interview. 2. The DON and Assistant Director of Nursing (ADON) completed an audit of all current residents on 10/12/2021 to identify any current resident that has a midline access device. The surveyor confirmed this through review of audit record and interview. 3. There was one current resident with a midline access device. The DON and ADONs reviewed the identified resident's medical record to determine if appropriate level of supervision and monitoring for complications was in place for the midline intravenous catheter. This was completed on 10/12/2021. Any changes in monitoring or supervision were noted in the medical record. The surveyor confirmed this through record review and interview. 4. On 10/12/2021, the Vice President of Operations observed the Ad Hoc Quality Assurance (QA) meeting and noted the committee was conducting a thorough and efficient review of the citations and abatement plan to maintain the highest practicable wellbeing for the residents with a peripheral midline catheter. The surveyor confirmed this through sign in sheet and interview. 5. The Administrator and DON reviewed facility policies related to administration, QAPI, and Midline Catheter access devices on 10/12/2021 and found the policies to be appropriate. The surveyor confirmed this through staff interview. 6. The Regional Director of Clinical re-educated the Administrator and Director of Nursing on the requirement for adherence to policies on 10/12/2021. The surveyor confirmed this through review of the sign in sheet and interview. 7. On 10/12/2021, the Vice President of Operations and the Regional Director of Clinical re-educated the facility leadership on the policy for QAPI including an ongoing comprehensive QAPI program to address a full range of care and services provided to the resident population they serve including incidents involving midline access devices. The surveyor confirmed this through review of the sign in sheet and interview. 8. On 10/12/2021, the Administrator added to the facility monthly QAPI report template review of the plan of correction as well as review of access devices or incidents involving access devices. The surveyor confirmed this through record review and interview. 9. On 10/12/2021, an Ad hoc QA meeting was convened to review the citations, review of the abatement plan and any further recommendations. In attendance was the Administrator, Director of Nursing, ADONs, Medical Records, Minimum Data Set (MDS) Nurse, Business Office Manager, Activities, Admissions, Staff Development Coordinator as well as the Medical Director by phone. An Ad hoc QA was conducted on 10/13/2021 to review additions to the plan of removal for F-600 and F-694 in attendance was DON, Administrator, ADON, SDC with the Medical Director attending by phone. The surveyor confirmed through review of sign in sheet and interview. 10. The DON or designee will review residents with midline access devices daily for 14 days to validate monitoring for complications and supervision of midline access devices then weekly for 10 weeks. Results will be reviewed with the QAPI committee monthly. The surveyor confirmed through record review and interview. 11. The Vice President of Operations or designee will monitor the QAPI committee monthly for three months to evaluate the QAPI program effectiveness in addressing a full range of care and services provided for the resident population they serve including incidents involving midline access devices. The surveyor confirmed through interview. 12. Concerns identified during the audits will be reviewed with the QAPI committee for further recommendations. The surveyor confirmed through interview. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. .

Based on policy review, job description review, medical record review, observation, and interview, the Administration failed to provide administration and oversight of its resources effectively and efficiently to ensure necessary services were provided safely to a resident with a Peripheral Midline Catheter (a special long Intravenous (IV) catheter that is placed into a large vein and requires safety mechanisms to prevent bleeding from the IV opening). The midline catheter has a clamp on the extension tubing between the catheter labeled junction and the catheter opening. The clamp should always be closed when the catheter is not in use. The Administration failed to provide administration and oversight of its resources effectively and efficiently to ensure the Peripheral Midline Catheter was monitored for complications, disconnection, and bleeding; failed to ensure orders were obtained for flushing the IV catheter and failed to investigate and develop corrective actions that would prevent recurrence to any residents requiring a Peripheral Midline Catheter. These failures resulted in Immediate Jeopardy for 1 of 2 sampled residents (Resident #1) with a Peripheral Midline Catheter and placed the two residents requiring an invasive Peripheral Midline Catheter at risk due to the potential of serious harm or death. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/12/2021 at 4:37 PM, in the Conference room. The facility was cited Immediate Jeopardy at F-600, F-694, F-835, and F-867. The facility was cited F-600 and F-694 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/24/2021 through 10/13/2021. An acceptable Removal Plan for F-835, which removed the immediacy of the jeopardy, was received on 10/13/2021 at 1:58 PM and was validated onsite by the surveyor on 10/14/2021 through observation, review of records, audit reviews, and staff interviews. The findings include: Review of the facility's policy titled, Administration of Facility, dated 1/1/2021, revealed .This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident .Facility will follow the accepted professional standards and principles of the various practice acts and regulations for the various licensed personnel within the facility. The facility will employ professionals necessary to carry out the provisions of requirements. An appropriately licensed Administrator, in good standing with the state in which the facility resides, will be appointed by the governing body to be responsible for the management and overall operation of the facility. The facility must have a governing body that is legally responsible for establishing and implementing policies regarding management and operation of the facility as well as QAPI [Quality Assurance Performance Improvement] . Review of the facility's undated Administrator job description revealed .Responsible for the efficient .operation of the facility, facility compliance with .policies and State and Federal rules and regulations, and providing the highest quality of care possible .Essential Functions: Leads planning process to develop goals for quality care .Manages the day-to-day operations of the facility .Directs and guides the activities of clinical, administrative and service departments. Implements control systems to ensure accountability of all departments .Monitors performance for achievement of goals and for improvement and takes corrective action when necessary .Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .Acts as chairperson of the facility's Performance Improvement Committee .Knowledge/Skills/Abilities: Ability to react decisively and quickly in emergency situations. Ability to organize and prioritize . Review of the facility's undated Director of Nursing job description revealed .Manages the facility nursing program in accordance with the Nurse Practice Act, applicable State and Federal regulations, and policies and procedures .Essential Functions: Rounds on unit at least once daily .Plans and facilitates meetings and committees to address resident care issues .Manages the Nursing Department with the goal of achieving and maintaining the highest quality of care possible. Develops and manages systems to assure clinical competencies .Identification of training needs .Investigate and resolve residents/family/employee concerns .Proactively addresses survey and/or standards of care issues .Participates in facility 'Performance Improvement Program'. Assures that all clinical protocols and nursing policies and procedures are followed .Assumes complete responsibilities for the Center in the absence of Administrator .Knowledge/Skills/Abilities: Ability to react decisively and quickly in emergency situations. Ability to organize and prioritize. Knowledge of training techniques for clinical staff .Knowledge of the Nurse Practice Act, stated and federal regulations, policies and procedures regarding nurse standards and delivery of care . Review of the facility's undated Registered Nurse (RN) job description revealed .Plans, coordinates and provides total nursing care for residents and provides supervision and guidance to clinical staff members .Essential Functions: Initiates and leads team conferences in development of individualized nursing care plans. Assesses and documents the resident's condition and nursing needs. Accurately and promptly implements physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Supervises, directs and evaluates LPNs [Licensed Practical Nurses], LVNs [Licensed Vocational Nurses], and CNAs [Certified Nursing Assistants]. Administers medications, starts IVs and performs treatments for assigned residents, and documents that treatment as required company, and local, state and federal rules and regulations. Participates in orientation and in-service training for personnel .Ensures that supplies are utilized economically, and that equipment is clean and maintained in a safe manner. Reports and records pertinent observations and reactions regarding residents .Assists with or institutes emergency measures for sudden adverse developments in residents . Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 1/1/2021, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . Review of the facility's policy titled, Investigating and Reporting Accidents and Incidents, dated 1/1/2021, revealed .Policy: All accidents or incidents involving residents .occurring on our premises must be investigated and reported to the Administrator .A Report of Incident/Accident must be completed for all accidents or incidents .Investigative Action on Incident Report: The nurse Supervisor/charge nurse and/or department director or supervisor must conduct an immediate investigation of the accident or incident. The following data, as it may apply, must be included on the Report of Incident/Accident: The date and time the accident or incident took place .The circumstances surrounding the accident or incident [fact reporting only, avoid unsupported assumptions, opinions or conclusions]; Where the accident or incident took place; The name[s] of witnesses and their accounts of the accident or incident; The injured person's account of the accident or incident .The condition of the injured person, to include his or her vital signs; The disposition of the injured person [i.e. transferred to hospital, put to bed, sent home, returned to work, etc.]; Any corrective action taken; Follow-up information; Other pertinent data as necessary or required; and The signature and title of the person completing the report as well as the date and time of completion . Review of the facility's policy titled, Maintaining Patency of Peripheral and Central Vascular Access Devices. IV Flush Policy and Procedure, dated 8/2016, revealed .Vascular access devices are flushed and aspirated for a blood return prior to each infusion [of medication or fluids] to assess catheter function and prevent complications. Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen [tube] .To succeed with saline flushing, a needleless connector with an anti-reflux [a safety mechanism to prevent bleeding from the catheter] design must be placed on the hub [opening] of EVERY lumen of EVERY vascular access device/catheter .All connections [IV tubing or syringes] will be made via the needleless connector, NEVER directly to the catheter hub . Review of the facility's policy titled, Assessment of the Patient Receiving IV Therapy, dated 8/2016, revealed .To enable the nurse administering infusion therapy to recognize and utilize appropriate interventions for infusion related problems or complications .Visually inspect the entire infusion system from the solution container progressing down the administration set to the catheter insertion site. Check for integrity of the system and the dressing .Assess vascular access device function by flushing and aspirating for a blood return prior to each intermittent use [intermittent medication administration] .Assess the catheter insertion site and surrounding area for redness, tenderness, swelling, and drainage by visual [looking at the site] inspection and palpation [touching] through the intact dressing. Recommended minimum assessment of midlines and central venous access devices is once every 24 hours .Assess every 1-2 hours for patients who have cognitive deficits .The nurse administering intravenous fluids or medications will recognize and utilize appropriate intervention for any IV related problems or complications. The nurse will document any IV related problems or complications according to facility documentation policies and procedures. Assess and document patient's response to therapy . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Order date 9/21/2021 [MEDICATION(S)] HCl Solution 2 GM [gram]/100 ml [milliliters] use 2 gram intravenously two times a day for elevated wbc [white blood cell] for 10 days .order date 9/21/2021 place midline for ABT [antibiotic] therapy . There were no orders for flushing the IV line with Normal Saline before or after the antibiotic administration. Review of Resident #1's Nurse's Notes and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no assessment of the Peripheral Midline Catheter site or monitoring for complications of the catheter documented in the resident's medical record from 9/21/2021 through 10/7/2021. There was no documentation of a Midline dressing change every 7 days, or Midline cap (needleless connector) change every 7 days as required by facility policy from 9/21/2021 through 10/7/2021. Review of Resident #1's Complete Blood Count (CBC) laboratory results collected on 9/21/2021 at 11:55 AM (prior to incident), revealed the following results: red blood cell (RBC) 3.15 (low) (L) normal range is 4.00 - 5.50 Hemoglobin (Hgb) 8.1 (L) normal range is 12.0 - 16.0 Hematocrit (Hct) 26.3 (L) normal range is 36.0 - 46.0 Review of Resident #1's Nurse's Note dated 9/24/2021 at 2:00 PM, revealed .When rounding, resident [Resident #1] was found with left midline leaking approx.[approximately] 30 ml - called for assistance, midline subsequently pulled [removed]. Tip of line noted intact, pressure held to site - no bleeding noted [from the site where the catheter was removed] and pressure dressing applied - will remove [dressing] in 24 hours. [Named Doctor (Dr)] and RP [Responsible Party] notified - orders received for labs [blood test] and reinsertion [of a midline catheter] .Resident vitals wnl [within normal limits] - will continue to closely monitor . Review of Resident #1's CBC laboratory results collected on 9/24/2021 at 10:26 PM (after the incident), revealed the following results: RBC 2.52 (L) Hemoglobin 6.4 (CL) (critical low) Hematocrit 20.5 Review of Resident #1's Nurse's Note dated 9/25/2021 at 3:07 PM, revealed .Obtained alert critical [extremely low] results lab: HCT 19.8 .HBG 6.2 [critical low] .relayed info [information] to [Named Dr] with order to transfer to hospital. RP notified, DON notified . Review of Resident #1's Emergency Department Provider Note dated 9/25/2021 at 5:10 PM, revealed .The patient presents .received her normal abx [antibiotic] at [Named Skilled Nursing Facility] however the cap [needleless connector safety mechanism] on her line was inadvertently removed and pt [patient] was found to have blood around her in bed. This occurred yesterday. Today they drew blood and noted low H/H [hematocrit and hemoglobin] .Pt recently [previously] admitted for b/l [bilateral] pneumonia and septic shock [a widespread infection in the body that can cause organ failure] .Lab results 9/25/2021 4:00 PM RBC 2.52, Hemoglobin 6.4, Hematocrit 19.9 .Transfusion one unit PRBC [packed red blood cells blood] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Lab values post transfusion 9/26/2021 at 5:15 PM RBC 2.76, Hemoglobin 7.2, Hematocrit 21.8 .discharged back to [Named Skilled Nursing Facility] 9/26/2021 . Review of the Nurse's Note dated 10/8/2021 revealed .midline to left upper extremity pulled [discontinued] at this time. catheter intact . During an interview on 10/11/2021 at 11:00 AM, the Staff Development Coordinator (SDC) stated, .I responded to the page overhead .When I arrived [Named Person] [RN #2] was holding pressure .The end cap broke off end of line .couldn't get another cap on .I held pressure .the other nurse had called the doctor and was told to pull [take out] the line .I pulled the line and applied pressure. No bleeding after I pulled the line. I put a pressure dressing on it [dressing] and told them to leave it for 24 hours .No, we never found the clamp or cap .we cleaned her up, changed her linen and never found them . During an interview on 10/11/2021 at 1:00 PM, RN #2 stated, .[Named Person] [RN #1] called me into the room I saw the midline leaking blood. There was lots of blood. It was a steady drip. Blood was on the resident's side of the gown, down her side onto the linen absorbed into the fabric the amount approximately size of a cantaloupe with some pooled-on top of the absorbed blood in the fabric .No, I did not see the clamp [safety mechanism] or the cap [needleless connector] both were missing the end was open .We never found the clamp or cap . RN #2 was asked where the supplies were for changing the cap (needleless connector safety mechanism to prevent bleeding) to IV lines. RN #2 walked into the Medication Room, pointed to a bin on the wall and stated, .Any supplies for IVs are kept up here in this bin .all I see is the dressing change supplies and there are no caps . RN #2 was asked who is responsible for keeping IV supply items stocked. She stated, .The nurses are responsible .but I don't know where to get those caps . During observation and interview in the Central Supply Room on 10/11/2021 at 1:25 PM, the Central Supply Clerk was asked where the IV supplies were. She pointed to a shelf to the left of her desk. Observations of the shelf revealed no caps (needleless connector). When the Central Supply Clerk was asked where the IV caps (needleless connector) were kept, she stated, .I don't know what they [IV caps] are .I don't have any because I don't keep up with that .what you see up there is what I keep . On the shelf were IV dressing change kits and IV tubings. During an interview on 10/11/2021 at 1:45 PM, the DON was asked where the IV caps (needleless connectors) were kept for the nurses to use as needed and change every seven days for the Midline catheters. She stated, .In the Med [medication] Rooms, we get our IV supplies from [Named Company] they deliver when they provide the IV medications . Observation in the 400 Hall Medication Room on 10/11/2021 at 1:45 PM, revealed the DON was in the Medication Room looking through the IV supply box provided by (Named Company). She stated, .There are no IV caps [needleless connector] in here . Observations of the supply list on the front of the box revealed no listing for IV caps (needless connector). The DON and surveyor proceeded to the 100 Hall and the 200 Hall's Medication Rooms. The DON looked through each IV supply box in the Medication Rooms as well as the Medication Room bins stocked by the facility and revealed no IV caps (needleless connector). She stated, .well I know we have some, somewhere . She confirmed there were no IV caps in the Central Supply, 100, 200 or 300 Halls' med rooms or supply boxes. During a telephone interview on 10/11/2021 at 2:05 PM, Named Person with the Named Pharmacy Company was asked if the pharmacy provides the facility with IV caps (needleless connector). He stated, .No, we don't provide the caps .we provide extension tubing with a cap built into the extension tubing . During an interview on 10/11/2021 at 4:30 PM, the DON and Administrator were asked if an investigation was done after this unusual occurrence. The Administrator stated the State Survey Agency (SSA) was in the building during the recertification survey on 9/24/2021 and did not leave until 9/25/2021, and the incident was not investigated. The Administrator was asked if the incident had been investigated after the SSA exited. The Administrator stated, .No, we did no investigation they just told me the cap broke off .No, there is no I & A [incident/accident] report .No, we did not investigate or have an ad hoc [as needed] QA [Quality Assurance] meeting .There was no I & A report. We would have if had an I & A report . The DON stated, .I'm trying to find out myself .I had no idea the clamp was missing and the cap till [until] you started questioning people .I was just told the cap broke off and you know things happen . The Administrator and the DON were asked how the facility could ensure a similar incident will not recur if there had not been an investigation or corrective actions had not been put into place. The Administrator and DON did not answer. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administration failed to ensure an unusual occurrence was investigated, failed to ensure interventions were put into place to prevent an incident from recurring, failed to ensure staff knew where to locate IV caps (needless connectors), and failed to ensure midline catheters were monitored for complications. Refer to F-600, F-694, and F-867. The Surveyor verified the Removal Plan by: 1. Resident #1 had their midline access device removed on 10/8/2021. The surveyor confirmed this through record review and staff interview. 2. The DON and Assistant Director of Nursing (ADON) completed an audit of all current residents on 10/12/2021 to identify any current resident that has a midline access device. The surveyor confirmed this through review of audit record and interview. 3. There was one current resident with a midline access device. The DON and ADONs reviewed the identified resident's medical record to determine if appropriate level of supervision and monitoring for complications was in place for the midline intravenous catheter. This was completed on 10/12/2021. Any changes in monitoring or supervision were noted in the medical record. The surveyor confirmed this through record review and interview. 4. On 10/12/2021, the Vice President of Operations observed the Administrator during Quality Assurance (QA) and the facility actions and noted the Administrator to be providing administration and oversight of its resources effectively and efficiently to ensure necessary services and maintain the highest practicable well-being for the residents with a Peripheral Midline Catheter. The surveyor confirmed with review of the sign in sheet and interview. 5. The Administrator and DON reviewed facility policies related to administration, QAPI, and Midline Catheter access devices on 10/12/2021 and found the policies to be appropriate. The surveyor confirmed this through staff interview. 6. The Regional Director of Clinical re-educated the Administrator and Director of Nursing on the requirement for adherence to policies on 10/12/2021. The surveyor confirmed this through review of the sign in sheet and interview. 7. On 10/12/2021, the Vice President of Operations re-educated the Administrator on the requirement to provide administration and oversight of its resources effectively and efficiently to ensure necessary services and maintain the highest practicable well-being for the resident with a Peripheral Midline Catheter. The surveyor confirmed this through review of the sign in sheet and interview. 8. On 10/12/2021, an ad hoc (impromptu) QA meeting was convened to review the citations, review of the abatement plan and any further recommendations. In attendance was the Administrator, Director of Nursing, ADONs, Medical Records, MDS Nurse, Business Office Manager, Activities, Admissions, Staff Development Coordinator as well as the Medical Director by phone. The surveyor confirmed through review of sign in sheet and interview. 9. The Vice President of Operations or designee will monitor the actions of the Administrator to evaluate if the Administrator is providing administration and oversight of its resources effectively and efficiently to ensure necessary services and maintain the highest practicable well-being for the residents to include midline access devices, at least every 2 weeks for 6 weeks then monthly for 3 months. The surveyor confirmed through interview. 10. Concerns identified during the audits will be reviewed with the QAPI committee for further recommendations. The surveyor confirmed through interview. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The facility is required to submit a Plan of Correction.

Based on review of Brunner & Suddarth's Textbook of Medical-Surgical Nursing 12th Edition, Merck Manual, [CONDITION(S)] in the Older Adult:10 Common Causes and (&) What to Ask article, policy review, medical record review, manufacturer guidelines for Midline Catheter device, observation, and interview, the facility failed to provide services safely to a resident with a Peripheral Midline Catheter (a special long Intravenous (IV) catheter that is placed into a large vein and requires safety mechanisms to prevent bleeding from the IV opening). The midline catheter has a clamp on the extension tubing between the catheter labeled junction and the catheter opening. The clamp should always be closed when the catheter is not in use. The facility failed to monitor the Peripheral Midline Catheter for complications of bleeding; failed to perform and document assessments of the IV site; failed to obtain orders for Normal Saline (NS) flushes and failed to investigate and develop corrective actions that would prevent recurrence to any residents requiring a Peripheral Midline Catheter. These failures resulted in Immediate Jeopardy for 1 of 2 sampled residents (Resident #1) with a Peripheral Midline Catheter and placed the two residents requiring an invasive Peripheral Midline Catheter at risk due to the potential of serious harm or death. Resident #1 was found with the Peripheral Midline Catheter clamp missing (a safety mechanism) and without a screw on cap (needleless cap a second safety mechanism) with a steady drip of blood from the opening of the catheter dripping blood on saturated linen (surface area approximately the size of a cantaloupe) with some blood pooling in the bed requiring pressure to be applied to the IV site. A blood test was obtained that revealed a critical low hemoglobin (blood cells that carry oxygen from the lungs to the rest of the body). Resident #1 was transferred to the emergency room and required a transfusion of one unit of packed red blood cells (blood). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/12/2021 at 4:37 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-694. The facility was cited at F-694 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/24/2021 through 10/13/2021. An acceptable Removal Plan for F-694, which removed the immediacy of the jeopardy, was received on 10/14/2021 at 11:43 AM and was validated onsite by the surveyor on 10/14/2021 through observation, review of records, audit reviews and staff interviews. The findings include: Review of Brunner & Suddarth's Textbook of Medical-Surgical Nursing 12th Edition revealed, .Potential Complications .Midline Catheters .bleeding . Review of the facility's policy titled, Vascular Access Devices Peripheral Midline Catheter, dated 8/2016, revealed .Description Midline Catheter: Inserted in the upper arm .in the antecubital area [around the elbow] through .veins of the upper arm. Catheter tip does not extend past the axilla [under the shoulder joint] . Review of the facility's policy titled, Maintaining Patency of Peripheral and Central Vascular Access Devices. IV Flush Policy and Procedure, dated 8/2016, revealed .Vascular access devices are flushed and aspirated for a blood return prior to each infusion [of medication or fluids] to assess catheter function and prevent complications. Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen [tube] .To succeed with saline flushing, a needleless connector with an anti-reflux [a safety mechanism to reduce the chance of bleeding from the catheter tube] design must be placed on the hub of EVERY lumen of EVERY vascular access device/catheter .All connections [IV tubing or syringes] will be made via the needleless connector, NEVER directly to the catheter hub [opening] . Review of the facility's policy titled, Needleless Connector Change, dated 8/2016, revealed .A needleless connector with an anti-reflux [safety mechanism to prevent bleeding from the catheter] design must be placed on the hub of every lumen [tube] of every vascular access device .Needleless connectors are changed no more often than every 96 hours but at least every 7 days or PRN [as needed] if the needleless connector is removed for any reason .Procedure .Clamp catheter. Don [put on] gloves .Remove the needleless connector .Securely attach new needleless connector onto catheter .Open clamp on catheter. Flush with saline per protocol. Resume infusion or clamp catheter . Review of the Manufacturer guidelines for named Access Systems Patient Guide titled, How to Care for Your Midline, dated 9/2016, revealed .A Midline Catheter is a long, thin, soft tube that provides access to the body's peripheral blood system. A midline is inserted into a vein in the arm and progresses toward the heart. The tip of a midline ends before or at the axilla, which is an area near the armpit. The midline provides access to the peripheral blood system and is used for delivery of IV fluids and medications, and to withdraw blood .The midline catheter has a clamp on the extension leg [tubing] between the catheter labeled junction and the catheter hub [opening]. The clamp should always be closed when the catheter is not in use .Possible Complications The potential exists for serious complications including the following .Bleeding . Review of the facility's policy titled, Dressing Change for Vascular Access Devices, dated 8/2016, revealed .Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present or for further assessment if infection is suspected. Transparent semipermeable [see through] membrane dressings are changed every 7 days and PRN . Review of the facility's policy titled, Assessment of the Patient Receiving IV Therapy, dated 8/2016, revealed .to enable the nurse administering infusion therapy to recognize and utilize appropriate interventions for infusion related problems or complications .Visually inspect the entire infusion system from the solution container progressing down the administration set to the catheter insertion site. Check for integrity of the system and the dressing .Assess vascular access device function by flushing and aspirating for a blood return prior to each intermittent use [medication administration] .Assess the catheter insertion site and surrounding area for redness, tenderness, swelling, and drainage by visual [looking at the site] inspection and palpation [feeling the site] through the intact dressing. Recommended minimum assessment of midlines .Assess every 1-2 hours for patients who have cognitive deficits .The nurse administering intravenous fluids or medications will recognize and utilize appropriate intervention for any IV related problems or complications. The nurse will document any IV related problems or complications according to facility documentation policies and procedures. Assess and document patient's response to therapy . Review of the facility's policy titled, Investigating and Reporting Accidents and Incidents, dated 1/1/2021, revealed .All accidents or incidents involving residents .occurring on our premises must be investigated and reported to the Administrator .A Report of Incident/Accident must be completed for all accidents or incidents .Investigative Action on Incident Report: The nurse Supervisor/charge nurse and/or department director or supervisor must conduct an immediate investigation of the accident or incident. The following data, as it may apply, must be included on the Report of Incident/Accident: The date and time the accident or incident took place. The nature of the injury/illness [incident] .circumstances surrounding the accident or incident [fact reporting only, avoid unsupported assumptions, opinions or conclusions]; Where the accident or incident took place; The name[s] of witnesses and their accounts of the accident or incident; The injured person's account of the accident or incident .The condition of the injured person, to include his or her vital signs; The disposition of the injured person [i.e. transferred to hospital, put to bed, sent home, returned to work, etc.]; Any corrective action taken; Follow-up information; Other pertinent data as necessary or required; and The signature and title of the person completing the report as well as the date and time of completion . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #1 was severely impaired cognitively for daily decision making and total dependence of staff for all activities of daily living (ADLs). Review of Resident #1's Care Plan revised on 9/8/2021, revealed there was no Care Plan for the Midline catheter, IV therapy, flushes of the IV catheter, or to monitor for complications. There was no revision of the Care Plan after the resident received the midline IV catheter. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for flushing the IV line with Normal Saline before or after the antibiotic administration. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no assessment of the Peripheral Midline Catheter site or monitoring for complications of the catheter from 9/21/2021 through 10/7/2021. There was no documentation a Midline dressing change had been performed every 7 days, or a Midline cap (needleless connector) change had been performed every 7 days as required by facility policy from 9/21/2021 through 10/7/2021. Review of Resident #1's Complete Blood Count (CBC) lab results collected on 9/21/2021 at 11:55 AM (before the incident), revealed the Red Blood Cell Count (RBC) was 3.15 (L) (low) normal is 4.00-5.50, Hemoglobin (Hgb) was 8.1 (L) normal is 12.0-16.0, Hematocrit (HCT) was 26.3 (L) normal is 36.0-46.0. Review of Resident #1's Nurse's Note dated 9/24/2021 at 2:00 PM, revealed .When rounding, resident [Resident #1] was found with left midline leaking approx. [approximately] 30 ml - called for assistance, midline subsequently pulled [removed]. Tip of line noted intact, pressure held to site - no bleeding noted [from the site when the catheter was removed] and pressure dressing applied - will remove in 24 hours. [Named Doctor (Dr)] and RP [Responsible Party] notified - orders received for labs [blood tests] and reinsertion [of the midline catheter] .Resident vitals wnl [within normal limits] - will continue to closely monitor . Review of Resident #1's CBC laboratory results collected on 9/24/2021 at 10:26 PM (after the incident), revealed the RBC was 2.52 (L), Hgb was 6.4 (critical low) (CL), and HCT was 20.5 (L). Review of Resident #1's Nurse's Note dated 9/25/2021 at 6:54 AM, revealed that alert (critical low results) labs were reported to the provider and an order was given to transfer Resident #1 to the emergency room (ER) for possible blood transfusion. Several ambulance services were called, and no one could transport the resident to ER. The provider was informed, and an order was given to recollect the CBC and to continue to try arranging transportation to ER. Review of Resident #1's Nurse's Note dated 9/25/2021 at 3:07 PM, revealed that alert critical lab results were obtained and were as follows: Hct 19.8 (L), Hgb 6.2 (CL). The lab results were reported to the doctor and an order to transfer to the hospital was received. The RP and DON were notified. Review of Resident #1's Emergency Department Provider Note dated 9/25/2021 at 5:10 PM, revealed .The patient presents .received her normal abx [antibiotic] at [Named Skilled Nursing Facility] however the cap [needleless connector] on her line was inadvertently removed and pt [patient] was found to have blood around her in bed. This occurred yesterday. Today they drew blood and noted low H/H [hematocrit and hemoglobin] .Pt recently [previously] admitted for b/l [bilateral] pneumonia and septic shock [a widespread infection in the body that can cause organ failure] .Lab results 9/25/2021 4:00 PM RBC 2.52, Hemoglobin 6.4, Hematocrit 19.9 .Transfusion one unit PRBC [packed red blood cells] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Lab values post transfusion 9/26/2021 at 5:15 PM RBC 2.76, Hemoglobin 7.2, Hematocrit 21.8 .discharged back to [Named Skilled Nursing Facility] 9/26/2021 . Review of Resident #1's Nurse's Note dated 9/26/2021 at 8:30 AM, revealed that Resident #1 returned to facility per ambulance from the Named Hospital ER after receiving 1-unit of PRBCs at the hospital. The post transfusion Hgb of 7.2 and Hct of 21.8 were reported to the doctor and no new orders were received. Review of the Nurse's Note dated 10/8/2021, revealed .midline to left upper extremity pulled [discontinued] at this time. catheter intact . Review of the facility's investigation dated 10/12/2021 (18 days after the incident) revealed, .Upon review of the resident's chart with the Nurse Practitioner, it was her opinion that her [Resident #1] initial HCT on 9/13 was 21.5 which is already low .The patient also has a history of Chronic [CONDITION(S)] and that is why a CBC was ordered . Review of the Merck Manual documented, .Health and Topics .Chronic blood loss .small amounts of bleeding may not be noticed .If a small amount of bleeding continues for a long time, a significant amount of blood may be lost . Review of the Betterhealthwhileaging.net article titled, [CONDITION(S)] in the Older Adult:10 Common Causes & What to Ask, written by [NAME] Kenisan, MD (Doctor of Medicine), dated 2016 and updated 11/2020, revealed .to detect [CONDITION(S)] clinicians rely on the hemoglobin level and the hematocrit, rather than on the red blood cell count .A low hemoglobin level - meaning, it's below normal - can be used to detect [CONDITION(S)]. Clinicians [Medical Personnel] often confirm the lower hemoglobin level by repeating the CBC [Complete Blood Count] test .The red blood cells in your blood use hemoglobin to carry oxygen from your lungs to every cell in your body. So when a person doesn't have enough properly functioning red blood cells, the body begins to experience symptoms related to not having enough oxygen .generally, a hemoglobin of 6.5 to 7.9 gm/dL [grams per deciliter] is often considered 'severe' [CONDITION(S)] .In general, a hemoglobin less than 6.5 gm/dL is considered life-threatening . During an interview on 10/11/2021 at 11:00 AM, the Staff Development Coordinator (SDC) stated, .I responded to the page overhead .When I arrived [Named Person] [Registered Nurse (RN) #2] was holding pressure .The end cap broke off end of line .couldn't get another cap on .I held pressure .the other nurse had called the doctor and was told to pull [take out] the line .I pulled the line and applied pressure. No bleeding after I pulled the line. I put a pressure dressing on it and told them to leave it for 24 hours .No, we never found the clamp or cap .we cleaned her up, changed her linen and never found them . Observation in the resident's room on 10/11/2021 at 12:30 PM, revealed Resident #1 was lying on the left side positioned with a wedge under the right side, the head of bed was elevated, and a mechanical ventilator (breathing machine) in use with a [CONDITION(S)]. During an interview on 10/11/2021 at 1:00 PM, RN #2 stated, .[Named person] [RN #1] called me into the room I saw the midline leaking blood. There was lots of blood. It was a steady drip. Blood was on the resident's side of the gown, down her side onto the linen absorbed into the fabric the amount approximately size of a cantaloupe with some pooled-on top of the absorbed blood in the fabric .No, I did not see the clamp [safety mechanism] or the cap [needleless connector] both were missing the end was open .We never found the clamp or cap . RN #2 was asked where the supplies were for changing the cap (needleless connector safety mechanism to prevent bleeding) to IV lines. RN #2 walked into the Medication Room, pointed to a bin on the wall and stated, .Any supplies for IVs are kept up here in this bin .all I see is the dressing change supplies and there are no caps . RN #2 was asked who is responsible for keeping IV supply items stocked. She stated, .The nurses are responsible .but I don't know where to get those caps . During observation and interview in the Central Supply Room on 10/11/2021 at 1:25 PM, the Central Supply Clerk was asked where the IV supplies were. She pointed to a shelf to the left of her desk. Observations of the shelf revealed no caps (needleless connector). When the Central Supply Clerk was asked where the IV caps (needleless connector) were kept, she stated, .I don't know what they [IV caps] are .I don't have any because I don't keep up with that .what you see up there is what I keep . On the shelf were IV dressing change kits and IV tubings. During an interview on 10/11/2021 at 1:29 PM, RN #3 stated, .I was at lunch and just returning when they [RN #1, RN #2 and SDC] were in the room. I did not go in, they were handling everything .She [Resident #1] was my patient and I had gone in at 9:00 AM with [Named Person] [RN #1] to flush the midline and hang the antibiotic .She [RN #1] watched me for last day of orientation .The clamp and connector cap was on the midline .I cleaned the cap, unclamped the line administered the flush followed with connection of the IV antibiotic to the cap and the antibiotic infused .After infusion I disconnected the IV antibiotic infusion line, flushed the cap, closed the clamp and left the patient .nothing unusual . During an interview on 10/11/2021 at 1:45 PM, the DON was asked where the IV caps (needleless connectors) were kept for the nurses to use as needed and change every seven days for the Midline catheters. She stated, .In the Med [medication] Rooms, we get our IV supplies from [Named Company] they deliver when they provide the IV medications . Observation in the 400 Hall Medication Room on 10/11/2021 at 1:45 PM, revealed the DON was in the Medication Room looking through the IV supply box provided by (Named Company). She stated, .There are no IV caps [needleless connector] in here . Observations of the supply list on the front of the box revealed no listing for IV caps (needless connector). The DON and surveyor proceeded to the 100 Hall and the 200 Hall's Medication Rooms. The DON looked through each IV supply box in the Medication Rooms as well as the Medication Room bins stocked by the facility and revealed no IV caps (needleless connector). She stated, .well I know we have some, somewhere . She confirmed there were no IV caps in the Central Supply, 100, 200 or 300 Halls' med rooms or supply boxes. During a telephone interview on 10/11/2021 at 2:05 PM, Named Person with the Named Pharmacy Company was asked if the pharmacy provides the facility with IV caps (needleless connector). He stated, .No, we don't provide the caps .we provide extension tubing with a cap built into the extension tubing . During a phone interview on 10/11/2021 at 3:32 PM, Registered Nurse (RN) #1 confirmed the documentation of the Nurse's Note dated 9/24/2021 at 2:00 PM. She stated, .At approximately 1:00 PM, I went into Ms. [Resident #1]'s room to restart the enteral feeding [nutrition administered through a tube in the stomach] and discovered bleeding from the end of the line [Peripheral Midline Catheter] I got help .[Named Nurse] [RN #2] came and I left the room to make calls . When asked why a CBC was done, she stated, .because of the blood loss . When asked what the integrity of the IV line was, she stated, .there was no clamp or cap [needleless connector] .the tip was open and blood was coming out . RN #1 confirmed at 9:00 AM on 9/24/2021 she had observed RN #3 flush and administer the IV antibiotic and once the antibiotic was infused, RN #3 flushed and disconnected from the midline. She stated, .at 9:00 AM the clamp and cap were on the midline . During a telephone interview on 10/11/2021 at 3:43 PM, Certified Nursing Assistant (CNA) #1 stated, Somewhere .[around] 10:00 AM, we [CNA #1 and CNA #2] went to clean up Ms. [Named Resident #1] .bath .we washed under her arms didn't notice anything disconnected .changed the gown didn't notice anything, nothing different about her [Resident #1] or the bed . During an interview on 10/11/2021 at 4:30 PM, the DON and Administrator were asked if an investigation was done after this unusual occurrence. The Administrator stated the State Survey Agency (SSA) was in the building during the recertification survey on 9/24/2021 and did not leave until 9/25/2021, and the incident was not investigated. The Administrator was asked if the incident had been investigated after the SSA exited. The Administrator stated, .No, we did no investigation they just told me the cap broke off .No, there is no I & A [incident/accident] report .No, we did not investigate or have an ad hoc [as needed] QA [Quality Assurance] meeting .There was no I & A report. We would have if had an I & A report . The DON stated, .I'm trying to find out myself .I had no idea the clamp was missing and the cap till [until] you started questioning people .I was just told the cap broke off and you know things happen . The Administrator and the DON were asked how the facility could ensure a similar incident will not recur if there had not been an investigation or corrective actions had not been put into place. The Administrator and DON did not answer. During an interview on 10/13/2021 at 1:50 PM, RN #1 was asked for clarification on 9/24/2021 when she found Resident #1 at approximately 1:00 PM and was asked if there was a clamp or cap (needless connector) on the midline. She stated, .There was no clamp or cap on the line and blood was dripping out. I was shocked. I went to grab the clamp to close it and there wasn't one. No clamp I was shocked . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS dated [DATE], revealed a BIMS score of 3 which indicated severely impaired cognition for daily decision making and total dependence of staff for all ADLs. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 10/11/2021 at 12:55 PM, revealed the SDC just completed a Peripheral Midline Catheter dressing change for Resident #2 as the surveyor walked in the door. Resident #2 was lying on the right side positioned with pillows under the left side, had a [CONDITION(S)] Air Vo and oxygen, and a Peripheral Midline Catheter in the right upper arm with a long purple tube with a purple clamp (located between the catheter hub and where the line enters the body) and a cap (needleless connector screw on type) intact on the end of the lumen. The Surveyor verified the Removal Plan by: 1. Resident #1 had their midline access device removed on 10/8/2021. The surveyor confirmed this through record review and staff interview. 2. The DON and Assistant Director of Nursing (ADON) completed an audit of all current residents on 10/12/2021 to identify any current resident that has a midline access device. The surveyor confirmed this through review of audit records and interview. 3. There was one current resident with a midline access device. The DON and ADONs reviewed the identified resident's medical record to determine if appropriate level of supervision and monitoring for complications was in place for the midline intravenous catheter. This was completed on 10/12/2021. Any changes in monitoring or supervision were noted in the medical record. The surveyor confirmed this through record review and interview. 4. The DON and ADONs reviewed current residents on 10/12/2021 to identify any with IV access and determine if monitoring was occurring at least every shift, and any corrections were made in the medical record. The surveyor confirmed this through record review and interview. 5. The DON/Designee beginning on 10/13/2021 and continuing every shift will complete an observation of licensed nurses for assessment and complication of residents receiving IV therapy. No licensed nurse will work after 10/13/2021 without having this observation. Nurses were educated on 10/13/2021 during in-service to make observations on IV sites while making rounds, during medication administration, and during patient care. The surveyor confirmed this through review of sign in sheet, review of IV access tool competency sheet and staff interviews on all shifts. 6. The Administrator and DON reviewed facility policies related to administration, QAPI (Quality Assurance Performance Improvement) and Midline Catheter access devices on 10/12/2021 and found the policies to be appropriate. The surveyor confirmed this through staff interview. 7. The Regional Director of Clinical re-educated the Administrator and Director of Nursing on the requirement for adherence to policy on 10/12/2021. The surveyor confirmed this through review of the sign in sheet and interview. 8. On 10/12/2021, the SDC or designee began re-education with current licensed staff on the policy for midline catheters to include monitoring of the catheter. This included a quiz to validate understanding. No licensed staff will work after 10/12/2021 without having had this re-education and quiz. The surveyor confirmed this through review of the sign in sheet, quiz, and staff interview on all shifts. 9. On 10/12/2021 the Administrator added to the facility monthly QAPI report template review of the plan of correction as well as review of access devices or incidents involving access devices. The surveyor confirmed this through record review and interview. 10. On 10/12/2021, an ad hoc QA meeting was convened to review the citations, review of the abatement plan and any further recommendations. In attendance was the Administrator, Director of Nursing, ADONs, Medical Records, MDS Nurse, Business Office Manager, Activities, Admissions, Staff Development Coordinator as well as the Medical Director by phone. An Ad hoc QA was conducted on 10/13/2021 to review additions to the plan of removal for F600 and F694 in attendance was DON, Administrator, ADON, Financial Chief Officer (FCO), SDC with medical director attending by phone. The surveyor confirmed through review of sign in sheet and interview. 11. The DON or designee will review residents with midline access devices daily for 14 days to validate monitoring for complications and supervision of midline access devices then weekly for 10 weeks. Results will be reviewed with the QAPI committee monthly. The surveyor confirmed through record review and interview. 12. Concerns identified during the audits will be reviewed with the QAPI committee for further recommendations. The surveyor confirmed through interview. The facility's noncompliance at F-694 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on review of Lippincott Manual of Nursing Practice 10th Edition, Review of Manufacturing Guidelines, review of [CONDITION(S)] in the Older Adult:10 Common Causes & (and) What to Ask article, policy review, medical record review, observation, and interview, the facility neglected to provide the standard of care for vascular services safely to 1 of 2 sampled residents (Resident #1) reviewed with a Peripheral Midline Catheter (a special long Intravenous (IV) catheter that is placed into a large vein and requires safety mechanisms to prevent bleeding from the IV opening). The midline catheter has a clamp on the extension tubing between the catheter labeled junction and the catheter opening. The clamp should always be closed when the catheter is not in use. The facility neglected to monitor the Peripheral Midline Catheter for complications of bleeding; neglected to assess the site; neglected to obtain orders for flushing the IV catheter, and neglected to investigate and develop corrective actions for the complications that would prevent recurrence to any residents requiring a Peripheral Midline Catheter. The facility's neglect resulted in Immediate Jeopardy when Resident #1 was found with the Peripheral Midline Catheter clamp and cap missing (safety devices to prevent bleeding from the patient through the IV catheter) and a steady drip of blood coming from the opening of the catheter with blood pooling on the bed linens. A laboratory blood test was drawn that revealed a critical low hemoglobin (the blood cells that carry oxygen from the lungs to other parts of the body). Resident #1 was transferred to the emergency room and required a transfusion of one unit of packed red blood cells (blood). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/12/2021 at 4:37 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/24/2021 through 10/13/2021. An acceptable Removal Plan for F-600, which removed the immediacy of the jeopardy, was received on 10/14/2021 at 11:43 AM and was validated onsite by the surveyor on 10/14/2021 through observation, review of records, audit reviews and staff interviews. The findings include: Review of Lippincott Manual of Nursing Practice, 10th Edition, revealed .Standards of Care Guidelines .Midline catheters .Complications of IV Therapy .Hemorrhage .Causes .Loose connection of tubing or injection port .Complications .Oozing or trickling of blood from .catheter . Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 1/1/2021, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . Review of the manufacturing guidelines for Named Access Systems Patient Guide titled, How to Care for Your Midline, dated 9/2016, revealed .The midline catheter has a clamp on the extension leg [tubing] between the catheter labeled junction and the catheter hub opening]. The clamp should always be closed when the catheter is not in use .Possible Complications .The potential exists for serious complications including the following .Bleeding . Review of the facility's policy titled, Maintaining Patency of Peripheral and Central Vascular Access Devices. IV Flush Policy and Procedure, dated 8/2016, revealed .Vascular access devices are flushed and aspirated for a blood return prior to each infusion [of medication or fluids] to assess catheter function and prevent complications. Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen [tube] .To succeed with saline flushing, a needleless connector with an anti-reflux [a safety mechanism to reduce the chance of bleeding from the catheter tube] design must be placed on the hub [opening] of EVERY lumen of EVERY vascular access device/catheter .All connections [IV tubing or syringes] will be made via the needleless connector, NEVER directly to the catheter hub . Review of the facility's policy titled, Needleless Connector Change, dated 8/2016, revealed .A needleless connector with an anti-reflux [safety mechanism to prevent bleeding from the patient's IV catheter] design must be placed on the hub of every lumen [tube] of every vascular access device .Needleless connectors are changed no more often than every 96 hours but at least every 7 days or PRN [as needed] if the needleless connector is removed for any reason .Procedure .Clamp catheter. Don [put on] gloves .Remove the needleless connector .Securely attach new needleless connector onto catheter .Open clamp on catheter. Flush with saline per protocol. Resume infusion or clamp catheter Review of the facility's policy titled, Assessment of the Patient Receiving IV Therapy, dated 8/2016, revealed .Purpose to enable the nurse administering infusion therapy to recognize and utilize appropriate interventions for infusion related problems or complications .Visually inspect the entire infusion system from the solution container progressing down the administration set to the catheter insertion site. Check for integrity of the system and the dressing .Assess vascular access device function by flushing and aspirating for a blood return prior to each intermittent use [medication administration] .Assess the catheter insertion site and surrounding area for .drainage by visual [looking at the site] inspection and palpation [feeling the site] through the intact dressing .Assess every 1-2 hours for patients who have cognitive deficits .The nurse administering intravenous fluids or medications will recognize and utilize appropriate intervention for any IV related problems or complications. The nurse will document any IV related problems or complications according to facility documentation policies and procedures. Assess and document patient's response to therapy . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment for daily decision making and total dependence of staff for all activities of daily living (ADLs). Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. 9/21/2021 .[MEDICATION(S)] HCl [[MEDICATION(S)]] Solution [an antibiotic] 2 GM [gram]/100 ml [milliliters] use 2 grams intravenously two times a day for elevated wbc [white blood cell count] for 10 days . b. 9/21/2021 .place midline [catheter] for ABT [antibiotic] therapy . There were no orders for flushing the IV line with Normal Saline before or after the antibiotic administration. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no assessment of the Peripheral Midline Catheter site or monitoring for complications of the catheter documented from 9/21/2021-10/7/2021. There was no documentation of a Midline dressing change every 7 days, or Midline cap (needleless connector) change every 7 days as required by facility policy from 9/21/2021-10/7/2021. Review of Resident #1's Complete Blood Count (CBC) laboratory results collected 9/21/2021 at 11:55 AM (prior to the incident), revealed .RBC [red blood cell] 3.15 (L [low]) normal 4.00 - 5.50, Hemoglobin [Hgb] 8.1 (L) normal 12.0 - 16.0, Hematocrit [HCT] 26.3 (L) normal 36.0 - 46.0 . Resident #1's Hgb was already low which put the resident at greater risk with the complication of bleeding from the IV catheter. Review of the Betterhealthwhileaging.net article titled, [CONDITION(S)] in the Older Adult:10 Common Causes & What to Ask, written by [NAME] Kenisan, MD (Doctor of Medicine), dated 2016 and updated 11/2020, revealed .to detect [CONDITION(S)] clinicians rely on the hemoglobin level and the hematocrit, rather than on the red blood cell count .A low hemoglobin level - meaning, it's below normal - can be used to detect [CONDITION(S)]. Clinicians [Medical Personnel] often confirm the lower hemoglobin level by repeating the CBC [Complete Blood Count] test .The red blood cells in your blood use hemoglobin to carry oxygen from your lungs to every cell in your body. So when a person doesn't have enough properly functioning red blood cells, the body begins to experience symptoms related to not having enough oxygen .generally, a hemoglobin of 6.5 to 7.9 gm/dL [grams per deciliter] is often considered 'severe' [CONDITION(S)] .In general, a hemoglobin less than 6.5 gm/dL is considered life-threatening . Review of Resident #1's Nurse's Note dated 9/24/2021 at 2:00 PM, revealed .When rounding, resident [Resident #1] was found with left midline leaking approx. [approximately] 30 ml [from the open IV catheter]- called for assistance, midline subsequently pulled [removed]. Tip of line noted intact, pressure held to site - no bleeding noted [from the site when catheter discontinued] and pressure dressing applied - will remove [dressing] in 24 hours. [Named Doctor [Dr] and RP [Responsible Party] notified - orders received for labs [blood tests] and reinsertion [of the midline catheter] .Resident vitals wnl [within normal limits] - will continue to closely monitor . Review of Resident #1's CBC laboratory results collected on 9/24/2021 at 10:26 PM (after the incident), revealed .RBC 2.52 (L), HGB 6.4 CL [critical low], HCT 20.5 (L) . Review of Resident #1's Nurse's Note dated 9/25/2021 at 6:54 AM, revealed .Alert labs [critical low and low blood test results] reported to provider and order was given to transfer resident to ER [emergency room ] for possible blood transfusion. Several ambulance services were called and no-one can transport resident to ER. Provider was informed and order was given to recollect CBC and continue to try arranging transportation to ER . Review of Resident #1's Nurse's Note dated 9/25/2021 at 3:07 PM, revealed .Obtained alert critical results lab: HCT [Hematocrit] 19.8, HGB [Hemoglobin] 6.2 [critical low] relayed info [information] to [Named Doctor] with order [received] to transfer to hospital. RP notified, DON notified . Review of Resident #1's Emergency Department Provider Note dated 9/25/2021 at 5:10 PM, revealed .The patient presents .received her normal abx [antibiotic] at [Named Skilled Nursing Facility] however the cap [needleless connector] on her line was inadvertently removed and pt was found to have blood around her in bed. This occurred yesterday. Today they drew blood and noted low H/H [Hemoglobin/Hematocrit] .Pt recently [previously] admitted for b/l [bilateral] pneumonia and septic shock [a widespread infection in the body that can cause organ failure] .Lab results 9/25/2021 4:00 PM RBC 2.52, Hemoglobin 6.4, Hematocrit 19.9 .Transfusion one unit PRBC [packed red blood cells] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Lab values post transfusion 9/26/2021 at 5:15 PM RBC 2.76, Hemoglobin 7.2, Hematocrit 21.8 .discharged back to [Named Skilled Nursing Facility] 9/26/2021 . Review of Resident #1's Nurse's Note dated 9/26/2021 at 8:30 AM, revealed .Resident returned to facility [Named Skilled Nursing Facility] .under [Named Dr] care per ambulance from [Named Hospital ER] from receiving 1-unit RBCs [blood] at hospital. post Hgb 7.2 and Hct 21.8. reported to [Named Dr]. No new orders received. RP notified of resident return to facility . The Nurse's Note dated 10/8/2021, revealed .midline to left upper extremity pulled [discontinued] at this time. catheter intact . During an interview on 10/11/2021 at 11:00 AM, the Staff Development Coordinator (SDC) stated, .I responded to the page overhead .When I arrived [Named Person] [Registered Nurse (RN) #2] was holding pressure .The end cap broke off end of line .couldn't get another cap on .I held pressure .the other nurse had called the doctor and was told to pull [take out] the line .I pulled the line and applied pressure. No bleeding after I pulled the line. I put a pressure dressing on it and told them to leave it for 24 hours .No, we never found the clamp or cap .we cleaned her up, changed her linen and never found them . During an interview on 10/11/2021 at 1:00 PM, RN #2 stated, .[Named Person] [RN #1] called me into the room I saw the midline leaking blood. There was lots of blood. It was a steady drip. Blood was on the resident's side of the gown, down her side onto the linen absorbed into the fabric the amount approximately size of a cantaloupe with some pooled-on top of the absorbed blood in the fabric .No, I did not see the clamp [safety mechanism] or the cap [safety mechanism needleless connector] both were missing the end [of the IV catheter] was open .We never found the clamp or cap . RN #2 was asked where the supplies were for changing the cap (needleless connector safety mechanism to prevent bleeding) to IV lines. RN #2 walked into the Medication Room, pointed to a bin on the wall and stated, .Any supplies for IVs are kept up here in this bin .all I see is the dressing change supplies and there are no caps . RN #2 was asked who is responsible for keeping IV supply items stocked. She stated, .The nurses are responsible .but I don't know where to get those caps . During observation and interview in the Central Supply Room on 10/11/2021 at 1:25 PM, the Central Supply Clerk was asked where the IV supplies were. She pointed to a shelf to the left of her desk. Observations of the shelf revealed no caps (needleless connector). When the Central Supply Clerk was asked where the IV caps (needleless connector) were kept, she stated, .I don't know what they [IV caps] are .I don't have any because I don't keep up with that .what you see up there is what I keep . On the shelf were IV dressing change kits and IV tubings. During an interview on 10/11/2021 at 1:29 PM, RN #3 stated, .I was at lunch and just returning when they [RN #1, RN #2 and SDC] were in the room. I did not go in, they were handling everything .She [Resident #1] was my patient and I had gone in at 9:00 AM with [Named Person] [RN #1] to flush the midline and hang the antibiotic .She [RN #1] watched me for last day of orientation .The clamp and connector cap was on the midline .I cleaned the cap, unclamped the line administered the flush followed with connection of the IV antibiotic to the cap and the antibiotic infused .After infusion I disconnected the IV antibiotic infusion line, flushed the cap, closed the clamp and left the patient .nothing unusual . During an interview on 10/11/2021 at 1:45 PM, the DON was asked where the IV caps (needleless connectors) were kept for the nurses to use as needed and change every seven days for the Midline catheters. She stated, .In the Med [medication] Rooms, we get our IV supplies from [Named Company] they deliver when they provide the IV medications . Observation in the 400 Hall Medication Room on 10/11/2021 at 1:45 PM, revealed the DON was in the Medication Room looking through the IV supply box provided by (Named Company). She stated, .There are no IV caps [needleless connector] in here . Observations of the supply list on the front of the box revealed no listing for IV caps (needless connector). The DON and surveyor proceeded to the 100 Hall and the 200 Hall's Medication Rooms. The DON looked through each IV supply box in the Medication Rooms as well as the Medication Room bins stocked by the facility and revealed no IV caps (needleless connector). She stated, .well I know we have some, somewhere . She confirmed there were no IV caps in the Central Supply, 100, 200 or 300 Halls' med rooms or supply boxes. During a telephone interview on 10/11/2021 at 2:05 PM, Named Person with the Named Pharmacy Company was asked if the pharmacy provides the facility with IV caps (needleless connector). He stated, .No, we don't provide the caps .we provide extension tubing with a cap built into the extension tubing . During a telephone interview on 10/11/2021 at 3:32 PM, RN #1 confirmed the documentation of the Nurse's Note dated 9/24/2021 at 2:00 PM. She stated, .At approximately 1:00 PM, I went into Ms. [Resident #1]'s room to restart the enteral feeding [nutrition through a tube inserted into the stomach] and discovered bleeding from the end of the line [Peripheral Midline Catheter] I got help .[Named Nurse] [RN #2] came and I left the room to make calls . When asked why a CBC was done, she stated, .because of the blood loss . When asked what the integrity of the IV line was, she stated, .there was no clamp or cap [needleless connector] .the tip was open and blood was coming out . RN #1 confirmed at 9:00 AM on 9/24/2021 she had observed RN #3 flush and administer the IV antibiotic and once the antibiotic had infused, RN #3 flushed and disconnected from the midline. She stated, .at 9:00 AM the clamp and cap were on the midline . During a telephone interview on 10/11/2021 at 3:43 PM, Certified Nursing Assistant (CNA) #1 stated, Somewhere .[around] 10:00 AM, we [CNA #1 and CNA #2] went to clean up Ms. [Named Resident #1] .bath .we washed under her arms didn't notice anything disconnected .changed the gown didn't notice anything, nothing different about her [Resident #1] or the bed . During an interview on 10/11/2021 at 4:30 PM, the DON and Administrator were asked if an investigation was done after this unusual occurrence. The Administrator stated the State Survey Agency (SSA) was in the building during the recertification survey on 9/24/2021 and did not leave until 9/25/2021, and the incident was not investigated. The Administrator was asked if the incident had been investigated after the SSA exited. The Administrator stated, .No, we did no investigation they just told me the cap broke off .No, there is no I & A [incident/accident] report .No, we did not investigate or have an ad hoc [as needed] QA [Quality Assurance] meeting .There was no I & A report. We would have if had an I & A report . The DON stated, .I'm trying to find out myself .I had no idea the clamp was missing and the cap till [until] you started questioning people .I was just told the cap broke off and you know things happen . The Administrator and the DON were asked how the facility could ensure a similar incident will not recur if there had not been an investigation or corrective actions had not been put into place. The Administrator and DON did not answer. During an interview on 10/13/2021 at 1:50 PM, RN #1 was asked for clarification on 9/24/2021 when she found Resident #1 at approximately 1:00 PM and was asked if a clamp or cap (needless connector) was present to the midline. She stated, .There was no clamp or cap on the line and blood was dripping out. I was shocked. I went to grab the clamp to close it and there wasn't one. No clamp I was shocked . Refer to F-694. The Surveyor verified the Removal Plan by: 1. Resident #1 had their midline access device removed on 10/8/2021. The surveyor confirmed this through record review and staff interview. 2. The DON and Assistant Director of Nursing (ADON) completed an audit of all current residents on 10/12/2021 to identify any current resident that has a midline access device. The surveyor confirmed this through review of audit records and interview. 3. There was one current resident with a midline access device. The DON and ADONs reviewed the identified resident's medical record to determine if appropriate level of supervision and monitoring for complications was in place for the midline intravenous catheter. This was completed on 10/12/2021. Any changes in monitoring or supervision were noted in the medical record. The surveyor confirmed this through record review and interview. 4. The DON and ADONs reviewed current residents on 10/12/2021 to identify any with IV access and determine if monitoring was occurring at least every shift, however any corrections were made in the medical record. The surveyor confirmed this through record review and interview. 5. The DON/Designee beginning 10/13/2021 and continuing every shift will complete an observation of licensed nurses for assessment and complications of residents receiving IV therapy. No licensed nurse will work after 10/13/2021 without having this observation. Nurses were educated on 10/13/2021 during in-service to make observations on IV sites while making rounds, during medication administration, and during patient care. The surveyor confirmed this through review of sign in sheet, review of IV access tool competency sheet, and staff interviews on all shifts. 6. The Administrator and DON reviewed facility policies related to administration, QAPI (Quality Assurance Performance Improvement) and Midline Catheter access devices on 10/12/2021 and found the policies to be appropriate. The surveyor confirmed this through staff interview. 7. The Regional Director of Clinical re-educated the Administrator and Director of Nursing on the requirement for adherence to policy on 10/12/2021. The surveyor confirmed this through review of the sign in sheet and interview. 8. On 10/12/2021, the SDC or designee began re-education with current licensed staff on the policy for midline catheters to include monitoring of the catheter. This included a quiz to validate understanding. No licensed staff will work after 10/12/2021 without having had this re-education and quiz. The surveyor confirmed this through review of the sign in sheet, quiz, and staff interview on all shifts. 9. On 10/12/2021, the Administrator added to the facility monthly QAPI report template review of the plan of correction as well as review of access devices or incidents involving access devices. The surveyor confirmed this through record review and interview. 10. On 10/12/2021, an Ad hoc QA meeting was convened to review the citations, review of the abatement plan and any further recommendations. In attendance was the Administrator, Director of Nursing, ADONs, Medical Records, MDS Nurse, Business Office Manager, Activities, Admissions, Staff Development Coordinator as well as the Medical Director by telephone. An Ad hoc QA was conducted on 10/13/2021 to review additions to the plan of removal for F600 and F694 in attendance was DON, Administrator, ADON, FCO (Financial Chief Officer), SDC with medical director attending by telephone. The surveyor confirmed through review of sign in sheet and interview. 11. The DON or designee will review residents with midline access devices daily for 14 days to validate monitoring for complications and supervision of midline access devices then weekly for 10 weeks. Results will be reviewed with the QAPI committee monthly. The surveyor confirmed through record review and interview. 12. Concerns identified during the audits will be reviewed with the QAPI committee for further recommendations. The surveyor confirmed through interview. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, review of the Family Member Guidance, review of the Safety Data Sheets (SDS) and Material Safety Data Sheets (MSDS), personnel record review, facility in-service log review, (Named Contracted Housekeeping Group) Fire Procedure and Evacuation Plan Laundry In-service review, medical record review, observation, and interview, the facility failed to ensure the environment was free from the accident hazards of chemicals, medications, aerosol sprays and sharps in 5 of 5 (station 3, station 1, station 5-secure unit, station 4, and station 2) resident units, and in 13 of 114 (Room #110, 509, 111, 311, 323, 505, 423, 429, 300, 127, 245, 132, and 324) resident rooms. The facility failed to ensure 1 of 3 (Laundry Aide (LA) #1) contract laundry personnel was trained and monitored on how to correctly respond to a fire alarm. The facility failed to ensure the environment was free from the accident hazards of medications in 1 of 15 (station 5 medication cart) medication storage areas. The facility also failed to follow a physician's orders [REDACTED].#205) sampled residents reviewed for falls. The facility's failure to protect vulnerable residents from access to hazardous chemicals, medications, aerosol sprays, sharps, and from a potential fire disaster placed all the residents in IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Regional Clinical Coordinator (RCC) were informed of this IMMEDIATE JEOPARDY, concerning the unsecured chemicals, medications, aerosol sprays sharps, and protection from a fire disaster, on 9/13/16 at 7:51 PM, in the conference room. The Administrator, DON, and the RCC were informed of a second IMMEDIATE JEOPARDY, concerning the unlocked medication cart on the secure unit, on 9/28/16 at 4:48 PM, in the conference room The facility was cited an IMMEDIATE JEOPARDY at F323, which is Substandard Quality of Care. An extended survey was conducted 9/28/19 - 9/30/16. The IMMEDIATE JEOPARDY is effective 9/12/16, and is ongoing. The findings included: 1. The facility's Hazardous Chemicals policy documented, Hazardous chemicals are utilized in the daily operations of the facility for cleaning and disinfection. In addition, resident care items may be considered hazardous if use is inconsistent with manufacturer's recommendations or label instructions .1. Hazardous Chemicals include, but are not limited to; a. Cleaning fluids; b. Disinfecting fluids; c. Can be aerosolized, liquid, or impregnated cloths; or d. Maintenance supplies (paint, glue, solvents, etc.). 2. Hazardous Chemicals will be secured to prevent accidental resident exposure. 3. Resident care items; a. Many resident care items are considered hazardous if use is inconsistent with label instructions. Therefore the facility will make every effort to secure personal care items to prevent misuse or accidental ingestion. b. Residents may keep care items if deemed appropriate per ability to safely use. c. Residents who keep care items shall keep them in an area of their room which is inconspicuous and/or secure to prevent unintended use per label instructions .4. Implementation suggestions .b. Assuring safety of chemicals and resident care items is the responsibility of staff . 2. The facility's Self-Administration of Drugs policy documented, .8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room . 3. The facility's Storage of Medications policy documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . 4. The facility's FAMILY MEMBER GUIDANCE documented, .6. Medications CAN NOT be brought from home and left at the resident's bedside. This includes over the counter medications such as aspirin, cold medicine, any medicated creams, or prescription medications. Medications needed for the resident will be ordered by the physician and kept in the medication cart for the residents use. This is a Federal Regulation that must be followed .Please do not bring in any air fresheners into the building unless we have a material safety data sheet (MSDS) on that particular item. Our housekeeping department has air fresheners and room deodorizers that can be used .14. Residents are not permitted to have knives or other potentially harmful objects . 5. The Safety Data Sheet (SDS) for ULTRA SHIELD ADVANCED BURNISHING FORMULA documented, .WARNING .Causes mild skin irritation. Causes eye irritation .Wear Protective gloves/eye protection/face protection .Do not breathe dust/mist/spray .Store locked up . 6. The MSDS for Restor-A Finish documented, .This material is flammable and may be ignited by heat, sparks, flame or static electricity .Potential aspiration hazard if swallowed; eye irritant .Signs and Symptoms of Exposure Headache, dizziness, nausea; eye and skin irritation .Avoid generating mists while handling. Avoid prolonged skin contact .Work in well ventilated area . 7. The SDS for FABULOSO ALL PURPOSE CLEANER LIQUID LAVENDER documented, .Hazard statements: .Causes skin irritation .May cause an allergic skin reaction .Causes serious eye irritation .May be harmful if swallowed in large quantities . 8. The MSDS for Comet Powder Cleanser documented, .Health Hazards: .Mild mucous membrane irritant .Mild eye irritant .Mild respiratory irritant .Mild skin irritant . 9. The SDS for DISINFECTANT CLEANER documented, .Danger .Harmful if swallowed or in contact with skin. Causes severe skin burns and eye damage .IF SWALLOWED: Call a POISON CENTER . 10. The MSDS For Lime-off documented, .HEALTH HAZARDS .Severe skin irritant. Prolonged or repeated contact can cause chemical burns or dermatitis .Severe eye irritant. Liquid and mist may burn or injure eyes, causing corneal damage. Inhalation: May be irritating to mucous membranes of the nose, throat, and lungs. Ingestion: Irritating and corrosive to the mouth and throat. May cause headache, nausea, abdominal pain, vomiting and diarrhea. Excessive amounts may cause collapse . 11. The SDS for RUG DOCTOR Multipurpose OxySteam documented, .Warning .Causes skin irritation causes serious eye irritation .Wear protective gloves/eye protection/face protection . 12. The MSDS for U-4 Power Cleaner .Heavy Duty Cleaner Degreaser documented, .HEALTH HAZARDS .Skin irritant. May cause moderate reddening, and swelling. Eyes: Severe Eye irritant. Liquid and mists may damage eyes, causing corneal damage. Inhalation: Vapors and mists may be irritating to mucous membranes in the nose, throat, and lungs. Ingestion: Irritating and corrosive to the mouth and throat. May cause headache, nausea, abdominal pain, vomiting, and diarrhea. Excessive amounts may cause collapse . 13. The SDS for .Isopropyl Alcohol .as active Ingredient documented, .HAZARDS IDENTIFICATION .Highly flammable; irritation to eyes; vapor may cause drowsiness and dizziness . 14. The MSDS for Mal Odor Eliminator documented, .For use by trained personnel only .HEALTH HAZARDS .Skin: Prolonged or repeated contact may cause dermatitis. Eyes: Eye irritant. May cause redness or swelling. Inhalation: Prolong or repeated breathing of vapors can cause dizziness, headache, nausea. Ingestion: May be irritating to the mouth, throat, and gastrointestinal system. Vomiting, and diarrhea expected with large doses . 15. The MSDS for Scope .Mouthwash . documented, HAZARDS IDENTIFICATION .Eye: May produce transient eye irritation. Skin: May produce transient skin irritation .Ingestion of large amounts may produce signs of alcohol intoxication and stomach irritation . 16. The MSDS for FRESHMINT DENTURE CLEANSING TABLETS documented, .HEALTH HAZARDS .Inhalation Dust may irritate nasal passages .cause irritation to respiratory tract .Eyes Can cause eye irritation .Ingestion Expected to be slightly toxic by ingestion . 17. The MSDS for Febreze .(Air Freshener) documented, .HAZARDS .Contents harmful if swallowed .Contact causes mild eye irritation .Moderately irritating to skin .Inhalation: Prolonged high level exposures may cause slight drowsiness, headache and/or mild respiratory tract irritation . 18. The MSDS for Listerine documented, .HAZARDS IDENTIFICATION .FLAMMABLE! MAY CAUSE EYE AND RESPIRATORY IRRITATION THIS PRODUCT CONTAINS ETHANOL WHICH CAN CAUSE LIVER CHANGES, CENTRAL NERVOUS SYSTEM EFFECTS .Inhalation Effects .Exposure to high concentrations may cause irritation, headache, drowsiness and symptoms of drunkenness .Ingestion of large quantities may cause headache, dizziness, nausea, vomiting, diarrhea, dehydration, and symptoms of drunkenness . 19. The MSDS for .Icy Hot Cream documented, .This is an OTC (Over the Counter) drug for topical use .In case of ingestion .Seek immediate medical attention or contact Poison Control Center . 20. The SDS for .SKIN PROTECTANT PASTE documented, Hazards Identification .Causes eye irritation May be harmful if swallowed . 21. Observations during initial tour in the station 3 hallway on 9/12/16 beginning at 10:43 AM, revealed the door labeled Housekeeping was unlocked and unsecured and contained the following hazardous chemicals readily accessible to residents: a. 1 bottle labeled spray buff mop on dressing b. 1 bottle of Restor-A-Finish c. 1 bottle Fabuloso Cleaner d. 1 bottle of Comet Powder with Bleach e. 1 bottle of Disinfectant f. 1 bottle of Lime-off Descaler g. 1 bottle of Oxy Deep Cleaner Carpet Cleaner h. 1 bottle labeled Grease Strip Plus i. 1 bottle 70 %(percent) Isopropyl Rubbing Alcohol Interview with the Housekeeping Manager (HM) on 9/12/16 at 3:53 PM, in the Housekeeping room, the HM was asked why the door was unlocked. The HM stated, This morning when everybody came in, he (my floor tech) came in and he forgot to lock it; it's (the door) normally locked. The HM was asked if it was acceptable for the door to be unlocked at any time. The HM stated, No ma'am . The HM was asked who has access to the keys of the door. The HM stated, 2 of my staff .one on day shift, and one on evenings . The HM was asked what types of risks the unlocked door could pose to residents in the facility related to the chemicals that were stored in there. The HM stated, .they could drink if if they think it's something that it's not . Interview with the Assistant Housekeeping Manager, (AHM) on 9/13/16 at 5:05 PM, in the station 3 hallway outside the Housekeeping room, the AHM was asked if she had access to the keys for the Housekeeping room. The AHM stated, Yes .I have a key and (named the HM) has a key. The AHM was asked if anyone else had a key to the Housekeeping room. The AMS stated, No. 22. Observations in room 110 on 9/12/16 at 3:38 PM, revealed 1 opened package of skin protectant lying on the bedside table and 1 opened package of skin protectant lying on the chest beside the bed. 23. Observations in room 509 on 9/12/16 at 3:38 PM, revealed, 1 package of skin protectant lying on the bedside table, and 1 opened package of barrier skin protectant lying on top of the chest. 24. Observations in room 111 on 9/12/16 at 3:56 PM, revealed 1 aerosol can of air freshener sitting on top of the chest. 25. Observations in room 311 (Resident #188's room) on 9/13/16 at 8:14 AM, revealed the following unsecured medications in the top drawer of the bedside table: a. 1 box of Gas X chewable tablets b. 1 bottle of extra strength pain reliever Acetaminophen 500 milligrams (mgs) tablets c. 2 bottles of Fluticasone Propionate nasal spray d. 1 box of Gas X soft gels e. 1 bottle of Milk of Magnesia f. 1 bottle of Reishi Mushroom 1000 mg tablets g. 1 bottle of Delsym cough syrup h. 1 Atrovent inhalation aerosol chamber i. 1 bottle of essential oil peppermint j. 1 bottle of Senna-Lax 8.6 mg tablets k. 1 bottle of Betasept antiseptic surgical scrub l. 1 box of Mucinex Sinus tablets m. 2 tablets of Tylenol Cold & Head tablets n. 3 tablets of Benadryl Ultra tablets o. 1 bag of cough drops Interview with Licensed Practical Nurse (LPN) #2 on 9/13/16 at 8:23 AM, in station 3 hallway, LPN #2 was asked if it was acceptable for residents to store medications in their bedside tables. LPN #2 stated, Um, can I check and get back with you with that answer? LPN #2 then walked away from the surveyor and returned on 9/13/16 at 8:28 AM and stated, The answer to your question is no, they are not allowed to have those items in their room . Interview with the Director of Nursing (DON) on 9/13/16 at 8:44 AM, in the DON office, the DON was asked if was acceptable for residents to store medications in their rooms. The DON stated, No, ma'am. 26. Observations in the station 3 hallway outside Resident #188's room on 9/13/16 at 8:55 AM, revealed LPN #3 exited Resident #188's room holding a ziplock bag full of medications. LPN #3 was asked if she had removed the medications from Resident #188's room. LPN #3 stated, Yes, we have had to remove items from his room daily, he has a girlfriend that brings in medications .have to check his room daily when he'll allow me to . LPN #3 was asked how often resident rooms are checked for hazards. LPN #3 stated, Daily during routine checks . Interview with Resident #188 on 9/13/16 at 11:20 AM, in his room, Resident #188 was asked if he had always been allowed to keep medications in his room. Resident #188 stated, Yes, nobody has ever said anything .I just brought in what I wanted .the only thing they said I couldn't have was pain medication or anything of the things that they have on the cart . 27. Observations in room 323 on 9/13/16 at 8:53 AM, revealed 3 unsecured disposable razors and a large bottle of Scope mouthwash sitting on top of the bedside table. 28. Observations in room 505 on 9/13/16 at 9:47 AM, revealed a plastic cylinder in the window sill that contained aerosol air freshener. 29. Observations in room 423B on 9/13/16 at 11:27 AM, revealed 1 Air Wick 4 in 1 aerosol air freshener sitting on the window sill. 30. Observations in room 429 on 9/13/16 at 11:32 AM, revealed 1 Air Wick aerosol air freshener in the bathroom. Interview with LPN #9 on 9/13/16 at 11:53 AM, at station 4 nurses' station, LPN #9 was asked if it was acceptable for residents to have cans of aerosol air freshener in their rooms. LPN #9 went into room 429, confirmed the aerosol was there and stated, No ma'am. 31. Observations in the storage room across from the station 2 nurses' station on 9/13/16 begining at 11:39 AM, revealed the door was unlocked and the room contained the following unsecured hazardous items: a. 12 disposable razors b. 8 individual packets of Bacitracin ointment c. 48 denture cleansing tablets d. 1 container of wooden manicure sticks with sharp pointed ends e. 3 syringes of 0.9 percent (%) Sodium Chloride for injection f. 1 open Chlora Step prep one- step with tint g. 2 packages of alcohol swab sticks h. 11 individual packets vitamin A & D ointment i. 1 package of Providone Iodine swabsticks j. 3 individual packets of Derma Septin ointment k. 12 individual packets of non sting skin prep l. 13 individual packets of Normal Saline 0.9% m. 17 packets of lemon glycerine swabsticks Interview with LPN #4 on 9/13/16 at 12:05 PM, at station 2 nurses' station, LPN #4 was asked if the storage room door is usually locked. LPN #4 stated, To be honest with you, we don't use it, it's (the storage room) an old storage area. LPN #4 was asked if the door should be locked. LPN #4 stated, I guess it should be, but I didn't know it wasn't . Interview with the Maintenance Assistant (MA) on 9/13/16 at 12:10 PM, at the station 2 storage room door, the MA removed the door knob from the storage room door and stated, The supply guy just called me and told me to put a lock on that door. The MA was asked how often he checked the storage room door. The MA stated, I don't do it .now (named the Maintenence Director) might check it .if it's medical, the nurses check it unless they tell us to. The MA was asked if the door knob and lock that he had removed were in proper working order. The MA stated, As far as I know it was .they just didn't lock it . Interview with the DON on 9/13/16 at 12:20 PM, at the station 2 nurses' station, the DON was asked if the door to the storage room should be locked. The DON stated, I thought that was just overflow and junk .(the storage room) used to be an office for the restorative nurse . The DON was asked if she was aware that chemicals and medical supplies were being stored in that room. The DON stated, No. The DON was asked how often she checked the doors to see if they were locked. The DON stated, Several times during the day .I'm making rounds all the time and it's the last thing I do before I leave at night . The DON was asked if it was acceptable for the storage room to be left unlocked. The DON stated, If there were chemicals in the room then no ma'am. The DON was asked if was acceptable for to razors to be unsecured. The DON stated, They have to be up on a shelf, some of the residents like to shave themselves, it's a dignity issue . 32. Observations in room 111 on 9/13/16 at 1:53 PM, revealed LPN #19 was in the room and obtained permission from Resident #262 to look into his chester drawer. LPN #19 then opened the 2 drawers of the chest and found the following hazardous items: a. 2 spray cans of Febreze b. 3 tubes of skin protectant c. 1 bottle of dry mouth spray d. 1 box of lens wipes e. 1 tube of Peri-Guard f. 1 tube of Adapt paste g. 1 tube of Icy Hot Advanced Relief h. 1 tube of A & D ointment i. 1 partial tube of A & D ointment j. 1 small bottle of no sting barrier k. 1 tube of Arthritis Pain Relief Interview with LPN #19 on 9/13/16 at 1:54 PM, at station 1 nurses' station, LPN #19 was asked if there should be aerosol cans in resident rooms. LPN #19 stated, No. LPN #19 was asked if there were any wanderers on station 1. LPN #19 stated, We have 1 with a wanderguard, I don't have any wanderers. 33. Observations in room 300 on 9/13/16 at 2:00 PM, revealed 1 package of Halls Mentholatum cough drops sitting on the bedside table. 34. Observations in room 127 on 9/13/16 at 2:05 PM, revealed the following hazardous items: a. 2 cans of cinnamon air freshener sitting on the floor b. 1 bottle of Pine Sol on the floor Interview with LPN #19 on 9/13/16 at 5:06 PM, in room 127, LPN #19 was asked if those items should be in the room. LPN #19 stated, No. 35. Observations in room 245 on 9/13/16 at 2:10 PM, revealed 1 can of Febreze aerosol spray air freshener on the dresser by the bed. Interview with LPN # 14 on 9/13/16 at 2:12 PM, in room 245, LPN #14 was asked if the aerosol can should be on the dresser. LPN #14 stated, No ma'am. 36. Observations in room 132B with LPN #19, on 9/13/16 at 2:11 PM, revealed the following hazardous items by bed B: a. Nail polish remover b. Glade solid, Sure Scents (small clear balls) in a clear square jar on the table and dresser c. 1 bottle of Listerine mouthwash on the night stand LPN #19 obtained permission to look in Resident #164's night stand and found the following additional hazardous items: d. 1 candle e. 3 razors f. 1 bottle of perfume g. 2 pairs of nail clippers h. 1 tube of denture cream i. 3 denture cleansing tablets j. 1 bottle of herbal oil k. 1 can of Glade aerosol air freshener Interview with LPN #19 on 9/13/16 at 2:12 PM, in room 132, LPN #19 was asked if the items should be in the resident's room. LPN #19 stated, No . 37. Observations in room 132A on 9/13/16 at 2:14 PM, revealed a bottle of Fleur de Paris perfume on top of the bedside table beside bed A. Interview with LPN #19 on 9/13/16 at 2:13 PM, in room 132, LPN #19 was asked if the perfume should be out in the room. LPN #19 stated, No, it can be consumed. 38. Observations in room 127A on 9/13/16 at 2:15 PM, revealed Certified Nursing Assistant (CNA) #7 was cleaning out the resident's drawer as the surveyor entered the room, 6 razors were found in the drawer. Interview with CNA #7 on 9/13/16 at 2:16 PM, in room 127, CNA #7 was asked if the razors should be in the room. CNA #7 stated, No. 39. Observations in room 324 on 9/13/16 at 3:05 PM, revealed 2 bottles of nail polish sitting on Resident #29's overbed table, and 2 additional bottles of nail polish in a clear plastic bin on top of the chest at the foot of the bed. 40. Interview on 9/13/16 at 11:26 AM, with Resident #53, in Resident #53's room in station 1, Resident #53 was asked if any residents have ever wandered into his room. Resident #53 stated, Sometimes, but not very often. 41. Review of the most recent Minimum Data Set (MDS) assessments and current care plans of the cognitively impaired wandering residents residing on station 1 (these residents can freely wander to station 1,2,3 and 4) revealed the following: a. Resident #32 had Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 1/27/16 and revised 7/20/16 documented, .The resident is a wanderer r/t (related to) impaired safety awareness . b. Resident #83 had a BIMS score of 3, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 6/13/16 documented, .Resident exhibits wandering behavior . c. Resident #117 had a BIMS score of 9, indicating moderate cognitive impairment on the MDS dated [DATE]. The care plan dated 7/20/16 and revised on 8/17/16 documented, .Resident exhibits wandering behavior . d. Resident #123 had a BIMS score of 4, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 7/11/16 and revised on 8/4/16 documented, .Resident exhibits wandering behavior . e. Resident #139 had a BIMS score of 8, indicating moderate cognitive impairment on the MDS dated [DATE]. The care plan dated 7/20/16 and revised on 8/18/16 documented, .Resident exhibits wandering behavior . f. Resident #253 had a BIMS score of 11, indicating moderate cognitive impairment on the MDS dated [DATE]. The care plan dated 7/20/16 documented, .Resident exhibits wandering behavior . 42. Review of the most recent MDS assessments and current care plans of the cognitively impaired wandering residents residing on station 2 (these residents can freely wander to station 1,2,3 and 4) revealed the following: a. Resident #16 had a BIMS score of 7, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 6/20/16 and revised on 9/9/16 documented, .Resident exhibits wandering behavior . b. Resident #138 had a BIMS score of 0, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 5/17/16 and revised on 7/30/16 documented, .risk for altered perception related to wandering behavior . c. Resident #147 had a BIMS score of 5, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 5/10/16 and revised on 8/15/16 documented, .Resident exhibits wandering/pacing behavior. d. Resident #177 had a BIMS score of 9, indicating moderate cognitive impairment on the MDS dated [DATE]. The care plan dated 4/1/16 and revised on 7/24/16 documented, .Resident exhibits exit seeking behavior . 43. Review of the most recent MDS assessments and current care plans of the cognitively impaired wandering residents residing on station 3 (these residents can freely wander to station 1,2,3 and 4) revealed the following: a. Resident #24 had a BIMS score of 6, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 5/26/16 and revised on 8/8/16 documented, .Resident exhibits wandering behavior . b. Resident #50 had a BIMS score of 3, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 5/2616 and revised on 7/15/16 documented, .Resident exhibits wandering behavior . c. Resident #115 had a BIMS score of 3, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 5/12/16 and revised on 8/7/16 documented, .Resident exhibits wandering behavior . d. Resident #157 had a BIMS score of 0, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 3/21/16 and revised on 8/30/16 documented, Risk for elopement R/T Resident exhibits desire to leave facility . e. Resident #195 had a BIMS score of 2, indicating severe cognitive impairment on the MDS dated [DATE]. The care plan dated 6/6/16 and revised on 8/11/16 documented, .Resident exhibits wandering behavior . 44. A total of 21 facility staff members were interviewed on 9/13/16 beginning at 5:00 PM regarding potential accident hazards in the facility. Fourteen (14) of the 17 staff members interviewed did not identify unsecured chemicals, unsecured medications, or unsecured sharps as potential accident hazards in the facility. 45. The (Named Contracted Housekeeping Group) Fire Procedure and Evacuation Plan Laundry In-service sheet documented, .All employees must be aware of the fire procedure and evacuation plan of the facility in which they work .All washers must be shut off using the red emergency button and dryers must be turned off just open the doors to ensure off. Laundry employee must then leave out of the laundry to check the halls outside of laundry to see if there are any residents/patients that need to be secured or evacuated. Employees is to locate the fire extinguisher. Employees are to remain in their designated areas until everything has cleared. Observations in the laundry room on 9/13/16 at 5:04 PM, revealed during a fire alarm sounding, 1 dryer was running, and 2 washing machines were running. LA #1 was in the clean laundry area folding linen. Interview with LA #1 on 9/13/16 at 5:05 PM, in the laundry room, LA #1 was asked if she heard the fire alarm sounding. She stated, Yes. LA #1 was asked if she knew what to do during a fire alarm. She stated, No, I don't know what to do. Interview with the Laundry Manager (LM), on 9/13/16 at 5:11 PM, in the laundry room, the LM was asked what should the laundry aide do when a fire alarm sounds. She stated, Everything is supposed to be cut off and they are supposed to come out in the hallway. The LM was advised that LA #1 said she was unaware of what to do in a fire alarm. The LM stated, She has been trained. I will get you her in-service sheet. Interview with LA #1 on 9/13/16 at 7:00 PM, in the laundry room, LA #1 was asked how do you turn off the washing machines. She stated, You push the red button. She pointed to the small red off buttons on each of the washing machines. Interview with the LM on 9/13/16 at 7:05 PM, in the laundry room, the LM was asked how do you turn off the washing machines. She pointed to the large red knobs on each of the washers and stated, you pull the red knobs out. LA #1 was then asked what she was in-serviced about today. LA #1 stated, to turn off the machines, the washers and dryers and turn off the fan. She was asked if she told the LM that she didn't know how to turn off the washers during that in-service. LA #1 stated, Yes, I told her. The LM confirmed that LA #1 told her she did not know how to turn off the washers. The LM also stated, I told her to pull the knob as she gestured pulling something in the air. She was asked if she actually demonstrated turning off the washers while at the washers to LA #1. The LM stated, No 46. The facility's Administering Medications policy documented, .8. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . 47. Observations in the station 5 (secure unit) hallway on 9/28/16 at 8:33 AM, revealed the station 5 medication cart was unlocked and unattended in the hallway. The surveyor remained in the hallway until LPN #5 returned to the medication cart. Interview with LPN #5 on 9/28/16 at 8:36 AM, in the station 5 hallway, LPN #5 was asked if the medication cart was supposed to be unlocked. LPN #5 stated, No ma'am . LPN #5 then locked the medication cart. Interview with LPN #6 on 9/29/16 at 4:34 PM, in the station 5 hallway, LPN #6 was asked how long she had been working on station 5. LPN #6 stated, Since June. LPN #6 was asked if she had ever had any trouble locking the medication cart. LPN #6 stated, No ma'am. Interview with LPN #1 on 9/29/16 at 4:37 PM, in the station 5 hallway, LPN #1 was asked how long she had been working on station 5. LPN #1 stated, 2 years. LPN #1 was asked if she was usually the day shift medication nurse. LPN #1 stated, Yes. LPN #1 was asked if she had ever had any trouble locking the medication cart. LPN #1 stated, No. The facility's video taped footage of the station 5 hallway for the period of time in question on 9/28/16 was reviewed by 2 surveyors in the presence of the facility's Administrator, Maintenance Director, and the Assistant DON on 9/30/16 at 9:06 AM, and the video footage revealed LPN #5 left the medication cart on 9/28/16 at 8:30:40 AM, and did not return to the medication cart until 8:36:24 AM, leaving the medication cart unlocked and unattended for a total of 6 minutes and 17 seconds in the secure unit hallway. 48. Review of the MDS assessments and current care plans of the 9 cognitively impaired ambulatory residents residing on station 5 (the secure unit) revealed the following: a. Resident #30 had a BIMS score of 2, indicating severe cognitive impairment on the MDS dated [DATE]. The current care plan documented, .Resident exhibits wandering behavior. (Wandering in and out of room/hallway .) b. Resident #45 had a BIMS score of 8, indicating moderate cognitive impairment on the MDS dated [DATE]. The current care plan documented, .Resident exhibits wandering behavior . c. Resident #93 had short term and long term memory problems, and moderately impaired cognitive skills for daily decision making on the MDS dated [DATE]. The current care plan documented, .Resident exhibits wandering behavior . d. Resident #107 had a BIMS score of 0, indicating severe cognitive impairment on the MDS dated [DATE]. The current care plan documented, .Altered cognitive function/memory . e. Resident #108 had a BIMS score of 3, indicating severe cognitive impairment on the MDS dated [DATE]. The current care plan documented, .Altered cognitive function/memory R/T short term memory deficits . f. Resident #149 had a BIMS score of 5, indicating severe cognitive impairment on the MDS dated [DATE]. The current care plan documented, .Resident exhibits wandering behavior . g. Resident #162 had a BIMS score of 99, indicating was unable to complete the interview, the resident had short and long term memory problems, and severely impaired cognitive skills for daily decision making on the MDS dated [DATE]. The care plan dated 8/

Based on the Administrator job description, medical record review, observation, and interview, the Administration failed to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents by failing to ensure an effective Quality Assurance (QA) program that recognized and developed an appropriate plan to ensure residents' environment was free from the accident hazards of chemicals, medications, aerosol sprays, and sharps. The Administration failed to ensure protection of residents from a fire disaster. The Administration failed to ensure a clean, comfortable, and sanitary environment. The Administration failed to ensure residents could have visitors at any time. The Administration failed to ensure the location of discharge was on the 30 day notice of discharge. The Administration failed to ensure thorough and timely investigations. The Administration failed to promote resident dignity, respect, choices, and prompt notification. Administration failed to ensure accurate assessments, accurate medical records, care plans were revised, care plans and physician orders were followed. The Administration failed to ensure communication between the facility and the [MEDICAL TREATMENT] residents. The Administration failed to ensure Activities of Daily Living were provided. The Administration failed to ensure the care and services were provided for pressure ulcers. The Administration failed to ensure the care and services were provided for Foley catheters and tube feedings. The Administration failed to ensure a medication error rate of less than 5 percent (%). The Administration failed to ensure infection control was maintained and the kitchen was sanitary. The Administration failed to ensure an effective pest control program. The Administration failed to ensure the Certified Nursing Assistants (CNAs) had the required number of in-service hours. The Administration failed to ensure laboratory tests were done as ordered. The Administration failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections. The facility's failure to protect vulnerable residents from access to hazardous chemicals, medications, aerosol sprays and sharps placed the residents in IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Regional Clinical Coordinator (RCC) were informed of this IMMEDIATE JEOPARDY, concerning the unsecured chemicals, medications, aerosol sprays, sharps, and protection from a fire disaster, on [DATE] at 7:51 PM, in the conference room. The Administrator, DON, and the RCC were informed of a second IMMEDIATE JEOPARDY, concerning the unlocked medication cart on the secure unit, on [DATE] at 4:48 PM, in the conference room The facility was cited an IMMEDIATE JEOPARDY at F323, which is Substandard Quality of Care. The facility was cited an IMMEDIATE JEOPARDY at F323, F431, F490, F493, F501 and F520. The facility was cited Substandard Quality of Care in Environment at F253. An extended survey was conducted [DATE] - [DATE]. The IMMEDIATE JEOPARDY is effective [DATE], and is ongoing. The findings included: 1. The facility's Administrator Job Description documented, .Responsible for the efficient and profitable operation of the facility, facility compliance with (Named Corporation) policies and State and Federal rules and regulations, and providing the highest quality of care possible .Essential Functions .Manages the day-to-day operations of the facility .Directs and guides the activities of clinical, administrative and service departments .Implements control systems to ensure accountability of all departments .Monitors performance for achievement of goals and for improvement, and takes corrective action when necessary .Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .Acts as chairperson of the facility's Performance Improvement Committee . 2. Administration failed to allow visitors in the building 24 hours a day. Refer to F 172. 3. Administration failed to include the location to which the resident was transferred or discharged on the 30 day notices of discharge. Refer to F203. 4. Administration failed to ensure a complete, thorough, and timely investigation was conducted for injuries of unknown origin. Refer to F225. 5. Administration failed to ensure staff promoted care that maintained residents' dignity, respect, and quality of care. Refer to F241. 6. Administration failed to honor resident choices. Refer to F242. 7. Administration failed to notify the resident's legal representative before a change in room assignments. Refer to F247. 8. Administration failed to maintain an environment that was clean, sanitary, orderly and free from foul odors. Refer to F253. 9. Administration failed to ensure accurate assessments for diagnoses, dental status, height and weight, and rejection of care. Refer to F278. 10. Administration failed to ensure care plans were revised to reflect the resident's care of a Percutaneous Endoscopic Gastrostomy (PEG) tube. Refer to F280. 11. Administration failed to ensure staff followed the resident's care plan interventions related to catheter care, Tube Feeding, accidents, and Activities of Daily Living (ADLs). Refer to F 282. 12. Administration failed to ensure communication between facility and [MEDICAL TREATMENT] clinic, and failed to ensure staff notified nursing of a missing wound dressing. Refer to F 309. 13. Administration failed to ensure ADLs were provided. Refer to F312. 14. Administration failed to ensure the care and services were provided for pressure ulcers. Refer to F314. 15. Administration failed to ensure the staff provided the appropriate care and services to prevent the potential spread of infection for residents receiving peri care and residents with catheters. Refer to F 315. 16. Administration failed to ensure physician's orders were followed for enteral tube feedings and a bed alarm. Refer to F322 and F323. 17. Administration failed to ensure the staff maintained the residents' environment free from chemicals, medications, aerosol sprays, and sharps, and from a potential fire disaster. The facility's failure to protect vulnerable residents from accident hazards and a potential fire disaster placed all residents in Immediate Jeopardy. Refer to F 323 and F431. 18. Administration failed to ensure medications were administered with a medication error rate of less than 5 percent (%). Refer to F332. 19. Administration failed to ensure food was stored, prepared, and served under sanitary conditions and failed to ensure staff members served food under sanitary conditions. Refer to F371. 20. Administration failed to ensure medications were properly stored and secure which placed residents in Immediate Jeopardy. Administration failed to ensure medications were not expired. Refer to F431. 21. Administration failed to ensure prevention of the potential spread of infection during medication administration pass and for residents in isolation. Refer to F441. 22. Administration failed to ensure the environment was sanitary as evidenced by unsanitary shower rooms. Refer to F465. 23. Administration failed to maintain an environment free of pests. Refer to F469. 24. Administration failed to ensure CNAs received at the required number of hours of in-service training. Refer to F497. 25. Administration failed to ensure laboratory tests were done as ordered. Refer to F502 and F504. 26. Administration failed to ensure medical records were complete and accurate. Refer to F514. 27. Administration failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections placed residents in Immediate Jeopardy. Refer to F520.

Based on the Quality Assessment and Process Improvement Committee (QAPI) policy, medical record review, observation, and interview, the facility failed to ensure there was an effective Governing Body (GB) responsible for the overall operation and management of the facility and to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents. The facility failed to communicate the correct members of the governing body to the survey team. The facility failed to ensure the GB managed an effective Quality Assurance (QA) program that recognized and developed an appropriate plan to ensure residents' environment was free from the accident hazards of chemicals, medications, aerosol sprays, and sharps. The facility failed to ensure the GB provided oversight to ensure medications were attended and properly secured, and contract laundry personnel was trained and monitored on how to correctly respond to a fire alarm. The facility failed to ensure the GB provided oversight to ensure effective housekeeping and maintenance services necessary to maintain an environment that was clean, sanitary, orderly and free from foul odors. The facility failed to ensure the GB provided oversight to ensure residents' rights to allow visitors in the building 24 hours a day were honored, resident choices were honored for bathing and getting out of bed, and Activities of Daily Living (ADLs) related to bathing were provided. The facility failed to ensure the GB implemented infection control techniques, maintained an effective pest control program, and promoted staff to follow physician's orders [REDACTED]. The facility failed to ensure the GB ensured accurate Minimum Data sheet (MDS) assessments, care plans were revised and followed. The facility failed to ensure the GB provided oversight to ensure complete,thorough,and timely investigation was conducted for an injury of unknown origin. The facility failed to ensure the GB promoted communication between the facility and the [MEDICAL TREATMENT] clinic for [MEDICAL TREATMENT] residents. The GB failed to provide oversight to ensure the facility provided care and services for the prevention and treatment of [REDACTED]. The facility's failure to protect vulnerable residents from access to hazardous chemicals, medications, aerosol sprays, sharps, and from a potential fire disaster placed sampled residents in 5 of 5 (station 3, station 1, station 5-secure unit, station 4, and station 2) resident units, and in 13 of 114 (room [ROOM NUMBER], 509, 111, 311, 323, 505, 423, 429, 300, 127, 245, 132, and 324) resident rooms resulted in IMMEDIATE JEOPARDY; and the failure to ensure 1 of 3 (Laundry Aide (LA) #1) contract laundry personnel was trained and monitored on how to correctly respond to a fire alarm resulted in IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Regional Clinical Coordinator (RCC) were informed of this IMMEDIATE JEOPARDY, concerning the unsecured chemicals, medications, aerosol sprays, sharps, and protection from a fire disaster, on [DATE] at 7:51 PM, in the conference room. The facility was cited an IMMEDIATE JEOPARDY at F323, F431, which is Substandard Quality of Care An extended survey was conducted [DATE] - [DATE]. The failure to ensure medications were attended and properly secured in 1 of 114 (room [ROOM NUMBER]) resident rooms and in 1 of 15 (station 5-secure unit) medication storage areas; the facility failed to ensure medications were properly stored and not expired in 4 of 15 (station 1 medication cart, station 3 medication cart, station 4 medication cart 2, and station 4 medication cart 1) medication storage areas resulted in IMMEDIATE JEOPARDY. The Administrator, DON, and the RCC were informed of this IMMEDIATE JEOPARDY on [DATE] at 4:48 PM, concerning the unlocked medication cart on the secure unit, in the conference room. The facility was cited an IMMEDIATE JEOPARDY at F323, F431, F490, F493, F501 and F520. The Immediate Jeopardy is effective [DATE], and is ongoing. The failure to provide effective housekeeping and maintenance services necessary to maintain an environment that was clean, sanitary, orderly and free from foul odors in 5 of 5 (station #1,2,3,4, and 5) resident units, affecting 94 of 114 (room [ROOM NUMBER], 102, 103, 104, 105, 106, 107, 108, 109, 110, 112, 113, 115, 118, 119, 120, 121, 122, 123, 124, 125, 127, 128, 129, 130, 131, 133, 205, 206, 207, 208, 209, 210, 212, 213, 214, 215, 216, 217, 218, 219, 221, 223, 225, 231, 233, 237, 235, 238, 239, 240, 241, 242, 243, 245, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 311, 319, 321, 322, 323, 324, 419, 423, 425, 429, 430, 431, 432, 435, 436, 438, 500, 501, 502, 503, 507, 509, 511, 513, 526, 527, 529, 531, and 533) resident rooms/bathrooms and the facility failed to ensure patient care equipment was clean and properly stored in 4 of 5 (station 1, 2, 3 and 5) resident units which resulted in a Substandard Quality of Care for the residents residing in all 5 units of the facility. This was cited at F253 as Substandard of Care. The findings included: 1. The Governing Body failed to provide oversight to ensure the residents' rights were honored to allow visitors in the building 24 hours a day; the facility promoted care that maintained residents' dignity, and respect; residents' choices were honored for bathing and getting out of bed, and ADLs related to bathing were provided. Refer to F172, F241, F242, and F312 2. The Governing Body failed to provide oversight to ensure complete,thorough, and timely investigation was conducted for injury of unknown origin. Refer to F225 3. The Governing Body failed to provide oversight to ensure resident's legal representative was notified immediately before a change in room assignments, and the 30 day discharge notice included the location to which the resident was transferred or discharged . Refer to F 247 and F203 4. The Governing Body failed to provide oversight to ensure care and services for the prevention and treatment of [REDACTED]. Refer to F314 5. The Governing Body failed to provide oversight to ensure medications were attended and properly and properly stored. The facility's failure to protect vulnerable residents from access of medications placed residents in Immediate Jeopardy. Refer to F431 6. The Governing Body failed to provide oversight to ensure medications were administered as ordered that resulted in a medication error rate of greater than 5 percent (%). Refer to F332 7. The Governing Body failed to provide oversight to ensure the facility's pest control program was effective. Refer to F469 8. The Governing Body failed to provide oversight to ensure the facility followed physician orders [REDACTED]. Refer to F309, F322, F504, and F502 9. The Governing Body failed to provide oversight to ensure food was stored, prepared, and served under sanitary conditions as evidenced by unsealed food in the freezer, dirt build-up in the freezer, disrepair of kitchen equipment and doors, dirty stove drip pan, carbon build-up on pans, and dirty floors, dusty items, and a dirty ice scoop holder, and staff failed to perform proper hand washing during dining. Refer to F371 10. The Governing Body failed to provide oversight to ensure the facility practiced infection control in order to prevent the potential spread of infection. Refer to F315 and F441 11. The Governing Body failed to provide oversight to ensure the facility documented accurate MDS assessments, and care plans were revised and interventions followed, and medical records were accurate. Refer to F278, F280, F282, and F514 12. The Governing Body failed to provide oversight to ensure the environment was clean, sanitary, orderly and free from foul odors. Refer to F253 and F465 13. The Governing Body failed to provide oversight to ensure the facility protected vulnerable residents from access to hazardous chemicals, medications, aerosol sprays, sharps. The facility's failure to protect vulnerable residents from access to hazardous chemicals, medications, aerosol sprays, sharps resulted in Immediate Jeopardy. Refer to F323 14. The Governing Body failed to provide oversight to ensure the facility's Certified Nursing Assistants (CNAs) employed the entire year of 2015 received at least 12 hours of in-service training. Refer to F 497 15. The Governing Body failed to provide oversight to ensure the facility had properly trained and monitored contract laundry personnel on how to correctly respond to a fire alarm. Refer to F323 16. The Governing Body failed to ensure the Quality Assurance program was effective in maintaining long term compliance with previous and ongoing deficient practices placing residents in Immediate Jeopardy. Refer to F520 The Quality Assessment and Process Improvement Committee (QAPI) policy documented, .2. The committee shall be a standing committee of the facility and will act as the governing body . Interview with Administrator, and the Director of Operations on [DATE] at 1:00 PM, in the dining room, they were asked who is the governing body. The Administrator looked at the Director of Operations, and stated, Would it be Greg? The Director of Operations stated, The administrator and staff is over this building. The Director of Operations was asked, Is there a governing body that oversees the facility operations? The Director of Operations stated, No, this building operates as an independent LLC, (Limited Liability Corporation) and the administrator oversees the building, as far as I know . Interview with the Administrator on [DATE] at 1:45 PM, in the hallway outside the conference room, the Administrator stated, (Named Director of Operations) was misinformed and the governing body is (Named LLC) The Administrator was asked to provide a list of names and titles of the people in the governing body. Interview with the Director of Operations on [DATE] at 3:50 PM, in the conference room, The Director of Operations provided a list of the members of the governing body which included: (Named CEO, Named Chief Legal Officer, Named Chief Clinical Officer, Named Chief Human Resource Officer and Named Chief Financial Officer).

Based on the Quality Assessment and Process Improvement Committee (QAPI) policy, Administrator's job description, Medical Director Agreement, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized and developed an appropriate plan to ensure resident's environment was free from the accident hazards of chemicals, aerosol sprays, sharps and medications. The facility failed to ensure the QA program ensured residents were safe from a fire disaster. The facility failed to ensure the QA program that kept vulnerable residents safe by ensuring medications were properly stored and secure. The facility failed to have a QA program that failed to ensure the residents' home environment was clean, sanitary and in good repair. The facility failed to ensure the QA program that was effective in ensuring family and friends were able to visit 24 hours a day. The facility failed to have a QA program that ensured residents received a an involuntary discharge notice that was complete with all the components according to the law. The facility failed to have a QA program that ensured residents protected health information remained private. The facility failed to have a QA program that ensured residents' choices were honored. The facility failed to have a QA program that ensured residents and families were notified timely of room changes. The facility failed to have a QA program that ensured physician's orders were written and followed, care plans were implemented, infection control maintained, and injuries of unknown origin were investigated timely. The facility failed to have a QA program program that ensured communication between the facility and the [MEDICAL TREATMENT] clinic for [MEDICAL TREATMENT] residents. The facility failed to have a QA program that ensured staff completed accurate assessments for the Minimum Data Set. The facility failed to have a QA program that ensured care plans were revised and followed. The facility failed to have a QA program that ensured Activities of Daily Living were provided to the residents. The facility failed to have a QA program that ensured residents with pressure injuries received accurate wound assessments, and treatments were administered as ordered. The facility failed to have a QA program that ensured residents received the correct dosage of the correct medications and medications were administered according to the infection control policy. The facility failed to have a QA program that ensured residents' living areas were free from flies and pests. The facility failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections from previous surveys. The facility failed to have a QA program that was effective in identifying issues and concerns within the facility and maintaining plans of correction from previous surveys and patterns of repeat deficiencies. (F241, F253, F278, F280, F282, F309, F312, F314, F322, F323, F431, F441, F465, F469, F502, F504 and F514.) The failure of the facility to have a QA program to ensure vulnerable residents' environment was free from the accidents and hazards of chemicals, medications, sharps and fire disaster placed residents in IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. On [DATE] at 7:51 PM, in the conference room,IMMEDIATE JEOPARDY was announced for F323 under 483.25 Quality of Care, to the Administrator, Director of Nursing, and the Regional Clinical Coordinator. On [DATE] at 4:48 PM, in the conference room, a second Immediate Jeopardy was announced for F323 and F431 to the Administrator, Director of Nursing, and the Regional Clinical Coordinator. They were notified that the previously accepted AoC was rescinded, and a new AoC would need to be submitted that addresses the unlocked medication cart. The IMMEDIATE JEOPARDY effective date is [DATE] and is ongoing at the time of the exit. The facility was cited an IMMEDIATE JEOPARDY at F323, F431, F490, F493, F501, and F520. An extended survey was conducted from [DATE] - [DATE]. The findings included: 1. The Quality Assessment and Process Improvement Committee (QAPI) policy documented, .Committee Authority The Quality Assessment and Process Improvement (QAPI) Committee advise the Administrator and/or governing board (body). The committee has the full authority to oversee the implementation of the QAPI Program, including, but not limited to, the following: 1. Identifying negative and positive outcomes of care and services; 2. Establishing quality measures, benchmarks and identifying pertinent standards of practice; and 3. Meeting with the governing board (body) to review quality-related items. 4. Implementation of an ongoing audit process .Committee Audit Process . 2. The QAPI Committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up. The process will identify individuals who will be responsible. 3. The committee shall track the progress of any active plans of correction .Coordinator The QAPI Coordinator will help other committees, individuals, departments, and/or services develop quality indicators, monitoring tools, criteria, and assessment methodologies, and help them identify and evaluate concerns impacting resident care and safety as well as employees and visitors .Focus 1. The following areas may be monitored for quality and appropriateness of resident care, and any trends in performance and outcomes and is not an all-inclusive list: Resident Rights . Infection Control . Admissions, Transfers, and Discharges Resident Behavior and Facility Practices Physical Environment Administration Resident Assessments and Care Plans Nursing Services . Medication Management Building Safety Pharmacy Services Dementia Care Customer Service . Disaster Preparedness Staff Development . Medical Records Physician Services 2. The Administrator job description documented, .Essential Functions .Leads planning process to develop goals for quality care, employee retention and financial performance .Manages the day-to-day operations of the facility .Directs and guides the activities of clinical, administrative and service departments. Implements control systems to ensure accountability of all departments .Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .Acts as chairperson of the facility's Performance Improvement Committee . 3. The Medical Director Agreement documented, .Physician shall address issues related to the coordination of medical care identified through the Facility's quality assessment and assurance committee and quality assurance program, and other activities related to the coordination of care, which may include, but is not limited to, helping the facility .3.4.7 Resolve issues related to continuity of care and transfer of medical information between the Facility and other care settings .3.4.9 Review individual resident cases as warranted to evaluate quality of care or quality of life concerns or other problematic situations and take appropriate steps to resolve the situation as necessary and as requested . 4. The QA program failed to ensure the facility allowed visitors in the building 24 hours a day. Refer to F172 5. The QA program failed to ensure 30 day discharge notices included the location to which the resident was transferred or discharged . Refer to F203. 6. The QA program failed to ensure a complete, thorough, and timely investigation was conducted for injuries of unknown origin. Refer to F225. 7. The QA program failed to ensure staff promoted care that maintained residents' dignity, respect, and quality of care. Refer to F241. 8. The QA program failed to ensure the facility honored resident choices. Refer to F242. 9. The QA program failed to ensure the facility notified the resident's legal representative before a change in room assignments. Refer to F247. 10. The QA program failed to maintain an environment that was clean, sanitary, orderly and free from foul odors. Refer to F253. 11. The QA program failed to ensure the facility performed accurate assessments for diagnoses, dental status, height and weight, and rejection of care. Refer to F278. 12. The QA program failed to ensure care plans were revised to reflect the resident's care of a Percutaneous Endoscopic Gastrostomy (PEG) tube. Refer to F280. 13. The QA program failed to ensure staff followed the resident's care plan interventions related to catheter care, Tube Feeding, accidents, and Activities of Daily Living (ADLs). Refer to F 282. 14. The QA program failed to ensure communication between facility and [MEDICAL TREATMENT] clinic, and failed to ensure staff notified nursing of a missing wound dressing. Refer to F 309. 15. The QA program failed to ensure ADLs were provided. Refer to F312. 16. The QA program failed to ensure care and services were provided for pressure ulcers. Refer to F314. 17. The QA program failed to ensure the staff provided the appropriate care and services to prevent the potential spread of infection for residents receiving peri care and residents with urinary catheters. Refer to F 315. 18. The QA program failed to ensure physician's orders were followed for enteral tube feedings and a bed alarm. Refer to F322 and F323. 19. The QA program failed to ensure the environment was free from accident hazards when chemicals, medications and sharps were found unsecured in the following resident units (station 3, station 1, station 5, station 4, and station 2), the following resident rooms (room [ROOM NUMBER], 509, 111, 311, 323, 505, 423, 429, 300, 127, 245, 132, and 324), and failed to ensure a medication cart was secure and locked while unattended on the secure unit placing residents in Immediate Jeopardy. Refer to F323 and F431 20. The QA program failed to ensure medications were administered with a medication error rate of less than 5 percent (%). Refer to F332. 21. The QA program failed to ensure food was stored, prepared, and served under sanitary conditions and failed to ensure staff members served food under sanitary conditions. Refer to F371. 22. The QA program failed to ensure medications were properly stored and secured placing residents in Immediate Jeopardy. The QA program failed to ensure medications were not expired. Refer to F431. 23. The QA program failed to ensure the prevention of the potential spread of infection during medication administration pass and for residents in isolation. Refer to F441. 24. The QA program failed to ensure the environment was sanitary as evidenced by unsanitary shower rooms. Refer to F465. 25. The QA program failed to maintain an environment free of pests. Refer to F469. 26. The QA program failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical and psychosocial well-being of residents placing residents in Immediate Jeopardy. Refer to F490 27. The QA program failed to ensure the governing body established and implemented policies regarding the management and operation of the facility placing residents in Immediate Jeopardy. Refer to F493 28. The QA program failed to ensure CNAs received at the required number of hours of in-service training in a calendar year. Refer to F497. 29. The QA program failed to ensure the Medical Director assisted with identifying, evaluating and addressing clinical concerns, coordinate the medical care and provide clinical guidance and oversight regarding the oversight of the implementation of resident care policies that reflect the current standards of practice. The Medical Director failed to help identify, evaluate, and address/resolve medical and clinical concerns and issues that affect resident care, medical care or quality of life for residents residing in the facility placing residents in Immediate Jeopardy. Refer to F501 30. The QA program failed to ensure laboratory tests were done as ordered. Refer to F502 and F504. 31. The QA program failed to ensure medical records were complete and accurate. Refer to F514. 32. The QA program failed to ensure The facility to protected residents from a potential fire disaster, when laundry personnel were not trained and monitored how to correctly respond to a fire alarm. Refer to F323. 33. The QA program failed to ensure the Quality Assessment and Assurance (QAA) committee implemented a method of identifying concerns and implementing plans of action to correct identified concerns placing residents in Immediate Jeopardy. Refer to F520 34. Interview with the Medical Director (MD) on [DATE] beginning at 9:03 AM, in the conference room, the MD was asked about Resident # 188. The MD stated, .He is a known drug abuser, prescription and illicit (drugs). He has a electric wheelchair now, he will be worse than ever. I am surprised you didn't find pot in there. he has been a special challenge . The MD was asked about Resident #208. The MD stated, He's um, a pretty demanding guy, not very understanding wants things done johnny on the spot .sad case . The MD was asked how his wound happen. The MD stated, I don't know .he would refuse care at times . Interview with the Maintenance Director and the Maintenance Assistant on [DATE] at 9:40 AM, in the conference room, the Maintenance Director was asked, have you previously identified any of the issues that we identified with you this survey. The Maintenance Director stated, On various times yes, I don't have a record of it . The Maintenance Director was asked did you bring these issues to the QA meeting. The Maintenance Director stated, Yes they come up in the QA meetings and they are addressed and taken care of. The Maintenance Director was asked how are you notified of pests in the building. The Maintenance Director stated, They will inform us verbally and sometimes write in the book or both. The Maintenance Director was asked what do you do with the book sheets. The Maintenance Director stated, We don't hang on to them. The Maintenance Director was asked if there were plans put in place in the QA meetings to address these issues. The Maintenance Director stated, The plan is to take care of things as soon as we can. Interview with the Administrator on [DATE] at 10:55 AM, in the conference room, the Administrator was asked about the QA process. The Administrator stated, .it is a continuous process and we are always in the process of correcting them (problems identified) .we have identified and worked on several projects. yes the hours our staff works and we continue to try to improve and take care of the patients. if they don't have cigarettes we buy them, we buy them clothes . The Administrator was asked who has the overall responsibility for the QA program. The Administrator stated, Here we do it a little different and it is shared responsibility. The Administrator was asked are you over QA? The Administrator stated, The DON and me. The administrator was asked who is the overall overseer of the program. The Administrator stated, well, I guess I am the overseer, but the DON contributes so do the other disciplines . The Administrator was asked to share some of the quality deficiencies they have identified and what they have done to correct them. The Administrator stated, Flies, our fly situation was our quality deficiency, we are across the street from a horse farm, hot weather, we kept on working on it. Everything that we have tried has worked .I instituted, and we paid employees to do fly patrol. They walked the building .there is a shortage of CNA's so we did a wage increase that helped .offered a sign on bonus of $1500.00 .We looked at the antipsychotics, and we are at the threshold or below, we looked at AIMS (Abnormal Involuntary Movement Scale) my DON does behavior notes. I believe we are below the threshold. The Administrator was asked if he is aware of any clinical care issues that they worked on. The Administrator stated, Nothing clinical, I would have to refer to my notes . The Administrator was asked about the environment. The Administrator stated, Cleanliness of the building was a process. (Named Contracted housekeeping group) hired over 30 people and they staff much better, and the building has been getting much cleaner. where we were and where we are is much better .We have 3 maintenance staff, our building needs to be constantly painted. We spend our money appropriately. We continue to work on it. The thresholds were plastic, they didn't hold and we are starting to install metal (thresholds). We continue to spackle and paint. The biggie was cleanliness .We had different supervisors (housekeeping). The Administrator was asked how the contract housekeeping staff are communicated with regarding issues and problems. The Administrator stated, Through their manager, and if we see anything during rounds we would address it there . The Administrator was asked was chemicals ever discussed in QA. The Administrator stated, When we find it we discard it or take it away. The Administrator was asked it he was made aware of the maggots. The Administrator stated, I was made aware of the maggots. We decided that this gentleman was non compliant so we did everything- checking dressings daily, and based on discussions with the Medical Director, he would go out for smoke breaks .the 2 (residents with maggots) were not related, and we have not had another occurrence .the gentleman stayed out all day and had poor hygiene, and he would go out to (Named Discount Store). The Administrator was asked if there was anything brought up in QA about the man's issues/non compliance etc. The Administrator stated, It has been awhile. (couldn't remember) The Administrator was asked if any care issues were identified in the last few months. The Administrator stated, I would have to refer to my notes .you put an action plan, then you monitor to see if its successful . The Administrator was asked if you could recall any issues you put a plan in place and it didn't work so you went back and tweaked it or changed it? The Administrator stated, I don't recall but I would have to refer to my notes. (He was told he could bring his notes to the interview, he left the meeting at 1 point to go get his notes, but when he returned he did not have any notes with him.)

Based on policy review, personnel file review, training record review, medical record review, observation, and interview, the facility failed to ensure medications were attended and properly secured in 1 of 114 (room [ROOM NUMBER]) resident rooms and in 1 of 15 (station 5-secure unit) medication storage areas; the facility failed to ensure medications were properly stored and not expired in 4 of 15 (station 1 medication cart, station 3 medication cart, station 4 medication cart 2, and station 4 medication cart 1) medication storage areas . The failure of the facility to protect vulnerable residents from access to medications placed residents in IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Regional Clinical Coordinator (RCC) were informed of this IMMEDIATE JEOPARDY, concerning the unsecured medications in the resident's room, on [DATE] at 7:51 PM, in the conference room. The Administrator, DON, and the RCC were informed of this IMMEDIATE JEOPARDY on [DATE] at 4:48 PM, concerning the unlocked medication cart on the secure unit, in the conference room. The facility was cited an IMMEDIATE JEOPARDY at F431, which is Substandard Quality of Care. An extended survey was conducted [DATE] - [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. The facility's Self-Administration of Drugs policy documented, .8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room . 2. The facility's Administering Medications policy documented, .8. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . 3. The facility's Storage of Medications policy documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . 4. The facility's FAMILY MEMBER GUIDANCE policy documented, .6. Medications CAN NOT be brought from home and left at the resident's bedside. This includes over the counter medications such as aspirin, cold medicine, any medicated creams, or prescription medications. Medications needed for the resident will be ordered by the physician and kept in the medication cart for the residents use. This is a Federal Regulation that must be followed . 5. Observations in room [ROOM NUMBER] (Resident #188's room) on [DATE] at 8:14 AM, revealed the following unsecured medications in the top drawer of the bedside table: a. 1 box of Gas X chewable tablets b. 1 bottle of extra strength pain reliever Acetaminophen 500 milligrams (mgs) tablets c. 2 bottles of Fluticasone Propionate nasal spray d. 1 box of Gas X soft gels e. 1 bottle of Milk of Magnesia f. 1 bottle of Reishi Mushroom [ROOM NUMBER] mg tablets g. 1 bottle of Delsym cough syrup h. 1 Atrovent inhalation aerosol chamber i. 1 bottle of essential oil peppermint j. 1 bottle of Senna-Lax 8.6 mg tablets k. 1 bottle of Betasept antiseptic surgical scrub l. 1 box of Mucinex Sinus tablets m. 2 tablets of Tylenol Cold & Head tablets n. 3 tablets of Benadryl Ultra tablets o. 1 bag of cough drops Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 8:23 AM, in station 3 hallway, LPN #2 was asked if it was acceptable for residents to store medications in their bedside tables. LPN #2 stated, Um, can I check and get back with you with that answer? LPN #2 then walked away from the surveyor and returned on [DATE] at 8:28 AM and stated, The answer to your question is no, they are not allowed to have those items in their room . Interview with the Director of Nursing (DON) on [DATE] at 8:44 AM, in the DON office, the DON was asked if was acceptable for residents to store medications in their rooms. The DON stated, No, ma'am. 6. Observations in the station 3 hallway outside Resident #188's room on [DATE] at 8:55 AM, revealed LPN #3 exited Resident #188's room holding a ziplock bag full of medications. LPN #3 was asked if she had removed the medications from Resident #188's room. LPN #3 stated, Yes, we have had to remove items from his room daily, he has a girlfriend that brings in medications .have to check his room daily when he'll allow me to . LPN #3 was asked how often resident rooms are checked for hazards. LPN #3 stated, Daily during routine checks . Interview with Resident #188 on [DATE] at 11:20 AM, in his room, Resident #188 was asked if he had always been allowed to keep medications in his room. Resident #188 stated, Yes, nobody has ever said anything .I just brought in what I wanted .the only thing they said I couldn't have was pain medication or anything of the things that they have on the cart . 7. Interview on [DATE] at 11:26 AM, with Resident #53 (an alert and oriented resident that was interviewed during Stage 1), in Resident #53's room, he was asked if any residents have ever wandered into his room. Resident #53 stated, Sometimes . 8. The failure of the facility to ensure medications were properly stored, secured and not unattended placed the 15 residents in a situation where the potential for harm or injury was very high. These 15 residents could freely wander to station 1,2,3 and 4. These 15 residents' Brief Interview for Mental Status (BIMS) score indicated cognitive deficits and their care plans indicated wandering behaviors. 9. A total of 21 facility staff members were interviewed on [DATE] beginning at 5:00 PM regarding potential accident hazards in the facility. Fourteen (14) of the 17 staff members interviewed did not identify unsecured chemicals, unsecured medications, or unsecured sharps as potential accident hazards in the facility. 10. Observations in the station 5 (secure unit) hallway on [DATE] at 8:33 AM, revealed the station 5 medication cart was unlocked and unattended in the hallway. The surveyor remained in the hallway until LPN #5 returned to the medication cart. Interview with LPN #5 on [DATE] at 8:36 AM, in the station 5 hallway, LPN #5 was asked if the medication cart was supposed to be to unlocked. LPN #5 stated, No ma'am . LPN #5 then locked the medication cart. Interview with LPN #6 on [DATE] at 4:34 PM, in the station 5 hallway, LPN #6 was asked how long she had been working on station 5. LPN #6 stated, Since June. LPN #6 was asked if she had ever had any trouble locking the medication cart. LPN #6 stated, No ma'am. Interview with LPN #1 on [DATE] at 4:37 PM, in the station 5 hallway, LPN #1 was asked how long she had been working on station 5. LPN #1 stated, 2 years. LPN #1 was asked if she was usually the day shift medication nurse. LPN #1 stated, Yes. LPN #1 was asked if she had ever had any trouble locking the medication cart. LPN #1 stated, No. The facility's video taped footage of the station 5 hallway for the period of time in question on [DATE] was reviewed by 2 surveyors in the presence of the facility's Administrator, Maintenance Director, and the Assistant DON on [DATE] at 9:06 AM, and the video footage revealed LPN #5 left the medication cart on [DATE] at 8:30:40 AM, and did not return to the medication cart until 8:36:24 AM, leaving the medication cart unlocked and unattended for a total of 6 minutes and 17 seconds in the secure unit hallway. 11. The failure of the facility to ensure medications were properly stored, secured and not unattended placed the 9 ambulatory residents, who reside in a secured unit, in a situation where the potential for harm or injury was very high. Of these 9 residents, 8 residents' Brief Interview for Mental Status (BIMS) score indicated cognitive deficits. One of the 9 residents was new admission, and the Minimum Data Set (MDS) assessment was not due to be completed at this time. These 9 residents' care plans indicated wandering behaviors and/or cognitive deficits. 12. The personnel files and training records of the nurses working in the secure unit were reviewed for the calendar year of 2016, and revealed the following: a. LPN #1 - on [DATE] in-service documented as Lock Cart and on [DATE] in-service documented as Locking Treatment Cart. b. LPN #3 - on [DATE] in-service documented as Lock Cart . c. LPN #5 - No in-services documented related to medication storage/locking med cart. (The nurse who left the medication cart unlocked and unattended). d. LPN #6 - in-service on [DATE] documented as, Lock Cart. e. LPN #11 - In-service on [DATE] documented as Lock Cart. f. LPN #15 - in-service on [DATE] documented as Locking Treatment Cart. g. LPN #16 - No in-services documented related to medication storage/locking med cart. h. LPN #17 - in-service on [DATE] documented as Locking Treatment Cart. i. LPN #18 - in-service on [DATE] documented as Locking Treatment Cart. j. LPN #20 - No in-services documented related to medication storage/locking med cart. k. LPN #21 - in-service on [DATE] documented as Lock Cart and on [DATE] training documented as Locking Treatment Cart. l. LPN #22 - No in-services documented related to medication storage/locking med cart. m. LPN #23 - in-service on [DATE] documented as Locking Treatment Cart. n. LPN #24 - No in-services documented related to medication storage/locking med cart. o. LPN #25 - in-service on [DATE] documented as Locking Treatment Cart. Review of a Performance Improvement Form dated [DATE] documented, .Expected Level of Performance: .Employee will keep medication cart locked (and) secured . p. Registered Nurse (RN) #4 - No in-services documented related to medication storage/locking med cart. q. RN #5 - in-service on [DATE] documented as Locking Treatment Cart. Refer to F323. The failure of the facility to protect vulnerable residents from access to medications placed residents in IMMEDIATE JEOPARDY. 13. The facility's Medications with Special Expiration Date Requirements INSULINS policy documented, .Humulin-R (Regular) vial .Opened, Refrigerated .In Use Not Refrigerated .28 days .Lantus .Opened, Refrigerated .In Use Not Refrigerated .28 days .The end of use expiration date begins after opening/puncturing the product or after removing from refrigerator . 14. Observations in station 1 in the medication cart on [DATE] at 4:34 PM, revealed 1 open multi-dose vial of Humulin R with an opened date of [DATE] and 1 Fleets Enema with an expiration date of [DATE]. Interview with LPN #7 on [DATE] at 4:35 PM, at station 1, LPN #7 was asked how long can insulin be used after it has been opened. LPN #7 stated, 28 days. LPN #7 confirmed the Humulin R insulin and the Fleets enema were expired. Observations in station 3 in the medication cart on [DATE] at 4:52 PM, revealed 1 open multi-dose vial of Lantus insulin with an opened date of [DATE]. Interview with LPN #8 on [DATE] at 4:36 PM, at station 3, LPN #8 was asked how long can insulin be used after it has been opened. LPN #8 stated, 28 days, and confirmed the Lantus insulin was expired. Observations in station 4 medication cart 2 on [DATE] at 4:57 PM, revealed 1 open and undated multi-dose vial of Lidocaine HCL 1 percent (%). Interview with LPN #9, on [DATE] at 4:59 PM, at station 4, LPN #9 was asked if there was a date opened on the vial of Lidocaine. LPN #9 stated There's not one. Observations in station 4 medication cart 1 on [DATE] at 5:03 PM, revealed 1 open multi-dose vial of Humulin R insulin with an opened date of [DATE]. Interview with LPN #10 on [DATE] at 5:04 PM, at station 4, LPN #10 was asked how long can insulin be used after it has been opened. LPN #10 stated, 30 days. LPN #10 was asked if the Humulin R insulin could still be used. LPN #10 stated, Nope. Interview with the DON on [DATE] at 10:38 AM, in the conference room, the DON was asked how long insulin could be used after it was opened. The DON stated, 28 days. The DON was asked what she expected nursing staff to do when they opened a multi-dose vial of medication. The DON stated, Date it and initial it.

Based on review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE", policy review, medical record review, observation and interview, it was determined the facility failed to prevent and identify the development of pressure ulcers and failed to accurately assess and treat a pressure ulcer for 2 of 8 (Residents #3 and 27) sampled residents with pressure ulcers. The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer resulted in actual harm to Resident #27. The findings included: 1. Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "p. 8...CategoryStage III: Full Thickness skin loss Full thickness tissue loss... slough may be present... p. 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." 2. Review of the facility's "Pressure Ulcer Risk Assessment" policy documented, "...General Guidelines... 4. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected... 6. Once a pressure ulcer develops, it can be extremely difficult to heal... 9. Pressure ulcers are a serious skin condition for the resident. 10. Routinely assess and document the condition of the resident's skin... Immediately report any signs of a developing pressure ulcer to the supervisor... Assessment... 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated... 3. b. Nurses are to be notified to inspect the skin if changes are identified..." 3. Medical record review for Resident #27 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident weekly skin audit sheet documented the following: 3/14/11 - "...Old healed areas to RL (right and left) bony prominences..." and 3/20/11 - "...Healed pink areas over bony prominences..." Review of the condition change form dated 3/27/11 documented, "...area to R (right) - hip that is noted c (with) a medium size open reddened area c small amt. (amount) of sloughing to wound bed..." Review of the wound care progress notes dated 3/28/11 documented, "Resident c Stage III to Rt (right) hip/trochanter... wound 75% (percent) pink/red c 25% slough..." Observations in Resident #27's room on 4/12/11 at 4:15 PM and on 4/13/11 at 8:00 AM, revealed Resident #27 lying in a low bed on his right side with an air mattress to the bed. During an interview at the 100 hall nurses' station on 4/13/11 at 1:15 PM, Nurse #9 stated, "...he has pink areas there, very thin... it (wound) had sloughing when I saw it, I saw it the next day after was found. The nurse did document sloughing on the day she found it also. This is all I have." During an interview at the 100 hall nurses' station on 4/13/11 at 2:25 PM, Certified Nursing Assistant (CNA #3) was asked if Resident #27 had any skin breakdown on 3/27/11. CNA #3 stated, "...I turned him over and was a place on his right hip that was bleeding. I reported this to the nurse." During an interview at the 100 hall nurses' station on 4/13/11 at 2:30 PM, CNA #4 was asked if Resident #27 had any skin breakdown on 3/25/11. CNA #4 stated, "...did not see any skin breakdown. I would get the nurse if I did." During an interview in the Director of Nursing's (DON) office on 4/13/11 at 2:50 PM, the DON stated, "I was concerned and we investigated it... I honestly was not sure if a Stage 3, but that is what was documented." During an interview in the conference room on 4/13/11 at 3:00 PM, Resident #27's physician stated, "...on a scar where had a wound for a long time... is 10 times more likely to break down... slough 25% pink 75%, sounds like Stage 3, truth is the truth, 25% slough is stage 3..." The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer resulted in actual harm to Resident #27. 4. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] documented, "...L (left) heel - open area..." Review of the resident weekly skin audit sheet dated 2/9/11 documented, "...0 (no) open areas noted Lt (left) heel has an old absorbed blister c 0 odor, 0 exudate 0 S/S (signs and symptoms) of opening float heels while in bed..." Skin audits dated 2/10/11, 2/17/11 and 2/24/11 documented, "...wound to left heel..." Skin audits dated 3/3/11, 3/10/11, 3/17/11, 3/24/11, 3/31/11, 4/7/11 and 4/13/11 documented "...0 skin issues..." The first assessment performed by Nurse #9, the wound care nurse, was on the wound care progress notes dated 3/2/11 which documented, "...Asked to assess Residents Lt (left) heel. Observed dry Black Area measuring approximately 0.7 (centimeters) x (by) 0.7 (centimeters) x UTD (unable to determine). New order for skin prep Q (every) Day." Review of the wound/skin healing record dated 3/2/11 documented, "...PRESENTS AS... Unstageable... WOUND BED... Black/Brown (eschar) ...SURROUNDING TISSUE/WOUND EDGES... Hardness..." Nurse #9 recorded weekly progress notes and the first documented change in the appearance of the wound was dated 4/11/11 documented, "...Stage 3...0.2 x 0.3 x 0.2... Slough... Response to Treatment... Deteriorated..." Review of the physician orders [REDACTED]. Observations in Resident #3's room on 4/11/11 at 10:06 AM and 4/13/11 at 10:30 AM, revealed the wound was approximately 2 cm x 2 cm hardened tan rough surface with an open center of approximately 0.2 cm length and 0.2 cm width. During an interview at the 100 hall nurses' station on 4/14/11 at 2:30 PM Nurse #6 was asked why the weekly skin audits did not address Resident #3's pressure ulcer. Nurse #6 stated, "They don't see the heel because the boot (heel protector) is on." During an interview in the conference room on 4/13/11 at 3:00 PM, Resident #3's physician confirmed the nurse incorrectly assessed the wound on admission. During an interview in the conference room on 4/13/11 at 4:20 PM, the DON was asked what she would expect the nurse to do if a wound was noted on admission. The DON stated, "To get an order for [REDACTED]. The DON stated that they (skin audits) were done on the night shift and should take the heel protectors off and complete a thorough skin assessment.