Every finding on record at The Blossoms at Dierks Rehab and Nursing Center

Based on observations, interviews, and facility policy review, the facility failed to ensure hazardous chemicals were secured and residents were prevented from having access to substances that could result in accidents or injuries, specifically failing to keep corrosive cleaning supplies out of the reach of ambulatory residents with dementia for 1 (Resident #50) of 2 sampled residents who were reviewed for accidents, resulting in one resident ingesting hydrogen peroxide cleaning solution. The findings include: The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2025 indicated Resident #50 had diagnoses of Alzheimer's disease, malnutrition, and depression, and had a Brief Interview for Mental Status (BIMS) score of 8 (8-12 indicates moderate cognitive impairment). A Nsg-I&A Progress Note, dated 11/13/2024 at 06:55 AM, indicated Resident #50 was sitting at the nurse's station and was observed with a spray bottle of disinfectant (Peroxide Multi Surface Cleanser and Disinfectant) the lid was off, the resident ingested an unknown amount of the disinfectant. The spray bottle was removed from the resident and locked in cart/housekeeping closet. Resident #50 was assessed with no signs or symptoms of injury, (name of disinfectant producer) was notified regarding the disinfectant and medical advice obtained. A review of Resident # 50's Care Plan dated 12/18/2024 indicated Resident #50 exhibited behavioral indicators of drinking cleaning chemicals, related to Alzheimer's disease, with a goal of care being the resident will cause no harm to self or others secondary to their behaviors. The intervention dated 11-13-24 indicated the spray bottle was removed from resident and locked in cart/housekeeping closet. A review of Resident #50 ' s Triage clinical report from a local hospital, dated 11/13/2024, indicated patient was an Alzheimer's patient that was thirsty and got in the cleaning cart and took one drink of peroxide multi-surface cleanser, ingesting this at 6:00 AM and vomiting once after breakfast. Resident #50 denied any complaint. During an interview on 06/10/2025 at 02:09 PM, the Medical Director stated they were notified of Resident #50 ingesting hydrogen peroxide cleaner, and the resident did not have any negative effects from possible ingestion of hydrogen peroxide cleaner. During an interview by telephone on 06/10/2025 at 02:30 PM, Certified Nursing Assistant (CNA) #2 reported not being present at the time of the incident, but from what they understood, the resident did not actually swallow the cleaner, just took in mouth and spit it out. CNA #2 reported being written up for leaving the housekeeping cart out. A form titled Employee Memorandum was completed on 11/13/2024, indicated CNA was given a write up (reprimand) for not putting housekeeping cart back in closet after completing her shift. During an interview on 06/10/2025 at 02:42 PM, the Treatment Nurse reported seeing Resident #50 with a bottle of cleaning solution up to mouth. The resident took some in their mouth and then spit it out. The resident got ahold of it because the housekeeping cart was left outside the housekeeper closet door unattended. The Treatment Nurse was asked how the facility had ensured this did not happen again and stated staff made sure the cart was locked and, in the closet, carts were not left out anymore. Training was completed requiring no carts were left out. During an interview on 06/10/2025 at 03:04 PM, the Director of Nursing (DON) stated she was notified Resident #50 was observed with a bottle of chemicals from the housekeeper cart, unsure how much ingested, but the resident vomited. The housekeeping cart had been left out for staff to clean rooms. The DON was asked how she ensured this did not happen again and the DON stated by monitoring during rounds and observing to make carts were not left out. Carts were always to be locked and put away. The DON was asked how staff could get the cleaning supplies if they needed them and stated, the staff must get the key from the nurse. The DON stated the resident had suffered no ill effects. The resident vomited once, then was fine. During an interview on 6/11/20 25 at 2:35 PM, Housekeeper #11 was asked what cleaning supplies were usually kept on the housekeeping cart. Housekeeper #11 stated bio-spray (alcohol-based cleaner) was on the cart, deodorant spray, and there was no bleach on cart. Housekeeper #11 verified that the compartment on the cart containing chemicals was to be kept locked, and when the cart was not in use it was locked in the janitor's closet. A review of a SDS (Safety Data Sheet) indicated the cleaner Resident #50 had allegedly consumed contained a dilution of Hydrogen Peroxide of 0.78% to 3.12%. The SDS indicated if swallowed to rinse mouth, get medical attention if symptoms occur. A review of a policy titled Incident and Accident Policy and Procedure that indicated residents will be assessed for interventions to prevent further incidents. A review of an In-service Form titled, Proper Storing Chemical indicated a training was conducted by the Administrator on 11/15/2024, and indicated staff are to ensure chemicals are store in secure areas at all times when not in use.

Based on observations, interviews, record review and policy review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) and applied appropriate Personal Protective Equipment (PPE) to prevent the potential for cross contamination when administrating medications through a feeding tube for 1 (Resident # 49) of 1 sampled resident. The findings include: During an observation on 06/11/2025 at 11:13 AM, Licensed Practical Nurse (LPN) #9 performed hand hygiene and prepared medications for Resident #49. LPN #9 put on gloves but did not put on a gown. An EBP sign was on the door leading to Resident #49 ' s room. LPN #9 administered the medications through the feeding tube, removed gloves, preformed hand hygiene, and exited the room. During an interview immediately following the observation, LPN #9 confirmed that Resident #49 was on EBP and that a gown, in addition to gloves, should have been worn when administering the resident's medications through the feeding tube. During an interview on 06/11/2025 at 11:25 AM, the Director of Nursing (DON) indicated Resident #49 was on EBP and required PPE. Specifically, a gown and gloves were required when giving medications or care for a feeding tube. The DON confirmed staff were alerted to EBP by a sign on the door. The DON stated, I am doing an in-service now. During an interview on 06/11/2025 at 2:23 PM, the Infection Preventionist (IP) stated Resident #49 was on EBP because the resident had a feeding tube and a gown and gloves should be worn when administering medications through the feeding tube. The IP stated that staff were made aware that residents were on EBP by a sign either on the resident's door, or by the resident's door. Residents were placed on EBP to prevent the spread of infection. The IP confirmed the nurse should have put on a gown, in addition to gloves, when administering the resident's medication through the feeding tube. A review of an annual Minimum Data Set with Assessment Reference Date of 03/27/2025, indicated Resident #49 had diagnoses which included end stage kidney disease, diabetes mellitus, and difficulty swallowing. The Brief Interview for Mental Status score of 10 revealed moderate cognitive impairment. A review of the Care Plan, with a revision date of 11/01/2024, indicated Resident #49 was on EBP related to a feeding tube. A review of an Order Summary Report dated 03/12/2025, indicated Resident #49 had a Physician's Order for EBP related to a feeding tube. A review of a policy titled Isolation Policy and Procedure EBP indicated EBP would be utilized for residents that have medical devices. PPE including a gown and gloves would be utilized for residents during high-contact resident care.

Based on observation, record review and interview, the facility failed to ensure 1 of 2 refrigerators and 1 of 2 freezers used for the storage of food items was within proper temperature range; food items stored in the refrigerator and freezers were dated with open and expiration dates to prevent potential cross-contamination and minimize the potential for food borne illness; dry goods on the shelves had expiration dates; open food packages were properly closed; failed to ensure a homelike environment by not removing meal items from serving trays; failed to ensure a sanitary environment with staff reaching through the serving window from the dining side, appliances were clean, and food items to be served were covered; and walls and floors were in sanitary condition. The findings are: 1. On [DATE] at 12:41 PM, Housekeeper #1 stood on the dining room side of the serving window and reached through the window to receive something from the Kitchen staff. The Director of Nursing (DON) confirmed that was a concern for infection control. 2. On [DATE] at 7:09 AM, 2 bowls of corn flakes and 3 bowls O shaped cereal were on the counter uncovered ready to be served. At 7:20 AM, the Surveyor observed a fly land in the last bowl of O shaped cereal. At 7:25 AM, the Administrator went to place the last bowl of O shaped cereal from the counter onto a residents' tray. The Surveyor informed the Administrator that a fly landed inside that bowl of O shaped cereal. The Administrator was unaware a fly landed inside of the bowl. Dietary Aide (DA) #1 confirmed the bowls were uncovered when they began serving the residents and that she would not have known about the fly. The fly would cause cross contamination. At 9:05 AM, the Administrator confirmed the fly could be an infection control concern. 3. On [DATE] at 7:10 AM, on a shelf above the serving line, a fly was flying around divided plates and serving covers with serving side up. 4. On [DATE] at 7:12 AM, a plastic bag of light brown cane sugar was left open on the counter by the stove after being used. At 7:50 AM, DA #1 confirmed the brown cane sugar should not have been left open. This could contaminate the food item if something got into the bag. 5. On [DATE] at 7:18 AM, a can opener had a blackish broken substance around the blade. At 9:01 AM, the Administrator confirmed there were particles around the blade and the item looked corroded. 6. On [DATE] at 7:20 AM, during observation empty boxes were observed on the floor in front of the Janitors Closet along with boxes stored directly on the floor of the paper good storage area. 7. On [DATE] at 9:03 AM, the Administrator confirmed the full boxes on the paper goods floor could cause cross contamination. 8. On [DATE] at 7:43 AM, observed a black substance built up between the tile grout behind the ice machine and on the flooring and floorboard under the puree preparatory counter/sink combination. The walls by the puree preparatory counter/sink and stove had a black built up smudge look. At 9:03 AM, the Administrator confirmed that the substance build up could be an infection control concern. 9. On [DATE] at 7:54 AM, observed breadcrumbs in a clear storage container over the puree food preparation area. The container did not have an expiration date and a scoop was left inside the container. DA #1 confirmed the scoop should not have been left in the container because it was not sanitary, because hands touched the scoop and could cross contaminate. 10. On [DATE] at 7:56 AM, the left side of Freezer #1 contained 10 pounds of oven ready par-fried whole grain breaded [NAME] sticks that was open and did not have an open date. 11. On [DATE] at 8:01 AM, the left side of Freezer #2 contained the following frozen items without an expiration date: i) 3 - 1 gallon freezer bags with mozzarella cheese. ii) 2 - 1 gallon freezer bags with sliced celery. iii) 3 - 1 gallon freezer bags with chopped broccoli. 12. On [DATE] at 8:07 AM, the right side of Freezer #2 contained the following items without an open date: i) 144 buttermilk pancakes. ii) 22.5 pounds of cheesy garlic bread sticks. 13. On [DATE] at 8:08 AM, the right side of Freezer #1 had a container used for keeping ice cream cold during meal serving time. The container had ice built up in the corners and unknown particles on the inside of the bottom. DA #1 confirmed the above findings in Freezer #1. 14. On [DATE] at 8:10 AM, in Freezer #1, the bottom right side vent cover was not properly attached. 15. On [DATE] at 8:12 AM, on the right inside of the refrigerator, the second shelf was held up with six (6) zip-ties on the left side shelf of the refrigerator. 16. On [DATE] at 8:13 AM, in the refrigerator, the following food items were stored in food containers and did not have expiration dates: i) Breaded Pudding. ii) Tomato Juice. iii) Tomato Soup. iv) 10 - one gallon containers of iced tea. v) 1 - one gallon container of lemonade. 17. On [DATE] at 8:15 AM, in the refrigerator was a storage container with apple sauce that expired on [DATE]. 18. On [DATE] at 8:35 AM, the following observations were made in the Dry Food Storage Room: i) 3 snack bags of corn chips without a received date or an expiration date. ii) 4 snack bags of vanilla wafers without an expiration date. iii) 5 snack bags of chocolate chip cookies without an expiration date. 19. On [DATE] at 8:44 AM, the Freezer in the Dry Storage Room showed a temperature of 16 degrees. There were 48 ciabatta rolls in the freezer that were not frozen solid to the touch. The rolls did not have a received date, an open date, or an expiration date. Human Resource confirmed the observation. 20. On [DATE] at 2:00 PM, the Consultant provided a policy titled, Cleaning Instructions: Food Preparation Appliances Policy and Procedure, which shows, Policy: Small appliances (such as mixers and food processors) will be cleaned and sanitized after each use . 21. On [DATE] at 1:45 PM, the Consultant provided policy titled, General Food Preparation and Handling, which shows Policy: Food items will be prepared to conserve maximum nutrition value, develop and enhance flavor and keep free of injurious organisms and substances. Procedure: .1. a. The kitchen and equipment are clean and sanitized as appropriate. 2. Food Storage .b.Food is covered for storage .4. Food Service .d .Use leftovers within 3 days or discard . 22. On [DATE] at 1:45 PM, the Consultant provided policy titled, Dry Storage Areas, which shows, Policy: Dry storage areas will be kept in a condition which protects stored foods from infestation. Procedure: 1. All items must be stored at least 6 inches off the floor .2. The floors, walls, shelves, and other storage areas are kept clean . Care of the Storeroom [ROOM NUMBER]. The staff will maintain care of the storeroom according to the following directions.c. Refrigerated and frozen foods are dated upon delivery. Foods with expiration dates are used prior to the date on the package. Canned and dry foods without expiration dates are used within six months of delivery or according to the manufacturer's guidelines. Canned goods should be dated, and staff should use the FIFO (first in/first out) method to rotate foods. d. The storeroom is cleaned on a regular basis. Floors are swept and mopped at least weekly and more often as needed. Refer to the cleaning schedule for details .

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents and hazards by leaving a spray bottle labeled floor cleaner and spray buff in the hallway unattended. The findings are: 1. On 04/16/2024 at 09:10 AM, Maintenance Staff #1 left a chemical spray bottle labeled floor cleaner and spray buff with a clear liquid in it hanging on the wall rail. At 09:20 AM, Maintenance Staff #1 returned to the spray bottle. Maintenance Staff #1 confirmed the bottle was left unsupervised by staff, that he meant to come right back, but a staff member caught him outside. He also said it was not good if residents grabbed it or anything, typically if the item has a warning label for children it is not good to leave out. 2. The label stated, .WARNING Keep out of reach of children. Read label before use . contains: Alkyl Polyglycolide, Linear Alcohol Ethoxylate . 3. The Material Safety Data Sheet for the floor cleaner documented: .Section 2: Hazard(s) Identification . May be harmful if swallowed Causes skin and eye irritation . Ingestion: Harmful if swallowed. Causes gastrointestinal irritation with nausea, vomiting and Diarrhea . Precautions to be taken in Handling: .Keep out of reach of children .

Based on record review, and interview, the facility failed to ensure medications were administered to the correct resident for 1 (Resident #3) of 3 (Residents #1, #2 and #3) sampled residents. This failed practice of past noncompliance had the potential to affect 29 residents on the 100 and 200 Halls who received medications as documented on a list provided by the Director of Nursing (DON) on 06/08/23 at 9:40 a.m. The findings are: 1. On 06/07/23 at 8:18 a.m., the Surveyor asked the Director of Nursing to provide a list of Medication Error Incidents in the past 60 days. 2. On 06/07/23 at 8:40 a.m., the Director of Nursing provided a report titled, Incidents by Incident Type. The document read, Medication Error Incidents . Resident #3 - 05/13/23 10:38 a.m.Total 'Medication Error' Incidents: 1 . 3. Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and had minimal difficulty hearing. 4. A Progress Note dated 05/13/23 by Licensed Practical Nurse (LPN) #1 documented, Incident Description: this LPN prepared medications for a.m. med [medication] pass, verbalized resident name aloud, resident did not correct this LPN when she stated the incorrect name to resident, therefore this LPN believed she was administering the correct medication to the correct person. This LPN then went to resident room to administer medication and resident stated she had already taken her medication while in the Dining Room. This LPN then believed that an error had occurred. Immediate intervention: Assessed resident vitals wnl [within normal limits], resident verbalized no complaints of feeling unwell at this time, reported med error to [Name] APRN [Advance Practice Registered Nurse]; [Name] DON; [Name] ADON [Assistant Director of Nursing]; [Name] Administrator . 5. A Progress Note dated 05/15/23 by the APRN documented, .Chief Complaint/Reason for this Visit - Staff and resident requesting visit after medication error . Resident unfortunately received another resident's medication on 05/13/23. The incorrect medication received was Plavix 75 mg [milligrams] and Singulair 10mg . 6. A One on One Counseling Report dated 05/13/23 provided by the DON on 06/08/23 at 10:00 a.m. documented, .Always ensure administering medication to appropriate resident. Verification of identity. 6 Rights of Medication Rights . 1. Right Resident . Signed by LPN #1 and the DON. 7. A facility policy titled, Medication Administration General Guidelines Policy and Procedure, provided by the DON on 06/08/23 at 9:40 a.m. documented, .Medications are administered as prescribed in accordance with good nursing principles and practices . Eight Rights - right resident . Residents are identified before medication is administered . 8. An In-Service Form dated 05/30/23 provided by the DON on 06/08/23 at 9:40 a.m. and signed by LPN #1 documented, 6 rights of med admin [administration] 9. A Form Titled, In-Service 05/30/23 provided by the DON on 06/08/23 at 9:40 a.m. documented, .Medication Administration - Please See Handout . 10. A Form Titled, Medication Pass Inservice which was provided by the Director of Nursing on 06/08/23 at 9:40 a.m. did not contain any instructions regarding verifying the resident's identity. 11. On 06/08/23 at 8:00 a.m., Resident #3 was in her room. Resident #3 stated, You will have to talk loud because I can't hear very well. The Surveyor asked, Have the nurses ever given you someone else's medicine? Resident #3 answered, Yes. The Surveyor asked, Can you tell me more about that? Resident #3 stated, I got upset. My blood pressure went up a little but not too bad. I decided that if it is my time to go, I will go. 12. On 06/08/23 at 9:30 a.m., the Surveyor asked LPN #1, Do you remember on May 13th when [Resident #3] got someone else's medication? LPN #1 answered, Yes. The Surveyor asked, Can you tell me more about that? LPN #1 answered, I was passing my meds [medications] and I approached [Resident #3]. I called her by another resident's name more than once and she never corrected me. So, I gave her that other resident's medicine by mistake. The Surveyor asked, How do you identify the residents? LPN #1 stated, I ask them their name. The Surveyor asked, How do you identify the residents who are not able to tell you their name? LPN #1 stated, I find someone who has worked here longer and ask them. 13. On 6/8/23 at 9:35 a.m., the Surveyor asked LPN #2, How do you identify the residents? LPN #2 stated, We have a photo of each resident on the MAR [Medication Administration Record] and I also ask the resident their name. The Surveyor asked, What do you do if the resident is not able to tell you their name? LPN #2 answered, The photos are pretty much up to date. 14. On 06/08/23 at 10:30 a.m., the Surveyor asked the DON, How do the nurses identify the residents during medication administration? She answered, They ask them their name. And there is a photo on the MAR. Or they can ask other staff. They should know. The Surveyor asked, What could happen if a resident took another resident's medication? She answered, It depends on the medication. There could be no adverse effect or it could be serious.

Based on observation, interview, and record review, the facility failed to ensure nail care was provided to maintain appropriate grooming for 1 (Resident #43) of 19 (Residents #1, #7, #12, #13, #18, #22, #24, #26, #32, #35, #37, #40, #43, #44, #49, #52, #58, #61 and #116) sampled residents who were dependent on staff for nail care according to a list provided by the Administrator on 03/16/23 at 10:36 AM. The findings are: 1. Resident #43 had a diagnoses of Non-Alzheimer's Dementia, Medically Complex Conditions, and Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/23 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision of one person for personal hygiene, and physical help of one person with bathing activity. a. The Care Plan with a revision date of 01/11/23 documented, .Focus: [Resident #43] has an ADL [Activity of Daily Living] self-care performance deficit r/t [related to] Dementia and history of falling BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 03/12/23 at 11:27 AM, Resident #43 was sitting in her recliner in her room. Her fingernails were varied in length with jagged edges and extended 1/8 to 1/4 inch past the end of the nail bed. The burgundy nail polish was chipped and there was a brown substance under some of the nails. c. On 03/13/23 at 8:40 AM., Resident #43 was sitting in her recliner Her fingernails varied in length with jagged edges and extended 1/8 to 1/4 inch past the end of the nail bed. The burgundy nail polish was chipped and there was a brown substance under some of the nails. d. On 03/14/23 at 9:00 AM, Resident #43 was sitting in her recliner in her room. Her fingernails varied in length with jagged edges and extended 1/8 to 1/4 inch past the end of the nail bed. The burgundy nail polish was chipped and there was a brown substance under some of the nails. e. On 03/15/23 at 11:35 PM, Resident #43 was ambulating to the Dining Room with her walker. Her fingernails varied in length with jagged edges and extended 1/8 to 1/4 inch past the end of the nail bed. The burgundy nail polish was chipped and there was a brown substance under some of the nails. f. On 03/16/23 at 9:30 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Can you please describe [Resident #43's] fingernails for me? LPN #1 stated, They are long and dirty underneath the nails. They need to be cleaned and clipped. The Surveyor asked, Who is responsible for providing nail care for the residents? LPN #1 stated, The CNAs [Certified Nursing Assistants] are unless the resident is a diabetic. The Surveyor asked, How often should nail care be provided for residents that depend on staff to provide nail care? LPN #1 stated, Nails should be checked daily and should be cleaned on their shower days. The Surveyor asked, Why is nail care important? LPN #1 stated, Because bacteria can get under the nails and nails that are too long can cause skin tears. g. On 03/16/23 at 09:40 AM, the Surveyor asked CNA #1, Can you please describe [Resident #43's] fingernails for me? CNA #1 stated, They are long and dirty. The Surveyor asked, Who is responsible for providing nail care for the residents? CNA #1 stated, The CNAs. The Surveyor asked, How often should nail care be provided for residents that depend on staff to provide nail care? CNA #1 stated, Nails should be cleaned daily and should be clipped weekly. The Surveyor asked, Why is nail care important? CNA #1 stated, Because germs can get under the nails. h. On 03/16/23 at 09:50 AM, the Surveyor asked CNA #2, Can you please describe [Resident #43's] fingernails for me? CNA #2 stated, They are long, dirty and the polish is chipped. The Surveyor asked, Who is responsible for providing nail care for the residents? CNA #2 stated, The CNAs are. The Surveyor asked, How often should nail care be provided for residents that depend on staff to provide nail care? CNA #2 stated, Nails should be cleaned daily and should be checked weekly to see if they need to be trimmed. The Surveyor asked, Why is nail care important? CNA #2 stated, Because of dignity, and germs can get under the nails. i. On 03/16/23 at 10:00 AM, the Surveyor asked the Director of Nursing (DON), Who is responsible for providing nail care for the residents? The DON stated, The CNAs are unless the resident is a diabetic then the nurse is. The Surveyor asked, How often should nail care be provided for residents that depend on staff to provide nail care? The DON stated, Nails should be cleaned daily and as needed and should be looked at every week to see if they need to be trimmed. The Surveyor asked, Why is nail care important? The DON stated, Because of health concerns and sanitization. The Surveyor asked, Can you please provide me with a policy on nail care for residents? The DON stated, Yes. j. The facility policy and procedure titled Nail Care Policy and Procedures, provided by the DON on 03/16/23 at 10:00 AM documented, .All residents will have nails cleaned and trimmed once weekly or as needed per resident request .

Based on record review, and interview, the facility failed to ensure an accurate assessment was completed for 1 (Resident #24) of 1 sampled residentwho received the antiplatelet medication Prasugrel (Effient) as an anticoagulant. This failed practice had the potential to affect 1 resident who received the Antiplatelet medication Prasugrel (Effient) according to a list provided by the Administrator on 03/16/23 at 10:36 AM. The findings are: 1. Resident #24 had diagnoses of Hypertension, Chronic Systolic (Congestive) Heart Failure, Anemia in Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an anticoagulant medication for 7 days of the 7 day look back period. a. The Physician's Order dated 01/30/20 documented, .Effient Tablet 10 MG [milligrams] (Prasugrel HCl) [Hydrochloride] Give 1 tablet by mouth one time a day related to ACUTE KIDNEY FAILURE, UNSPECIFIED .) b. On 03/16/23 at 9:23 am., the Surveyor asked the Director of Nursing (DON) Who is the MDS Nurse? The DON stated, Well her last day was yesterday so we are now looking for a new MDS Nurse. The Surveyor asked, Does Resident #24 take an anticoagulant at this time? The DON looked in Resident #24's Electric Health Record and stated, Let me look, I don't see one. The Surveyor asked, Does Resident #24 take Prasugrel medication? The DON stated, Yes, she takes that. The Surveyor asked, Can you tell me what the Quarterly MDS information dated 01/19/23 documents for Anticoagulant? The DON looked in the Quarterly MDS and stated, It shows Anticoagulant for last 7 days. The Surveyor asked, What classification is the medication Prasugrel? The DON stated, In our system it comes up as a Hematological medication when we click on it in [Facility Computer Software]. The Surveyor asked, Should the Quarterly MDS dated [DATE] show documentation as the resident taking an anticoagulant for the last 7 days? The DON stated, No, it should not. c. On 03/16/23 at 10:20 am., the Surveyor requested a policy for Accuracy of Assessments/MDS from the DON. d. On 03/16/23 at 10:36 am., the Administrator stated, We do not have a policy on accuracy of MDS Assessments. I did print this off and that we use showing .Complete resident's assessments per Resident Assessment Instrument (RAI) guidelines . e. The facility policy and procedure titled, Resident Assessment Policy and Procedure, provided by the Administrator om 3/16/23 at 10:35 AM documented, Purpose: To identify the resident's care needs. To develop a comprehensive plan of care for the resident . To assist the resident to attain the highest practical level of mental and physical function and well-being. Policy: The facility shall complete resident's assessments via MDS 3.0 according to the RAI guidelines . 4. Complete resident's assessments per RAI Manual guidelines .

Based on observation and interview, the facility failed to ensure cold food items were maintained at or below a temperature of 41 degrees Fahrenheit on the serving line to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 58 residents who received meals from the kitchen (total census: 59), as documented on a list provided by the Dietary Manager on 10/14/2021 at 9:35 a.m. The findings are: On 10/12/21 at 12:05 PM, Dietary Employee #1 started serving trays. The first tray contained mechanical soft chicken with gravy, potatoes with gravy, green beans, a pudding cup and a [MEDICATION(S)] sandwich. The cook handed the tray to another staff member, who placed drinks placed on the tray and handed the tray through the window to a staff member to serve. Before the staff member took the tray out of the window, the surveyor ask the cook what kind of sandwich was being served. She stated, [MEDICATION(S)]. She was asked, Can you temp [check the temperature of] this sandwich? The temperature of the sandwich was 62.4 degrees. The Dietary Employee was asked, Is this a correct temp for a sandwich? She stated, No, it has to be at or under 41 degrees. She was asked, What could happen if this was served? She stated, It could hurt them. On 10/12/21 at 12:07 PM, the Dietary Manager was asked, Should a [MEDICATION(S)] sandwich be served at 62.4 degrees? She stated, The resident could become ill.

Complaint # (AR 583) was substantiated, all or in part, in these findings: Based on record review and interview, the facility failed to ensure resident trust funds and personal fund accounts were maintained, safeguarded, managed, and accounted for with proper spending of resident personal funds with resident and/or responsible party consent on items of resident choice and/or needs of room decorations for 2 (Residents #1 and #2) of 4 (Residents #1, #2, #3 and #4) case mix residents who had a personal trust fund account and items purchased for the resident's room decor. This failed practice had the potential to affect 4 residents who had room decorations purchased with personal funds in the past 60 days according to a list provided by the Administrator on 10/23/2020. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/22/2020 documented the resident scored 9 (8-12 indicates moderately impaired) per a Brief Interview for Mental Status (BIMS). a. A Durable Power of Attorney form provided by the Business Office Manager (BOM) on 10/23/2020 documented, Pursuant to the Arkansas Durable Power of Attorney for Health Care Act .I hereby designate and appoint (Name) as my agent or attorney in fact, . b. A Trust Transaction History form documented, .09/29/2020 .Shopping Debit $278.29 . c. A Trust Transaction History form documented, .09/29/2020 . Shopping Debit $486.22 . d. On 10/23/2020 at 12:10 p.m., the Activity Director was asked if she had purchased room decorations for the resident's room and the Activity Director stated, I had spent some at (Store #2) and some at (Store #3) I think. The Activity Director was asked if she had spoken with the Power of Attorney (POA) about what to purchase for the resident and the Act. Dir. stated, No I did not. e. A sales receipt from (Store #1) provided by the BOM on 10/23/2020 at 3:30 p.m. documented, .Total Items Sold: 8 .Total $278.29 .Check .$278.29 .Date: 09/29/2020 . f. A sales receipt from (Store #2) provided by the BOM on 10/23/2020 at 3:30 p.m. documented, .SALE .Home Decor ($)39.99 .Christmas ($)2.99 .Floral ($)79.99 .Christmas ($)19.16 .Christmas ($)2.99 .Home Decor ($) 24.99 .Home Decor ($)99.98 .Home Decor ($)39.99 .Home Decor ($) 29.99 .Home Decor ($) 29.99 .Floral ($)73.99 SUBTOTAL ($)444.04 TAX TOTAL ($)42.18 TOTAL ($) 486.22 Check ($)486.22 . g. A Grievance Form dated 10/02/2020 documented, Statement of Concern: .family does not agree with facility spending resident money that has accrued. Explained to family that acct (account) cannot have (greater than) $2000.00 for resident to continue Medicaid. Sent .pictures of items.told me what she wanted sent back.Nature of resolution: returned items purchased on 10/6 . h. A sales return receipt from (Store #1) provided by the Administrator on 10/23/2020 documented, .Total $65.68 .10/15/20 . and a receipt documented, .Total $98.75 .10/6/20 . i. A sales return receipt from (Store #2) provided by the Administrator on 10/23/2020 documented, .RETURN .Total $458.86 .10/15/20 . j. On 10/23/2020 at 3:55 p.m., the BOM was asked, Who made the purchases listed for $486.22 and $278.29? The BOM stated, The Activities Director. The BOM was asked if the POA was asked about the spending of the funds shopping. The BOM stated, I called her and asked her if she (Resident #1) could use something for her room and I told her the Activity Director was going shopping. The BOM was asked if she had told the POA what was purchased. The BOM stated, She had called that morning and she didn't think room decor was something for her mother. 2. Resident #2 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/08/2020 documented the resident scored 9 (8-12 indicates moderately impaired) per a BIMS. a. An Authorization to Manage Personal Funds form provided by the BOM on 10/23/2020 documented, I (Resident #2) authorize the (Facility) to hold, safeguard, manage, and keep records of transactions for my personal funds with the Facility. b. On 10/23/2020 at 10:45 a.m., Resident #2's room had wall decorations of a large faced clock, a round wood metal tree shaped wall ornament, a large mirror with decorative trim around the mirror, and a large flat screen television on the wall. Resident #2 stated, I wanted a mirror but not that one. They told me it cost over $200.00. I've had to watch my pennies. I would never buy a mirror for $200.00 and I didn't need a television that big. They came in here and hung these things on the wall and I thought they were from them here. I didn't know I paid for them. Resident #2 was asked if she was referring to the facility. Resident #2 stated, Yes. I didn't need that clock. Resident #2 pointed to a large faced round clock mounted on the wall next to the television opposite of the resident's bed and recliner. Resident #2 was asked if the items were paid for with her personal trust funds. Resident #2 stated, Yes. Resident #2 was asked if she had been consulted about the items before they were purchased. Resident #2 stated, No. c. On 10/23/2020 at 11:52 a.m., the Activity Director was asked if she did shopping for residents and the Activity Director stated, Yes. The Activity Director was asked how she knew about the resident's funds being available for shopping. and The Activity Director stated, I figure it out with the (BOM). The Activity Director was asked if she had shopped for room / (and or) wall decorations for Resident #2. The Activity Director stated, Yeah I did. The Activity Director was asked, Who would be the person who should choose the decorations for the resident's room? The Activity Director stated, She would be. The Activity Director was asked if the choice of the wall decorations and mirror was discussed with the resident before the purchase. The Activity Director stated, No. The Activity Director was asked if the purchase of the large flat screen television or any of the room decor items were discussed by her with the resident before any purchases were made so the resident had a choice. The Activity Director stated, No. d. A sales receipt from (Store #2) provided by 10/23/2020 from the BOM documented, .Home Decor ($)219.99 .Home Decor ($)34.99 .Home Decor ($)36.99 .Home Decor ($)19.99 .Home Decor ($)29.99 .($)74.99 SUBTOTAL ($)416.94 TAX TOTAL ($)39.61 TOTAL ($)456.55 Check 456.55 .Number of Items Purchased: 6 .9/29/20 02:20 PM . e. A (Store #4) form provided by the BOM on 10/23/2020 documented, .We're processing your order. Hello (Resident name) Thanks for making your payment. We're processing your order now and we'll email you again when there are status updates .Arrives by Tue (Tuesday), Sep (September) 22 .Item Samsung 50 (inches) Class 4K Ultra HD (High Definition) . Smart . TV . Qty (Quantity) 1 Total $647.99 .Arrives by Thu (Thursday), Sep 24 .Item . Tilting TV Wall Mount Kit for 24 to 84 TVs . Qty 1 Total $24.88 .Order summary Order subtotal $672.87 . shipping: Free Total tax: $68.97 Order total: $741.84 Billing information .Billing address: (Resident name) (Facility address) Payment method(s): Cash f. A sales receipt from (Store #4) provided by the BOM on 10/23/2020 documented, .Order Date: 09/16/2020 Order Status: PAID Order Total: 741.84 Order Pay .741.84 Subtotal 741.84 Total 741.84 Check Tend 741.84 .09/17/20 . g. A copy of check number 2187 provided by the BOM on 10/23/2020 documented, .Date 9.16.20 . (Store #4) .$741.84 .For (Resident #2) . signature of (Administrator) . h. On 10/23/20 at 4:55 p.m. the BOM was asked who had made the order to have purchased the television for (Resident #2). The BOM stated, I did. The BOM was asked, What was the decoration that was purchased in the amount of $219.99 from (Store #2)? The BOM stated, I think it's that mirror but I don't know for sure. The BOM was asked, Who purchased the room decoration items for (Resident #2)? The BOM stated, (Activity Director). The BOM was asked, Who decided on the purchase of the particular items for (Resident #2)? The BOM did not response. 1. An Arkansas Resident Rights form provided by the Administrator on 10/22/2020 documented, Each Patient in the Facility has the following rights: .(4) The right to manage his or her own financial affairs or to delegate such responsibility to the licensee but only to the extent of the funds held in trust by the licensee for the Patient.(B) However, upon written authorization of a Patient, the Facility must hold, safeguard, manage, and account for the personal funds of the Patient deposited with the Facility as follows: (i) The Facility must establish and maintain a system that ensures a full, complete, and separate accounting, according to generally accepted accounting principles or regulations established by the Office of Long-Term Care, of each Patient's personal funds entrusted to the facility on the Patient's behalf .

Based on observation, record review, and interview, the facility failed to ensure a transfer was not conducted by lifting under the arms to prevent the potential for injury for 1 (Resident #1) of 4 (Residents #1, #4, #5, and #6) case mix residents who were dependent on staff for transfer assistance. This failed practice had the potential to affect 20 residents who were dependent on staff for physical assistance with transfers as documented on a list provided by the Administrator on 11/03/2020. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 10/22/2020 documented the resident scored 3 (0-7 indicates severely impaired) per a Brief Interview for Mental Status and required extensive 2 person physical assistance for transfer, was not steady with balance moving from seated to standing position and not steady with balance for surface to surface transfer between chair and bed. a. The Care Plan with a revised date of 10/27/2020 documented, (Resident) has pain r/t (related to) [MEDICAL CONDITION] causing pain in legs . Assist with mobility and transfers as needed . (Resident #1) has an ADL (activities of daily living) self-care performance deficit .Transfer: The resident requires (extensive assistance) by (1) staff to move between surfaces as necessary. b. An ADL Care Plan form located inside the closet door in Resident #1's room documented, .Assistance -Transfers (check mark) One . (check mark) Wt. (weight) bearing . c. On 11/02/2020 at 2:18 p.m., Resident #1 was seated in a Broda chair next to the bed with Certified Nursing Assistant (CNA) #1 standing in front of Resident #1 and CNA #2 positioned behind the wheelchair. CNA #1 faced the resident, placed arms underneath the axilla with a hand directly on each side of the ribcage of the resident's chest and lifted upwards. CNA #1 instructed Resident #1 to Stand up. Resident #1's knees were bent, and her feet were not full weight bearing while CNA #1 turned Resident #1. CNA #1 then sat the resident down onto the bedside while CNA #2 held the back the chair. d. On 11/02/2020 at 3:35 p.m., CNA #1 was asked, What type of transfer does (Resident #1) require? CNA #1 stated, She's a total, 1 sometimes 2. CNA #1 was asked what was meant by total. CNA #1 stated, She needs total to get out of bed. CNA #1was asked, How do you know what type of transfer a resident should have? CNA #1 stated, There's a care plan that's in their closet that's updated. CNA #1 was asked how the resident had been transferred from the chair to the bed. CNA #1 stated, Locked her wheels for safety (chair), get under her arms, count to 3, rotate her so she doesn't put any weight on her body. CNA #1 was asked how the resident should have been transferred properly and the CNA #1 stated, We should probably be using a gait belt. CNA #1 was asked if the resident could stand independently or bear weight. CNA #1 stated, I would say no because we always assist her. CNA #1 was asked, What could occur from transferring (Resident #1) by placing her hands under (Resident #1's) arms and on the chest. CNA #1 stated, Tear their skin .You could probably break something . e. On 11/03/2020 at 12:22 p.m., the Director of Nursing (DON) was asked if (CNA # 1) and (CNA #2) should have used a gait belt when they transferred (Resident #1) instead of placing their hands on the resident's chest underneath the axillae. The DON stated, Yes . The DON was asked if the staff should have lifted (Resident #1) by placing hands around the chest and under the arms. The DON stated, No. 2. A Safe Lifting and Movement of Residents policy provided by the Administrator on 11/02/2020 at 4:08 p.m. documented, Policy Statement. In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: . b. Resident's mobility (degree of dependency); . d. Weight-bearing ability; e. Cognitive status . 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) . 6. Only staff with documented training on the safe use and care of . equipment used in this facility will be allowed to lift or move residents.

Based on record review and interview the facility failed to ensure a risk versus benefits statement was provided by the physician for not ordering a dose reduction per recommendations by the pharmacist for 1 (Resident #50) of 16 (Residents #4, #6, #8, #9, #13, #14, #17, #27, #32, #34, #35, #36, #43, #44, #46, and #50) sampled residents who were on an antidepressant. This failed practice had the potential to affect 32 residents who were on an antidepressant based on a list provided by the Administrator on 07/17/2020. The findings are: Resident #50 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 07/02/2020 documented the resident scored 15 (13-15 indicated cognitively intact) per a Brief Interview of Mental Status and required supervision with bed mobility, locomotion in the unit, eating, toilet uses, and personal hygiene; required limited assistance with transfers, and dressing; and did not walk. Received an antidepressant medication 7 out of the last 7 days. a. A physician order [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) Tablet 7.5 MG (milligrams) Give 1 tablet by mouth at bedtime related to Other Recurrent [MEDICAL CONDITION] . b. A Pharmacy Record Review dated 07/11/2019 documented, a recommendation for reduction or if continued requested a rationale for its continued use. The physician documented to continue the medication but gave no rationale for its continued use. c. The Pharmacy Record Review dated 07/07/2020 noted no discrepancies were found and did not a recommend a dose reduction for the reduction of [MEDICATION NAME]. c. On 07/15/2020 at 4:47 P.M., a review of the medical record documented the pharmacist had reviewed the resident's orders monthly. The [MEDICATION NAME] had not been addressed since 07/11/2019, at which time the pharmacist recommended reduction. The physician wrote to continue the current med regimen. No reasoning, no risks versus benefit was documented. [MEDICATION NAME] had not been addressed in 2020. d. On 07/16/2020 at 4:06 P.M., the Administrator was asked, When was the resident's last reduction attempt on [MEDICATION NAME] done? She looked in the resident's record and replied, On 07/11/2019 the monthly pharmacy checked (physician's orders [REDACTED]. The Doctor said continue current med (medication) regime with no changes. She was asked if there was a benefits versus risks documented. She replied No, there was a pharmacy review in 2020 but it did not address the [MEDICATION NAME]. e. On 07/16/2020 at 4:11 P.M., the Tapering Medications and Gradual Drug Dose Reduction policy documented, . a. During the first year in which a resident is admitted on a psycho pharma logical medication (other than antipsychotic or a sedative/hypnotic) or after the facility has initiated such medications, the facility will attempt to taper the medication during at least to separate quarters (with at least one month between the attempts), unless clinically contraindicated. The tapering may be indicated if: (1) The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability .

Complaint (AR 126) was substantiated, all or in part, with deficiency cited at F761 Based on observation, record review and interview the facility failed to ensure discontinued non-narcotic medications were accounted for and secure from the date of discontinuation until the consultant pharmacist destroyed the medications for 2 (Resident #4, and #5) sampled residents. The findings are: 1. Resident #4 was admitted on [DATE] and expired in the facility under Hospice care on [DATE]. a. Resident #4's medical record had no documentation of a physician's orders [REDACTED]. b. A progress note written by Licensed Practical Nurse (LPN #1) on [DATE] documented, (Hospice RN (Registered Nurse) #1) (Hospice) here new orders received and noted [MEDICATION NAME] 2.5mg (milligrams) times one now [MEDICATION NAME] 1mg (milligram) SL (sublingual) every 6 hours as needed for anxiety agitation or restlessness . c. Photos #16, #17, and #18 provided by the complainant documented, a medication bottle with a pharmacy label with Resident #4's name, the nursing facility name, [MEDICATION NAME] concentrate 2mg/ml (milligrams per milliliter), dispense date [DATE] filled by (Pharmacy) and Rx (prescription) number. The background of the photo reveals bubble pack cards of unknown medication. Unable to determine where the photos were taken. d. On [DATE] at 11:00 a.m., LPN#1 was asked, Do you remember when you wrote a progress note back in March for Resident #4 saying (Hospice RN #1) gave you an order for [REDACTED]. She was asked, Can you look on the electronic record and find where that order was put in the record and on the MAR? She replied, Let me look and I will get back with you. e. On [DATE] at 12:30 p.m., LPN #1 stated, I don't think I ever wrote the order for that [MEDICATION NAME] or put it in the computer. I told (Hospice RN #1) that we could get the injectable [MEDICATION NAME] from the E (emergency)-kit and give an IM (intramuscular) injection but that we didn't have any sublingual. I don't think I ever wrote the order or made a progress note saying we changed it. To my knowledge the sublingual medicine was never ordered and never came from the pharmacy. She was asked, What is the protocol for the destruction of discontinued non-narcotic medications? She replied, There is a tub in the med room and a blue book to log the medicine in. Sometimes we log them in and sometimes the DON does it. Then the pharmacy comes to waste it. She was asked, Who has access to the discontinued medication cabinet? She replied, Just the med (medication) nurses, the DON, and ADON (Assistant Director of Nursing). She was asked, Is it possible for a nurse to remove discontinued medicine from the discontinued medication cabinet between the date that a med is discontinued and the date the pharmacist comes? She replied, Sure. I guess anything is possible. f. On [DATE] at 4:00 p.m., Hospice RN #1 was asked, How does the facility receive medications for residents who receive hospice care? She replied, If it's during normal working hours, we use (Pharmacy) in (City) and one of our staff members delivers it to the facility. If it's after normal working hours, we use (Pharmacy), but we have their courier deliver it to the facility. If it's a STAT (immediate) order, we use the backup pharmacy - the local pharmacy in (City) because that is the one the DON wants us to use, and they deliver it. She was asked, Are you familiar with Resident #4? She replied, Yes. She was asked, Do you recall on [DATE] you talked to LPN #1 about giving [MEDICATION NAME] sublingual? She replied, Yes. LPN #1 told me that they did not have the sublingual in their E-kit, but they had the injectable. So, we immediately changed it to the injectable. She was asked, Was the sublingual medication ever ordered from the pharmacy? She replied, Not to my knowledge because we changed it right then. I know I did not call it in. She was asked, What happens to a resident's medication when they expire, and they are in hospice care? She replied, The facility is responsible for the medication. They are responsible for the count if it's a narcotic. They are responsible for everything including the destruction of the medication. g. On [DATE] at 8:25 a.m., Pharmacist #1 was asked, Who called in the prescription for Resident #4 to the pharmacy and who received the medication? She replied, (Hospice RN #1) called it in. It was picked up by the (Hospice RN #2). h. On [DATE] at 11:00 a.m., Hospice RN #2 was asked, Do you remember Resident #4? She replied, Yes. She was asked, Do you remember picking up [MEDICATION NAME] suspension from the pharmacy and delivering it to (Facility)? She replied, Yes. She was asked, Do you remember who you gave it to? She replied, Let me check my notes I'm sure I wrote it down. She stated, If I remember correctly, we never had to administer it because she was comfortable, and we ended her continuous care. She stated, I gave it to LPN #1 at the facility. She was asked, When a resident dies, does the hospice nurse take the resident's meds from the facility? She replied, No. The facility disposes of the meds according to their protocol. i. On [DATE] at 9:40 a.m., LPN #4 was asked, What is the protocol for destruction of discontinued non-narcotic medications? She replied, There is a DC (discontinued) bin under the sink in the med room. The DON and the pharmacist count the meds and log it in a blue book and destroy the meds in a sharps container. She was asked, Who has access to the bin under the sink in the med room? She replied, Pretty much anyone who has access to the med room. She was asked, Could it be possible for someone to remove meds from the bin before the pharmacist comes? She answered, Yes. She was asked, Do you remember Resident #4 had an order for [REDACTED]. She was asked, Have you ever taken a resident's discontinued medication from the facility? She replied, No ma'am. j. On [DATE] at 11:30 a.m., the DON opened an unlocked cabinet under the sink in the medication room. The discontinued non-narcotic medications were in a grey plastic bin with medication cards and other routes of medications. She stated, We do the narcs (narcotics) a different way. I keep them in my office and send them to the state. She was asked, What is the procedure for destroying discontinued non-narcotic medications? She replied, The nurses put them under here in this bin. When the pharmacist comes, we log them in the blue book and destroy them together and they sign off. She was asked, Is that the only time medications are logged in the book? She replied, Well, if the bin gets too full, I go ahead and log them in and they sign off after me. She was asked, How often does a pharmacist come? She replied, Once a month. Last time they were here was [DATE]rd. The Blue Medication Destruction Book had stickers from the pharmacy applied to the pages and a number hand-written on each sticker. The DON was asked, What is that number? She replied, That's how many pills there were. She was asked, Who has access to the discontinued medication cabinet? She replied, The med nurses, me, the ADON and the Administrator. She was asked, Could a nurse remove medication from the discontinued medication cabinet between the date a med is discontinued and the date the pharmacist comes? She replied, I guess anything could happen. She was asked, Can you find where Resident #4's [MEDICATION NAME] Conc (Concentrate) 2mg/ml was logged in and destroyed? She looked at several pages and answered, I don't see where it was ever logged in. Let's look in my office and see if they were sent back with the narcotics. She checked the binder in her office. There was no record the [MEDICATION NAME] Conc was surrendered to the state after the death of Resident #4. She stated, I wasn't sure if that was a narcotic or not. One day it is, one day it's not. k. A Discharge Summary dated [DATE] documented . All meds were given to the DON (Director of Nursing) for destruction . 2. Resident #5 was admitted to the facility on [DATE]. a. A physician's orders [REDACTED]. [MEDICATION NAME] 200mg Give one capsule three times a day for cough . The [DATE] Medication Administration Record [REDACTED]. b. A physician's orders [REDACTED]. [MEDICATION NAME] Capsule 100 MG ([MEDICATION NAME]) Give 100 mg by mouth every 8 hours as needed for cough for 14 Days . The [DATE] MAR indicated [REDACTED]. c. As of [DATE], there was not an active physician's orders [REDACTED].#5'smedical records. d. Photos #9, #10, and #11 provided by the complainant documented bubble packed cards of [MEDICATION NAME] 100mg capsules with 2 capsules in each blister, with Resident #5's name, (Pharmacy), Rx number and dispense date [DATE]. Photo #9's background shows a bathroom sink and countertop with makeup and personal care items and possible nasal spray. e. On [DATE], no sink resembling the sink in photo #9 was in the facility. (Photos of facility sinks taken.) f. On [DATE] at 2:00 p.m., the DON was asked to contact the pharmacy and find out who ordered the cards of [MEDICATION NAME] 100mg caps for Resident #5 on [DATE]. She called (Pharmacy) and was told the medication was reordered on [DATE] by (LPN #3). The ADON provided 4 pages faxed from (Pharmacy) titled Consolidated Delivery Sheets for Resident #5. Page 1 dated [DATE] documented, [MEDICATION NAME] 200mg capsules 15 cap (capsules) 3 items sent. Page 2 dated [DATE] documented, [MEDICATION NAME] 100mg cap 30 caps. Page 3 dated [DATE] documented, [MEDICATION NAME] 200mg capsules 15 cap 3 items sent. Page 4 dated [DATE] documented, [MEDICATION NAME] 100mg capsules 100 capsules 2 items sent and received in the facility at 1615 (4:15 p.m.) on [DATE]. g. On [DATE] at 2:10 p.m., LPN #3 was asked, Do you remember reordering Resident #5's [MEDICATION NAME] 100mg caps on [DATE]? He replied, I don't remember it, but I do remember she had an order for [REDACTED]. h. On [DATE] at 2:30 p.m., the DON looked in the Blue Medication Destruction book. There was no documentation of [MEDICATION NAME] 100mg capsules for Resident #5 logged into the blue book for destruction. The DON stated Let me go look one more place in the med room. There's a place where we keep overflow meds. Maybe it's there. i. On [DATE] at 9:15 a.m., the DON was asked, Did you find the cards of [MEDICATION NAME] for Resident #5 that you were going to look for yesterday? She replied, No I never found it. j. On [DATE] at 9:40 a.m., LPN #4 was asked, Do you remember from December when Resident #5 had a prescription for [MEDICATION NAME] capsules? She replied, Not really. I am working the COVID unit today and my computer is too far away for me to look anything up. k. On [DATE] at 1:45 p.m., the DON was asked, Who is responsible for ensuring all medications are placed in the discontinued bin when a medication is discontinued or when a resident dies? She replied, The nurse who is working when the medication is discontinued or when the resident dies. She was asked, Is it ever acceptable for medications to be missing from the facility? She replied, No, that is never acceptable.

Based on observation, record review and interview the facility failed to ensure that the physician's orders were followed on oxygen administration for 1 (Resident #13) of 7 (Resident's #4, #6, #13, #27, #31, #36, and #45) sampled residents. This failed practice had the potential to affect 9 residents who were on oxygen therapy based on a list provided by the Administrator on 07/16/2020. The findings are: Resident #13 had a [DIAGNOSES REDACTED]. An Annual Minimum Data Set with an Assessment Reference Date of 04/22/2020 documented the resident scored 13 (13-15 indicated cognitively intact) per a Brief Interview of Mental Status and oxygen therapy while a resident. a. The July 2020 physician order documented, Oxygen @ (at) 2L (liters) VIA NC (nasal cannula) PRN (as needed) SOB (shortness of breath) every shift related to [MEDICAL CONDITION] With (Acute) Exacerbation . b. On 07/13/2020 at 11:41 A.M., the resident was receiving oxygen via nasal cannula. The gauge on the resident's oxygen concentrator was set on 3 liters. c. On 07/14/2020 at 10:00 A.M., t the resident was receiving oxygen via nasal cannula. The gauge on the resident's oxygen concentrator was set on 3 liters. d. On 07/16/2020 at 11:01 A.M., the resident was in bed and receiving oxygen at 3 liters via nasal cannula. e. On 07/16/2020 at 11:24 P.M., Licensed Practical Nurse #1 was asked, What the gauge on the resident's oxygen concentrator was set on? She replied, Looks like 3 (3 liters). The tube is dated 07/08/2020. She was asked, What does the resident's order state? She looked on the computer at the resident's Physician orders and stated, Right there it is saying 2 (2 liters). f. On 07/16/2020 at 4:09 P.M., the policy and procedure for oxygen administration provided by the Administrator documented, . Steps in the procedure . 8. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . g. On 07/16/2020 at 4:41 P.M., the Administrator was asked, Who is responsible for checking the gauge to ensure the physician ordered amount of oxygen is being delivered and how often should it be checked? She replied, LPN's are to ensure the oxygen level setting is correct every shift.

Based on record review and interview the facility failed to ensure a resident who had a decline in 2 or more areas of activities of daily living had a Significant Change Minimum Data Set (MDS) to ensure accuracy and the development of an appropriate plan of care for 1 (Resident #13) sampled resident. This failed practice had the potential to affect all 49 residents based on the Resident's Census and Condition of Residents provided by the Administrator on 07/14/2020. The findings are: Resident #13 had [DIAGNOSES REDACTED]. An Annual MDS with an Assessment Reference Date of 04/22/2020 documented the resident scored 13 (13-15 indicates cognitively intact) per a Brief Interview of Mental Status and required supervision with bed mobility, transfers, walking, locomotion, personal hygiene; limited assistance with dressing, toileting; independent with eating and required physical assistance with bathing. a. On 07/14/2020 at 08:45 P.M., a comparison of the Annual MDS with an ARD of 04/22/2020 and a Discharge MDS with an ARD of 12/31/2019 showed the resident had a decline in bathing, dressing and toilet use. The resident had a Discharge MDS with ARD of 02/20/2020 and one on 03/04/2020. A 5- day MDS with ARD of 03/14/2020 documented an improvement in 7 areas of ADL and 1 decline of ADL. b. On 07/16/2020 at 11:40 A.M., the MDS Coordinator was asked the criteria for doing a significant change MDS. She stated, If they have a significant change in Activities of Daily Living, and changes to hospice services. He (Resident #13) participated in Physical Therapy and made improvements. He is back ambulating. He was in a wheelchair. She was asked if a Significant Change MDS should have been done for Resident #13. She stated, I tried to capture the changes on the 5-day (MDS). I refer to the consultant and go with her (go with her advice). She was asked if he had had a decline in more than two areas of ADL's. She stated, Not that I am aware of, but I can follow up on that in the future. I think the only sig (significant) changes I've done is with hospice or palliative care. c. On 07/16/2020 3:36 P.M., the Administrator was asked the criteria for doing a significant change MDS. She stated, I do know if there are two or more areas of decline in ADLs and if they go or come off of hospice (a significant change MDS would be done).

Based on observation, record review and interview, the facility failed to ensure physician's order were followed for a free water flush before and after bolus feeding through a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 (Resident #25) resident. This failed practice had the potential to affect 2 residents who received nutrition and fluids via a feeding tube, as documented on the Roster Matrix that was provided by the Director of Nursing on 07/13/2020 at 1:52 P.M. The findings are: Resident #25 had a [DIAGNOSES REDACTED]. a. A Care Plan dated 06/08/2020 documented, . has potential fluid deficit r/t (related to) NPO (nothing by mouth), all feedings / (and or) liquids consumed through feeding tube. O. will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor . b. A Physician's Order dated 06/17/2020 documented, . [MEDICATION NAME] @ (at) 50mls/hr (milliliters per hour) for 14 hours 6 p.m. to 8 a.m. Day time bolus feedings [MEDICATION NAME] 1.5 - 1 can (250mls) BID (twice a day) which will provide 1,800kcal (kilocalories), 81 grams of protein, 933cc (cubic centimeter) free fluid, with 110cc H20 (water) Flush before and after each feeding bolus and continuous weekly weights one time a day . c. A Registered Dietician's (RD) Offsite Consultation dated 07/07/20 documented, . RD follow up due to TF (tube feeding) -3% weight change BMI (body mass index) -24.4 Reviewed weekly skin audit, labs available Estimated needs- 1,770kcal, 59 grams of protein, 1,770cc fluid TF order - [MEDICATION NAME] @ 50mls/hr (milliliters per hour) for 14 hours 6 p.m. to 8 a.m. Day time bolus feedings [MEDICATION NAME] 1.5 1 can (250mls) BID which will provide 1,800kcal, 81 grams of protein, 933cc free fluid, with 110cc H20 Flush before and after each feeding bolus and continuous RD recommends- continuing weekly weights . d. On 07/15/2020 at 11:15 A.M., LPN #1 administered a bolus tube feeding for Resident #25. She obtained a 250ml (milliliter) container of [MEDICATION NAME] 1.5cal (calorie) formula and 2 plastic drinking cups from the medication cart and water from the resident's bathroom sink. LPN #1was asked, How much water is in each cup? She replied, 90 cc's (cubic centimeters). She removed the plunger from the syringe and flushed with 90 ml water by gravity. She poured the formula into the syringe and allowed the formula to instill via bolus. She flushed with 90ml water by gravity. e. On 07/16/2020 at 3:16 P.M., LPN #1 was asked, I see an order to give 110ml H2O flushes before and after bolus. You gave 90 ml. Can you tell me why you gave 90? She replied, It was on the MAR (Medication Administration Record) to give 95 ml. That order was written on 6/12/20. But I guess it changed. She was asked, Is the current order for 90, or 95, or 110? She replied, It is 110 actually. f. A Policy titled Enteral Tube Feeding by Syringe (Bolus) provided by the Assistant Director of Nursing on 07/16/2020 at 1:59 P.M., documented, 1. Verify there is a Physician's Order for this Procedure . Equipment and Supplies . 7. Sixty (60) ml water (room temperature) . Initiate Feeding . 4. Unless otherwise ordered, follow the feeding with 30 - 60 ml of warm water . g. On 07/16/2020 at 3:32 P.M., the Administrator was asked, What could happen if a resident did not receive the ordered amount of free water flushes through their feeding tube? She replied, If it is not enough, they won't get the right amount of water and it could cause issues in lots of different areas like skin integrity, dehydration, and nutritional intake. Even though it's just water they still need it.

Based on observation, record review, and interview, the facility failed to ensure residents in the therapy room were wearing masks and/or social distancing to prevent the potential for the spread of communicable diseases for 5 (Residents #1, #2, #3, #4, and #5) of 5 sampled residents. This failed practice had the potential to affect 28 residents who frequented the therapy room with or without scheduled therapy based on lists provided by the Administrator on 6/19/20. The findings are: 1. On 06/18/20 at 2:47 PM, Therapist #1 and Resident #1 were sitting on a workout cot in the Therapy Room. To their right was Resident #5 and beside him was Resident #4. Resident #3 was facing the work out cot and to the left of the work out cot was Resident #2. Resident # 2 wore a mask part of the time, Resident #4 wore a mask and Resident #3 had a mask on that fell below her mouth. Residents #1 and #5 did not have a mask on. Residents #2, #3, #4 and #5 who were in wheelchairs or rolling seated walkers were approximately 3 feet to at least one other resident and to the cot. At no time did the staff direct the residents to pull their mask up, put a mask on or to distance at least 6 feet apart. 2. On 06/18/20 at 3:12 PM, Therapist #2 took Residents #3 and #4 across the hall to the day room via their rolling walkers. Therapist #2 instructed the residents to sit on a love seat, where they sat side by side. Resident #4 had a mask on Resident 5's mask was not covering her nose or mouth. The therapist did not direct Resident #5 to cover her mouth nor did she direct them to distance themselves. 3. On 06/18/20 at 4:11 PM, the Administrator was asked if the facility practiced social distancing, and she stated Yes. She was asked if therapy staff had been trained or in-serviced relating to social distancing and she stated, Not from me. I'll reach out to them and see if they trained their staff. 4. On 06/18/20 at 4:20 PM, an interview was conducted with the Director of the Rehabilitation, Therapist #1. She was asked if they did group therapy sessions, and she stated, We don't do group treatments here. We don't have the appropriate residents to work together and we don't have appropriate equipment. She then stated, (Resident #1) was my patient and (Resident #3) was (Therapist #2's) patient. (Residents #2, #4, and #5) just joined us. (Resident #5) is on our case load, but he was treated this morning. She was asked if he had just come to hang out, and she said, Yes, Ma'am. We try to keep the furniture spaced and we typically have them sit in a chair. When they come down on their own, they just roll in and sit. She was then asked if residents can come in at any time and she stated, Yes. She was then asked, How do you keep them distanced? She said, Well we try to keep them apart or sometimes we have to turn them away and tell them to come back at a later time. She stated they ask them to wear one at all times. She also said at the beginning they had been spaced but at the end they got closer. When asked if they had been six feet apart, and she stated No. 5. On 06/18/20 at 4:38 PM, the Administrator provided an in-service document titled Incite Rehab Guidance on Preparing Workplaces for Covid 19 and signed by Therapist #1 and #2 that documented, . 3. Group and concurrent treatment is to be pre-approved and patients must be at least 6 feet apart . 6. On 06/19/20 at 3:55 PM, an interview was conducted with the Director of Nursing. She was asked if she was aware that residents were grouping together in the therapy department. She replied, I was not aware until yesterday.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling food items or clean equipment, and between dirty and clean tasks; and, expired food items were used or promptly discarded on or before the expiration or use by dates to decrease the potential for food borne illness for residents who received food from 1 of 1 kitchen. These failed practices had the potential to affect 49 residents who received meals from the kitchen (total census: 52), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 11:38 a.m., Dietary Employee #2 had gloves on her hands. She removed cartons of thickened water from the refrigerator and placed them in a pan. She removed a marker from her pocket and used it to write dates on the cartons of water. Without changing gloves and washing her hands, she used her contaminated gloved hand to pick up clean glasses by their rims and placed the glasses in a pan. The glasses contained beverages to be served to the residents for the lunch meal. 2. On [DATE] at 11:45 a.m., Dietary Employee #3 was wearing gloves on her hands. She picked up a bag of bread from the bread rack and placed it on the counter. She picked up a zip lock bag that contained slices of cheese and placed it on the counter. She used matches to light the stove. Without changing gloves and washing her hands, she removed slices of bread from the bag of bread and placed them in a pan on the stove. She removed slices of cheese from the zip lock bag, placed them on the slices of bread, and prepared grilled cheese sandwiches to be served to the residents who requested a grilled cheese sandwich with their meal. 3. On [DATE] at 12:12 p.m., there were three packages of hot dog buns, each one containing 12 buns, stored in a rubber container on a shelf in the kitchen storage room. The labels on the packages of hot dog buns documented best used by [DATE]. The labels on the packages documented the packages of hot dog buns were received ,[DATE]. Dietary Employee #2 was asked to remove one of the buns from the bag to check for freshness. She did so, and stated, It doesn't look good. The color is not good. The buns are discolored. 4. On [DATE] at 4:32 p.m., Dietary Employee # 2 opened the microwave oven and removed a bowl of baked beans. She placed the bowl of baked beans on the counter. Without washing her hands, she picked up a clean blender blade and attached it to the base of the blender to be used in pureeing food for the residents who received pureed diets. 5. On [DATE] at 5:07 p.m., Dietary Employee #1 was wearing gloves. She walked back into the kitchen from the dining room. Without changing gloves and washing her hands, she picked up glasses by their rims and poured beverages into the glasses to be served to the residents for the supper meal. 6. [DATE] at 5:26 p.m., Dietary Employee #1 was on the tray line assisting with the meal service. She picked up cartons of health shakes, milk, and cartons of ice cream and placed them on trays. Dietary Employee #1 did not wash her hands after placing the cartons of beverages on the meal trays. She used her contaminated hand to pick up clean glasses by their rims and placed them on trays. The glasses contained beverages to be served to the residents for the supper meal. At 5:29 p.m., she removed a pitcher of punch from the refrigerator and placed it on the counter. Without changing gloves and washing her hands, she picked up clean glasses by their rims and poured the punch from the pitcher into the glasses to be served to the residents for the supper meal.

Based on observation, record review, and interview, the facility failed to ensure the comprehensive care plan was developed or revised to include coordination of services with the hospice provider, to promote continuity of care for 1 (Resident #53) of 1 (Residents #53) sampled residents who received hospice services; and failed to ensure the comprehensive care plan addressed a physician-ordered fluid restriction, including the necessary assessments and monitoring related to hydration status, to minimize the potential for adverse events for 1 (Resident #17) of 1 (Residents #17) sampled residents who had physician orders [REDACTED]. The failed practices had the potential to affect 6 residents who required hospice services, according to the Resident Census and Conditions of Residents form dated 3/25/19, and 1 resident who had physician orders [REDACTED]. The findings are: 1. Resident #53 had a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/19 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive two plus persons assistance with bed mobility, toilet use, personal hygiene, and transfers; required extensive one person assistance with dressing; was totally dependent with two persons assistance with bathing; required a wheelchair for mobility; required supervision and one person assistance with locomotion on and off the unit; and received hospice services. a. A physician's orders [REDACTED].Admit to (Name) Hospice for 5 day respite . b. A Nursing Admission assessment dated [DATE] contained no documentation to indicate the resident had previously received, or was to receive, hospice services at the facility. c. On 3/27/19 at 12:10 p.m., Licensed Practical Nurse (LPN) #1 was asked, What information is on the Closet Care Plan? LPN #1 stated, Important information regarding the resident's care that the CNAs (Certified Nursing Assistants) need to know. She was asked, How do the licensed nurses communicate new orders or changes in a resident's condition? She stated, We use a written Nurse-to-Nurse Communication sheet. She was asked, How do you communicate changes in a resident's condition to your staff? She stated, I tell the CNAs. They don't need to know all the orders for medication changes, but important things, I tell them. She was asked, Where are the Closet Care Plans kept? She stated, On the inside of the resident's closet door. She was asked, Does (Resident #53) have a Closet Care Plan on the inside of his closet door? After looking in the resident's closet, she stated, No, I don't know where his Care Plan is. d. On 3/27/19 at 2:38 p.m., the Assistant Director of Nursing (ADON) was asked, Who completes the Care Plan when a resident is admitted ? The ADON stated, The nurses on the hall do the Baseline Care Plan when someone is admitted . It pulls from the Nursing Readmit Screener. She was asked, Who is responsible for doing the Closet Care Plans when someone is admitted ? She stated, The Restorative CNA (Certified Nursing Assistant) does the Closet Care Plans. There is someone here every day on the day shift. e. On 3/27/19 at 2:42 p.m., the Director of Nursing (DON) was asked, Who updates the Closet Care Plans when there is a new order or a change in the resident's condition? The DON stated, We all work together on the Care Plans, but it would be the Restorative Aide who would add it to the Closet Care Plan. She was asked, Who would do the update if the Restorative Aide was not here? She stated, We have a Restorative Aide all the time. She was asked, For clarification, you have a Restorative Aide on all three shifts, seven days a week? The DON stated, No, that would be nice, but we have a Restorative Aide seven days a week on the day shift. f. On 3/28/19 at 10:05 a.m., the Director of Nursing was asked, Do you have a paper chart on (Resident #53)? The Director of Nursing stated, No, he was a new admit, and all of his information is on the computer. The Director of Nursing was asked, Where do you keep your information from Hospice on (Resident #53)? The Director of Nursing stated, In a binder, at the nurse's station. The Director of Nursing looked at the nurse's station but, was unable to locate a binder for (Resident #53). The Director of Nursing stated, I guess I need to call them. The Director of Nursing was asked, In regard to hospice, who communicates and coordinates between the facility and hospice? The Director of Nursing stated, We all do. The hospice nurse comes one or two times per week, and they are on call 24/7 (24 hours per day, seven days per week). As far as communication, hospice always checks in with our LPNs (Licensed Practical Nurses) to see if there are any problems. I call hospice if I need anything and the Social Director calls if the resident needs anything. The Director of Nursing was asked, Can you describe what the facility's responsibilities are compared to what services hospice provides? The Director of Nursing stated, Hospice comes in when the patient has six months or less. They are here to support the patient through their disease process and support the family. They evaluate the patient, head to toe, evaluate for signs and symptoms of pain, anxiety, and they communicate with the Hospice physician. They are extra for someone who is at the end of life. They have a Hospice CNA (Certified Nursing Assistant) that has scheduled visits two or three times per week, and they do personal care, like baths. The Director of Nursing was asked, Where would this (information) be documented? The Director of Nursing stated, I call the Hospice and coordinate this, and then I put in the P[NAME] (Plan of Care) where the CNAs document their ADLs (Activities of Daily Living). The Director of Nursing was asked, Where would the items that hospice provides be listed? The Director of Nursing stated, In the Hospice binder. g. As of 3/28/19 at 10:30 a.m., there was no documentation in the resident's Baseline Care Plan dated as initiated on 3/4/19, the Comprehensive Admission Care Plan dated as initiated and revised on 3/12/19, nor the resident's Closet Care Plan (not dated) regarding hospice services. 2. Resident #17 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/18/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS); required supervision only for bed mobility and locomotion on and off the unit, and was independent with eating. a. A physician's orders [REDACTED]. Nursing to give 120 ml Q (every) Med (Medication) Pass (5 (times) Daily) . Dietary to give 200 ml with meals . b. As of 3/26/19, the Comprehensive Care Plan with a revised date of 2/28/19 contained no documentation related to the need for a fluid restriction. c. On 3/26/19 at 2:19 p.m., Certified Nursing Assistant (CNA) #6 and CNA #7 were asked, How are you made aware of new orders or changes in the resident's condition? CNA #6 stated, The outgoing shift tells report, and the nurses let us know as well. The patient's condition can change all the time. CNA #7 stated, The LPN (Licensed Practical Nurse) will let us know new orders. We have a 1 to 1 with the residents, and when we see a change in their condition, we report to the nurse. CNA #6 and CNA #7 were asked, Do you know (Resident #17)? Both CNAs stated, Yes. CNA #6 and CNA #7 were asked, Are you aware of any fluid restrictions for (Resident #17)? CNA #6 stated, Yes. CNA #7 stated, She is on fluid restriction because her sodium is low. The nurse told us. d. On 3/26/19 at 2:52 p.m., LPN #2 was asked, How do you communicate changes in the resident's condition to your staff? LPN #2 stated, I talk to the CNAs on the hall and let them know about order changes or resident changes. LPN #2 was asked, Are you aware of a fluid restriction on (Resident #17)? LPN #2 stated, Yes. I got the order. I then let the DON (Director of Nursing) and Kitchen, (Dietary Employee #3), know of the new orders. We sat down and figured the amount she could have from each department. e. On 3/27/19 at 11:30 a.m., Dietary Employee #3 was asked if (Resident #17) was on any special restrictions. Dietary Employee #3 stated, Fluid restriction as of last Friday. The nursing RD (Registered Dietician) set it up. (Resident #17) asked for it. Said she had been on it for years off and on. It was set up for 1200 milliliters. Dietary Employee #3 was asked, Can you show me how much fluid you give her from the kitchen? Dietary Employee #3 stated, She does not want anything to drink for breakfast, and she gets 8 ounces of unsweetened iced tea for lunch and supper. f. On 3/27/19 at 11:40 a.m., CNA #8 was asked, How are you made aware of new orders or changes in a resident's condition? CNA #8 stated, We look at their Care Plan. The Care Plan keeps us updated on their condition. Also, we have a Communication Log for CNAs at the Nurse's station. CNA #8 was asked, Can you show me in the Communication Book about (Resident #17's) fluid restriction? CNA #8 looked and stated, I do not see it written in the Communication Book. g. On 3/27/19 at 11:50 a.m., CNA #9 was asked, How are you made aware of new orders or changes in a resident's condition? CNA #9 stated, Most of the time, the nurses or DON (Director of Nursing) tell us when we come in. I just got told about it on Monday. The resident told me about it. We also have Closet Care Plans, and the resident's care would be on the Closet Care Plan. h. As of 3/27/19 at 12:00 p.m., the resident's Care Plan dated as initiated on 2/12/19 and the resident's Closet Care Plan contained no documentation regarding the resident's fluid restriction.

Based on observation, record review, and interview, the facility failed to ensure an anti-hypertensive medication was accurately and safely administered, to prevent potential complications for 1 (Resident #53) of 9 (Residents #53, #12, #17, #26, #28, #39, #44, #48, and #52) sampled residents who had physician's orders [REDACTED]. This failed practice had the potential to affect 28 residents who received oral medications on the 100 Hall and the 200 Hall, as documented on a list provided by the Administrator on 3/28/19. The findings are: Resident #53 had a [DIAGNOSES REDACTED]. a. The Medication Review Report dated 1/16/19 documented, .Losartan Potassium Tablet ([MEDICATION NAME]) Give 12.5 mg by mouth one time a day related to .Hypertension . Give ½ of a 25mg tab to (equal) 12/5 mg) .order date . 1/16/19 . b. On 3/26/19 at 8:12 a.m., during the 8:00 a.m. medication administration pass, Licensed Practical Nurse (LPN) #1 was administering medications for Resident #53. Resident #53 was sitting in his wheelchair at the dining room table with his family. LPN #1 prepared several oral medications for the resident, including Clear Lax 17 gram (gm) powder, 81 milligrams (mg) Aspirin [MEDICATION NAME] Coated Delayed Release tablet (Tab), [MEDICATION NAME] 75 mg tablet,[MEDICATION NAME] Release (ER) 30 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] XL ER 50 mg tab, [MEDICATION NAME] Delayed Release (DR) 40 mg tab, and [MEDICATION NAME] 500 mg. She placed the medications in a clear medication cup and handed the cup of medications to the resident. The resident poured the medication from the cup onto his food tray. He placed one pill at a time in his mouth and took sips of water. As he was taking his medications, a male family member stated, He dropped a pill. LPN #1 looked on the floor and searched the resident's lap for the medication. She did not recover a pill during her search. Without finding the pill, LPN #1 punched a green pill from the medication bubble pack card ([MEDICATION NAME] 25 mg tablet) and placed it in a clear medication cup. She placed the medication cup on the resident's food tray. The resident placed the pill in his mouth. A male family member stated, He dropped it again. The resident stated, No, I didn't. No one looked for the second suspected dropped pill. Another team member observed the resident and his family in the dining room until they left at 8:50 a.m. No one recovered a pill. The resident's sons escorted the resident to his room. c. On 3/26/19 at 8:58 a.m., the resident was sitting in his wheelchair in his room, and his two sons were present. The resident's sons were asked if they recovered the pill he dropped this morning in dining room. They both stated, No. d. On 3/26/19 at 9:10 a.m., Housekeepers #1 and #2 were sweeping the floor in the dining room near the area Resident #53 sat during meals. They were both asked if they found a pill on the floor. They both stated, No ma'am. We didn't find a pill. They were both asked if they had finished sweeping the floor. They both stated, Yes, ma'am. e. On 3/26/19 at 11:23 a.m., the Director of Nursing (DON) stated, We ordered another [MEDICATION NAME] pill since (LPN #1) dropped one this morning. The facility will pay for the pill. She was asked, Did she recover the pill, and how did she know he dropped the pill? The DON stated, She told me. She was asked if LPN #1 told her where the pill was found. The DON stated, No. f. On 3/26/19 at 1:41 p.m., Licensed Practical Nurse (LPN) #1 was asked, why did you administer Resident #53 another [MEDICATION NAME] pill during the morning medication pass? She stated, Because he dropped the first pill I gave him. I saw it fall, but I couldn't ever find it. LPN #1 was asked if you should find the pill before administering a duplicate pill. She stated, Yes, ma'am. LPN #1 was asked if follow-up monitoring was implemented. She stated, I notified the family and the physician. We are doing every 2-hour blood pressure checks on him (the resident).

Based on observation, record review, and interview, the facility failed to ensure foods were served at temperatures that were acceptable to the residents, to maintain palatability, encourage adequate nutritional intake, and enhance the dining experience for residents who received meals in their room on 2 (100 Hall and 400 Hall) of 4 halls. This failed practice had the potential to affect 10 residents who received meals in their rooms on the 100 Hall and 10 residents who received meals in their rooms on the 400 Hall, according to lists provided by Dietary Employee #3 on 3/26/19. The findings are: 1. On 3/25/19 at 3:12 p.m., Resident #17, whose Quarterly Minimum Data Set with an Assessment Reference Date of 1/18/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), was asked if the facility served food at acceptable temperatures. She stated, The food is cold all the time. I eat in my room, and when they bring that cart down the hall they leave the cart door open, so the food is cold. Resident #17 resided on the 100 Hall. 2. On 3/26/19 at 12:24 p.m., an unheated tray cart containing 10 resident trays and one test tray for the lunch meal was delivered to the 100 Hall by Certified Nursing Assistant #1. At 12:40 p.m., immediately after the last resident received their tray on the 100 Hall, the temperatures of the food items on the test tray were checked and read by Certified Nursing Assistant #4 with the following results: a. Milk - 50 degrees Fahrenheit. b. Chicken fried steak - 90 degrees Fahrenheit. Certified Nursing Assistant #3 felt the meat and stated, It's warm. c. Mashed Potatoes - 100 degrees Fahrenheit. d. Regular potatoes - 110 degrees Fahrenheit. e. Brussels sprouts - 105 degrees Fahrenheit. f. Pureed chicken fried steak - 90 degrees Fahrenheit. g. Pureed Brussels sprouts - 90 degrees Fahrenheit. 3. On 3/26/19 at 12:32 p.m., an unheated tray cart containing 10 resident trays and one test tray for the lunch meal was delivered to the 400 Hall by Certified Nursing Assistant #3. At 12:40 p.m., immediately after the last resident received their tray on the 400 Hall, the temperatures of the food items on the test tray from the cart were checked and read by Certified Nursing Assistant #5 with the following results: a. Milk - 50 degrees Fahrenheit. b. Chicken fried steak - 90 degrees Fahrenheit. Certified Nursing Assistant #5 felt the meat with her fingers and stated, It's warm. c. Mashed Potatoes - 100 degrees Fahrenheit. d. Regular potatoes - 110 degrees Fahrenheit. e. Brussels sprouts - 105 degrees Fahrenheit. f. Pureed chicken fried steak - 90 degrees Fahrenheit. g. Pureed Brussels sprouts - 90 degrees Fahrenheit. 4. On 3/26/19 at 12:57 p.m., Certified Nursing Assistant #2 was asked if the door to the tray cart should be closed each time a tray was removed from the cart to serve to a resident. She stated, It makes it easier to get trays out (to leave the door open).

Complaint # (AR 539) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure the provision of necessary care and services to maintain the highest physical well-being for Residents #1 and #2. The facility failed to ensure staff were trained and competent in emergency procedures in the event of total dislodgement of the [MEDICAL CONDITION] and how to provide [MEDICAL CONDITION] resuscitation during CPR (cardiopulmonary resuscitation) for 1 (Resident #1) and failed to ensure there was an emergency [MEDICAL CONDITION] kit available at the bedside in the event of an emergency situation for 1 (Resident #2) of 2 (Resident #1 and 2) case mix residents who had a [MEDICAL CONDITION]. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #1, who had a [MEDICAL CONDITION] and went into respiratory/[MEDICAL CONDITION], and had the potential affect Resident #2, who had a [MEDICAL CONDITION] according to the Resident Census and Conditions of Residents form dated [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:30 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE]. The Hospital History and Physical documented, "admitted [DATE] ...Chief Complaint: Found unresponsive at the nursing home. Reason for hospitalization : [MEDICAL CONDITION] with pressor dependent shock. History of Presenting Illness: ...has a history of stroke, [MEDICAL CONDITION], [DIAGNOSES REDACTED] with ejection fraction in the 40% range, history of previous dysphagia and PEG (percutaneous endoscopic gastrostomy) tube placement, history of left [MEDICATION NAME] axillary vein [MEDICAL CONDITION] ([MEDICAL CONDITION], functional [MEDICAL CONDITION], critical illness [DIAGNOSES REDACTED] ...ET (endotracheal tube) got dislodged and subsequent attempts at intubation multiple times were unsuccessful (at local emergency room ) and the patient was transferred here urgently ...further attempts were made in ICU (intensive care unit), but ET tube would not pass beyond vocal chords. Subsequently (Physician) had to be called in urgently and performed an emergent bedside [MEDICAL CONDITION] which was successful in establishing an airway ....The patient was in significant respiratory acidosis at (local medical center) ...Assessment Plan: ...7. Extremely difficult airway with concern for tracheal obstruction which has required emergency [MEDICAL CONDITION]." The resident was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; was totally dependent on 2 plus persons for bed mobility and transfer/locomotion in unit/off unit did not occur; required oxygen therapy, suctioning, [MEDICAL CONDITION] care, and Hospice. a. A DNR (Do Not Resuscitate)/CPR Instructions and Physician order [REDACTED]." A Physician's Telephone/Verbal Order dated [DATE] documented, "Pt. (patient) is a Full Code." b. Nurses Notes dated [DATE] documented the following: 1) 1400 (2:00 p.m.), "Resident resting in bed (with) eyes closed [MEDICAL CONDITION] clear with O2 (oxygen) (at) 2 LPM (liters per minute) via mask..." 2) 1800 (6:00 p.m.), " ...Trach Clear with O2 intact at 2 LPM via mask..." 3) 1810 (6:10 p.m.), "Family member called to check on resident, other family member just left, informed family member that we would keep an eye on the resident." 4) 1829 (6:29 p.m.), "This LPN ((Licensed Practical Nurse) #1) to res (resident) room to check on res. [MEDICAL CONDITION] to be out. This LPN notified other LPN (LPN #2) on duty. When LPN eval (evaluated) res. res responsive, resp (respirations) noted, skin warm to touch, pulse palp (palpable) while assessing res LPN noted resp stopped. LPN called code at 1830 (6:30 p.m.), this LPN (LPN #1) got crash cart (and) called 911, notified need for first responders (and) ambulance. While other LPN began chest compressions. CNA (Certified Nursing Assistant (CNA) #1) assist (with) ambu bag. 1836 (6:36 p.m.), 9 sets of compressions (and) breathing completed. 1837 (6:37 p.m.) LPN noted weak thready pulse. CPR continued to try (and) revive pt. (patient). 1840 (6:40 p.m.), While LPN giving compressions noted thick brown secretions exiting through [MEDICAL CONDITION]. 1840 14 sets of compressions (and) breaths completed via ambu bag. First responders arrive on scene. AED (automatic external defibrillator) applied by first responder. AED assessed heart rhythm, no shock advised, compressions continued, 15 sets complete at 1841 (6:41 p.m.) LPN suctioned resident (with) yonker. 1843 (6:43 p.m.)AED advised no shock. Compressions continued. 1845 (6:45 p.m.) 20 sets compressions completed. 1850 (6:50 p.m.) 30 sets completed. AED advised (no) shock. 1851 (6:51 p.m.) 31 sets completed. AED advised (no) shock. 1852 (6:52 p.m.) 32 sets completed. AED advised (no) shock. 1853 (6:53 p.m.) 33 sets completed. AED advised (no) shock. 1854 (6:54 p.m.) 37 sets completed (and) AED advised no shock. 1855 (6:55 p.m.) 39 sets completed. EMTs (Emergency Medical Technicians) arrive on scene. EMTs applied heart monitor. No heart rhythm noted. 1856 (6:56 p.m.) medic called time of death. Blood tinged discharge noted [MEDICAL CONDITION]." The Nurses Notes did not document any attempt to re-insert the [MEDICAL CONDITION] when the resident went into respiratory distress. There was no documentation that the staff attempted to maintain the airway through the stoma or to seal the stoma off to maintain an intact airway and ensure adequate ventilation. c. The Volunteer Fire Department EMS (Emergency Medical Service) Incident Record dated [DATE] documented, "Time of Call: 18:30 (6:30 p.m.). Time on Scene: 1837 (6:37 p.m.). Level of Consciousness: Unresponsive. Comments: Arrived on scene to assist nursing home with CPR. We put the AED on her and nurses performed CPR until the ambulance got there." The Ambulance Service Patient Care Record documented, " Time of assessment 1855 (6:55 p.m.) ...Pt (patient) ...unconscious no v/s (vital signs). Pt nurse state they found [MEDICAL CONDITION] out and laying beside the bed pt obvious DOA (dead on arrival) with mild lividity to the back of the arms and buttock area No v/s EKG (electrocardiogram) asystole in all leads Pt DOA." d. On [DATE] the following interviews were conducted: 1) At 11:30 a.m., CNA #1 was interviewed via phone call and asked if she remembered the resident and if she was her caregiver on [DATE]? She stated, "Yes." The CNA was asked, "Was [MEDICAL CONDITION] intact?" She stated, "Yes." The CNA was asked, "Did the resident stop breathing and if so what happened afterwards?" She stated, "Yes, prior to the arrest, I saw her just before 5:00 p.m. I answered the call light and her friend was in there. She seemed uncomfortable, itching behind the strap on her trach. (CNA #2) and I was in the room. She (the resident) nodded yes to do you want your mouth swabbed. After I swabbed her mouth I asked if she was okay, then I left the room and went to assist in the dining room. At 6:30 p.m., I heard my name on the intercom. I met (LPN #2) with the crash cart. When I entered the room [MEDICAL CONDITION] on the bed, I lowered the bed, the resident wasn't breathing." The CNA was asked, "Was CPR started and if so, who performed CPR?" She stated, "Yes, I started compressions, they brought the crash cart. (LPN #2) was at the head giving breaths." The CNA was asked, "Where did she give the breaths?" She stated, "In the mouth with the ambu bag." This Surveyor stated, "I missed that, who gave the breaths and where was the ambu bag placed?" She stated, "The nurse, (LPN #2). The ambu bag was placed on the mouth. Several sets in we felt a weak pulse for 15 seconds. Her heart stopped again. First responders arrived with AED, placed it on and it read, 'No shock, advance continue CPR'." The CNA was asked, "Was any of the family there during that time?" She stated, "No, her friend had left during supper. So, we continued chest compressions. Every now and then I'd look up when (LPN #2) did breaths." The CNA was asked, "Was there a tight seal around the the ambu bag on the mouth? " She stated, "Yes, you could not hear air around the mouth." The CNA was asked, "Have you been trained in BLS (basic life support)/CPR?" She stated, "Yes, I am an EMT trained in CPR and emergent situations at the (name of university)." The CNA was asked, "Was there any drainage noted?" She stated, "Yes, now this is just my opinion, I could see blood and what looked to be tube feeding (formula) coming out [MEDICAL CONDITION]. I could feel that I broke several ribs during chest compressions." The CNA was asked, "Were there any other staff present?" She stated, "Yes, there were three other nurses, (LPNs #1, #3 and #4.)" At 3:45 p.m., CNA #1 was asked via phone call what time was CPR started and she stated, "Not for certain, I believe 6:32 p.m." The CNA was asked, "Did first responders do CPR?" She stated, "No, already in progress they brought an AED." The CNA was asked, "Did the EMTs do CPR?" She stated, "No, they hooked the resident to the cardiac monitor." 2) At 12:00 p.m., LPN #1 was asked what happened to the resident on [DATE]. She stated, "her family member had just left around 6 PM. I went right in after he left to make sure the safety mat was in place." The LPN was asked, "Was [MEDICAL CONDITION] then?" She stated, "Yes, and she was resting peacefully, not anxious or anything." The LPN was asked, "Has the resident ever pulled [MEDICAL CONDITION]?" She stated, "No, not that I know of. Not since admission." The LPN was asked, "When was the last time that you checked on the resident?" She stated, "At 6:01 p.m.." The LPN was asked, "Was she unresponsive?" She stated, "No, she was resting peacefully." The LPN was asked, "When did you check on her again? She stated, "At 6:29 p.m., I went in to check on her again. I noticed she had pulled out her trach. I called for the other nurse (LPN #2) to help me. When (LPN #2) got there she was still responsive. (LPN #2) stayed in the room and I went to get the crash cart and called 911. I told them that we needed first responders and an ambulance. When I got back in the room, (CNA #1) had started compressions, (LPN #2) started breaths as soon as we got the ambu bag off of crash cart." The LPN was asked, "Where was the the ambu bag placed?" She stated, "Over her mouth." The LPN was asked, "Was there a perfect seal with bag to mouth?" She stated, "Yes." The LPN was asked, "We did CPR until the ambulance arrived." The LPN was asked, "Are the nurses here trained [MEDICAL CONDITION]?" She stated, "Yes, taking them out and cleaning them." The LPN was asked, "What would you do in an emergent situation?" She stated, "She had completely pulled [MEDICAL CONDITION]." She was asked, "Did you try to put [MEDICAL CONDITION] in?" She stated, "No, I feel that was absolutely out of my scope of practice as an LPN, because I've never been trained in inserting a trach." The LPN was asked, "What kind of emergency supplies do you keep in the room at bedside [MEDICAL CONDITION]?" She stated, "The [MEDICAL CONDITION]." The LPN was asked, "What is in the [MEDICAL CONDITION]?" She stated, "I've never been trained in it, I don't know." The LPN was asked, "Was there an [MEDICAL CONDITION] the resident's room?" She stated, "I don't know." The LPN was asked, "Did the resident respond at all to CPR?" She stated, "At 6:37 p.m., we did feel a pulse again, it was very weak." The LPN was asked, "When doing CPR was there any drainage noted?" She stated, "Yes, she did have a mucus drainage from [MEDICAL CONDITION]." The LPN was asked, "What color was it?" She stated, "I don't remember the color." The LPN was asked, "Are the CNAs here trained in CPR?" She stated, "I don't know." The LPN was asked, "What about the LPN's?" She stated, "I am certified." The LPN was asked, "Does the facility do a BLS or CPR training?" She stated, "In the eight months that I've worked here, I haven't seen one, but they could have had one before I started." The LPN was asked, "Did the resident have an extra [MEDICAL CONDITION] in her room?" She stated, "I'm not sure because I'm not sure what all is in that kit." The LPN was asked, "Did you try to put [MEDICAL CONDITION] in?" She stated, "No." The LPN was asked, "Were there any other CNAs present during the code?" She stated, "No." At 3:40 p.m., LPN #1 was asked via phone call what time was CPR started and she stated, "about 6:26 p.m. or 6:30 p.m." 3) At 1:10 p.m., LPN #2 was asked how long she had worked in the facility. She stated, "Since 2010, I started as a CNA." The LPN was asked, "Did you assist in the CPR (Resident #1 on [DATE])?" She stated, "I did assist. The nurse (LPN #1) came and got me down the hall and told me that she (Resident #1) had pulled [MEDICAL CONDITION] and could I come look at her. I came from 100 hall, went in the room and the resident was holding [MEDICAL CONDITION] her hand. She was breathing and responsive. I asked are you ok? She nodded her head yes. I told her (Resident #1), that I would sit with her until the ambulance arrives, so that we can send her to the hospital [MEDICAL CONDITION]." The LPN was asked, "Were you her nurse that evening?" She stated, "No, the other nurse (LPN #1) was I had stayed over. I was her nurse until the end of that day shift. I turned the pump (feeding) off, unplugged it and was talking with her (Resident #1). At about 6:25 p.m., she took one deep breath in and never exhaled. I knew she was a full code, so I hollered for (LPN #1) to get the crash cart. As she (LPN #1) was on the phone and got hold of them (first responders), I stated, Resident coding, Need first responders now." The LPN was asked, "What did you do when she went unresponsive?" She stated, "I hollered for the crash cart, lowered the bed, and started CPR on her." The LPN was asked, "Who did CPR?" She stated, "I was on the ambu bag, and there was (LPN #2, LPN #3, LPN #4) assisting with compressions, and (CNA #1) started them." The LPN was asked, "When doing the ambu bag was there a tight seal around the mouth?" She stated, "I don't think she had natural teeth, so it was hard, we had to hold it to get it sealed." The LPN was asked, "Are the nurses here trained to care for trachs?" She stated, "We clean them, do routine care and suction trachs ... the only reason that we called (CNA #1) is she had been through EMT school. Nurses, we learned it in nursing school, but they don't require you to keep your CPR license here." The LPN was asked, "Did the resident have an [MEDICAL CONDITION] her room?" She stated, "Yes, she had an [MEDICAL CONDITION] the top drawer." The LPN was asked, "Did you try to put [MEDICAL CONDITION]?" She stated, "No, I didn't because I'm not trained in that. Her PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) levels are high and I didn't want her to bleed out." The LPN was asked, "Was there any drainage seen while doing CPR?" She stated, "Yes." The LPN was asked, "Where?" She stated, "From the trach." The LPN was asked, "Can you describe the drainage?" She stated, "It was brown maybe resembled tube feeding, and blood tinged toward the end of CPR." The LPN was asked, "Did you have any concerns after the Code?" She stated, "My concern is I would like to be trained on the emergency trach. I would like for us to be able to have an AED and CPR would always be a plus, like CPR ongoing training." The LPN was asked, "Do you feel you were competent to handle the situation?" She stated, "Yes, CPR. Not on the emergency trach." 4) At 2:30 p.m., LPN #3 was asked if she assisted with the code involving Resident #1 on [DATE] and she stated, "Yes, I was there." The LPN was asked, if the resident ever took [MEDICAL CONDITION] and she stated, "No, I never knew the resident to take [MEDICAL CONDITION] before." The LPN was asked, "What happened?" She stated, "I was at lunch break. The nurse (LPN#1) from the other side asked (LPN #2) to help her and she called me to the resident's room. (LPN #1) was bringing in the crash cart. (CNA #1) had already started chest compressions. (LPN #2) was doing the ambu bag. She was able to get a good breath in." The LPN was asked, "Around the mouth?" She stated, "Yes, around the mouth. (LPN #1) called 911, I started switching compressions with (CNA #1). First responders arrived and the AED was hooked up. The AED said No shock ordered, continue CPR. AED again said no shock. The EMTs here, hooked the resident up to the monitor, and it showed flat line. They called 'Time UP'." The LPN was asked, "Are the CNA's trained to do CPR?" She stated, "I know (CNA #1) is because she had EMT training." The LPN was asked, "Did the resident have an [MEDICAL CONDITION] in her room?" She stated, "She had an [MEDICAL CONDITION]." The LPN was asked, "Did anyone try to insert [MEDICAL CONDITION]?" She stated, "No one tried to insert an emergency trach." The LPN was asked, "Was there any drainage noted during the code?" She stated, "At first no, she did start having secretions, mucous yellow in color, but then blood tinged toward the end of the code." 5) At 2:35 p.m., the DON was asked, "Are your nurses trained to care for trachs?" She stated, "Yes." The DON was asked, "How often?" She stated, "We have check off sheets with their annual evaluations." The DON was asked, "Are they trained [MEDICAL CONDITION] insertion?" She stated, "No, they have never been checked off on that. I haven't either." The DON was asked, "Are your CNAs trained in CPR?" She stated, "No, we do have some that are trained outside for their classes and so forth, but it is not a requirement to work here." The DON was asked, "Did the resident have an [MEDICAL CONDITION] her room?" She stated, "Yes." The DON was asked, "Do you think the situation was handled well?" She stated, "I do, from what they told me." The DON was asked, "Would you have changed anything with the CPR?" She stated, "Not from what I would do differently, no. I don't think that would have changed the outcome of the situation." The DON was asked, "Do you have any concerns after the situation?" She stated, "For the [MEDICAL CONDITION] if we could get that set up, it would be beneficial to the nurses." The DON was asked, "Have you ever had [MEDICAL CONDITION] come out before?" She stated, "No, we call the ambulance to take them to the hospital, either in Nashville or De Queen." The DON was asked, "Had the resident ever taken [MEDICAL CONDITION] before?" She stated, "No." The Rand McNally Maps/Directions documented the distance from the facility to Nashville was 19 miles and 41 minutes. The distance from the facility to DeQueen was 21 miles, 39 minutes and 13 seconds. At 4:30 p.m., the DON and ADON were asked if they had a policy for emergency [MEDICAL CONDITION] placement and they stated, "No, there was only a policy on [MEDICAL CONDITION] care." 6) At 2:35 p.m., the Assistant Director (ADON) was asked, "Are your nurses trained to care [MEDICAL CONDITION]?" She stated, "Yes." The ADON was asked, "How did they receive that training?" She stated, "In nursing school, and then we have check offs here." The ADON was asked, "How often?" She stated, "When hired, and every month audits. Trachs are not always on monthly audits." The ADON was asked, "Do your nurses know what to do in an emergent situation with a trach?" She stated, "Yes, they know how to care for a trach." The ADON was asked, "Are your CNA's trained to do CPR?" She stated, "It's not required of them to have a CPR license. It's not required of the nurses either who work here to have it. Some of them are trained." The ADON was asked, "Did the resident have an [MEDICAL CONDITION]?" She stated, "Yes." The ADON was asked, "Did anyone try to put [MEDICAL CONDITION] into the resident?" She stated, "To my knowledge, no." 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS, required total assistance of 2 plus persons for activities of daily, and required suctioning and [MEDICAL CONDITION] care. a. The Plan of Care documented, "Problem Date: [DATE], Resident has potential for difficulty breathing related to chronic condition of [MEDICAL CONDITION]. Goal: Resident will be maintained at his respiratory baseline with a patent airway and unlabored respirations through next review date. Approaches: Administer/monitor effectiveness of treatments (see current physicians orders) oxygen nebulizer treatments, suction [MEDICAL CONDITION] care..." b. On [DATE] at 10:06 a.m. the resident was in bed [MEDICAL CONDITION] intact, gauze [MEDICAL CONDITION]. Oxygen was going [MEDICAL CONDITION] 2 LPM. The suction machine was covered and sitting on the bedside table, with suction catheters. There was [MEDICAL CONDITION] on the overbed table, that did not contain an emergency trach. There was no [MEDICAL CONDITION] in the room. At 12:45 p.m., the resident was in bed with O2 on at 2 LPM via trach. There was no [MEDICAL CONDITION] among the supplies in the resident's room. At 4:00 p.m., the DON was asked do you keep an extra [MEDICAL CONDITION] in the resident's room and at the bedside for [MEDICAL CONDITION], and she stated, "Yes, we do." This Surveyor informed her that the resident did not have an [MEDICAL CONDITION] in his room. This Surveyor accompanied the DON to the resident's room. The DON looked in the drawers on the bedside table and in the closet, but did not find an [MEDICAL CONDITION]. c. The [MEDICAL CONDITION] Care Policy Procedure Guidelines documented, "Change [MEDICAL CONDITION] in accordance with established policy ....A replacement [MEDICAL CONDITION] must be available at the bedside at all times ...." 3. On [DATE] at 6:40 p.m., the Medical Director (MD) was asked, "How long have you been Medical Director at the facility?" He stated, "Since 2003." The MD was asked, "How often do you visit the facility?" He stated, "Once a week." The MD was asked, "Do you attend the QA (Quality Assurance) meetings?" He stated, "Yes, every month." The MD was asked, "Can the facility reach you at all times? " He stated, "Yes, they can reach me 24 hours." The MD was asked, "Do you have input into facility policy/procedures?" He stated, "Yes, I do have input." The MD was asked, "Can the facility handle complex/special needs residents, such as trachs?" He stated, "Yes, they have a check off for trachs." The MD was asked, "Were you aware that the facility did not effectively perform CPR and [MEDICAL CONDITION] to (Resident #1) on [DATE]?" He stated, "No, I was not here, I did hear about the incident. No, I did not know about the ineffective CPR or the [MEDICAL CONDITION] care." The MD was also informed of Resident #2 not having an [MEDICAL CONDITION] in his room in the event of an emergent need [MEDICAL CONDITION]. The MD was asked if the facility communicated with him promptly with issues and concerns. He stated, "Yes, I take my own calls, so they can call me twenty four hours." On [DATE] at 12:21 p.m., the Medical Director was interviewed via phone call and asked if he knew that the staff at the facility were not trained in [MEDICAL CONDITION] re-insertion/replacement in the event of an emergent situation?" He stated, "No, I did not." 4. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on [DATE] at 6:00 p.m., when the facility implemented the following plan of removal: At 6:00 p.m., the DON was trained in emergency tracheotomy care by a medical doctor in the emergency room . At 6:50 p.m. the DON adopted a Policy/Procedure for "Emergency [MEDICAL CONDITION] Placement." The DON will train the ADON and both will train at least one employee per shift in the next 24 hours and then all other nurses will be trained by their next scheduled work day on [MEDICAL CONDITION] replacement. Inservice initiated by Nursing Service on proper CPR for residents with tracheotomies and a yearly inservice will be done for nursing staff on CPR and Emergency [MEDICAL CONDITION] replacement. All new hires will be trained on emergency [MEDICAL CONDITION] replacement and CPR during orientation. Rooms of residents with a [MEDICAL CONDITION] must contain all necessary equipment for emergency [MEDICAL CONDITION] care including [MEDICAL CONDITION] Care Kit, Emergency Care Kit (outer cannula, inner cannula, obturator, a towel, sterile water lubricant, gloves, syringe), a suction machine and tubing. Charge Nurse to check to ensure supplies are in proper location once per shift and document it on the resident's MAR (Medication Administration Record). DON or designee will verify that the supplies are available daily. The DON and ADON developed a policy and procedure for emergency [MEDICAL CONDITION] replacement on [DATE] for all new and current residents with a [MEDICAL CONDITION]. The new policy and procedure will be discussed at the October QA meeting with the IDT (Interdisciplinary Team) and will address accordingly. The Medical Director was notified on [DATE] of new policy and procedures and will also attend October QA meeting.

Complaint # (AR 539) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, Nursing Administration failed to ensure staff were trained and competent in emergency procedures in the event of total dislodgement of the [MEDICAL CONDITION] and how to provide [MEDICAL CONDITION] resuscitation during CPR (cardiopulmonary resuscitation) for 1 (Resident #1) and failed to ensure there was a emergency [MEDICAL CONDITION] kit available at the bedside in the event of an emergency situation for 1 (Resident #2) of 2 (Resident #1 and 2) case mix residents who had a [MEDICAL CONDITION]. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #1, who had a [MEDICAL CONDITION] and went into respiratory/[MEDICAL CONDITION], and had the potential affect Resident #2 who had a [MEDICAL CONDITION] according to the Resident Census and Conditions of Residents form dated [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:30 p.m. The findings are: 1. The Job Description: for the DON documented, "Purpose:To manage overall operations of the Nursing Service Department in accordance with facility policies, standards of nursing practices and governmental regulations so as to maintain excellent of all resident needs. Essential Job Functions: Cooperate with the Assistant Director in developing nursing care policies and procedures. Plan, organize and direct in cooperation with the Assistant Director or Executive Director, effective administration of nursing unit and patient care given based on the established goals and objectives, standards, policies and procedures of this facility." 2. Resident #1 was admitted to the facility on [DATE]. The Hospital History and Physical documented, "admitted [DATE] ...Chief Complaint: Found unresponsive at the nursing home. Reason for hospitalization : [MEDICAL CONDITION] with pressor dependent shock. History of Presenting Illness: ...has a history of stroke, [MEDICAL CONDITION], [DIAGNOSES REDACTED] with ejection fraction in the 40% range, history of previous dysphagia and PEG (percutaneous endoscopic gastrostomy) tube placement, history of left [MEDICATION NAME] axillary vein [MEDICAL CONDITION] ([MEDICAL CONDITION], functional [MEDICAL CONDITION], critical illness [DIAGNOSES REDACTED] ...ET (endotracheal tube) got dislodged and subsequent attempts at intubation multiple times were unsuccessful (at local emergency room ) and the patient was transferred here urgently ...further attempts were made in ICU (intensive care unit), but ET tube would not pass beyond vocal chords. Subsequently (Physician) had to be called in urgently and performed an emergent bedside [MEDICAL CONDITION] which was successful in establishing an airway ....The patient was in significant respiratory acidosis at (local medical center) ...Assessment Plan: ...7. Extremely difficult airway with concern for tracheal obstruction which has required emergency [MEDICAL CONDITION]." The resident was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; was totally dependent on 2 plus persons for bed mobility and transfer/locomotion in unit/off unit did not occur; required oxygen therapy, suctioning, [MEDICAL CONDITION] care, and Hospice. a. A DNR (Do Not Resuscitate)/CPR Instructions and Physician order [REDACTED]." A Physician's Telephone/Verbal Order dated [DATE] documented, "Pt. (patient) is a Full Code." b. Nurses Notes dated [DATE] documented the following: 1) 1400 (2:00 p.m.), "Resident resting in bed (with) eyes closed [MEDICAL CONDITION] clear with O2 (oxygen) (at) 2 LPM (liters per minute) via mask..." 2) 1800 (6:00 p.m.), " ...Trach Clear with O2 intact at 2 LPM via mask..." 3) 1810 (6:10 p.m.), "Family member called to check on resident, other family member just left, informed family member that we would keep an eye on the resident." 4) 1829 (6:29 p.m.), "This LPN ((Licensed Practical Nurse) #1) to res (resident) room to check on res. [MEDICAL CONDITION] to be out. This LPN notified other LPN (LPN #2) on duty. When LPN eval (evaluated) res. res responsive, resp (respirations) noted, skin warm to touch, pulse palp (palpable) while assessing res LPN noted resp stopped. LPN called code at 1830 (6:30 p.m.), this LPN (LPN #1) got crash cart (and) called 911, notified need for first responders (and) ambulance. While other LPN began chest compressions. CNA (Certified Nursing Assistant (CNA) #1) assist (with) ambu bag. 1836 (6:36 p.m.), 9 sets of compressions (and) breathing completed.1837 (6:37 p.m.) LPN noted weak thready pulse. CPR continued to try (and) revive pt. (patient). 1840 (6:40 p.m.), While LPN giving compressions noted thick brown secretions exiting through [MEDICAL CONDITION]. 1840 14 sets of compressions (and) breaths completed via ambu bag. First responders arrive on scene. AED (automatic external defibrillator) applied by first responder. AED assessed heart rhythm, no shock advised, compressions continued, 15 sets complete at 1841 (6:41 p.m.) LPN suctioned resident (with) yonker. 1843 (6:43 p.m.)AED advised no shock. Compressions continued. 1845 (6:45 p.m.) 20 sets compressions completed. 1850 (6:50 p.m.) 30 sets completed. AED advised (no) shock. 1851 (6:51 p.m.) 31 sets completed. AED advised (no) shock. 1852 (6:52 p.m.) 32 sets completed. AED advised (no) shock.1853 (6:53 p.m.) 33 sets completed. AED advised (no) shock. 1854 (6:54 p.m.) 37 sets completed (and) AED advised no shock. 1855 (6:55 p.m.) 39 sets completed. EMTs (Emergency Medical Technicians) arrive on scene. EMTs applied heart monitor. No heart rhythm noted. 1856 (6:56 p.m.) medic called time of death. Blood tinged discharge noted [MEDICAL CONDITION]." The Nurses Notes did not document any attempt to re-insert the [MEDICAL CONDITION] when the resident went into respiratory distress. There was no documentation that the staff attempted to maintain the airway through the stoma or to seal the stoma off to maintain an intact airway and ensure adequate ventilation. c. The Volunteer Fire Department EMS (Emergency Medical Service) Incident Record dated [DATE] documented, "Time of Call: 18:30 (6:30 p.m.). Time on Scene: 1837 (6:37 p.m.). Level of Consciousness: Unresponsive. Comments: Arrived on scene to assist nursing home with CPR. We put the AED on her and nurses performed CPR until the ambulance got there." The Ambulance Service Patient Care Record documented, " Time of assessment 1855 (6:55 p.m.) ...Pt (patient) ...unconscious no v/s (vital signs). Pt nurse state they found [MEDICAL CONDITION] out and laying beside the bed pt obvious DOA (dead on arrival) with mild lividity to the back of the arms and buttock area No v/s EKG (electrocardiogram) asystole in all leads Pt DOA." d. On [DATE] the following interviews were conducted: 1) At 11:30 a.m., CNA #1 was interviewed via phone call and asked if she remembered the resident and if she was her caregiver on [DATE]? She stated, "Yes." The CNA was asked, "Was [MEDICAL CONDITION] intact?" She stated, "Yes." The CNA was asked, "Did the resident stop breathing and if so what happened afterwards?" She stated, "Yes, prior to the arrest, I saw her just before 5:00 p.m. I answered the call light and her friend was in there. She seemed uncomfortable, itching behind the strap on her trach. (CNA #2) and I was in the room. She (the resident) nodded yes to do you want your mouth swabbed. After I swabbed her mouth I asked if she was okay, then I left the room and went to assist in the dining room. At 6:30 p.m., I heard my name on the intercom. I met (LPN #2) with the crash cart. When I entered the room [MEDICAL CONDITION] on the bed, I lowered the bed, the resident wasn't breathing." The CNA was asked, "Was CPR started and if so, who performed CPR?" She stated, "Yes, I started compressions, they brought the crash cart. (LPN #2) was at the head giving breaths." The CNA was asked, "Where did she give the breaths?" She stated, "In the mouth with the ambu bag." This Surveyor stated, "I missed that, who gave the breaths and where was the ambu bag placed?" She stated, "The nurse, (LPN #2). The ambu bag was placed on the mouth. Several sets in we felt a weak pulse for 15 seconds. Her heart stopped again. First responders arrived with AED, placed it on and it read, 'No shock, advance continue CPR'." The CNA was asked, "Was any of the family there during that time?" She stated, "No, her friend had left during supper. So, we continued chest compressions. Every now and then I'd look up when (LPN #2) did breaths." The CNA was asked, "Was there a tight seal around the the ambu bag on the mouth? " She stated, "Yes, you could not hear air around the mouth." The CNA was asked, "Have you been trained in BLS (basic life support)/CPR?" She stated, "Yes, I am an EMT trained in CPR and emergent situations at the (name of university)." The CNA was asked, "Was there any drainage noted?" She stated, "Yes, now this is just my opinion, I could see blood and what looked to be tube feeding (formula) coming out [MEDICAL CONDITION]. I could feel that I broke several ribs during chest compressions." The CNA was asked, "Were there any other staff present?" She stated, "Yes, there were three other nurses, (LPNs #1, #3 and #4.)" At 3:45 p.m., CNA #1 was asked via phone call what time was CPR started and she stated, "Not for certain, I believe 6:32 p.m." The CNA was asked, "Did first responders do CPR?" She stated, "No, already in progress they brought an AED." The CNA was asked, "Did the EMTs do CPR?" She stated, "No, they hooked the resident to the cardiac monitor." 2) At 12:00 p.m., LPN #1 was asked what happened to the resident on [DATE]. She stated, "her family member had just left around 6 PM. I went right in after he left to make sure the safety mat was in place." The LPN was asked, "Was [MEDICAL CONDITION] then?" She stated, "Yes, and she was resting peacefully, not anxious or anything." The LPN was asked, "Has the resident ever pulled [MEDICAL CONDITION]?" She stated, "No, not that I know of. Not since admission." The LPN was asked, "When was the last time that you checked on the resident?" She stated, "At 6:01 p.m.." The LPN was asked, "Was she unresponsive?" She stated, "No, she was resting peacefully." The LPN was asked, "When did you check on her again? She stated, "At 6:29 p.m., I went in to check on her again. I noticed she had pulled out her trach. I called for the other nurse (LPN #2) to help me. When (LPN #2) got there she was still responsive. (LPN #2) stayed in the room and I went to get the crash cart and called 911. I told them that we needed first responders and an ambulance. When I got back in the room, (CNA #1) had started compressions, (LPN #2) started breaths as soon as we got the ambu bag off of crash cart." The LPN was asked, "Where was the the ambu bag placed?" She stated, "Over her mouth." The LPN was asked, "Was there a perfect seal with bag to mouth?" She stated, "Yes." The LPN was asked, "We did CPR until the ambulance arrived." The LPN was asked, "Are the nurses here trained [MEDICAL CONDITION]?" She stated, "Yes, taking them out and cleaning them." The LPN was asked, "What would you do in an emergent situation?" She stated, "She had completely pulled [MEDICAL CONDITION]." She was asked, "Did you try to put [MEDICAL CONDITION] in?" She stated, "No, I feel that was absolutely out of my scope of practice as an LPN, because I've never been trained in inserting a trach." The LPN was asked, "What kind of emergency supplies do you keep in the room at bedside [MEDICAL CONDITION]?" She stated, "The [MEDICAL CONDITION]." The LPN was asked, "What is in the [MEDICAL CONDITION]?" She stated, "I've never been trained in it, I don't know." The LPN was asked, "Was there an [MEDICAL CONDITION] the resident's room?" She stated, "I don't know." The LPN was asked, "Did the resident respond at all to CPR?" She stated, "At 6:37 p.m., we did feel a pulse again, it was very weak." The LPN was asked, "When doing CPR was there any drainage noted?" She stated, "Yes, she did have a mucus drainage from [MEDICAL CONDITION]." The LPN was asked, "What color was it?" She stated, "I don't remember the color." The LPN was asked, "Are the CNAs here trained in CPR?" She stated, "I don't know." The LPN was asked, "What about the LPN's?" She stated, "I am certified." The LPN was asked, "Does the facility do a BLS or CPR training?" She stated, "In the eight months that I've worked here, I haven't seen one, but they could have had one before I started." The LPN was asked, "Did the resident have an extra [MEDICAL CONDITION] in her room?" She stated, "I'm not sure because I'm not sure what all is in that kit." The LPN was asked, "Did you try to put [MEDICAL CONDITION] in?" She stated, "No." The LPN was asked, "Were there any other CNAs present during the code?" She stated, "No." At 3:40 p.m., LPN #1 was asked via phone call what time was CPR started and she stated, "about 6:26 p.m. or 6:30 p.m." 3) At 1:10 p.m., LPN #2 was asked how long she had worked in the facility. She stated, "Since 2010, I started as a CNA." The LPN was asked, "Did you assist in the CPR (Resident #1 on [DATE])?" She stated, "I did assist. The nurse (LPN #1) came and got me down the hall and told me that she (Resident #1) had pulled [MEDICAL CONDITION] and could I come look at her. I came from 100 hall, went in the room and the resident was holding [MEDICAL CONDITION] her hand. She was breathing and responsive. I asked are you ok? She nodded her head yes. I told her (Resident #1), that I would sit with her until the ambulance arrives, so that we can send her to the hospital [MEDICAL CONDITION]." The LPN was asked, "Were you her nurse that evening?" She stated, "No, the other nurse (LPN #1) was I had stayed over. I was her nurse until the end of that day shift. I turned the pump (feeding) off, unplugged it and was talking with her (Resident #1). At about 6:25 p.m., she took one deep breath in and never exhaled. I knew she was a full code, so I hollered for (LPN #1) to get the crash cart. As she (LPN #1) was on the phone and got hold of them (first responders), I stated, Resident coding, Need first responders now." The LPN was asked, "What did you do when she went unresponsive?" She stated, "I hollered for the crash cart, lowered the bed, and started CPR on her." The LPN was asked, "Who did CPR?" She stated, "I was on the ambu bag, and there was (LPN #2, LPN #3, LPN #4) assisting with compressions, and (CNA #1) started them." The LPN was asked, "When doing the ambu bag was there a tight seal around the mouth?" She stated, "I don't think she had natural teeth, so it was hard, we had to hold it to get it sealed." The LPN was asked, "Are the nurses here trained to care for trachs?" She stated, "We clean them, do routine care and suction trachs." She stated, "... the only reason that we called (CNA #1) is she had been through EMT school. Nurses, we learned it in nursing school, but they don't require you to keep your CPR license here." The LPN was asked, "Did the resident have an [MEDICAL CONDITION] her room?" She stated, "Yes, she had an [MEDICAL CONDITION] the top drawer." The LPN was asked, "Did you try to put [MEDICAL CONDITION]?" She stated, "No, I didn't because I'm not trained in that. Her PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) levels are high and I didn't want her to bleed out." The LPN was asked, "Was there any drainage seen while doing CPR?" She stated, "Yes." The LPN was asked, "Where?" She stated, "From the trach." The LPN was asked, "Can you describe the drainage?" She stated, "It was brown maybe resembled tube feeding, and blood tinged toward the end of CPR." The LPN was asked, "Did you have any concerns after the Code?" She stated, "My concern is I would like to be trained on the emergency trach. I would like for us to be able to have an AED and CPR would always be a plus, like CPR ongoing training." The LPN was asked, "Do you feel you were competent to handle the situation?" She stated, "Yes, CPR. Not on the emergency trach." 4) At 2:30 p.m., LPN #3 was asked if she assisted with the code involving Resident #1 on [DATE] and she stated, "Yes, I was there." The LPN was asked, if the resident ever took [MEDICAL CONDITION] and she stated, "No, I never knew the resident to take [MEDICAL CONDITION] before." The LPN was asked, "What happened?" She stated, "I was at lunch break. The nurse (LPN#1) from the other side asked (LPN #2) to help her and she called me to the resident's room. (LPN #1) was bringing in the crash cart. (CNA #1) had already started chest compressions. (LPN #2) was doing the ambu bag. She was able to get a good breath in." The LPN was asked, "Around the mouth?" She stated, "Yes, around the mouth. (LPN #1) called 911, I started switching compressions with (CNA #1). First responders arrived and the AED was hooked up. The AED said No shock ordered, continue CPR. AED again said no shock. The EMTs here, hooked the resident up to the monitor, and it showed flat line. They called 'Time UP'." The LPN was asked, "Are the CNA's trained to do CPR?" She stated, "I know (CNA #1) is because she had EMT training." The LPN was asked, "Did the resident have an [MEDICAL CONDITION] in her room?" She stated, "She had an [MEDICAL CONDITION]." The LPN was asked, "Did anyone try to insert [MEDICAL CONDITION]?" She stated, "No one tried to insert an emergency trach." The LPN was asked, "Was there any drainage noted during the code?" She stated, "At first no, she did start having secretions, mucous yellow in color, but then blood tinged toward the end of the code." 5) At 2:35 p.m., the DON was asked, "Are your nurses trained to care for trachs?" She stated, "Yes." The DON was asked, "How often?" She stated, "We have check off sheets with their annual evaluations." The DON was asked, "Are they trained [MEDICAL CONDITION] insertion?" She stated, "No, they have never been checked off on that. I haven't either." The DON was asked, "Are your CNAs trained in CPR?" She stated, "No, we do have some that are trained outside for their classes and so forth, but it is not a requirement to work here." The DON was asked, "Did the resident have an [MEDICAL CONDITION] her room?" She stated, "Yes." The DON was asked, "Do you think the situation was handled well?" She stated, "I do, from what they told me." The DON was asked, "Would you have changed anything with the CPR?" She stated, "Not from what I would do differently, no. I don't think that would have changed the outcome of the situation." The DON was asked, "Do you have any concerns after the situation?" She stated, "For the [MEDICAL CONDITION] if we could get that set up, it would be beneficial to the nurses." The DON was asked, "Have you ever had [MEDICAL CONDITION] come out before?" She stated, "No, we call the ambulance to take them to the hospital, either in Nashville or De Queen." The DON was asked, "Had the resident ever taken [MEDICAL CONDITION] before?" She stated, "No." The Rand McNally Maps/Directions documented the distance from the facility to Nashville was 19 miles and 41 minutes. The distance from the facility to DeQueen was 21 miles, 39 minutes and 13 seconds. At 4:30 p.m., the DON and ADON were asked if they had a policy for emergency [MEDICAL CONDITION] placement and they stated, "No, there was only a policy on [MEDICAL CONDITION] care." 6) At 2:35 p.m., the Assistant Director (ADON) was asked, "Are your nurses trained to care [MEDICAL CONDITION]?" She stated, "Yes." The ADON was asked, "How did they receive that training?" She stated, "In nursing school, and then we have check offs here." The ADON was asked, "How often?" She stated, "When hired, and every month audits. Trachs are not always on monthly audits." The ADON was asked, "Do your nurses know what to do in an emergent situation with a trach?" She stated, "Yes, they know how to care for a trach." The ADON was asked, "Are your CNA's trained to do CPR?" She stated, "It's not required of them to have a CPR license. It's not required of the nurses either who work here to have it. Some of them are trained." The ADON was asked, "Did the resident have an [MEDICAL CONDITION]?" She stated, "Yes." The ADON was asked, "Did anyone try to put [MEDICAL CONDITION] into the resident?" She stated, "To my knowledge, no." 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS, required total assistance of 2 plus persons for activities of daily, and required suctioning and [MEDICAL CONDITION] care. a. The Plan of Care documented, "Problem Date: [DATE], Resident has potential for difficulty breathing related to chronic condition of [MEDICAL CONDITION]. Goal: Resident will be maintained at his respiratory baseline with a patent airway and unlabored respirations through next review date. Approaches: Administer/monitor effectiveness of treatments (see current physicians orders) oxygen nebulizer treatments, suction [MEDICAL CONDITION] care..." b. On [DATE] at 10:06 a.m. the resident was in bed [MEDICAL CONDITION] intact, gauze [MEDICAL CONDITION]. Oxygen was going [MEDICAL CONDITION] 2 LPM. The suction machine was covered and sitting on the bedside table, with suction catheters. There was [MEDICAL CONDITION] on the overbed table, that did not contain an emergency trach. There was no [MEDICAL CONDITION] in the room. At 12:45 p.m., the resident was in bed with O2 on at 2 LPM via trach. There was no [MEDICAL CONDITION] among the supplies in the resident's room. At 4:00 p.m., the DON was asked do you keep an extra [MEDICAL CONDITION] in the resident's room and at the bedside for [MEDICAL CONDITION], and she stated, "Yes, we do." This Surveyor informed her that the resident did not have an [MEDICAL CONDITION] in his room. This Surveyor accompanied the DON to the resident's room. The DON looked in the drawers on the bedside table and in the closet, but did not find an [MEDICAL CONDITION]. c. The [MEDICAL CONDITION] Care Policy Procedure Guidelines documented, "Change [MEDICAL CONDITION] in accordance with established policy ....A replacement [MEDICAL CONDITION] must be available at the bedside at all times ...." 3. On [DATE] at 6:40 p.m., the Medical Director (MD) was asked, "How long have you been Medical Director at the facility?" He stated, "Since 2003." The MD was asked, "How often do you visit the facility?" He stated, "Once a week." The MD was asked, "Do you attend the QA (Quality Assurance) meetings?" He stated, "Yes, every month." The MD was asked, "Can the facility reach you at all times? " He stated, "Yes, they can reach me 24 hours." The MD was asked, "Do you have input into facility policy/procedures?" He stated, "Yes, I do have input." The MD was asked, "Can the facility handle complex/special needs residents, such as trachs?" He stated, "Yes, they have a check off for trachs." The MD was asked, "Were you aware that the facility did not effectively perform CPR and [MEDICAL CONDITION] to (Resident #1) on [DATE]?" He stated, "No, I was not here, I did hear about the incident. No, I did not know about the ineffective CPR or the [MEDICAL CONDITION] care." The MD was also informed of Resident #2 not having an [MEDICAL CONDITION] in his room in the event of an emergent need [MEDICAL CONDITION]. The MD was asked if the facility communicated with him promptly with issues and concerns. He stated, "Yes, I take my own calls, so they can call me twenty four hours." On [DATE] at 12:21 p.m., the Medical Director was interviewed via phone call and asked if he knew that the staff at the facility were not trained in [MEDICAL CONDITION] re-insertion/replacement in the event of an emergent situation?" He stated, "No, I did not." 4. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on [DATE] at 6:00 p.m., when the facility implemented the following plan of removal: At 6:00 p.m., the DON was trained in emergency tracheotomy care by a medical doctor in the emergency room . At 6:50 p.m. the DON adopted a Policy/Procedure for "Emergency [MEDICAL CONDITION] Placement." The DON will train the ADON and both will train at least one employee per shift in the next 24 hours and then all other nurses will be trained by their next scheduled work day on [MEDICAL CONDITION] replacement. Inservice initiated by Nursing Service on proper CPR for residents with tracheotomies and a yearly inservice will be done for nursing staff on CPR and Emergency [MEDICAL CONDITION] replacement. All new hires will be trained on emergency [MEDICAL CONDITION] replacement and CPR during orientation. Rooms of residents with a [MEDICAL CONDITION] must contain all necessary equipment for emergency [MEDICAL CONDITION] care including [MEDICAL CONDITION] Care Kit, Emergency Care Kit (outer cannula, inner cannula, obturator, a towel, sterile water lubricant, gloves, syringe), a suction machine and tubing. Charge Nurse to check to ensure supplies are in proper location once per shift and document it on the resident's MAR (Medication Administration Record). DON or designee will verify that the supplies are available daily. The DON and ADON developed a policy and procedure for emergency [MEDICAL CONDITION] replacement on [DATE] for all new and current residents with a [MEDICAL CONDITION]. The new policy and procedure will be discussed at the October QA meeting with the IDT (Interdisciplinary Team) and will address accordingly. The Medical Director was notified on [DATE] of new policy and procedures and will also attend October QA meeting.