Every finding on record at The Blossoms at Woodland Hills Rehab & Nursing Cen

Based on interview and record review the facility failed to protect the residents' right to be free from neglect. Specifically, the facility failed to obtain a urine sample in a timely manner to rule out a Urinary Tract Infection (UTI) for Resident #1 and failure to order an antibiotic in a timely manner for Resident #1 to treat a UTIIt was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to eCFR S483.12(Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K.The IJ began on [DATE] at 6:02 PM, when Resident #1 had a written physician order to obtain a Urinary Analysis (UA) to rule out a UTI. On [DATE] at 6:06 PM, according to a lab report, resident's urine sample was obtained. On [DATE] at 11:46 AM, the lab report contained a critical result which required antibiotic treatment that was not received. The Administrator and Director of Nursing (DON) were notified of IJ on [DATE] at 1:14 PM. A removal plan was requested. The removal plan was accepted by the State Agency on [DATE] at 7:23 PM.The findings include: Review of an admission Record revealed Resident #1 was admitted on [DATE] with diagnoses which included dementia, encephalopathy, urinary incontinence, bipolar disorder, anxiety, and painful micturition [urination]. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had a Staff Assessment of Mental Status (SAMS), which indicated the resident was moderately impaired for decision making. The MDS also included that Resident #1 was frequently incontinent with urine, and occasionally incontinent with bowel. Review of Resident #1's Care Plan, initiated on [DATE], revealed the medical doctor should be called as needed for agitation, confusion, and change in eating habits. Review of a Physician Order dated [DATE] indicated to obtain a Urine Analysis (UA) [urine test] to rule out UTI and treat if indicated. The order was signed as being entered by Assistant Director of Nursing (ADON) #1 and dated [DATE]. Review of a Lab Results Report with a collection date of [DATE] revealed Resident #'s1 lab results indicated positive for a UTI and was flagged as a critical result. Review of an Order Note dated [DATE] revealed an order for an antibiotic to be given one capsule by mouth four times a day for UTI for five days. The medication order was created by Assistant Director of Nursing (ADON) #2. Review of the Medication Administration Record (MAR) with a start date of [DATE] revealed a Physician Order for an antibiotic to be given four times a day for five days. Review of Progress Notes dated [DATE] at 12:35 PM and [DATE] at 6:38 PM electronically signed by LPN #2 revealed a note text indicating med not available. Review of a Progress Note dated [DATE] at 1:25 AM and electronically signed by LPN #5 revealed a note text indicating could not locate med.Review of a Visit Note dated [DATE] revealed Advanced Practice Registered Nurse (APRN) #2 indicated the reason for the visit was to follow up on lab. The note indicated that Resident #1 did not interact much and was not eating and drinking on their own. The note indicated that Resident #1 was on antibiotics for a UTI, and labs for chloride, calcium, and lithium were elevated. The note indicated to send Resident #1 to the emergency room if the resident was not willing to take in more fluids. Review of Resident #1's Hospital Records dated [DATE] indicated that Resident #1 was admitted to the Intensive Care Unit on [DATE]. The Hospital Records indicated that Resident #1 was admitted with a diagnosis of septic shock (a life-threatening infection), respiratory failure, strep pneumonia (bacterial infection), acute kidney failure, leukocytosis (high white blood cell count), and metabolic acidosis (results from kidney failure). The hospital records also indicated that Resident #1 was pronounced deceased on [DATE] at 1:33 AM. During a phone interview on [DATE] at 10:32 PM, a visitor for Resident #1 indicated she came to visit Resident #1 on [DATE] and Resident #1 was not their normal self. The visitor indicated that Resident #1 was usually walking around and talking, and on [DATE] the resident was in bed moaning, scratching their skin, and appeared to be in pain. The visitor indicated that she was informed by Licensed Practical Nurse (LPN) #2 that Resident #1 had not had anything to eat or drink in a couple of days. The visitor indicated that LPN #2 stated, Resident #1 needed an Intravenous (IV) antibiotic, but he was scared she would pull it out. The visitor indicated that she asked LPN #2 to send Resident #1 to the hospital. The visitor indicated that Resident #1 was sent to the hospital and the visitor had received report that Resident #1's UTI had become septic (a life-threatening medical emergency), and that Resident #1 was in organ failure, had pneumonia, and strep. This information was verified by surveyor review of the hospital records. The visitor stated that she felt the facility was neglectful in caring for Resident #1. During an interview on [DATE] at 11:15 AM, Certified Nursing Assistant (CNA) #13 indicated that she had been employed for one and a half years at the facility. CNA #13 indicated that Resident #1 was walking when the resident was first admitted to the facility. CNA #13 indicated that she had reported to the nurses that Resident #1 was hurting a lot but that she did not remember what nurses she informed. During an interview on [DATE] at 12:40 PM, ADON #2 indicated that she had been employed at the facility for two weeks. ADON #2 indicated that the APRN would write orders on a handwritten physician order note and would give the nurses and ADON #2 a copy of the orders. ADON #2 indicated that she would put the orders in the electronic system if the nurses did not put the order in. ADON #2 indicated that ADON #1 had put the urine lab order in the system for Resident #1. ADON #2 indicated that ADON #1's last day had been on [DATE]. ADON #2 indicated that when lab orders were received, they go directly on the MAR. ADON #2 indicated that lab orders fall off the MAR within 24-48 hours after they were placed on the MAR. ADON #2 indicated that if the nurse could not obtain a urine specimen, then the oncoming nurse should be informed until the urine specimen was obtained. During a phone interview on [DATE] at 1:39 PM staff at [the local Pharmacy ] indicated that her records indicated that facility staff did not pull an antibiotic from the [Name Brand] emergency medication dispensing cabinet. During a phone interview on [DATE] at 1:58 PM, the account manager from [the local Pharmacy ] indicated that there were no medications pulled from the [Name Brand] emergency medication dispensing cabinet for Resident #1 while a resident at this facility. During a phone interview on [DATE] at 2:34 PM, with a staff member at [the local Pharmacy ] she indicated that she received a call from an unknown staff member at the facility on [DATE] at 11:30 AM with a request to order an antibiotic for Resident #1. She indicated that she reviewed all of Resident #1's records and there was not a request for this medication prior to [DATE]. During an interview on [DATE] at 2:45 PM, ADON #2 indicated that she faxed the order for Resident #1's antibiotic to the pharmacy on [DATE]. She indicated that she never received the confirmation report that the pharmacy received the order. ADON #2 indicated that the administrator also faxed orders. ADON #2 indicated that if the nurses had an order for an antibiotic, they should get it from the emergency kit within two hours. ADON #2 indicated that the antibiotic ordered for Resident #1 should have been in the emergency kit. ADON #2 indicated that if the antibiotic was not in the emergency kit, the nurses should call the pharmacy so that the medication could be delivered the same day. During an interview on [DATE] at 3:20 PM, the DON indicated that Adult Protective Services called the administrator and requested that Resident #1 be sent to the hospital on [DATE]. The DON indicated she had not completed an assessment on Resident #1, that the ambulance had already picked Resident #1 up to go to the hospital when she made it to the residents' room to perform an assessment. During a phone interview on [DATE] at 3:25 PM, ADON# 1 indicated that she wanted to obtain a UA on Resident #1 because the resident was not acting normally. ADON #1 indicated that she put the order in the computer for the urine sample on [DATE]. ADON #1 indicated that the floor nurses were responsible for obtaining the urine samples. ADON #1 indicated that she did not contact the doctor when she was not able to get the urine sample. ADON #1 indicated that she gave Resident #1 more water and informed LPN #12 that a urine sample was needed for Resident #1. During an interview on [DATE] at 3:35 PM, LPN #2 indicated that if medication was not available the number 9 was put in a box on the medication record indicating the medication was not available. LPN #2 indicated that the pharmacy should be called if a medication was not available. LPN #2 indicated that he called the pharmacy informing them that the antibiotic was needed for Resident #1. LPN #2 indicated that he did not recall what day he contacted the pharmacy. LPN #2 indicated that he was not sure if he checked the emergency stock for the medication. LPN #2 indicated that when medication was not available the pharmacy would usually bring the medication the evening the mediation was ordered. LPN #2 indicated that the nurses inform the oncoming nurse in report if a urine sample was needed. LPN #2 indicated that the information was passed to each nurse, on every shift until the urine sample was obtained. LPN #2 indicated that he was never informed that a urine sample was needed for Resident #1. During a phone interview on [DATE] at 12:24 AM, LPN #5 indicated that she saw Resident #1 once before the resident went to the hospital. LPN #5 indicated that it was at night when she saw Resident #1 and the resident was OK. LPN #5 indicated that she could not remember if she ordered the antibiotic for Resident #1. LPN #5 indicated that the floor nurses were responsible for getting the urine samples. LPN #5 indicated that she was never informed that Resident #1 needed a urine sample. During an interview on [DATE] at 8:53 AM, the DON indicated that the lab staff (an outside vendor) were not responsible for collecting urine samples, the facility staff collect the urine samples, and the lab staff pick up the samples. During an interview on [DATE] at 9:05 AM, LPN #12 indicated that she had been employed at the facility over a year on an as needed basis. LPN #12 indicated that Resident #1 walked around and required prompting to take medications. LPN #12 indicated the APRN would give the floor nurse, DON, and ADON a copy of all orders. LPN #12 indicated that the nurses were responsible for putting the orders in the electronic system. LPN #12 indicated that the orders will show up on the medication record after they were put in the electronic system. LPN #12 indicated that the lab (outside vendor) picked up urine samples after it was collected by the nurses. LPN #12 indicated that she was informed to attempt to collect urine on Resident #1. LPN #12 indicated that ADON #1 informed her that she could not do an in and out catheter on Resident #1. LPN #12 indicated that Registered Nurse (RN) #11 obtained the urine sample for Resident #1 but was not sure what day the urine sample was obtained. LPN #12 indicated that a requisition was printed off and placed on the tubing. LPN #12 indicated that if the lab order to obtain a urine specimen was on the medication record, then the nurse should sign it indicating that it was completed. During a phone interview on [DATE] at 9:33 AM, APRN #2 indicated that when an order was given for a urine culture, it was expected to be collected that day. APRN #2 indicated that the nurses should call one of the APRN's or the doctor if they were not able to collect the urine sample. APRN #2 indicated that she was not contacted about staff not being able to get a urine sample for Resident #1. APRN #2 indicated that she expected the nurses to give antibiotics the same day they were ordered. APRN #2 indicated that the pharmacy usually delivered antibiotics the evening they were ordered. APRN #2 indicated that she was not notified that the antibiotic was not available for Resident #1. APRN #2 indicated that a UTI should not be left untreated. APRN #2 indicated that she assumed the antibiotic was being given as ordered. During a phone interview on [DATE] at 9:57 AM, the Medical Director (MD) indicated that he expected urine to be collected the same day for lab orders. The MD indicated that urine should be collected within 24-48 hours after a UA was ordered to rule out a UTI. The MD indicated that he expected the nurses to contact him or the APRN'S if they could not get the specimen, and if the lab results were out of range. The MD indicated that he was not aware of any delays staff experienced obtaining the urine specimen for Resident #1. The MD indicated that he saw Resident #1 on [DATE] before the resident was discharged . The MD indicated that Resident #1 looked dehydrated, when he had seen the resident on [DATE]. The MD indicated that he informed the staff to send Resident #1 to the emergency room if the resident did not drink anything. The MD indicated that Resident #1 was sent to the hospital the next day. During an interview on [DATE] at 10:10 AM, APRN #3 indicated when a urine sample was ordered she expected the nurses to get the urine sample the same day. APRN #3 indicated that she was never notified that nurses could not obtain a lab for Resident #1 and had not found out the labs were not obtained until she was at the facility to see the residents. APRN #3 indicated that she has had a lot of problems with the facility not completing orders that she had given them. APRN #3 indicated that she would give the original orders to the Administrator. APRN #3 indicated that she started scanning the orders, and sending them to herself, ADON #1, ADON 2, DON, DON #2, admissions director, and the administrator, because she would write orders three or four times and they were not being completed. APRN #3 indicated that all doctor orders were written on paper orders and the nurses put the orders in the electronic system. APRN #3 indicated that a urine sample to check for a UTI was collected if the resident was having symptoms, and any time a UTI was not treated it could lead to sepsis. During an interview on [DATE] at 11:55 AM, the Administrator indicated that she was not a nurse, and she was not sure how the nurses communicated the lab orders for urine specimens. The Administrator indicated that the nurses should contact the doctor if an antibiotic was not available the same day that it was ordered. During a phone interview on [DATE] at 4:34 PM, LPN #7 indicated the pharmacy should be contacted when a medication was not available. LPN #7 indicated that an unknown Medication Technician (Med Tech) was giving medications when she arrived at work on [DATE]. LPN #7 indicated that she was not sure if the Med Tech had given Resident #1 the antibiotic. LPN #7 indicated that Resident #1 didn't get her antibiotic on [DATE] because of the lack of communication. LPN #7 indicated that she signed the medication off on the medication record on [DATE] at 8:00 PM, and on [DATE] at 6:00 AM although she did not give it. LPN #7 indicated that the floor nurse at the time that the lab order for urine was given would be responsible for getting the urine sample. LPN #7 indicated that she did not recall anyone telling her that a urine sample that was needed for Resident #1. LPN #7 stated nurses should notify the oncoming nurse if they were not able to obtain a urine sample until the sample was collected, and the doctor should be notified if a urine sample was not able to be obtained. During an interview on [DATE] at 8:10 AM, the DON indicated that she started working at the facility on [DATE]. The DON indicated that urine lab orders would stay on the MAR for 24-48 hours and then it would fall off. The DON indicated that if the nurses did not get the urine sample in 48 hours, they must inform the next nurse until the lab was collected. During a phone interview on [DATE] at 8:55 AM, RN #11 indicated that she had been off since [DATE] and returned to work on [DATE]. RN #11 indicated that she did not work with Resident #1 until [DATE] after returning to work. RN #11 indicated that Resident #1 was walking without assistance in January, but when RN #11 returned in April the resident was not walking. RN #11 indicated that she did not have any problems getting the lab for Resident #1. RN #11 indicated that the nurse that relieved her did not tell her that Resident #1 needed lab but was made aware that Resident #1 had an order to obtain a urine specimen through a group message on her personal phone that she received on [DATE]. RN #11 indicated that communication was not good between the nurses, and the nurses did not update the nurse reports. RN #11 indicated that the lab orders fall off the MAR after they were in the system for so long, and if you were not told a resident had lab orders, then you would not know. During a phone interview on [DATE] at 4:45 PM, APRN #1 indicated that she wrote an order for a urine sample to be obtained for Resident #1 on [DATE]. APRN #1 indicated that Resident #1 was usually up moving around, but when she saw the resident on [DATE], the resident was not acting normally. APRN #1 indicated that she expected the nurses to obtain the urine sample immediately, but at least within 24 hours of when the order was placed. APRN #3 indicated that when she wrote an order, she gave a copy to the nurse assigned to the resident, ADON, DON, and the Administrator. Review of a facility policy titled, Abuse, Neglect, and Exploitation revealed that neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when a facility is aware of, or should have been aware of, goods or services that a resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort of safety, resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Staff are trained upon hire, during orientation, then annually, on the policy regarding reporting abuse, the types of abuse, detecting abuse, and the recognition of signs and symptoms of abuse which include, but are not limited to, the following: unexplained crying, sudden change in mood or behaviors, suspiciousness, suspicious behaviors on the part of family or caregivers. Review of a facility policy titled, Resident Rights revealed that residents have the right to equal access to quality of care. Review of a facility policy titled, Medication Administration revealed that the Director of Nursing Services will supervise and direct all nursing personnel who administer medications. Medications must be administered according to orders, including required time frames. The individual administering the medication will record in the resident's medical record the signature and title of the person administering the medication. Review of a facility in-service form titled, In-service Education Report revealed an in-service was conducted on abuse and neglect on [DATE]. The form had 13 signatures on it.Removal Plan:On [DATE] immediately on notification DON initiated in-service with nurses working on the floor to ensure nurses were doing the following: -putting lab orders in the computer as Physician Ordered,- collecting lab specimens based on urgency, facility workflow, and lab access, with routine being collected within 24 hours and stat collected as soon as possible on the same day while respecting resident rights to participate in the lab collection, -notifying Physicians of problems obtaining labs -notifying Physician of critical results to be completed immediately, for residents that currently reside in the facility and newly admitted . Resident #1 no longer resides in the facility. On [DATE] immediately on notification the DON initiated in-services with nurses currently working on the following: -ordering medication based on urgency, facility workflow, and pharmacy access. - Routine medication will be ordered the same day, new meds needed soon but not stat will be ordered immediately after the order was written, or stat should be ordered immediately for current residents and newly admitted , Resident #1 no longer resides in the facility. On [DATE], 101 residents have the potential to be affected that reside in the facility according to the census.On [DATE], DON/Unit Manager initiated match back with Physician Orders and lab requisition for the past month to ensure nurses were:- putting lab orders in the computer as Physician Ordered,- collecting lab specimens based on urgency, facility workflow, and lab access, with routine [orders] being collected within 24 hours and stat collected as soon as possible on the same day while respecting resident rights to participate in the lab collection, -notifying Physicians of problems obtaining labs and -notifying Physician of critical results immediately, for current residents, with no negative findings.On [DATE], DON/Unit Manager interviewed nurses on duty, for current residents, to ensure Physicians have been notified of problems obtaining lab and critical labs have been reported, with no negative findings. On [DATE], DON/Unit Manager initiated match back with Physician Orders and medications for the past month for current residents to ensure the facility ordered medication in a based on urgency, facility workflow, and pharmacy access. Routine medication will be ordered the same day, new meds that were needed soon but not stat would be ordered immediately after the order was written, or stat should be ordered immediately for residents with the potential to be affected. The facility completed all medication reviews on [DATE] for current residents, last 30 days, with no negative findings. On [DATE] DON/Unit manager began re-education of all nurses currently working and DON/Designee would provide 1:1 education with all nurses, using an employee nurse roster, either in-person or via phone prior to starting their next shift to ensure nurses were putting lab orders in the computer as Physician Ordered, collecting lab specimens based on urgency, facility workflow, and lab access, with routine being collected within 24 hours and stat collected as soon as possible same day while respecting resident rights to participate in the lab collection, notifying Physicians of problems obtaining labs and notifying Physician of critical results would be done immediately.On [DATE] DON began re-education of all nurses currently working and DON/Designee would provide 1:1 education with all nurses using an employee nurse roster, either in-person or via phone prior to starting their next shift on duty on ordering Medication in a based on urgency, facility workflow, and pharmacy access: Routine medication would be ordered the same day, new meds needed soon but not stat will be ordered immediately after the order was written, or stat should be ordered immediately prior to starting their shift. Beginning [DATE] DON/Unit Manager during clinical start-up will complete a clinical start up sheet to document the match back with Physician Orders and lab requisition using a log to ensure nurses were putting lab orders in the computer as Physician Ordered, collecting lab specimens based on urgency, facility workflow, and lab access, with routine being collected within 24 hours and stat collected as soon as possible same day while respecting resident rights to participate in the lab collection, notifying Physicians of problems obtaining labs and notifying Physician of critical results would be done immediately, to prevent re-occurrence. Beginning [DATE] DON/Unit Manager during clinical start-up would complete a clinical start up sheet to document match back Physician Orders and medications to ensure the facility ordered the medication based on urgency, facility workflow, and pharmacy access. Routine medication will be ordered the same day, new meds needed soon but not stat will be ordered immediately after the order was written, or stat should be ordered immediately to prevent re-occurrence. DON/designee using a start-up form will observe lab orders, Physician Orders, 24-hour communication sheets, and lab floor to ensure nurses were putting lab orders in the computer as Physician Ordered, collecting labs specimen based on urgency, facility workflow, and lab access, with routine being collected within 24 hours and stat collected as soon as possible same day while respecting resident rights to participate in the lab collection, notifying physician of problems obtaining labs and notifying Physician or critical results would be done immediately. Monitoring would be three times a week for eight weeks, making corrections as necessary and reporting negative findings to the administrator.DON/designee using a monitoring log will observe Physician Orders and medications to ensure medications were ordered based on urgency, facility workflow, and pharmacy access. Routine medication would be ordered the same day, new meds needed soon but not stat will be ordered immediately after the order was written, or stat should be ordered immediately this would be monitored for three times a week for eight weeks, making corrections as necessary and reporting negative findings to the administrator.DON/designee will report negative findings to the QAPI committee for review and recommendations. Onsite verification of the Removal Plan began on [DATE] at 11:25 AM, The IJ was removed on [DATE] at 12:35 PM after the survey team performed onsite verification that the Removal Plan had been implemented. when on [DATE], at 1:14 PM, it was determined that the following occurred on [DATE] at 6:02 PM:Element 1: Resident #1 had a written Physician Order to obtain a urinary analysis (UA) to rule out a urinary tract infection. On [DATE] at 6:06 PM, according to a lab report, resident's urine sample was obtained. On [DATE] at 11:46 AM, the lab report contained a critical result. Facility immediately began in-services, with nurses on the floor, for entering physician orders into the computer, collecting lab specimens based on urgency, lab access with routine being collected within 24 hours and stat collected as soon as possible, same day, physician notification of issues obtaining labs and notifying physician of critical results. In-services with nurses currently working on ordering medication based on urgency, facility workflow and pharmacy access. Routine medications ordered the same day, new medications needed soon, not stat, ordered immediately after the order is written or stat should be ordered immediately for current residents and newly admitted residents. Element 2: The Director of Nurses initiated a match back of lab requisitions with physician orders for the past month. Interviewed nurses on duty for current residents to ensure physicians have been notified of problems obtaining lab and critical labs have been reported. A match back of medications with physician orders for the past month. Element 3: DON/Unit manager began 1:1 re-education of all nurses currently working using nurse roster, in person or via telephone prior to starting the next shift, on putting lab orders into the computer, collecting lab specimens, lab access and notification of physician with problems obtaining specimens and critical lab results. DON/Unit manager began 1:1 re-education on medication ordering. Element 4: DON/Unit Manager during clinical start-up will complete start up sheet to document match back with physician orders and lab requisition using log to ensure nurses are putting lab orders in the computer, physician ordered collecting lab specimens and lab access, notifying physician of problems obtaining labs and notifying physician of critical results. Complete clinical start-up sheet to document match back physician orders and medications. Element 3: DON/designee using start up form will observe lab orders, physician orders I the computer as physician ordered, collecting lab specimens, notifying physician of problems obtaining labs and notifying physician of critical results will be done immediately, three times a week for 8 weeks. Using monitoring log will observe physician orders and medications to ensure mediations are ordered based on urgency 3 times a week for 8 weeks. DON/designee will report negative findings to the QAPI committee for review and recommendations. A total of 11 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Administrator, Director of Nursing, Registered Nurses, Licensed Practical Nurses, and Certified Medication Tech (CMT). The staff interviewed verified they had been trained on how to take and enter a physician order for medications into the computer, how to notify the pharmacy of the order, routine medication versus stat order, checking the emergency kit, reordering medication, identifying sexual abuse, how to report, and who to report to. How to enter lab orders into the computer, how to notify the laboratory, collect routine and stat labs, obtaining results, notifying physicians of problems obtaining labs and notifying physician of critical labs results. During an interview, the DON explained the match back process and reporting of findings. A review of in-service sheets provided indicated 24 of 37 staff in-serviced were provided training. Those staff who were not physically present to receive the 1:1 in-services were provided with the 1:1 by telephone or in-service prior to the start of their next shift. 13 of the 37 were PRN who had not worked and were terminated. A review of CMT, LPN and RN statements indicated physicians were notified of problems obtaining lab and critical labs were provided to physicians. A review of the QAPI meeting indicated 8 members in attendance for Ad Hoc meeting on deficiency findings. A review of match back documents provided by DON indicated all medication orders and lab orders were reviewed with no negative findings.

Based on observations, interviews, and facility document review, it was determined that the facility failed to ensure a Licensed Practical Nurse (LPN) held an active and unencumbered license while working in the facility as an LPN. Based on interviews, facility document review, and facility policy reviews, it was determined that the facility failed to ensure a Licensed Practical Nurse (LPN) held an active and unencumbered license while working in the facility as an LPN. The findings include: During an interview on [DATE] at 1:29 PM, the Administrator indicated the facility does utilize agency nurses. She reported that the agency hires the nurses, verifies the nurse's credentials and that the facility does not verify the nurse's credentials. She stated, We do not have a policy for hiring agency nurses. She indicated the facility does not keep an employee record for agency nurses. During an interview on [DATE] at 4:07 PM, the Administrator indicated LPN #10 worked at the facility through an agency starting in [DATE] and applied to work for the facility in [DATE]. She reported she found out on [DATE] that LPN #10 had an expired license. She stated LPN #10 did work here after that date but it was through the agency, so the license was good then. During an interview on [DATE] at 9:13 AM, the Administrator reported LPN #10 did not work in the facility [DATE] through [DATE] and LPN #10 was not hired at the facility. Review of the facility's Employee File, for LPN #10 revealed a hire date for LPN #10's of [DATE] and a date of termination was [DATE]. Review of an Agency Documentation of Dates and Times document indicated LPN #10 worked 18 shifts through the agency in the facility from [DATE] through [DATE], including [DATE], [DATE] and [DATE]. Review of an Employee Arkansas State Board of Nursing (ASBN) Probation Noncompliance document dated [DATE], indicated on [DATE] LPN #10 entered an eighteen-month contract with ASBN indicating LPN #10's licensure placed on probation. Also indicated LPN #10, shall not secure employment or be employed through a staffing agency. Review of an employee record titled QuickConfirm License Verification Report, indicated the facility confirmed on Tuesday [DATE], at 7:13 am that LPN #10 did not have an active license and license status was expired as of [DATE]. Review of a facility document titled, Licensed Practical Nurse (LPN) Job Description indicated the LPN must possess a current, unencumbered, active license to practice as an LPN in this state. Review of a facility policy titled, PP The Blossoms at AR New Employee/Hiring Policy indicated pre-employment screenings and new hire paperwork are completed to ensure health and safety of staff and residents. General guidelines included license verification licensure verification must be completed on all new hires if applicable.

Based on observations, interviews, and record reviews, the facility failed to provide nail care for one (Resident #6) of three residents reviewed for nail care, and to ensure staff answered one (Resident #8) of four resident ' s call lights in a timely manner. The findings include: 1. A review of Resident #6 ' s Order Summary Report indicated the facility admitted the resident on 11/22/2024, with diagnosis which included type 2 diabetes mellitus without complications. Resident #6 ' s Order Summary Report also indicated the resident should be evaluated by a podiatrist and treated as needed. A review of Resident #6 ' s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A review of Resident #6 ' s Care Plan initiated 12/03/2024, revealed the resident was independent with all activities of daily living, but required cueing at times. The Care Plan had interventions which included to check fingernails and toenails, trim as needed and to notify the nurse if the resident was a diabetic. During an interview on 06/26/2025 at 9:20 AM, Resident #6 indicated their toenails had not been cut since they were admitted on [DATE]. The resident stated when they took showers, the aides would tell the resident they used to cut toenails, but they did not anymore. Resident #6 indicated they were told by staff a week and a half ago they were going to cut the resident ' s nails. During an interview on 06/26/2025 at 9:20 AM, the Assistant Director of Nursing (ADON) indicated Resident #6 ' s toenails were clipped by the podiatrist, as needed. During an interview on 06/26/2025 at 9:46 AM, Licensed Practical Nurse (LPN) #1 stated the Certified Nursing Aides (CNAs) were responsible for cutting Resident #6's toenails, because the resident was not an active blood sugar check. During an observation on 06/26/2025 at 9:47 AM, CNA #3 removed both of Resident #6's socks. The resident ' s toenails were approximately 1/2 to 1 inch long. Some of the resident ' s toenails were curved and had sharp points on them. Resident #6's feet were dry with white flakes. CNA #3 stated the aides did not cut Resident #6's toenails, because the resident was diabetic. During an interview on 06/26/2025 at 9:48 AM, Resident #6 stated their toenails were sharp, and that they could only wear open-toed shoes because their toenails were too long to wear regular shoes. During a concurrent interview and observation on 06/26/2025 at 10:03 AM, the Administrator verified that the nurse or the podiatrist were responsible for cutting Resident #6's toenails. The Administrator confirmed Resident #6's toenails were long, curved, and needed to be clipped. During an interview on 06/26/2025 at 10:06 AM, the ADON revealed Resident #6 did not have any records on file indicating that the resident had seen the podiatrist since admission. During a concurrent interview and observation on 06/26/2025 at 1:29 PM, the Director of Nursing (DON) stated she did not know how often the staff provided nail care for Resident #6. The DON verified Resident #6's toenails were too thick for staff to cut them, and the resident needed to see a podiatrist. 2. During an observation on 06/18/2025 from 11:15 AM to 11:40 AM, this surveyor observed that Resident #8's call light was on. During an observation on 06/18/2025 at 12:15 PM, this surveyor observed that Resident #8's call light was on, and Licensed Practical Nurse (LPN) #1 was sitting at the nurse's desk. A review of Resident #8 ' s Order Summary Report indicated the facility re-admitted the resident on 09/02/2022, with diagnoses which included type 2 diabetes mellitus without complications. A review of Resident #8 ' s quarterly MDS with an ARD of 04/11/2025, revealed the resident had a BIMS score of 12, which indicated moderate cognitive impairment. A review of Resident # 8 ' s Care Plan, initiated 02/08/2022, revealed the resident was at risk for falls related to balance and unsteady gait. The Care Plan included interventions to ensure the call light was within reach and to encourage the resident to use the call light for assistance as they needed. Staff were to respond promptly to all requests for assistance from the resident. During an interview on 06/25/2025 at 11:58 AM, Resident #8 stated their call light had been on for 30 minutes. The resident indicated they told CNA #2 they were hurting, and CNA #2 told Resident #8 she could not put them in bed until after lunch. During an interview on 06/25/2025 at 12:24 PM, CNA #2 stated she could not answer Resident #8's call light, because she was on her lunch break. CNA #2 indicated she informed LPN #1 she was going on break. CNA #2 confirmed Resident #8 told her they wanted to get in bed, and CNA #2 asked the resident to wait until she returned from lunch. During an interview on 06/25/2025 at 1:07 PM, LPN #1 verified that CNA #2 told Resident #8 she was going on break. LPN #1 stated she did not realize Resident #8's call light had been going off for 30 minutes. LPN #1 indicated she was completing a medication pass on the C Hall, and did not realize there were no staff on the A Hall. During an interview on 06/26/2025 at 9:24 AM, Resident #8 stated it took staff a long time to answer the call lights. The resident indicated that sometimes the call lights never got answered, especially at night. During an interview on 06/26/2025 at 1:30 PM, the DON confirmed resident call lights should be answered immediately. During an interview on 06/26/2025 at 2:41 PM, the Administrator stated staff should not tell a resident to wait until they come back from break to be put in bed. The Administrator indicated the facility did not have a policy on call lights.

Based on observations and interviews, the facility failed to ensure that cross contamination did not occur during lunch service for one of one kitchen observed. The findings include: On 04/02/2025 at 11:07 AM, this surveyor observed Dietary Aide (DA) #4 using bare hands to place four slices of cake in bags. DA #4 then placed the bagged cake slices in a stainless-steel bin. The Dietary Manager requested five (5) slices of cake for purees. With bare hands, DA #4 added 5 slices of cake to the stainless-steel container for puree. DA #4 was observed with cake coated on all ten fingertips. The Dietary Manager proceeded to use the cake for puree diets in the building. This surveyor observed the cake being served for all diets in the facility, during the lunch meal service. On 04/02/2025 at 11:10 AM, during an interview, DA #4 stated that this was their first time on days, and you do not touch food with bare hands. DA #4 stated they were unsure why. On 04/02/2025 at 11:45 AM, this surveyor observed the blade from the food processor fall into the pureed pasta. The Dietary Manager removed the blade and asked this surveyor if that could be cross contamination. On 04/02/2025 at 12:15 PM, this surveyor observed Dietary [NAME] (DC) #5 take three plates at a time out of the stack and place them on the line with bare hands. DC #5 then placed their whole ungloved hand in the middle of the plate. This surveyor observed this pattern throughout the lunch service while filling carts. On 04/03/2025 at 12:40 PM, during an interview, the Dietary Manager stated that touching food, touching plates, and a blade in puree was cross contamination which could cause foodborne illness in the residents. On 04/03/2025 at 1:05 PM, during an interview, DC #5 stated that the process was not to touch plates bare handed and to use the suction thing to prevent cross contamination. Then stated that a negative outcome could be sickness for the residents.

Based on observations, record review, and interviews, the facility failed to ensure that residents were living a dignified existence for two residents (Resident #6 and Resident #67) of two sampled residents reviewed for dignity. The findings include: A review of the facility policy Resident Dignity effective on 04/2021, indicated that Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. A review of the facility policy Resident Rights effective on 04/2021, indicated that, These rights include the resident's right to a dignified existence. 1. A review of an Admission Record indicated that Resident #67 was admitted with diagnoses that included stroke, cognitive communication deficit, and mood disorder. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/2025, revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated resident had severe cognitive impairment. A review of the Care Plan initiated on 01/29/2025, indicated Resident #67 takes clothes off and wears hospital gown. A review of Progress Notes revealed on 02/9/2025 at 11:47 AM, Care Plan Note: Resident #67 refuses to keep clothes or briefs on. Resident #67 lifts leg and places it on the wall. Resident #67 hits themselves and cries out and is unable to be redirected. Staff keep privacy curtain partially pulled to provide privacy and dignity to Resident #67. On 03/31/2025 at 8:30 AM, this surveyor observed staff passing trays on Unit D. Resident #67's door was open. This surveyor observed Resident #67 in bed, with the hospital gown removed, a blanket against the wall, and the resident was exposed to the hallway. No privacy curtain was observed to be hanging in the room. This surveyor attempted to interview Resident #67 who was not able to answer questions. On 03/31/2025 at 10:45 AM, this surveyor observed Resident #67 exposed from doorway of room with hospital gown removed and underneath [pronoun] head. No blanket was observed in the bed at this time. No privacy curtain was observed to be hanging in the room. On 04/01/2025 at 9:43 AM, this surveyor observed Resident #67 lying in bed, hospital gown removed, exposed from doorway of the room. A blanket was observed by the resident's feet in the bed. A full lift pad was observed underneath the resident from shoulders to the back of their knees. A male housekeeper cleaning the rooms on the unit walked past the room, with Resident #67 unclothed in clear view. No privacy curtain was observed to be hanging in the room. On 04/01/2025 at 2:20 PM, this surveyor observed Resident #67 exposed from the doorway of the room with hospital gown removed and lying in the bed, by the wall. A blanket was observed at the foot of bed. A full lift pad was observed underneath the resident from shoulders to the back of their knees and the resident ' s brief was pulled down, exposing the genital region. On 04/02/2025 at 9:40 AM, this surveyor observed Resident #67 exposed from the doorway of the room with hospital gown removed and lying underneath the resident ' s head. A pillow was in the floor, a blanket was observed at the foot of the bed, and the resident ' s brief was pulled down exposing the genital region. No privacy curtain was observed hanging in the room. A male housekeeper was observed to be cleaning rooms on the unit. 2. A review of an Admission Record indicated Resident #6 was admitted to the facility with diagnoses that included type 2 diabetes, dementia, depressive disorder, and heart failure. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of March 10, 2025, indicated that Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8, which indicates moderate cognitive impairment. A review of the Care Plan initiated on 03/24/2025, indicated Resident #6 required cuing and supervision with all activities of daily living related to cognitive loss, an intervention indicated they were able to choose clothing for the day and to assist/cue as needed. A review of the Document Survey Report indicated for Resident #6, was marked as independent or supervision on the lower body dressing task, for the month of March. On 04/01/2025 at 2:00 PM, during a concurrent interview and observation, Resident #6 was observed walking up and down the hallway on Unit D with a t-shirt on and a hospital gown over it. Resident #6 was not wearing pants. The resident ' s lower body and brief were exposed. Resident #6 asking Where are my pants? and attempted to cover [pronoun] exposed lower half by holding gown closed in the back while walking. Certified Nursing Assistant (CNA) #3 stated they were waiting on laundry to bring more pants. CNA #3 stated Resident #6 would take clothes off and on in their room making a mess of them. CNA #3 stated the night aide did not tell her in report that the resident was low on clothes. CNA #3 also stated when laundry delivered the resident ' s clothes she planned to dress the resident. CNA #3 stated she was not aware of any extra clothes in the laundry room to get for Resident #6. CNA #3 stated Resident #6 had been uncomfortable. On 04/01/25 at 2:15 PM, Resident #6 was observed walking up and down hallway with lower half exposed, using left hand to hold the back of the hospital gown closed. On 04/01/2025 at 2:20 PM, Resident #6 was observed knocking on the window of the unit doors, asking Where are my pants? Resident #6 was holding the back of the hospital gown and then sat in a chair. On 04/01/2025 at 2:30 PM, Resident #6 got out of the chair, held the back of the gown, and was observed knocking on the unit window again asking, Where are my pants? Resident #6 remained in this position for a few minutes before returning to the chair. This surveyor attempted to interview the resident, but the resident was not able to be directed. On 04/01/2025 at 2:30 PM, Resident #6 rose out of chair, held the back of the gown and knocked on the unit window asking about laundry. CNA #3 tied the second string on the back of the gown the resident was wearing. Resident #6 sat down in the chair. On 04/01/25 at 3:05 PM, during an interview, CNA #3 stated she was familiar with the residents on the secure unit. CNA #3 stated Resident #67 had not had a privacy curtain for a while. CNA #3 stated that they place the lift pad under Resident #67 to use when repositioning the resident. CNA #3 stated the resident had a full lift pad under them because the CNA could not leave to get a green pad to put under the resident due to CNA #3 was the only staff member on the unit. CNA #3 stated this was to help me pull [the resident] up for lunch when the restorative aide came back here for a minute. CNA #3 stated the negative outcome for the resident taking clothes off with no privacy curtain was dignity because it exposed the resident unknowingly to staff and other residents that walked by. CNA #3 stated the negative outcome for Resident #6 was that the resident was wandering around exposed, and that would be embarrassing. It was a dignity issue. CNA #3 stated, I did notice [the resident] trying to cover [pronoun] bottom. CNA #3 stated that she was going to get the nurse ' s attention to go to the laundry for Resident #6 and that the resident had been wearing a hospital gown since eleven that morning. On 04/02/2025 at 2:34 PM, during an interview, LPN #2 stated that Resident #67 was exposed from the doorway, and that could be embarrassing. LPN #2 stated there was no privacy curtain hanging in the resident ' s room. LPN #2 stated a resident should wear clothes to prevent them from being embarrassed, and for dignity. On 04/03/2025 at 12:15 PM, the Minimum Data Set Coordinator stated that Resident #67's behaviors of stripping off clothes could be a dignity issue if they were exposed from the doorway and a privacy curtain would be an intervention that could be added into the Care Plan to help. On 04/03/2025 at 12:30 PM, the Director of Nursing (DON) stated residents should not be exposed to other residents or staff and it could make them uncomfortable or embarrassed. The DON stated Resident #67 should have a privacy curtain hanging in the room to ensure that the resident did not expose themself related to behavior.

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADL) care such as facial hair removal, and nail care were completed for two (Resident #6 and Resident #67) of five sampled residents reviewed for ADL care. The findings include: 1. A review of the Admission Record indicated Resident #6 was admitted with diagnoses that included type 2 diabetes, dementia, depressive disorder, and heart failure. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of March 10, 2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. A review of a Care Plan initiated on 03/24/2025, indicated that Resident #6 required cuing and supervision with all activities of daily living related to cognitive loss. Interventions indicated the resident was able to choose clothing for the day and to assist/cue as needed. A review of the Document Survey Report used to track behaviors, indicated Resident #6, for the month of March had one documented day for refusal of care on night shift on 3/11/2025, and for bath, given on Tuesday, Thursday, and Saturday; one refusal charted on 3/8/2025, was blank for 3/15/2024, and 3/29/2024, charted not applicable on 3/22/2025, and the rest were given. On 03/31/2025 at 9:00 AM, this surveyor observed Resident #6 wandering up and down the hallway on Unit D. The resident had facial hair across their upper lip that connected with facial hair that covered the length and width of Resident #6's chin. On 03/31/2025 at 1:00 PM, this surveyor observed Resident #6 wandering the hallway with no changes in facial hair. On 04/01/2025 at 9:00 AM, this surveyor observed Resident #6 wandering the hallway with no changes in facial hair. On 04/01/2025 at 2:30 PM, this surveyor observed Resident #6 wandering the hallway with no changes in facial hair. On 04/02/2025 at 9:30 AM, this surveyor observed Resident #6 wandering the hallway with no changes in facial hair. 2. A review of the Admission Record indicated Resident #67 was admitted with diagnoses that included stroke, cognitive communication deficit, and mood disorder. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/2025, revealed Resident #67 had a Brief Interview for Mental Status (BIMS) revealed a score of 0, which indicated the resident had severe cognitive impairment. Section GG revealed Resident #67 was dependent on staff for activities of daily living care. A review of the Care Plan, initiated on 2/5/2025, indicated Resident #67 required extensive assist x 2 staff with bed mobility, transfer, dressing, toileting, personal hygiene, bathing and required extensive assist x 1 staff with eating and locomotion; Interventions include: Please check my fingernail and toenail length and trim as needed unless I am diabetic. Please notify my nurse if I need my toenails trimmed and please give me my shower/bath as per my bath schedule and if needed give me a sponge bath on non-shower days. A review of the Documentation Survey Report used to track behaviors, indicated Resident #67's bath days were on Monday, Wednesday, and Friday and in March all days were marked not applicable except March 5th,10th, 26th, and 28th, which were marked as given. On 03/31/2025 at 8:30 AM, this surveyor observed Resident #67 hit themselves in the chest and abdomen and hit the side rails. Resident #67 ' s fingernails on the left hand were short, broken, and jagged, with all having sharp edges/points and matter that appeared to be food under them. On the right hand, nails were observed to be long, and jagged, having sharp edges and points and what appeared to be food matter underneath them. This surveyor observed Resident #67 eating food with their hands with staff supervising. On 03/31/2025 at 10:45 AM, this surveyor observed Resident #67 rubbing their facing, hitting themselves in the arms and on side rails. No changes to fingernails were observed. On 04/01/2025 at 9:40 AM, this surveyor observed Resident #67 using their left hand to scratch their right arm and chest, then started to hit the side rails, and crying out. No changes to fingernails were observed. On 04/01/2025 at 12:30 PM, this surveyor observed Resident #67 feeding themselves lunch with their hands, with staff supervising. On 04/02/2025 at 9:20 AM, this surveyor observed Resident #67 flailing their left hand back and forth hitting the side rails frantically. The resident was observed scratching themselves and crying out. No changes to fingernails were observed. On 04/02/2025 at 2:30 PM, this surveyor observed Resident #67 hitting themselves in the abdomen and scratching themselves. No changes to fingernails were observed. On 04/01/2025 at 9:32 AM, during an interview, Certified Nursing Assistant (CNA) #3 stated that activities of daily living care should be performed daily, as needed, and on bath days. CNA #3 stated the negative outcome for unkempt facial hair was hygiene, confidence and dignity. CNA #3 stated that the negative outcome for uncut nails was germs and hygiene. CNA #3 stated that it could affect confidence, for nails to be uncut and for facial hair to be not shaved. CNA #3 stated that Resident #6 and Resident #67 do not refuse bath days or trims for facial hair and nails. CNA #3 described Resident #6's facial hair as a goatee that needed to be shaved. CNA #3 described Resident #67's nails as long, broken, and uneven, with sharp edges or points, and food matter under them. CNA #3 continued stating Resident #67 hits themselves all the time, nails like this could cause them to hurt themselves. CNA #3 stated baths were usually done on Monday, Wednesday and Friday on the unit, and they should have been done yesterday. On 04/02/2025 at 2:30 PM, during an interview Licensed Practical Nurse (LPN #2) stated she was with an agency and had been back here the last two days. LPN #2 described Resident #6's facial hair as a goatee, and it needed trimmed. LPN #2 described Resident #67's nails as jagged, long, with sharp points, and needed trimmed. LPN #2 stated unkempt facial hair could be seen as embarrassing definitely a dignity issue. LPN #2 stated that nails were to be trimmed for hygiene and to prevent skin breakdown. LPN #2 stated that facial hair and nail care should be done as needed and on bath days. LPN#2 stated that uncut nails can cause skin breakdown, and facial hair could be seen as unkempt. On 04/02/2025 at 2:40 PM, during a concurrent interview and observation, CNA #3 stated that baths were not completed because CNA #3 was the only staff member on the unit. CNA #3 stated they planned to attempt to do baths tonight while floating until 7:00. This surveyor observed Resident #6 sitting in a chair with facial hair and no changes. On 04/03/2025 at 12:30 PM the Director of Nursing (DON) stated activities of daily living care such as nails and facial hair should be done on an as needed basis and on shower days. The DON stated negative outcomes for uncut nails could be hygiene or even scratching themselves. The DON stated negative outcomes for unkempt facial hair could be that it's embarrassing for residents. The DON stated that it could be seen as a dignity issue for facial hair to not be shaved. The DON stated activity of daily living care helped meet the needs of the resident.

49981 Based on observation, record review, and interview, the facility failed to ensure cigarettes and lighters were properly stored, to prevent residents from having and using cigarettes and lighters without staff knowledge, on 1 of 1 observation, to prevent accidental burns and injury. This failed practice had the potential to affect 4 (Resident #29, #40, #61, and #84) of 18 sampled residents, reviewed for smoking tobacco or nicotine use to ensure safe interventions were in place. The facility also failed to ensure 1 resident (Resident #59) of 1 sampled resident was not in the smoking area with cigarettes and lighter stored in a personal cigarette case to prevent possible injury. The findings include: Review of Medical Diagnosis revealed Resident #84 had diagnoses that included seizure disorder and aphasia. Review of Resident #84 ' s admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Resident #84 was observed sitting in a specialty chair in the courtyard smoking area. Review of Medical Diagnosis revealed Resident #61 had diagnoses that included Huntington's disease and anxiety. Review of admission MDS dated [DATE], revealed Resident #61 had a BIMS of 15, which indicated no cognitive impairment. Resident #61 was observed sitting on the right side of the courtyard smoking area. Review of Care Plan revealed interventions for Resident #61 included storing smoking materials, including cigarettes and lighters, in the Administrator ' s office. Review of Medical Diagnosis revealed Resident #29 had diagnoses that included schizophrenia, stroke, and seizure disorder. Review of Resident #29 ' s quarterly MDS dated [DATE], revealed a BIMS of 11, which indicated moderate cognitive impairment. Resident #29 was observed sitting on the left side in the courtyard smoking area. Review of Care plan revealed interventions include must wear an apron to smoke and storing smoking materials including cigarettes and lighter, in a locked area of the Administrator ' s office, and the nurse's station. Review of facility policy titled Smoking Policy, dated 02/2024, revealed smoking privileges and restrictions should be documented in the care plan. All residents will require monitoring, and residents cannot keep smoking materials including cigarettes, tobacco, etcetera. The facility stores all smoking material and retains the right to confiscate smoking articles from residents not adhering to policy. Review of an in-service titled Resident Smoke Break, dated 1/20/25, revealed residents need to be timely for their assigned smoke breaks, but did not address storage of smoking materials. On 03/31/2025 at 1:14PM, the Activity Director (AD) was observed placing smoke aprons on residents. The AD was asked what the process was and how residents who wore a smoking apron were identified. The AD stated all residents were to wear an apron, and the residents were not given more than two (2) cigarettes at a time. On 03/31/25 at 1:24 PM, Resident #84 lifted [pronoun] right leg and a pack of [brand name] cigarettes was observed to be resting under Resident #84's upper thigh. Resident #69 said Resident #84 has had cigarettes on their person before and they were always smashed flat under [pronoun] leg. Certified Nursing Assistant (CNA) #3 and CNA #8 removed the cigarettes from the resident ' s possession and revealed 12 cigarettes were in the pack. On 03/31/2025 at 1:25 PM, during an interview, CNA #3 was asked to describe the events that just occurred. CNA #3 said she suspects a friend or relative brought Resident #84 cigarettes. CNA #8 stated residents were only given 2 cigarettes at a time with each smoke break. CNA #3 stated she did not have a concern with residents having cigarettes, but knowing they were bringing them in [the building] was a concern. CNA #3 said CNA #8 had a lighter and would light them. CNA #8 confirmed nobody was supposed to light their own cigarette. Resident #61 was observed reaching in the left pocket of the resident ' s jacket, pulled out a lighter, and lit a cigarette, after throwing aside the smoker's apron. This surveyor looked to the left and observed Resident #29 and Resident #84 lighting their own cigarettes. On 03/31/2025 at 1:26 PM, CNA #3, CNA #8, and the AD were observed talking to Residents #29, Resident #61, and Resident #84 while CNA #8 attempted to confiscate three (3) lighters. On 03/31/2025 at 1:27 PM, the Administrator was asked what concerns they had about residents having lighters and cigarettes on their person. The Administrator stated smokers had all signed a contract and should not have cigarettes or lighters. CNA #8 took possession of all the lighters and placed three (3) lighters in the Administrator ' s hand. The Administrator stated the facility and staff needed to monitor residents' cigarettes but also make sure residents smoke safely. The Administrator revealed that smoking materials were locked in her office, and the AD put cigarettes in a plastic bag for the day. The bags are locked up at the nurse ' s station and used during smoke breaks. On 03/31/2025 at 2:02 PM, review of a list titled, Residents Who Smoke revealed Resident #29, Resident #61, and Resident #84 were included. On 04/01/25 at 9:28 AM, Resident #84 revealed that [pronoun] saw an opportunity one (1) day ago to pick up a lighter while smoking outside and grabbed it. My brother chewed me out because I was going through lighters that he gave me and cigarettes. Resident #84 revealed family and friends gave [pronoun] cigarettes and lighters. The resident said [pronoun] did not remember being told [pronoun] could not keep cigarettes and lighters. On 04/01/25 at 9:38 AM, the MDS Nurse stated she was the C Hall nurse today and Resident #61 constantly comes back with stuff not allowed like fingernail clippers, cigarettes and lighters after going on family leave. Resident #61 did not like anyone in their room or space and got very mad when questioned. Resident #61 would sometimes slam doors. The MDS Nurse stated Resident #84's family does the same thing and puts things in drawers. The MDS Nurse stated she sometimes would ask about items and try to get things out that residents should not have like lighters and cigarettes. We have educated both families about this. On 04/01/2025 at 11:20 AM, the Medical Director said he was aware from time-to-time residents got cigarettes and lighters from family and friends. They are here for a reason, and confusion plays a part in their understanding. The Medical Director was not aware of any recent incidents and stated it was the facility policy that residents did not keep cigarettes or lighters. On 04/01/25 at 12:15 PM, during an interview, the Director of Nursing (DON) stated educating residents and families on not bringing in cigarettes and lighters was an ongoing battle. The facility had provided education during resident council, smoking contracts, and re-educated when they suspected a resident was smoking. The DON was asked when Resident #84 was assessed last for smoking and provided an Admission/Readmission Nursing Evaluations Packet, dated 12/19/24, that revealed in VI. evaluation indicated Resident #84 was not a smoker. The DON stated she remembered that Resident #84 changed their mind about smoking after admission, and said Resident #84 should have been reassessed. The DON said she would like everyone to wear a smoker's apron and has ordered more of them. On 04/01/2025 at 12:38 AM, review of Resident #61 ' s Admission/Readmission Nursing Evaluations Packet, dated 01/08/2025, revealed Resident #61 smoked and required supervision, and a smoker ' s apron. On 04/1/2025 at 2:40 PM, the [NAME] Director of Operations (RDO) said that smoking assessments were done quarterly. On 04/02/25 at 1:50 PM, this surveyor observed a yellow chair resting against the wall outside Resident #40's room. This Surveyor asked the RDO if Resident #40 was on 1:1, and if so, could she explain why. The RDO revealed that Resident #40 had been caught smoking in their personal room this morning, and the resident ' s father had been contacted for a 30-day discharge. The facility called the resident ' s dad because he was responsible for all the resident ' s decisions and had already been working on a place for Resident #40 to go. On 04/02/25 at 2:00 PM, the RDO provided a copy of a letter titled 30-Day Discharge Notice, dated 04/02/2025, which informed Resident #40 that due to smoking in their room on April 2, 2025, they were considered a danger to self and others and the decision was made to discharge Resident #40 from the facility. The facility had offered to assist in finding placement. Appeal information was included. On 04/02/25 at 3:35 PM, the Administrator provided evidence regarding the smoking area incident. Residents observed had BIMS of 11-15, and residents have rights. The Administrator provided additional evidence and stated that witness statements were taken from staff and residents, and residents said after smoking they planned to turn their lighters into the staff. The Administrator stated her evidence included the smoking in-service, employee handbook and resident rights policy, because residents have rights, and staff cannot search residents and their belongings without infringing on the resident's rights. On 04/03/25 at 9:15 AM, CNA #7 said most of the time she found things in resident rooms when she was getting their underwear from a drawer or something like that. CNA #8 stated that she looked at what was out in the room but did not look through personal belongings. On 04/03/25 at 9:25 AM, during smoke break, [a food delivery service] brought a [Brand name coffee shop] bag to Resident #40. CNA #8 observed cigarettes resting under the frozen [Brand name coffee shop] drink. CNA #8 confiscated cigarettes, and the Administrator was observed taking possession of the cigarettes. The Administrator confirmed residents were not allowed to have cigarettes or lighters on their person. On 04/01/2025 at 4:08 PM, in the facility's designated smoking area, Resident #59 was observed producing a small case approximately six (6) inches long, four (4) inches wide, and about two (2) inches thick. Resident #59 opened the case and pulled out a cigarette and lighter and proceeded to light and smoke the cigarette. On 04/01/2025 at 4:10 PM, the Administrator and RDO were notified of the incident. The Administrator and RDO were asked if they were aware Resident #59 had possession of the items. The Administrator stated that all residents were aware of the smoking policy and that no resident should be in possession of cigarettes or lighter. On 04/01/2025 at 4:28 PM, the Administrator confirmed that the resident agreed to give cigarettes and lighter over to be stored until designated smoking times.

Based on observation, record review, and interview, the facility failed to ensure three (3) syringes of [Name Brand Anti-anxiety medication] were documented in a narcotic book to maintain receipt and accounting of a narcotic during 1 of 1 observation to prevent diversion for 1 (Resident #71) resident. The findings include: Review of Medical Diagnosis revealed Resident #71 had diagnoses of dementia, schizophrenia, and urinary retention. Review of Care Plan for Resident #71 dated 12/09/2024, indicated Resident #71 used antianxiety medication related to an agitation disorder. On 04/02/2025 3:15 PM, this surveyor accompanied the Unit Manager to the medication room outside the unit. The narcotic box was permanently affixed and contained antianxiety medication 2mg/ml (milligram/milliliter) x2 syringes and there was a bag labeled Resident #71 containing antianxiety medication 2mg/ml x3 syringes, dated 12/06/2024. The Unit Manager was asked to show where Resident #71's antianxiety medication was documented in the narcotic book. The Unit Manager was unable to locate the requested documentation. On 04/02/2025 at 3:20 PM, the Unit Manager walked to central supply where she was joined by the Director of Nursing (DON) in searching narcotic books for documentation on Resident #71's antianxiety medication. On 04/02/2025 at 3:30 PM, the DON stated Resident #71's antianxiety syringes were not documented in any of the narcotic books. The DON stated that when the medication was delivered nursing staff should have documented it right away. The DON stated it was unknown why the antianxiety medication was not in the narcotic books. The DON stated Resident #71 moved from C to E Hall and any narcotics should have been transferred from one narcotic book to another. The DON was accompanied back to the medication room where she removed Resident #71's antianxiety medication and stated that there was not a narcotic book page number written on the prescription label and it was never logged in. The DON stated it could have easily been diverted, because it was not documented in a narcotic book. On 04/03/2025 at 10:57 AM, the Administrator stated she was surprised to hear that Resident #71's antianxiety medication was not documented in a narcotic book. The administrator was asked for documentation that the antianxiety medication was signed for by a nursing staff member. This surveyor requested policies on medication storage, narcotics, and any nursing in-services on documenting medications. On 04/03/2025 at 11:59 AM, Licensed Practical Nurse (LPN) #6 was asked the process for receiving medications from the pharmacy. LPN #6 stated when the pharmacy brings medications, nursing staff look at the documentation to make sure it was the right medication dose and quantity. If the quantity was wrong that would be noted/corrected on the documentation, then the nurse that accepted it would write it in the narcotic book, if the medication was a narcotic. The medication would then be placed in locked storage. Review of a Pharmacy Manifest dated 12/6/2025, indicated Resident #71 received antianxiety medication 2mg/ml syringes x4. A review of Medication Administration Record for Resident #71 did not show a current order for antianxiety medication. Review of a policy titled Label/Store Drugs and Biologicals, dated 01/2024, revealed drugs and biologicals are to be stored in a safe, secure and sanitary manner. The policy did not address documentation of narcotics. Reviewed an in-service on Medication Storage, dated 4/2/25, revealed all narcotic medication was to be accurately logged in and stored according to policy.

Based on observation, record review, and interview, the facility failed to ensure that medications were locked away and stored in a manner that prevented resident access for 1 of 1 observation of the central supply room. Specifically, a box of medications was found resting on a pallet in central supply and the doorknob was broken. The door was ajar and could not be closed. The facility failed to ensure 13 bottles of expired [name brand] supplemental feeding were removed from the supply shelf to prevent nursing staff from using them on residents with feeding tubes for 1 of 1 observation. The findings include: On [DATE] at 6:34 AM, the central supply door was observed as being propped open ,d+[DATE] inches by a broken inner doorknob. Paint outside the door appeared scuffed off in the area of the doorknob. In central supply an open box was observed resting on a pallet containing: a. Clear lax 17.9oz (ounce) bottles x5 b. Sleep aid 3mg (milligram) x3 250ct (count) c. Sleep aid 5mg x3 90ct d. Zinc 50mg x3 100ct e. Aspirin x1 36ct f. Acetaminophen 325mg x2 1000ct g. Vitamin D3 x3 25mcg 300ct h. Iron 325mg x2 200ct i. NSAID (nonsteroidal anti-inflammatory drugs) 200 mg x5 300ct j. Stool Softener 100mg x3 200ct k. Glucose Gel 15g (gram), 3 tubes l. Magnesium 400mg x1 120ct m. Antacid x2 750mg 96ct (1 bottle of antacid had been open) On [DATE] at 6:40 AM, the Administrator was asked to explain the process for storing the open box of medications. The Administrator identified the box of medications as over the counters and stated they should be stored locked at the nurse ' s station. The Administrator stated residents should not have access to this room with medications. The Administrator stated the damage to the wall outside central supply, at the inner doorknob level was new. The Administrator did not know the door could not be closed to central supply. The Administrator stated residents would have told nursing staff if they found the open box of medications. On [DATE] at 6:45 AM, the Director of Nursing (DON) was asked if the supplemental feeding, stored on the central supply room shelf, was in date for use. The DON confirmed that the supplemental feeding was available for use. The DON was asked about 13 bottles of [name brand] supplemental feeding. The DON confirmed an expiration date of ,d+[DATE] and said it should have been returned. The Administrator stated maintenance should have been called to fix the central supply doorknob. On [DATE] at 7:00 AM, Registered Nurse (RN) #1 was asked the process for storing drugs in the medication room. RN #1 revealed medications should be behind a locked door, and she did not notice that the door was not closed all the way during her 12-hour shift. RN #1 stated a resident could have taken any of the medications that were left out in the open. RN #1 was unable to confirm if any residents were receiving the expired supplemental feeding. On [DATE] at 10:33 AM, the Medical Director confirmed he did not know medications were being stored in an open box resting on a pallet in central supply. The Medical Director said the concern would be diversion of the mediations. Review of a policy titled Label/Store Drugs and Biologicals, dated ,d+[DATE], revealed drugs and biologicals are to be stored in a safe, secure and orderly manner. Drugs should be locked away when not in use, and out of date drugs should be returned to the pharmacy or destroyed. Review of an in-service titled Medication Storage, dated [DATE], revealed all narcotic medication is to be stored accurately, logged in and stored according to policy.

Based on observations, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 (Resident #1, Resident #2, Resident #3, Resident #4) of 4 sampled residents reviewed of physical environment. The findings are: 1) On 12/3/24 at 8:54 AM, the Surveyor observed the community shower room with one (1) door on E Hall, which had been left open. The surveyor entered the shower and observed the following: a. Several areas of the shower floors, walls, and edges with broken and/or missing tiles, with rough edges. b. The doorframe of the bathroom, in the shower room, was rusted out on both sides of the frame. It is not secured to the wall on either side. The frame moved back and forth. Rust was on the floor at the base of the frame, on both sides. c. Several holes in the tile baseboards around the showers with broken tiles, leaving large holes in the walls. d. The grout was black and brown between the tiles. 2) The Surveyor asked Certified Nursing Assistant (CNA) #8 if she could come into the shower room with surveyor. CNA #8 entered shower room [ROOM NUMBER] on E hall. The Surveyor interviewed CNA #8. CNA #8 said she was not aware the door had been left ajar until she saw this surveyor open the door. CNA #8 said I thought oh no. CNA #8 said the door should have been locked to prevent a resident from entering the room, because if a resident got in this room the resident could fall, and no one would know anything about it. CNA #8 said the doorknob was broken off on the inside so a resident would not be able to open it to get out, and a resident could get locked in there and we would not be able to find them. The Surveyor asked how long these missing tiles, cracks in the tiles, and broken edges had been that way. CNA #8 said she had been on leave since the first part of August and was just getting back, but they were not busted when she left. CNA #8 said she was concerned that if a wheelchair or shower bed rolled in the crack of missing tiles it could fall or tilt over causing a resident to fall. The Surveyor asked CNA #8 what concerns she had with the cabinet being opened and unlocked. CNA #8 said she was concerned about a resident getting the items in the cabinet and drinking them or getting them in their eyes because these items could hurt a resident if they drank them. 3) CNA #8 assisted this surveyor in identifying the items in the cabinet. The contents were: a. A perineal cleanser with a caution label showing it may cause eye irritation and keep out of reach of children. b. Five (5) deodorant sprays - with warning labels of do not use on broken skin, avoid contact with eyes, ask doctor before using if you have kidney disease, if swallowed, contact Poison Control Center right away. c. Twenty-four (24) bath cleansers for skin and hair - with labels with a caution statement for external us only, avoid contact with eyes. d. Two (2) silicone creams - with labels for external use only. e. Seven (7) tubes of skin protectant - with labels with a warning in case of ingestion contact a physician or Poison Control Center right away. f. Derma vera skin and hair - 2.5 gallons g. Nine (9) daily moisturizing lotion with/ aloe vera. h. One (1) clinical cleanse no -rinse - with a bold statement that showed for external use only. i. One (1) and 1/8 bottles of baby oil - with a label with bold print that showed for external use only and a safety tip to keep out of reach of children. j. One (1) bottle of conditioner. k. One (1) bottle of soothing lotion 32 oz. l. As identified by the CNA, 1/8 of a bottle of hair conditioner. m. Three (3) travel size cans of shaving cream. n. Two (2) 3.5 oz. containers of baby powder - with warning labels which included - for external use only; not for consumption; keep out of reach of children; avoid contact with eyes; Do not use on broken skin; Keep powder away from child ' s face to avoid inhalation. o. Antifungal powder - 1 contains Miconazole Nitrate 2.0% p. One (1) hand sanitizer wipe with a label that showed for external use only; Flammable; avoid contact with eyes; if skin becomes irritated contact doctor; if swallowed get medical attention or contact poison control right away. q. Twenty-four (24) blue razors were in the unlocked/unsecured cabinet and two (2) blue razors were lying on shower bed located in the room. r. Four (4) packages of adult washcloths wipes were in the unsecured cabinet. s. Two (2) boxes of vinyl gloves size medium were in the unsecured cabinet. t. Two (2) boxes of medium, two (2) boxes of large, and two (2) boxes of large latex gloves were in the unsecured cabinet. 4) The surveyor asked CNA #8 what the brown spot on the shower bed was. CNA #8 said it looked like dried up bowel movement (BM). CNA #8 said her concern with the dried brown substance was that it could be infectious. BM has germs in it. CNA #8 stated that it could be from a resident with clostridium-difficile and another resident smear it and then put their hands in their mouth and become sick due to the germs. CNA #8 said if a resident got one of the razors, they could play in the BM with it and cut themselves. The second shower bed, with a long blue foam lying on top, had a brown/black substance on the blue shower bed where the foam was lying. CNA #8 said, Now that looks like mold. The shower bed was noted to be frayed along the sides of the mesh. 5) The second shower room on Hall E had broken tiles along the outside corner of the shower stall, leaving sharp rough edges. The floor of the shower had missing and broken tiles in the shower floor where a resident would stand to shower, leaving sharp rough edges. The grout was black and brown between the tiles. 6) The shower room on Hall D contained shower stalls with missing tiles in the center of the shower floor, leaving sharp rough edges. The ceiling had two (2) large areas where it was peeling off, leaving particles on the floor. The grout was black and brown between the tiles. 7) On 12/2/24 at 11:32 AM, Resident #4's over-the-bed tabletop had large sections of the finish peeling off, leaving the pressed board exposed. The surveyor asked the resident how long the table had been like that. Resident #4 indicated it was not known. At the entrance to Resident #4's bathroom, the tiles were cracked and missing, leaving sharp edges. 8) On 12/3/24 at 11:00 AM, Resident #4's over-the-bed tabletop had large sections of the finish is peeling off, leaving the pressed board exposed. 9) On 12/3/24 at 1:50 PM, this surveyor and the Maintenance Supervisor made observations in shower room [ROOM NUMBER] on E hall. The Maintenance Supervisor said he was not aware of the shower room door needing a knob on the inside until today. The Maintenance Supervisor said the shower had been closed a couple of weeks to allow him time to do some repairs on the tiles. The Maintenance Supervisor said he was not aware the bathroom door was rusted out. The Maintenance Supervisor stated the staff had stopped using the Maintenance Request Log months ago. He stated needed repairs were not being written on the log anymore, but employees tell him things as he goes down the hall. He said he had started to make his own spreadsheet to keep up with things. The Maintenance Request Log, given to the surveyor by the Maintenance Supervisor identified numerous items not completed. 10) On 12/4/24 at 8:15 AM, the Surveyor and Administrator made observation rounds in the shower rooms. The Administrator said she had shut the shower room [ROOM NUMBER] on E Hall down in September or October to have the room repaired for a more therapeutic look. The Administrator said she wanted it painted, and the tiles repaired. The Administrator said she was concerned that the door was open on two (2) occasions, because a resident could get in the shower room alone. Residents could get a skin tear from the broken tiles. The Administrator said she was not aware of the doorframe of the bathroom being rusted and detached like that and the rusted-out doorframe had taken years to get that bad. It was not an overnight problem. 11) On 12/3/2024 at 10:02 AM., a surveyor observed an outlet under the sink in the shower room on D Hall pushed into the sheetrock with large holes on both sides. On 12/4/24 at 8:15 AM, during rounds the Administrator said she had told the Maintenance Supervisor to repair that outlet under the sink on Monday. An electrical cord was observed hanging from a fan above the sink. The outlet did not have a set/reset button on it to indicate it was a Ground Fault Circuit Interrupter outlet. The outlet was pushed into the wall on the right side with a large hole the length of the cover approximately 1 inch by 3 inches and a large gap on the other side approximately 1 inch by 1.5 inches.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure kitchen ceiling tiles, air vents, walls, storage racks, exhaustion fan, and garbage disposal were cleaned, door frames were free of chips, and dietary staff thoroughly washed their hands and changed gloves when contaminated, before handling food and clean equipment for 2 of 2 meals observed. The findings are: 1. On 12/02/2024 at 9: 58 AM, the following observations were made in the kitchen: a. The ceiling vent, close to a rack where clean pans were stored, had rust and black stains on it. b. The ceiling tile between the steam table and the 3- compartment sink had rust over it. c. The metal support bracket, attached to the pole across the ceiling tiles from the area where a rack that contained clean pans were stored extending to the area leading to the dish machine room, had accumulations of sage and black colors on them. On 12/04/2024 8:35 AM, the Maintenance Supervisor was interviewed and asked to describe the appearance of the ceiling tiles he stated ceiling tiles had sage buildup. d. The wall leading to the dish washing machine and walls and ceiling tiles in the dish washing room had accumulation of a sage color. e. The door frames leading to the dish washing machine room had sage or gray colors and were chipped. The areas that were chipped showed exposed metal. f. The garbage disposal was not operational. There were leftover food items and black stains inside the disposal. There was strong odor permeating from the disposal. On 12/04/2024 at 8:35 AM, the Maintenance Supervisor was asked if the garbage disposal was working. He stated it stopped working for about three (3) weeks ago and that was the reason it looked like that. g. The bottom right side of frame leading to the dish machine room was rotted and exposing the cement. h. The door leading to A, B, C, and D halls from the kitchen had sage colors on them. The frames were chipped, and the areas that were chipped were exposing the metals. i. The wall above and below the dish washing machine, where the exhaustion fan was located on the clean side, had a mixture of brown and sage accumulation of grease build up on them. The edges of the exhaustion fan above the counter, where clean dish racks were kept drying, had greasy dust build up on it. j. The ceiling tile, above the ice machine was chipped, exposing the cement. k. The metal shelf, below the steam table, had buildup of rust on it and was bent. 2. On 12/02/2024 at 10:07 AM, Dietary Aide (DA) #2 pushed a utility cart from the dish washing machine room into the kitchen. Without washing his hands, he removed gloves from the glove box and placed them on his hands, contaminating the gloves. Without changing gloves and washing his hands, he picked plates, to be used in portioning food items to be served to the residents for lunch meal, and placed them on the plate warmer, with his fingers inside the plates. 3. On 12/02/2024 at 10:23 AM, Dietary [NAME] (DC) #1 removed a box of dinner rolls from the freezer and placed it on the counter. DC #1 turned on the hand washing sink faucet and washed his hands. After washing his hands, he turned the faucet off with his hands, contaminating his hands. Without washing his hands, DC#1 removed dinner rolls from the bag inside the box and placed them on the pans, to be baked and served to the residents for lunch meal. 4. On 12/02/2024 at 11:11 AM, the DC #1 turned on the food preparation sink and washed the blender blade, bowl, and lid with hot water. DC #1 did not use soap when washing the blade, bowl, and lid or sanitize them properly. DC #1 then attached the blade, which was not thoroughly washed, at the base of the blender, to be used in grounding food items to be served to the residents who required mechanical soft diets. As DC #1 prepared to place food items into the blender, DC #1 was asked what he should have done after touching dirty objects and before handling clean equipment, he stated he should have re-washed his hands. 5. A review of the facility policy titled, Hand Washing, not dated, provided by the Dietary Manager on 12/3/2024, indicated employees should wash their hands when entering the kitchen, at the start of a shift, and after engaging in other activities that contaminate the hands.

Based on observation, record review and interview the facility failed to ensure personal care including bathing and toenail care was provided for residents that required activity of daily living (ADL) assistance to promote good hygiene and prevent infections. This failed practice affected 1 sampled (Resident #11) resident of 2 sampled (Resident #10, and Resident #11) residents reviewed for personal care. The findings include: The medical diagnoses revealed Resident #11 with diagnoses of delusions, hallucinations, bipolar disorder, and anxiety. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/13/2024, suggest a Brief Interview for Mental Status (BIMS) score of 04 (0-7 indicates severe cognitive impairment). a. Review of a policy titled Care of Fingernails/Toenails, revised October 2010, revealed procedures were in place to clean the nail bed and trim nails to prevent infections. Nails that are too hard or thick to trim should be reported to the nurse supervisor, and unless permitted do not trim the nails of diabetics. b. Review of Resident #11's Care Plan, dated 08/28/2024, revealed Resident #11's nails were to be checked on bath day, and if they need trimmed it should be reported to the nurse. It was documented, Resident #11 needed the partial assistance of 1 staff member during bathing. c. A review of an In-Service taught by the Director of Nursing (DON), on 10/15/2024, revealed a skills fair was done that included Certified Nursing Assistant (CNA) skills check offs. d. On 12/02/2024 at 10:50 AM, Resident #11 was observed on the closed unit with feet in the air. Dry, white flaky skin on both arms and legs was observed. [NAME] flakes were resting in the bed from the knees to feet. The right and left great toenails were thick and extended an estimated 1/2 inch from the nail bed, curving over the front of the toe. The Surveyor observed Resident #11 had purple looking polish like substance on the top half of the toenails. The surveyor and asked if the resident liked to have nails polished. Resident #11 stated they liked polish, and my skin has stuff on it. When asked when the resident's last bed bath or shower was, Resident #11 did not know. e. On 12/03/2024 at 10:00 AM, Certified Nursing Assistant (CNA) #9 was asked if they have shower aids, and she confirmed they did. CNA #9 does not give showers on the closed unit. The CNA was asked what they would do if the shower aid went home, and a resident needed a bath. CNA #9 revealed that residents have personal care wipes at the bedside, and she would clean them up with a wipe. CNA #9 confirmed there was not a shower room on the closed unit. The Surveyor asked where a resident would go to get a shower. CNA #9 stated that she did not know. f. On 12/03/2024 at 9:20 AM, Resident #11 was observed resting in bed, arms and legs appeared dry, white, and flaky. The left and right great toes were extending well above the bed of the toenails. g. During an interview with the Administrator, on 12/03/2024 at 11:00 AM, the Administrator was asked to provide a bathing sheet for Resident #11 and a list of residents scheduled to see the podiatrist. h. On 12/03/2024 at 3:50 PM, the Administrator provided a bathing sheet showing 1 shower in the month of November 2024 and a podiatrist list that did not include Resident #11. The surveyor asked the Administrator how many baths or showers Resident #11 had received. The Administrator confirmed it looked like one (1) but was sure that was not correct. The Administrator stated the Director of Nursing, (DON) could better explain the shower sheet. i. During an interview with the DON, on 12/03/2024 at 3:33 PM, the DON stated that CNAs had stopped charting all the baths and showers. She did not know why but was letting staff go due to this practice. The DON stated she was certain Resident #11 was getting baths or showers. The DON accompanied the surveyor to the bedside. She stated Resident #11 should have been referred to the podiatrist list after inspecting the resident's feet. The surveyor asked if there was any risk to a resident with toenails extending well above the bed of the toenail. The DON stated if she were to walk on them, it might bother the top of the toes. The DON stated she could give the resident a bath right now and the resident's skin would look the same way tomorrow. The surveyor asked who was responsible for reporting toenails that needed clipped. The DON stated when a resident was bathed or showered the CNAs are responsible for letting someone know if someone needs to be seen for toenail care. The surveyor requested the facility policy and procedures for nail care. j. On 12/03/2024 at 4:10 PM, CNA #10 accompanied the surveyor to Resident #11's room. CNA #10 confirmed the resident's left and right great toenails are too long and needed to be clipped. CNA #10 also confirmed the resident's skin appeared dry. When asked what process CNAs follow when they find residents that need toenail care, CNA #10 said she would report it to the nurse and let them follow their procedure because the resident might be a diabetic. CNA #10 revealed she had never seen Resident #11's feet before, because she usually wears socks.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and storage area were covered or sealed to maintain freshness and prevent potential cross contamination of food and beverages; expired food items were promptly removed/discarded by the expiration or use by dates; kitchen vents were cleaned to provide a sanitary environment for food preparation; floors, kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, debris, rust, and dirt; 2 of 2 ice scoop holders, and 1 of 2 ice machines were maintained in clean and sanitary condition to prevent food and beverages contamination; and hot food items were maintained at or above 135 degrees Fahrenheit while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 62 residents who received food from the kitchen (total census 66), as documented on a list provided by the Dietary Supervisor. The findings are. 1. On [DATE] at11:02 AM, during the initial tour of the kitchen with the Dietary Supervisor, the following observations were made in the dry storage room: a. An opened package of 5 pound, 10 ounce box of corn meal mix was on a shelf. The package was not sealed. 2. On [DATE] at11:06 AM, the Walk in Refrigerator temperature was 40 degrees Fahrenheit and a piece of jewelry, a ring, was noted in the onion box. 3. On [DATE] at11:09 AM, the following observations were made in the freezer: a. An opened box of frozen dinner roll dough balls dated [DATE] was on a shelf. The box was not covered, and the bag was not tied. b. An opened box of southern style biscuit dough was on a shelf. The box was not covered or sealed. 4. On [DATE] at 11:15 AM, an opened resealable plastic bag that contained an unsealed bag of brown gravy mix was on the counter, exposing it to air. 5. On [DATE] at 11:33 PM, an opened box of sausage was on a shelf in the refrigerator. The box was not covered or sealed. On [DATE] at 11:35 AM, the following observations were made in the walk-in freezer: a. An opened box of fish was on a shelf in the freezer. The box was not covered or sealed. b. An opened box of chocolate chip cookies was on a shelf in the freezer. The box was not covered or sealed. c. An opened box of polish sausage was on a shelf in the walk-in freezer. The box was not covered or sealed. 6. On [DATE] at 11:39 AM, the ice scoop holder by the ice machine in the kitchen had a wet black residue on it. The ice scoop was resting directly in contact with the black residue. The Surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. The Dietary Supervisor stated, That it is black in color. The Dietary Supervisor was asked who uses the ice from the ice machine and how often do you clean it? She stated, We use it to fill beverages served to the residents at mealtimes. They clean it after every meal. They probably didn't get to it. 7. On [DATE] 11:48 AM, the following observations were made in the kitchen: a. The ceiling air vent by the 2-compartment sink had rust on it. The area around the air vent was chipped and peeled off, exposing the sheet rock. There were dust particles in the air vent and ceiling tile. b. The floor tiles leading to the Janitor's closet were missing, exposing the cement. c. The door frames leading to the dish washing machine room and the door frame leading to the A, B, and C Halls from the kitchen were rotten. d. The wall facing leading to the storage room was chipped, exposing the metal. 8. On [DATE] at 12:00 PM, the following observations were made in the storage room: a. Three of 3 boxes that contained 48, 4 ounce unopened honey thickened orange juice with an expiration date of [DATE]. b. Two of 2 unopened boxes that contained 48, 4 ounce honey thickened orange juice with an expiration date of [DATE]. c. An unopened box of apple juice with expiration date of [DATE]. 9. On [DATE] at 12:05 PM, the following observations were made in the kitchen: a. The ceiling air vent by the door leading to the storage room was chipped, exposing the sheet rock. b. The floor leading to the storage had smeared black matter on it. c. The metal wall between the walk-in freezer and the walk-in refrigerator has a drain attached to it. Water dripped from the faucet onto the metal wall before dripping in the drainage below the wall. The area of the metal wall where water touches, had 60 inches of wet rust on it that could be rubbed off with a finger. The baseboard on the wall leading to the freezer was loose and had brown stains on it. d. The baseboard on the wall leading to the walk-in refrigerator was loose. There was a sage color on the baseboard. 10. On [DATE] at 12:30 PM, the temperatures of the food items checked and read on the steam table by Dietary Employee (DE) #1 were as follows: a. Chicken nuggets - 103 degrees Fahrenheit. b. Mashed potatoes - 130 degrees Fahrenheit. c. Gravy - 125 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 11. On [DATE] at 01:45 PM, the left inside corner of the ice machine opposite the nurses' station for the D, E, and F halls had a wet black residue on it. The Surveyor asked the Dietary Supervisor to wipe the area where the black residue was observed. She used a tissue to wipe the area inside of the ice machine which had a wet black residue on it that was easily transferred from the ice machine onto the tissue. The Surveyor asked the Dietary Supervisor to describe the residue observed inside the ice machine that showed on the tissue. The Dietary Supervisor stated, It is dirty and black in color. The Surveyor asked who uses the ice from the machine and how often do you clean it? She stated, I think the Maintenance Man cleans it. 12. On [DATE] at 01:47 PM, the ice scoop holder on the wall by the ice machine by the corner facing the nurse's station had a wet black residue on it. The ice scoop was resting directly in contact with the black residue. The Surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. The Dietary Supervisor stated, That is black in color. The Dietary Supervisor was asked who uses the ice from the ice machine and how often do you clean it? The Dietary Supervisor stated, That's the ice the CNAs [Certified Nursing Assistants] use to fill the water pitchers in the resident's rooms. 13. On [DATE] at 08:39 AM, the Surveyor asked the Maintenance Man how often do you clean the ice machine and the scoop holder? The Maintenance Man stated, I clean the ice machine quarterly. The nurses clean the scoop holder.

Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner to ensure residents requests for assistance were addressed promptly for 2 (Residents #24 and 41) of 2 sampled residents whose call lights were activated. The findings are: 1. Resident #41 had diagnoses of Type 2 diabetes mellitus without complications and Hypertension. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/23 documented Resident #41 had a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact) and did not receive oxygen (O2) while being a resident. a. A Care Plan with a completion date of 12/15/23 documented, .I have a dx [diagnosis] of Hypertension . monitor/document/report to MD [Medical Doctor] PRN [as needed] any s/sx [signs / symptoms] .difficulty breathing (Dyspnea) . b. A Progress Note dated 2/12/24 at 16:58 (4:58 PM) documented, .New order received for PRN oxygen at 2 liters via [by way of] nc [nasal cannula] . c. On 02/12/24 at 11:24 AM, the Surveyor was speaking with Resident #41 when the nasal cannula came out of Resident #41's nose and the Surveyor activated the call light for assistance. The Surveyor stepped outside of the resident's room and waited to see what time someone would come to assist the resident. The light on the wall in the room had a yellow hue. The light outside of the resident's room had a white hue. The Surveyor did not hear a sound coming from the call light on the wall at this time. At 11:28 AM, a staff member was in the hallway and entered another resident's room that did not have a call light on. At 11:28 AM, the Surveyor observed a staff member at the nurse's station. At 11:35 AM, the Surveyor was standing in the hallway and Resident #41's light remained activated. At 11:36 AM, Licensed Practical Nurse (LPN) #2 entered Resident #41's room and stated, I'm gonna have to go get you a concentrator. The light was activated for 12 minutes before a staff member went into the resident's room to address the resident's need. 2. Resident #24 had diagnoses of Partial traumatic amputation at elbow level, right arm and Acquired absence of left upper limb below elbow. A Modified Quarterly MDS with an ARD of 1/17/24 documented the resident had a BIMS score of 15 (13-15 indicates cognitively intact). a. A Care Plan with a completion date of 1/29/24 documented, .I am total dependent on x [times] 1 staff for personal hygiene, bathing, eating and locomotion. I require 2 person mechanical lift for transfers . b. On 02/14/24, at 5:47 AM, this Surveyor approached the nursing station for Halls E, F, G, and H, and there were two call lights activated at the nursing station, E12 was solid and H5 was flashing and there was an intermittent buzz coming from the nurse's station. This Surveyor walked down the E Hall towards the light, and it was E12. The Resident's door was open, and this Surveyor knocked and entered. The Resident was greeted and then asked how long had [Resident #24] light been on, and the resident stated, It's only been on about five minutes. He'll be down here in a little bit to take care of me. This Surveyor exited the resident's room and approached the nursing station and observed another person with navy blue pants on and a gray sweater with the hood on sitting opposite the nursing station looking down at a cellphone and the buzzing sound could be heard coming from the nursing station. This Surveyor entered the nursing station and two lights, E12 (solid) and H5 (flashing) were on. The staff member, who identified themselves as [Certified Nursing Assistant (CNA) #3] and said that they were assigned to H hall, then got up and walked away from the area. At 5:51 AM, CNA #3 entered room H5 and the light then went off outside that room. At 6:04 AM, CNA #5 entered Room E12 and stated, I'm making my way down to you [Resident #24]. The light outside the door went off and CNA #5 exited the room. (E12 call light had been on for 17 minutes while the Surveyor was in observance). At 6:38 AM, E12 call light came on again outside the door. At 6:46 AM, E12 call light went off and at 6:48 AM, CNA #5 was observed in the room looking through the resident's closet. (Call light was on 8 minutes). c. On 2/14/24 at 6:41 AM, CNA #3 was asked, Who is responsible for answering the call lights? CNA #3 stated, All CNAs. CNA #3 was asked, How do you know when the call lights are on? CNA #3 stated, You hear like a humming sound and there's a light at the top of the beginning of the halls and the rooms. CNA #3 was asked, How long should it take for a call light to be answered? CNA #3 stated, Depending on if you are already dealing with a resident, one to five minutes. If you're not doing anything, ASAP [as soon as possible]. CNA #3 was asked, If you are working with another resident and step out to get something and see another call light on and you go answer it, how long should it be before you go back to that resident to take care of the issue? CNA #3 stated, I wouldn't go in unless I'm going to answer it and take care of what they needed. CNA #3 was asked, If you leave a room and see a call light on, go to that room and let the resident know that you will be back shortly when you are done taking care of another resident and when you are done with resident care, should you go to the room that had the call light on or to another resident's room that does not have a call light on? CNA #3 stated, Go to the room that had the call light on. d. On 02/15/24 at 9:54 AM, LPN #4 was asked, How do you all know when a resident's call light is on? LPN #4 stated, Right above their room, it will be yellow. LPN #4 was asked, What is that faint buzzing sound I'm hearing here at the nursing station? LPN #4 stated, To be exact, I don't know but it sounds like the call light. LPN #4 was asked, What is that light at the top of the H hall? LPN #4 stated, That indicates that is a call light. e. On 02/16/24 at 12:14 PM, the Director of Nursing (DON) was asked, Who is responsible for answering call lights? The DON stated, Everyone. The DON was asked, When should they be answered? The DON stated, Within five to seven minutes but ASAP (as soon as possible). The DON was asked, When should a resident whose call light was answered concern / issue be taken care of? The DON stated, Immediately. The DON was asked, If a staff member is not busy and a call light is on, should they try to see if he/she can provide assistance to the resident? The DON stated, Yes. f. On 2/16/24 at 2:16 PM, the Administrator confirmed the facility did not have a policy on call lights.

Based on observation, interview, and record review, the facility failed to ensure the smoking area outside of the dayroom for Halls E through H was safe to utilize for smoking for 1 (Resident #24) of 7 (Residents #4, #7, #18, #24, #30, #38 and #43) sampled residents who utilized the smoking area outside of the dayroom for Halls E through H; the facility failed to ensure that nail trimmers were not stored in residents room or within easy reach of the resident or other residents to prevent possible harm. This failed practice affected 1 (Resident #4) of 14 (Residents #18, #38, #43, #12, #47, #46, #30, #14, #44, #33, #31, #7, #63) sampled residents who ambulate or self-propel in the facility. The findings are: 1. Resident #24 had diagnoses of Nicotine dependence, cigarettes, Partial traumatic amputation at elbow level, right arm, and Acquired absence of left upper limb below elbow. A Modified Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/24 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A Care Plan with a completion date of 1/29/24 documented, .I choose to smoke; potential for injury . Close monitoring while smoking in the smoking area . b. On 02/12/24 at 1:33 PM, Resident #24 was waiting in the dayroom to go out to smoke. After all the other residents had their smoking aprons on and a Certified Nursing Assistant (CNA) (name not identified at this time) had issued each resident a cigarette, the CNA placed a smoking apron on Resident #24 and propelled the resident out to the smoking area, where a cigarette was placed in Resident #24's mouth, lit the cigarette, and held it so Resident #24 could smoke it. c. On 02/14/24 at 9:53 AM, Resident #24 was observed outside the dayroom in the smoking area for Halls E through H while a staff member was holding a lit cigarette to the resident's mouth to smoke. There was a smoking container that was full, and another resident was observed putting tissue paper in it. d. On 02/15/24 at 9:55 AM, Resident #24 was observed in the smoking area outside the dayroom for Halls E through H. There was a smoking container that had white tissue paper in it that was being used by residents to put used cigarette butts in after smoking. e. On 02/15/24 at 10:06 AM, Certified Nursing Assistant (CNA) #4 was asked, Tell me what could happen if a resident puts tissue paper in a container with used cigarette butts that smoke is coming from? and stated, I don't know, but if someone catches on fire, we do have a fire bag out here and you just have to pull it down. e. On 02/15/24 at 10:15 AM, Housekeeper (HK) #1 was asked, Are the receptacles that the cigarette butts are placed in ever emptied? and stated, Yes. HK #1 was asked, When is it done? and stated, Maybe between when their smoke breaks are over with. HK #1 was asked, Tell me what could happen if a resident puts tissue paper in a container with used cigarette butts that smoke is coming from? and stated, It could catch fire. f. A Smoking Policy provided by the Administrator on 2/12/24 documented, .Purpose: To provide a healthy and safe smoke environment as possible for all residents, staff, and visitors . PROCEDRE: .The resident will be educated as to safe smoking practices . 2. Resident #4 had a diagnosis of Chronic atrial fibrillation. A Quarterly MDS with an ARD of 12/18/2023 documented the resident was taking an anticoagulant. A care plan with date initiated of 10/11/2023 stated, .Check nail length and clean and/or trim on bath day as necessary. Report any changes to the nurse . On 02/12/2024 at 12:14 PM, 2 sets of nail trimmers were in Resident #4's room within easy reach of resident. On 02/13/2024 at 11:30 AM, 1 set of nail trimmers were in Resident #4's room in front of the TV on the dresser. On 02/14/2024 at 10:19 AM, 1 set of nail trimmers were on the dresser in front of the TV, at which time the Surveyor asked Resident #4, Do you clip your own fingernails? Resident #4 stated, Yes I do. On 02/14/2024 at 01:57 PM, CNA #5 was asked, Are you familiar with the care of Resident #4? CNA #5 Replied, Yes. The Surveyor then asked, Is [Resident #4] assessed to trim their own fingernails? CNA #5 replied, I don't know. CNA #5 was then asked, Are residents able to keep nail trimmers in their room? CNA #5 replied, No. The Surveyor asked, What is the reason for not having nail trimmers in the room? CNA #5 replied, For safety, they could be diabetic or pinch the skin and cause a skin break that could cause an infection, or another resident could get them cause harm to themselves unintentionally. On 02/14/2024 at 02:01 PM, Licensed Practical Nurse (LPN) #5 was asked, Are you familiar with the care of Resident #4? LPN #5 Replied, Yes The Surveyor then asked, Is [Resident #4] assessed to trim their own fingernails? LPN #5 replied, No. The LPN was then asked, Are residents able to keep nail trimmers in their room? LPN #5 replied, No, we don't give trimmers to them. The Surveyor asked LPN #5, What medication is [Resident #4] on that would be a reason not to have the trimmers in the room? LPN #5 stated, Eliquis and 81 mg Aspirin. The surveyor asked, What is the reason for not having nail trimmers in the room? LPN #5 replied, The resident could bleed. On 02/14/2024 at 02:09 PM, the Director of Nursing (DON) was asked, Are you familiar with the care of Resident #4? The DON Replied, Yes The Surveyor asked, Is Resident #4 assessed to trim their own fingernails? The DON replied, We don't perform a formal assessment, but she can trim her nails. The DON was then asked, Are residents able to keep nail trimmers in their room? The DON replied, We prefer them not to keep nail trimmers in their room. The Surveyor asked the DON, What medication is she on that would be a reason not to have the trimmers in the room? The DON stated, Blood Thinners. The Surveyor asked, What is the reason for not having nail trimmers in the room? The DON replied, The resident could bleed if they cut themselves. On 02/15/2024 at 12:15 PM, the administrator provided a policy titled Accidents and Hazards Policy that documented, .The facility strives to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents . 48630

Based on observation, record review and interview, the facility failed to ensure oxygen was administered only under the direction of a Physician's order for 1 (Resident #41); proper signage was posted outside the room pertaining to the use of oxygen for 2 (Residents #41 and #46); and the oxygen concentrator was free of debris for 1 (Resident #46) of 2 sampled residents who were receiving oxygen. The findings are: 1. Resident #41 had diagnoses of Type 2 Diabetes Mellitus Without Complications and Hypertension. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/23 documented Resident #41 did not receive oxygen while a resident. a. A Care Plan with a completion date of 12/15/23 documented, .I have a dx [diagnosis] of Hypertension . monitor/document/report to MD [Medical Doctor] PRN [as needed] any s/sx [signs/symptoms] .difficulty breathing (Dyspnea) . b. A Progress Note dated 2/12/24 at 16:58 (4:58 PM) documented, .New order received for PRN oxygen at 2 liters via [by way of] nc [nasal cannula] . c. The February 2024 Order Summary did not contain a Physician's Order for O2 administration. d. On 2/16/24 at 2:16 PM, the February 2024 electronic Medication Administration Record (eMAR) did not contain documentation of oxygen administration. e. On 02/12/24 at 11:17 AM, Resident #41's door did not have an Oxygen in Use sign posted outside the door. Resident #41 was in the bathroom sitting in a wheelchair and a green portable oxygen tank was inside the room to the left of the door with a nasal cannula attached and it was draped over the tank. Certified Nursing Assistant (CNA) #2 propelled Resident #41 from the bathroom and placed the nasal cannula in the resident's nose. The oxygen tank was set at 3 liters per minute and the tubing was not dated. At 11:24 AM, the Surveyor was speaking with the resident and the nasal cannula came out of Resident #41's nose and the Surveyor activated the call light for assistance. At 11:36 AM, Licensed Practical Nurse (LPN) #2 entered the resident's room and stated, I'm gonna have to go get you a concentrator. She stated, They did your chest x-ray and I'm just waiting on your results. f. On 02/13/24 at 11:31 AM, Resident #41 was not in the room and the O2 concentrator was on and set at 2 liters per minute. g. On 2/13/24 at 3:34 PM, Resident #41's door was closed and there was no O2 signage posted outside the door. The concentrator was set at 2 liters per minute, and it was on. Resident #41 was not in the room at this time. h. On 02/14/24 at 9:48 AM, Resident #41 was not in the room. There was an O2 concentrator in the room and there was no signage posted outside the door. i. On 2/16/24 at 12:14 PM, the Director of Nursing (DON) was asked, Do you have standing orders for oxygen administration to residents? The DON stated, Not standing orders. Some of them do that have COPD [Chronic Obstructive Pulmonary Disease] or Asthma. The DON was asked, Why should the tubing/humidifier bottle be dated? The DON stated, To make sure that it hasn't been sitting too long. The DON was asked, What is the time frame for them to be changed? The DON stated, On Sundays, but sometimes the bottles are changed more often. The DON was asked, Why should oxygen be administered at the physician ordered flow rate? The DON stated, For safety. j. On 2/16/24 at 2:16 PM, the Administrator provided a list of all residents with Physician's orders for Oxygen and Resident #41 was not listed. 2. Resident #46 had a diagnosis of Acute Respiratory Failure with Hypoxia. A Quarterly MDS with an ARD of 11/15/2023 documented Resident #46 was receiving oxygen therapy while a resident and on admission. a. A Physicians order dated 09/07/2023 noted Resident #46 had an order for oxygen at 2 liters per minute via nasal cannula as needed for SOB (Shortness of Breath). b. On 02/12/2024 at 12:12 PM, an oxygen concentrator was in Resident #46's room. No oxygen signage was on the door. c. On 02/13/2024 at 08:54 AM, Resident #46 was on portable oxygen in the resident's room. No oxygen signage was on the door. d. On 02/14/2024 at 10:39 AM, the oxygen concentrator had a noticeable thick brown dried substance on the top right side. No oxygen signage was on the door. e. On 02/15/2024 at 02:55 PM, no oxygen signage was on Resident #46's door. The oxygen concentrator had a thick brown dried substance on top right side. f. On 02/15/2024 at 02:56 PM, the Surveyor asked LPN #4, What is in the room beside the [Resident #46's] bed? LPN #4 stated, An oxygen concentrator. The Surveyor asked, Can you describe the appearance of the concentrator? LPN #4 stated, It is dirty, unclean, not clean at all, and looks rigged up. The Surveyor asked, Should anything be placed outside the room? LPN #4 stated, There should be an Oxygen in Use sign on the door to show that oxygen is in use for safety and to prevent possible fire. g. On 02/15/2024 at 03:04 PM, the Surveyor asked the DON, What is in the room beside the residents bed? The DON stated, An oxygen concentrator. The Surveyor asked, Can you describe the appearance of the concentrator? The DON stated, There is something on it. They should be cleaning the oxygen concentrator on Sundays and when there is something visible on it. The Surveyor asked, Should anything be placed outside the room? The DON stated, There should be an Oxygen in Use sign on the door for safety. The staff is supposed to be checking that on rounds. h. On 02/15/2024 at 04:40 PM, the Administrator provided a policy titled, Oxygen Administration-Resident which stated, .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . b. When oxygen is in a room, there must be signing on the door to indicate Oxygen In Use . 48630

Based on observation, record review and interview, the facility failed to ensure the refrigerated narcotic medications in the medication storage room across from the nursing station for Halls A, B, C and D were stored in a permanently affixed compartment for 1 of 1 medication storage room to prevent the potential of misappropriation of resident property, and failed to ensure no medication was remaining in the chamber of a nebulizer to decrease the potential for health complications 1 (Resident #226) of 1 sampled resident who had physician orders for an updraft treatment. The findings are: 1. On 02/15/24 at 2:18 PM, Licensed Practical Nurse (LPN) #2 and the Surveyor were in the medication storage room located across from the nursing station for Halls A, B, C and D. LPN #2 was asked what this room contained and after listing the items, LPN #2 stated, There's a narc [narcotic] box in the refrigerator. LPN #2 was asked, What's in the narc box? LPN #2 stated, Liquid narcs. LPN #2 asked if the Surveyor wanted to see it, and the Surveyor stated, Yes. LPN #2 unlocked the refrigerator lock, opened the door, picked up a metal box and sat it on top of the refrigerator. LPN #2 unlocked the metal box, and the following medications were inside: a. Resident #26 - Two Morphine Sulfate 100 mg [milligrams]/5 ml [milliliter] (20 mg/ml) 30 ml suspension bottles. b. Resident #26 - One, Lorazepam 2 mg/ml (30 ml bottle that was opened with a dropper in the top). c. Resident #26 - One, Lorazepam 2 mg/ml (30 ml bottle unopened). d. (Non-sampled Resident) - Two, Ativan 2mg/ml vials (blue caps in place). e. Stock Ativan - Two, 2 mg/ml vials (blue caps in place). 2. On 2/15/24 at 2:18 PM, LPN #2 was asked, Do you have any residents taking these meds [medications]? LPN #2 stated, No ma'am. LPN #2 was asked, Who does these meds go to after the resident is no longer taking them? LPN #2 stated, The DON [Director of Nursing]. LPN #2 was asked, When? LPN #2 stated, As soon as we can. LPN #2 was asked, Has the narc box ever been attached to anything in the refrigerator? LPN #2 stated, I've been here over a year, and I don't think so. 3. On 2/16/24 at 12:14 PM, the DON was asked, Should the black box in the medication refrigerator located on the A, B, C, D halls be permanently affixed to the inside? The DON stated, Yes. The DON was asked, Tell me why? The DON stated, At the risk of someone taking it. I was told to do that, but I've been trying to find the right kind of lock. 4. Resident #226 had a diagnosis of Atelectasis (a partial collapse of the lung causing shortness of breath) A Physicians Order dated 02/09/2024 documented, Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 2 ml inhale orally two times a day for shortness of breath . A Care Plan dated 2/13/24 documented, [Resident #226] has altered respiratory status requiring respiratory inhalers . Administer medication/puffers as ordered . On 02/12/24 at 3:54 PM, Resident #226 was lying in bed. A nebulizer chamber was at the bedside with liquid in it. On 02/13/24 at 8:51 AM, Resident #226 was lying in bed. A nebulizer chamber with a light discolored liquid in it was at the bedside. On 02/13/24 at 1:51 PM, Resident #226 was lying in bed. A nebulizer chamber was at the bedside. There was a light discolored liquid with a faint odor in the nebulizer chamber. On 02/14/24 at 12:02 PM, LPN #1 was asked to accompany the Surveyor to Resident #226 ' s room to observe the nebulizer. LPN #1 was asked to check the chamber. LPN#1 stated, That's some of the med [medication] in there. LPN #1 was asked to remove the liquid with a syringe. 0.4 milliliter was removed from the chamber. LPN #1 stated, That must be from last night because I sit with her when I give her updraft. LPN #1 was asked, why is it important for all meds to be completely taken. LPN #1 stated, One. It could contaminate the next dose. Two. The resident can be overdosed, and Three. The resident doesn't get the full dose ordered. LPN #1 was asked if this was acceptable practice. LPN #1 stated, No. On 2/15/24 at 9:10 AM, the Director of Nursing (DON) was asked if she expected the nurses to completely administer medications. The DON stated, Yes, then clean it out. The DON was asked the importance of physician ordered medications to be completely given. The DON stated, If they need a med then it needs to be given completely to get the full effect of it. The DON was asked if leaving a partial dose not given, was ok. The DON stated, No. 46868

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had the potential to affect 31 residents who received meal trays in their rooms on the A, B, and C, Hall, 18 residents who received their meal trays in the room on the D, E and F Hall (Back) Hall, as documented on a list provided by the Regional Dietary Manager. The findings are: 1. On 02/12/24 at 11:45 AM, the Surveyor asked Resident #44 how the food was, and was the hot food hot when it arrived to the room on a tray cart? Resident #44 stated, The food is ice cold. 2. On 02/13/24 at 08:15 AM, when the Surveyor entered Hall A the breakfast cart was on the hall. At 08:21 AM, Resident #56 received his tray. He had 3 pieces of bacon, pancake, and eggs (large portions). Certified Nursing Assistant (CNA) #1 sat the tray in front of him and left. CNA #1 did not take off the lid or open any condiments. At 08:35 AM, CNA #1 went in to assist the resident. Resident #56 stated that his food was cold. The Dietary Supervisor was asked to check the temperature of the food items on the tray. She did so, and the scrambled egg was 80 degrees Fahrenheit, and the pancake was 61 degrees Fahrenheit. 3. On 02/12/24 at 01:14 PM, an unheated food cart that contained 10 trays for the lunch meal for A- Hall was delivered to the nurses' station for A, B and C Halls by Dietary Employee (DE) #2. At 01:39 PM, immediately after the last resident received their tray in their room on C Hall, the temperatures of food items on a test tray from the food cart were checked and read by the Dietary Supervisor with the following, results: a. Ground breaded fried pork chops - 109 Degrees Fahrenheit. b. Scalloped potatoes - 113 Degrees Fahrenheit. c. Mixed vegetables - 99.8 Degrees Fahrenheit. 4. On 02/13/24 at 07:45 AM, an unheated food cart that contained 10 trays for the breakfast meal was delivered to the A hall by DE #4. At 08:20 AM, immediately after the last resident received their tray in their room on the A hall, the temperatures of food items on a test tray from the food cart were checked and read by the Dietary Supervisor with the following results: a. Scrambled eggs - 100 degrees Fahrenheit. b. Pancake - 70 degrees Fahrenheit. c. Sausage links - 80 degrees Fahrenheit. The Dietary Supervisor asked for new food trays from the kitchen. 5. On 02/13/24 at 07:55 AM, an unheated food cart that contained 20 trays for the breakfast meal were delivered to the B, C, and D Halls by DE #4. At 08:31 AM, immediately after the last resident received their tray in their room on the A hall, the temperatures of food items on a test tray from the food cart were checked and read by the Dietary Supervisor with the following results: a. Milk - 50 degrees Fahrenheit. b. Pancake - 88 degrees Fahrenheit. c. Scrambled eggs - 101 degrees Fahrenheit. d. Sausage links - 80 degrees Fahrenheit. e. Oatmeal - 100 degrees Fahrenheit. f. Ground sausage with gravy - 100 degrees Fahrenheit.

Based on observation, record review and interview, the facility failed to ensure the grounds of the smoking area outside of the dayroom for halls E through H was cleared of smoking remnants and the receptacles used to collect the smoking remnants were emptied after use to promote a clean and healthy environment for 1 (Resident #24) of 7 sampled residents who utilized the area outside of the dayroom to smoke as documented on a list provided by the Administrator; and failed to ensure a resident's environment was functional and sanitary for 1 (Resident #7) of 1 sampled resident who had a sheet with unknown substances wrapped around the plumbing under the sink. The findings are: 1. Resident #24 had diagnoses of Nicotine Dependence, Cigarettes, Partial Traumatic Amputation at Elbow Level, Right Arm and Acquired Absence of Left Upper Limb Below Elbow. A Modified Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/24 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. a. A Care Plan with a completion date of 1/29/24 documented, .I choose to smoke; potential for injury . Close monitoring while smoking in the smoking area . b. On 02/12/24 at 1:33 PM, Resident #24 was waiting in the dayroom to go out to smoke. After all the other residents had their smoking aprons on and a Certified Nursing Assistant (CNA) had issued each resident a cigarette. The CNA placed a smoking apron on Resident #24 and propelled the resident out to the smoking area, where a cigarette was placed in Resident #24's mouth and the CNA held a lighter to the cigarette and lit it and held it so Resident #24 could smoke it. There were used cigarette butts in the smoking area on the concrete seating area and on the grounds. c. On 02/14/24 at 9:53 AM, Resident #24 was outside the dayroom for halls E through H and a staff member was holding a cigarette to Resident #24's mouth to allow the resident to smoke. There was a smoking container that was full, and another resident was observed putting tissue paper in it. There were cigarette butts on the ground around the bottom of the containers. There were several cigarette butts on the concrete area where the residents were sitting, and they were too numerous to count. d. On 02/15/24 at 9:40 AM, 13 residents were assisted to the smoking area outside the dayroom for halls E through H. The area had multiple (too many to count) cigarette butts on the ground, and a cigarette container had white paper inside it. e. On 02/15/24 at 10:06 AM, CNA #4 was asked, Who is responsible for cleaning the smoking area outside the dayroom between G and H halls? CNA #4 stated, I don't know. I've been here a month and I've never seen anyone come out here. CNA #4 looked to the right and stated, Maybe we are supposed to be cleaning it up because there's a broom over there, but I don't know. The Surveyor asked, Why should cigarette butts be picked up off the ground? CNA #4 stated, So nobody will pick it up and smoke it. f. On 02/15/24 at 10:15 AM, Housekeeper #1 was asked, Who is responsible for cleaning the smoking area outside the dayroom between G and H halls? Housekeeper #1 stated, Housekeeping. The Surveyor asked, Are the receptacles that the cigarette butts are placed in ever emptied? Housekeeper #1 stated, Yes. The Surveyor asked, When is it done? Housekeeper #1 stated, Maybe between when their smoke breaks are over with. The Surveyor asked, Tell me why cigarette butts should be picked up off the ground? Housekeeper #1 stated, Because to make it look presentable. It makes it look like don't nobody care. The Surveyor asked, What could happen if a resident picks up a cigarette butt? Housekeeper #1 stated, They can catch a disease, or they could smoke it. g. On 02/15/24 at 10:25 AM, the Housekeeping Supervisor was asked, Are the housekeepers responsible for cleaning the smoking areas? The Housekeeping Supervisor stated, They are responsible for cleaning the inside of the smoking area. The Surveyor asked, Please explain? The Housekeeping Supervisor stated, The dining area, the inside dayroom area is what we are responsible for cleaning. The outside cleaning is assigned to maintenance, which comes under ground keeping. Sometimes we go outside and help them clean. h. On 02/15/24 at 10:32 AM, Maintenance was asked, Is maintenance responsible for cleaning the smoking area? Maintenance stated, No. The Administrator stated she wanted nursing to clean the area because they are the ones who go out with the smokers. i. On 02/16/24 at 1:19 PM, the Administrator was asked, Who is responsible for cleaning the smoking area? The Administrator stated, On paper, maintenance is responsible for the smoking area. We have established it to be cleaned once a day in the morning by the Lead CNA and housekeeping. j. A Smoking Policy provided by the Administrator on 2/12/24 documented, .To provide a healthy and safe smoke environment as possible for all residents, staff, and visitors . PROCEDURE: .4. All smoking remnants will be discarded into an appropriate / approved receptacle by staff or under staff supervision . 2. The following observations were made in Resident #7's room: a. On 02/12/2024 at 12:04 PM, a sheet was wrapped around the plumbing under the sink, there was a brown and back dried substance on the fabric. b. On 02/14/2024 at 10:30 AM, a sheet remained around the plumbing below the sink with bath blankets on the floor. The sink faucet handles were rotated, and no water was produced. c. On 02/15/2024 at 02:40 PM, a sheet remained around the plumbing below the sink with bath blankets on the floor. The sink faucet handles were rotated, and no water was produced. d. On 02/15/2024 at 02:47 PM, Certified Nursing Assistant (CNA) #6 was asked, How is [Resident #7] able to wash their hands? CNA #6 stated, [Resident #7] would have to go to another room since [Resident #7's] sink is not working. The Surveyor asked, How long has the sink not worked? CNA #6 stated, For sure a couple days. e. On 02/15/2024 at 02:50 PM, Licensed Practical Nurse (LPN) #4 was asked, How is [Resident #7] supposed to wash their hands or brush their teeth? LPN #4 stated, Their sink is not working they will not be able to. The Surveyor asked, What is under the sink? LPN #4 stated, It appears to be some type of sheet and wrapped for leaking purposes. The Surveyor asked LPN #4 to describe the appearance. LPN #4 stated, Its dirty and nobody wants to look at that. I have not reported it to maintenance. f. On 02/15/2024 at 03:08 PM, the Surveyor asked the Maintenance Director, Can you turn on the residents sink? The Maintenance Director stated, The sink won't turn on. The Surveyor asked, Can you describe the appearance? The Maintenance Director stated, It appears to be wrapped in a sheet and the water is shut off. This is a mess. The Surveyor stated, Why is it important to fix the sink? The Maintenance Director stated, This is their home and it's not comfortable to them. g. On 02/15/2024 at 03:09 PM, the Surveyor asked the Director of Nursing (DON), Can you describe what you see under the sink? The DON stated, It is not providing a homelike environment. h. On 02/15/2024 at 4:40 PM, the Administrator stated there was no policy regarding the resident's environment. 48630

Based on interview and record review, the facility failed to ensure that the resident rights were honored on room placement. This failed practice had the potential to affect all 66 residents that reside in the facility. The findings are: On 02/15/24 at 03:24 PM, Resident #14 was asked, How is everything going? Resident #14 stated, It's terrible now that they have changed rooms. Resident #14 was asked, What is going on with the roommate? Resident #14 stated, I can't play the TV, it's either too loud or something else. Resident #14 was asked, How is your roommate and how long have you been in the room? Resident #14 stated, The roommate is just hateful, and the change happened two weeks ago. Resident #14 was asked, Have you reported this to anyone? Resident #14 stated, I have told the social worker. They don't care. Resident #14 was asked, What did the Social Services Director do once you told her? Resident #14 stated, The Social Worker told my roommate what I said when I was not in the room. My roommate told me she knew what all I was saying. Resident #14 was asked, How does this situation make you feel? Resident #14 stated, Makes me feel bad they have took everything from me. Resident #14 was asked, How often do you go to your room? Resident #14 stated, I hate to go to that room. I stay up until I go to bed and that is in the evening late. Resident #14 was asked, Is there any other residents that you talk with and are friends with? Resident #14 stated, I talk to some in the dayroom. On 02/15/2024 at 04:18 PM, the Surveyor reached out to the Social Services Director (SSD) via telephone. The Surveyor asked the SSD, Has Resident #14 reached out to you concerning the relationship with the roommate? The SSD confirmed that the resident reached out the day after the move to the new room. The SSD was asked, Have you followed up with the resident or spoken with the direct resident staff concerning the situation? The SSD confirmed a followed up on the situation had not been done because the resident has not come back with anymore concerns following the first night. On 02/16/2024 at 09:10 AM, the Surveyor asked the Director of Nursing (DON), Have you been made aware of the relationship between Resident #14 and their roommate? The DON stated, I am not aware. The Surveyor asked, What is one thing that [Resident #14] likes to do? The DON replied, [Resident #14] watches a lot of TV. The DON confirmed that Resident #14 is out of the room all day and doesn't watch TV in the room anymore. On 02/16/2024 at 10:30 AM, the Administrator was asked for a policy on Resident Rights. No policy was provided.

Complaint # (AR 342) was substantiated, all or in part, with these findings. Complaint # (AR 415) was substantiated, all or in part, with these findings. Complaint # (AR 426) was substantiated, all or in part, with these findings. Complaint # (AR 429) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure residents discharged from the facility on [DATE] and [DATE], were treated with respect and dignity during the transfer process within a 24-hour period to protect residents' right and prevent increased anxiety for all 64 residents. These failed practices resulted in potential psychological harm for all 64 residents in the facility, at the time of the mass discharges according to lists provided by the Regional Director on [DATE] between 11:34 AM and 3:34 PM via emails. The findings are: I. Sample Selected Residents: 1. Resident #1 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On [DATE] at 1:32 PM, Resident #1 was asked via phone interview if she was upset about having to move to another facility. She said, At first I was upset. She was asked if she was given a choice to stay if she wanted to and was also asked if not, was she given a choice of where she wanted to go. She said, No, I was not given an option to stay and no option to go where I wanted to go. b. On [DATE], Resident #1's daughter was interviewed via phone and was asked if her mother received all her personal belongings when she moved. She said, No, her hearing aid and glasses did not go with her. I didn't know that they were not sent with her until (Facility #1) called me to come pick them up the following Monday ([DATE]). I took them to her after I picked them up on Monday. She went from Thursday ([DATE]) until Monday without her hearing aids and her glasses, a total of 4 days. 2. Resident #2 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Quarterly MDS with an ARD of [DATE] documented a BIMS score of 13 (13 - 15 indicates cognitively intact). a. On [DATE] at 10:38 AM, Resident #2 was asked via phone interview if she was upset about the move and being discharged to the other facility after 11:00 PM Thursday night. She said, I don't understand why all of us had to move over here. They could have put those people somewhere else. I got moved over her about midnight. I was the last one left in the building at (Facility #1). They said we were being moved because they were going to use that building for the sick people. That new flu going around. They said everybody had to move but we could move back when this was over. I told them they would have to sterilize the building before I'll come back. 3. Resident #3 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Annual MDS with an ARD of [DATE] documented a BIMS score of 14 (13 - 15 indicates cognitively intact). a. On [DATE] at 10:50 AM, Resident #3 was asked via phone interview if she was upset about having to move, if they told her why she was having to move, if they gave her the option of staying and if not was she given a choice of where she wanted to go. She said, We were not given an option to stay. We were told they were closing the Nursing Home down and they were turning it into a Coronavirus home, and we couldn't stay. 4. Resident #4 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Quarterly MDS with an ARD of [DATE] documented a BIMS score of 15 (13 - 15 indicates cognitively intact). a. On [DATE] at 11:20 AM, Resident #4 was asked via phone interview if she was upset about the move, was she given an option to stay, if not, was she given a choice of where she wanted to go and if they gave her a reason for making her move. She stated, They told us we had to move because of the coronavirus they were putting people over there with [MEDICAL CONDITION] and I didn't want us to get it; so, I chose to move and not risk getting it. 5. Resident #5 had a [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of [DATE] documented a BIMS score of 15 (13 - 15 indicates cognitively intact). a. On [DATE] at 11:14 AM, Resident #5 was asked via phone interview if he was upset about having to move, was he given a reason for the move, was given an option to stay and if not was he given a choice of where he wanted to move to. He stated, I was upset about having to move because it came so sudden; no time to prepare for it. I was not given an option; I was told I had to move. They told me it was because of the coronavirus. They were going to use if for people who had [MEDICAL CONDITION]. I was not given a choice of where to move. 6. Resident #6 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Significant Change in Status MDS with an ARD of [DATE] documented a BIMS score of 15 (13 - 15 indicates cognitively intact). a. On [DATE] at 11:14 AM, Resident #6 was asked via phone interview if he was upset about the move, was he given a reason for the move, was he given an option to stay and if not, was he given the choice of where he wanted to move to. He said, I was told the night before that I would be moving the next morning around 9 AM. I left actually about 11 - 12. They said the Federal Government was taking the building over and if you had the coronavirus you would go there. They told us that they were told at the last minute and that was the reason for such short notice. I was not given the option to stay and I had a best friend in there, but they split us up. They sent him to (Facility #4) and I'm here (Facility #2). 7. Resident #7 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of [DATE] documented a BIMS score of 14 (13 - 15 indicates cognitively intact). a. On [DATE] at 2:40 PM, Resident #7 was asked via a phone interview if he was upset about the move, what he was told the reason he was having to move, if he was given an option to stay and if not, was he given a choice of where he wanted to go. He said, When I first was told I had to move, I was upset about moving. They did not notify my family; I did but by the time I notified my family I had already been moved. b. On [DATE] at 3:49 PM, Resident #7 family was interviewed via phone and she was asked if she was notified prior to his move and if so when, if she was told why he had to move, if he was given an option of staying and if not, was he given a choice where he wanted to go. She said, No ma'am, I was not notified. I called him that Wednesday morning and asked if he was getting his baths. He said he was going downtown, and I said downtown where, and I told him to hang up and I was calling up there to see what was going on. I called facility and spoke with the DON (Director of Nursing) and she told me they were moving him to (Facility #6). He was there before going to (Facility #1). She told me they were moving everybody out because getting corona (coronavirus) patients. She said it was such a short notice; nobody knew anything. I was very upset about this. I would have took it better if we had gotten a letter or something and some time so we could better adjust. I don't think (Resident #7) was too happy about leaving. If they had notified me and let me know beforehand, I could have found a place that I wanted him to go. I was given no type of choice; none of us were. When I got his things, I found a paper stuck inside one of the bags that said residents' names; where they were going and what time they were going. They called me Friday morning and told me I had to get his things that day. They said they were getting patients with [MEDICAL CONDITION] on Monday. She also said that (Resident #7) wasn't given a chance; no one was given a chance to stay. 8. Resident #9 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Admission MDS with an ARD of [DATE] documented a BIMS score of 2 (0 - 7 indicates severe cognitively impaired). a. On [DATE] at 4:20 PM, a Friend/Responsible Party of Resident #9 was interviewed via phone and was asked if she was notified prior to her being discharged , if she was given a reason for the discharge, if she was given an option of her staying and if not, was she given a choice of where she wanted to go and if she was upset about having to move. She said, I'm not sure who called me or when they called; it sounded like a male. I was told that the Nursing Home was going to be used to house the COVID-19 patients. (Resident #9) has been completely abandoned by her family and I'm all she has now. We've been friends for about [AGE] years now. She had a stroke in December, and she has been crying since then. Since I've not been able to visit her with all this going on, I don't know if this has worsened or not. 9. Resident #11 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Annual MDS with an ARD of [DATE] documented a BIMS score of 15 (,[DATE] indicates cognitively intact). a. On [DATE] at 4:02 PM, Resident #11 was interviewed via phone and was asked if she was upset about having to move, was she given a reason for the move, was she given an option to stay and if not, was she given a choice of where she wanted to go. She said, I was upset at first. They told me they were closing down because they were going to be taking care of people with [MEDICAL CONDITION]. She said that she wasn't given an option to stay because they told us everybody had to leave. She also said she was not given a choice of where she wanted to go either. 10. Resident #12 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The significant change MDS with an ARD of [DATE] documented a BIMS score of 15 (13 - 15 indicates cognitively intact). a. On [DATE] at 3:15 PM, Resident #12 was interviewed via phone and was asked if she was upset about having to move, was she given a reason for the move, was she given an option to stay and if not, was she given a choice of where she wanted to go. She said, Yes, I was told about the move, but they let us know the night before. They told us it was because of the coronavirus and they were going to start taking people in. I was upset they were going to use that place as a quarantine area. I didn't get an option to stay or where I wanted to go. 11. Resident #13 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The significant change MDS with an ARD of [DATE] documented a BIMS score of 9 (8 - 12 indicates moderate cognitive impairment). a. On [DATE] at 3:36 PM, Resident #13 was interviewed via phone and he was asked if he was upset about having to move, was he given a reason for the move, was he given an option to stay and if not, was he given a choice of where he wanted to go. He said, I was upset because I had to move. They didn't tell me why I was moving; they just came and told me I had to move, and I was moved that day. b. On [DATE] at 3:11 PM, Resident #13's family was interviewed via phone and she was asked if he was upset about having to move, was she notified prior to him moving, was she told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. She said, Someone from there called me and told me they were moving him to (Facility #2). I can't remember when they called me though. I haven't talked to him since the transfer. They told me that (Facility #1) was a COVID facility and that's why they were notifying people. I wasn't upset because of the reason they were moving him. I knew they couldn't be there with COVID people. 12. Resident #14 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of [DATE] documented a BIMS score of 15 (13 - 15 indicates cognitively intact). a. On [DATE] at 3:22 PM, Resident #14 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not, was he given a choice on where to go. He said, My memory is not all that great . I want to say yes, I had a great deal of anxiety when they first told me, and it was rather abrupt, and it was a major stressor. I do remember being a little upset; wasn't to the point that I acted out or anything. I wished more time could have been allotted. The way we moved was like, Hey, pack it up, we got to leave. I was not given an option to stay. To my knowledge no one was given an option to stay. 13. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented a BIMS score of 15 (13 -15 indicates cognitively intact). a. On [DATE] at 3:06 PM, Resident #15 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. He said, They told me I was moving because of the overflow from the hospital to make room for people coming from the hospital. Sure, I was upset; they told me I had to move. I wasn't given an option, they said they needed the beds. I was upset, I didn't know what place they were sending me. 14. Resident #16 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of [DATE] documented a BIMS score of 15 (13 - 15 indicates cognitively intact). a. On [DATE] at 12:43 PM, Resident #16 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. He said, I wasn't upset about it, but they didn't give me a notice. I found out I was being moved about 10 minutes prior to the move. II. Non-Sample Selected Resident Interviews: 1. On [DATE] at 2:20 PM an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She stated, My sugar had dropped to 31. They (Facility #1) sent me out to (Hospital #1). I stayed there until I was stable; about 3 days, then I was sent to (Facility #6). I thought I was going back to (Facility #1) but they sent me here (Facility #6). I don't know why they sent me here. I think they called my momma after they got me here. I told them (Facility #6) I wanted to talk to my momma because my phone was dead since I didn't have my phone charger with me. After I got my phone charger and charged my phone, I called my momma and told her where I was at. a. At 2:33 PM, surveyor spoke with (Facility #6) Administrator and asked him if and when he notified the above Resident's momma that she was sent here; and not (Facility #1). He said, I talked to her mother the day she got here. They (Facility #1) had not told her that she would not be going back there. 2. On [DATE] at 2:32 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She said, I was not told reason I was moving, and I was not given a choice on where I was moving too, and no one came and told me I was going to be moving before they moved me. 3. On [DATE] at 2:37 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was he given a choice of where they wanted to go. He said, I was not given an option to stay. No, no reason given either; just told me we had to move. No, not given any options. 4. On [DATE] at 3:50 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was he given a choice of where they wanted to go. He said, I don't think they gave me an option to stay. They told us it was because of the flu. 5. On [DATE] at 4:44 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was given a choice of where they wanted to go. He said, I was not given a reason for moving. I was upset about having to move. I was not given an option to stay. I was not given a choice of what facility I wanted to go to. 6. On [DATE] at 4:46 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She said, I was not given an option to stay. I was not given a choice of what facility I wanted to go to. I was upset about moving because they did it all in one day. The (Certified Nurse Assistant) CNAs told me as they were moving me it was because they were going to be moving peoples with the coronavirus in there. 7. On [DATE] at 5:05 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. She said, I was not given an option to stay and I don't think I was given a choice of where I wanted to go. Yes, I was upset about moving. You get in a routine and get secure with it and it gets pulled out from under you. They said I was having to move because they were putting the COVID-19 in there. They told me I was having to move, and they moved me the next day. III. Non-Sampled Resident Family Interviews: 1. On [DATE] at 10:15 AM, an interview was conducted via phone with a Non-Sample Selected Residents Family and they were asked if they were upset about their loved one having to move, were they notified prior to them moving and if so when, if they were given an option to stay if not, were they given a choice of where they wanted them to go. They said, I was very upset. They called me late in the evening and told me they were moving her the next day. They picked the Nursing Home and I never had a chance to check it out. I was not given an option of her to stay at (Facility #1). They said she had to go. She was transferred to (Facility #8). We called (Facility #8) that evening as soon as they called, and they accepted her. 2. On [DATE] At 10:22 AM, an interview was conducted via phone with a Non-Sample Selected Residents Family and they were asked if they were upset about their loved one having to move, were they notified prior to them moving and if so when, if they were given an option to stay if not, were they given a choice of where they wanted them to go. They said, We were very upset. I was feeling very dissatisfied with the Nursing Home prior to the transfer of the Residents. I had contacted another facility (Facility #9) about transferring my mother. My mother had been at (Facility #1) for 5-plus years. We had been unhappy but kept her there because of the CNA's who had been with her all of these years. We were disappointed with management staff. We were not aware of them getting ready to ship everyone out. Another patient's family member told me. I told her they haven't called us. I called (Facility #1) and asked them what's going on. I asked if they had the coronavirus and I was told no. I told them they knew we were in the process of moving my mother and they said we had to have her out by Thursday. I talked to the facility; I think it was the 17th; then I was panicking. I called the other facility and told them what was going on and how could I expedite. (Facility #1) told me she was going to (Facility #3). They knew we were in the process of going to (Facility #9). They had already sent all of the paperwork to (Facility #9). I kept asking them, Why, why, why are you doing this? I was worried about how my mother was going to react because we haven't been able to visit. The same day I learned they were going to transfer her, I told her please wait, I'm on my way there. When I got there, I was unable to get in. Someone let me in and then they told me you can't come in here. My mother is at (Facility #8). This whole ordeal was a total nightmare. They should have notified us. 3. On [DATE] at 11:08 AM, an interview was conducted via phone with a Non-Sample Selected Residents Family and they were asked if they were upset about their loved one having to move, were they notified prior to them moving and if so when, if they were given an option to stay if not, were they given a choice of where they wanted them to go. They said, I got a call from someone at the facility, they left a message. I couldn't completely understand what they were saying. I immediately called back. I think her name was (Licensed Practical Nurse (LPN) #2). They couldn't get her to the phone. I left a message with (Employee #3). I told her I was calling about the message they had left about transferring her. I told her they better not transfer her until I knew where she was going. They did not give me an option of where she was going. Said she was going to one of their sister facility's. They notified me one day in advance. They did not tell me why until I went to get some of her things after she was already transferred. They told us they were going to move all of her things, but they didn't. When we got there, they had 4 of those contractor trash bags full of stuff. When we went and got her things, I was told they were going to be housing COVID patients. It took a week of calling and finally threatening them to take her TV off the wall so I could get it picked up because I wasn't going in there after the COVID patients got there. I talked to (CNA #3) and he said he would let (Maintenance Director) know. Then I talked to the (Business Office Manager, (BOM)) about her account. She suggested I send an email to the Administrator regarding the TV. I had it the next day. My mom didn't throw too much of a fit. She was at (Facility #6) prior to (Facility #1). When someone at (Facility #6) called me, she said she wanted to let me know where my mother was going. I told her she is supposed to be going to (Facility #6). She said she was calling because some of the other Resident families didn't know they were or where they were going. My big thing was I didn't understand the big rush. III. Observations: On [DATE] multiple snap shots of the video footage on [DATE] and [DATE] were received by (Employee #1) via email. They included pictures of multiple large contractor trash bags and plastic and cardboard boxes full of Resident personal belongings piled on top of wheelchairs, serving carts, tables and floor. There were also pictures of clusters of various non-bagged or non-boxed unidentifiable items. Amongst the clutter were some pictures of residents in wheelchairs and/or chairs as well as multiple staff members; including the Maintenance Director. (Photos are available for further details) IV. Staff Interviews: 1. On [DATE] at 12:10 PM, (Employee #1) called and stated that she was so upset about what happened to their residents that were sent out of their facilities on the 18th and 19th. They were pulled out of their beds and put in their wheelchairs and put out in the hallways lined up like cattle. (Resident #11) was crying and non-sample selected Resident and (Resident #3) were very mad and (Resident #6) was very upset and he went to hospital for [MEDICAL TREATMENT] 3 times a week. Also, (Resident #9) (non-verbal) was so upset she was crying (more than usual), also (Resident #12, #13, #14 and #15) were also upset about the move and (Resident #10) passed away right after the move but I don't know what he died from. 2. On [DATE] at 12:45 PM, (Contracted Staff #1) called and reported that he assisted with transporting 8 residents on Wednesday and 4 - 5 residents on Thursday. He said that he had been transporting (Resident #6) previously to [MEDICAL TREATMENT] before he was discharged from that facility. He said that (Resident #6) was appalled and furious about having to move. He also said that since last Thursday all of the residents' personal belongings were in trash bags and sitting in the lobby and hallway in front at (Facility #2) which saddened me since so many of these residents that is all they have left to their name and it was tossed about like it was nothing. Seemed as though they weren't thinking or caring about the Residents' wellbeing. He went on to say that the only person he currently trusted was the previous Administrator; that they have fired for not lying to us. He said that he was witnessed to families not being told that their loved ones were being moved, patients belongings in trash bags out in the hallways of (Facility #1) and it appeared that some of the residents whom he transported had not received care before they were sent out. He said that he also heard last Friday the DON and Social Service Director talking about throwing away residents' personal belongings and heard (Nurse Consultant) saying to them, We're not taking their things to them and I don't care what you do with them; toss them for all I care. He was asked if he was aware of the last resident being sent out late the night of the 19th. He said, Yes, I can attest to that because they asked me to transport (Resident #2) around 11:00 PM that night but I was already on my way to (out of state) and was not able to do that transfer. 3. On [DATE] at 4:11 PM, spoke to LPN #2 via phone. She was asked what her involvement was in the mass discharge of the facility's previous residents on the 18th and 19th. She said, On Tuesday, I believe it was the 17th, (Nurse Consultant) from Corporate came in the building around 9:00 to 10:00 and told all of the Department Heads that we would be moving all of the residents out of this facility within the next 2 days because we are going to be a designated COVID-19 facility. We were given a typed message of what we were to tell the Residents/Families. They should be able to get you a copy of that letter. They also had a list of the residents and where they were going to be transferred to so we could get them lined up awaiting transfer to the various facilities. We all had a certain hall we were assigned to go call the POAs (Power of Attorneys) or tell the residents what was going on. Another staff member and I had the (E) hall. I tried to put in the Residents Progress Notes who I talked to but, I don't know about my partner or any of the other ones what they did or told the residents and/or their families. I have been so upset about all this; spent all weekend crying. They did it in such a way that stripped them (Residents) of their dignity, rights and basically left them in a very fragile emotional state of mind. They were lined up like cattle going to slaughterhouses. They tossed all of their belongings out in the hallways in trash bags and many of the residents saw what was happening to all of their personal belongings. (Resident #8) was sitting at the back with other residents they had lined up awaiting transport. He waved at me and I went back to him and he was unable to talk but was shaking his head; grabbed my arm hanging onto it. I told him it was going to be okay and he would be taken care of. But I felt like I was lying to him trying to make him feel better about what was going on. (Resident #9) is a very depressed resident and has a tendency to cry anyway; she was sitting in her wheelchair with tears running down her face. I tried to console her as well. She is non-verbal most of the time. (Resident #5) was in his room and he asked me, 'Can you tell me where he's going (pointing at his roommate; (Resident #10). He said I'd like to go where he's going because I've always looked after him.' I told him I would check. I did but, they did send them to separate facilities. I was told (Resident #10) expired shortly after the move but I do not know what from. I felt like the DON, SSD could care less and just wanted to get this done. The DON did not come out of her office much at all on the 18th and 19th to help us nor console any of the residents. There was no notice given to anyone and no one was given an option to stay. 4. On [DATE] at 4:35 PM, an interview was done with Employee #3 and she was asked what her involvement was when all of the previous residents were all sent out to other facilities on the 18th and 19th of March. She said, (Regional Director) and (Nurse Consultant) told us through the DON and the Previous Administrator to tell State the residents had a choice if they wanted to move or stay and choice of facility. None of the Resident's wanted to move. (Resident #11) cried and (Resident #6) told them You are violating my (expletive) rights! He voiced this when he was going out the door. The (Non-Sample Selected Resident's) family was upset, another (Non-sample Selected Resident's) family was upset, also (Non-sampled Selected Resident's) and (Resident #16) families were upset as well as another (Non-sampled Selected Resident's) family was upset. They all knew about all of this too. II. Policy and Procedures: The Resident Rights provided by the Administrator on [DATE] at 11:11 AM documented, .Resident Rights. a.) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the facility, including those specified in this section. (1) a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. (2) . a facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. b). Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (1) the facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility (2) the resident has the right to be free from interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supportive by the facility in the exercise of his or her rights as required under this subpart. (3) in the case that the resident who has not been adjudged incompetent by the State/Court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercis (TRUNCATED)

Complaint # (AR 342) was substantiated, all or in part, with these findings. Complaint # (AR 415) was substantiated, all or in part, with these findings. Complaint # (AR 426) was substantiated, all or in part, with these findings. Complaint # (AR 429) was substantiated, all or in part, with these findings. Based on record review and interviews the facility failed to ensure Residents and/or Responsible Parties were notified promptly, in writing or via phone call, prior to discharging residents from the facility on 3/18/20 and 3/19/20 to promote resident well-being and keep residents' responsible parties informed. This failed practice had the potential to affect all 64 residents discharged from the facility on 3/18/20 and 3/19/20 per emails received from the Regional Director on 3/25/2020 between 11:34 AM and 3:34 PM. The findings are: I. Sample Selected Residents: 1. Resident #1 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/20 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 3/27/2020 at 1:32 PM, Resident #1 was asked via phone interview if she was upset about having to move to another facility. She said, At first I was upset. She was asked if she was given a choice to stay if she wanted to and was also asked if not, was she given a choice of where she wanted to go. She said, No, I was not given an option to stay and no option to go where I wanted to go. b. On 4/2/2020 Resident #1 daughter was interviewed via phone and was asked if her mother received all her personal belongings when she moved. She said, No, her hearing aid and glasses did not go with her. I didn't know that they were not sent with her until (Facility #1) called me to come pick them up the following Monday (3/23/20). I took them to her after I picked them up on Monday. She went from Thursday (3/19/20) until Monday without her hearing aids and her glasses, a total of 4 days. 2. Resident #2 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Quarterly MDS with an ARD of 2/28/20 documented a BIMS score of 13 (13-15 indicates cognitively intact). a. On 3/27/2020 at 10:38 AM, Resident #2 was asked via phone interview if she was upset about the move and being discharged to the other facility after 11:00 PM Thursday night. She said, I don't understand why all of us had to move over here. They could have put those people somewhere else. I got moved over her about midnight. I was the last one left in the building at (Facility #1). They said we were being moved because they were going to use that building for the sick people. That new flu going around. They said everybody had to move but we could move back when this was over. I told them they would have to sterilize the building before I'll come back. 3. Resident #3 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Annual MDS with an ARD of 12/25/19 documented a BIMS score of 14 (13-15 indicates cognitively intact). a. On 3/27/2020 at 10:50 AM, Resident #3 was asked via phone interview if she was upset about having to move, if they told her why she was having to move, if they gave her the option of staying and if not was she given a choice of where she wanted to go. She said, We were not given an option to stay. We were told they were closing the Nursing Home down and they were turning it into a Coronavirus home, and we couldn't stay. 4. Resident #4 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Quarterly MDS with an ARD of 2/3/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 11:20 AM, Resident #4 was asked via phone interview if she was upset about the move, was she given an option to stay, if not, was she given a choice of where she wanted to go and if they gave her a reason for making her move. She stated, They told us we had to move because of the coronavirus they were putting people over there with [MEDICAL CONDITION] and I didn't want us to get it; so, I chose to move and not risk getting it. 5. Resident #5 had a [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 1/24/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 11:14 AM, Resident #5 was asked via phone interview if he was upset about having to move, was he given a reason for the move, was given an option to stay and if not was he give a choice of where he wanted to move to. He stated, I was upset about having to move because it came so sudden; no time to prepare for it. I was not given an option; I was told I had to move. They told me it was because of the coronavirus. They were going to use if for people who had [MEDICAL CONDITION]. I was not given a choice of where to move. 6. Resident #6 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Significant Change in Status MDS with an ARD of 1/30/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 11:14 AM, Resident #6 was asked via phone interview if he was upset about the move, was he given a reason for the move, was he given an option to stay and if not, was he given the choice of where he wanted to move to. He said, I was told the night before that I would be moving the next morning around 9 AM. I left actually about 11 to 12. They said the Federal Government was taking the building over and if you had the coronavirus you would go there. They told us that they were told at the last minute and that was the reason for such short notice. I was not given the option to stay and I had a best friend in there, but they split us up. They sent him to (Facility #4) and I'm here (Facility #2). 7. Resident #7 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 12/19/19 documented a BIMS score of 14 (13-15 indicates cognitively intact). a. On 3/27/20 at 2:40 PM, Resident #7 was asked via a phone interview if he was upset about the move, what he was told the reason he was having to move, if he was given an option to stay and if not, was he given a choice of where he wanted to go. He said, When I first was told I had to move, I was upset about moving. They did not notify my family; I did but, by the time I notified my family I had already been moved. b. On 4/1/2020 at 3:49 PM, Resident #7 family was interviewed via phone and she was asked if she was notified prior to his move and if so when, if she was told why he had to move, if he was given an option of staying and if not, was he given a choice where he wanted to go. She said, No ma'am, I was not notified. I called him that Wednesday morning and asked if he was getting his baths. He said he was going downtown, and I said downtown where, and I told him to hang up and I was calling up there to see what was going on. I called facility and spoke with the DON (Director of Nursing) and she told me they were moving him to (Facility #6). He was there before going to (Facility #1). She told me they were moving everybody out because getting corona (coronavirus) patients. She said it was such a short notice; nobody knew anything. I was very upset about this. I would have took it better if we had gotten a letter or something and some time so we could better adjust. I don't think (Resident #7) was too happy about leaving. If they had notified me and let me know beforehand, I could have found a place that I wanted him to go. I was given no type of choice; none of us were. When I got his things, I found a paper stuck inside one of the bags that said residents' names; where they were going and what time they were going. They called me Friday morning and told me I had to get his things that day. They said there were getting patients with [MEDICAL CONDITION] on Monday. She also said that (Resident #7) wasn't given a chance; no one was given a chance to stay. 8. Resident #9 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Admission MDS with an ARD of 2/12/20 documented a BIMS score of 2 (0-7 indicates severe cognitively impaired). a. On 4/1/2020 at 4:20 PM, a Friend/Responsible Party of Resident #9 was interviewed via phone and was asked if she was notified prior to her being discharged , if she was given a reason for the discharge, if she was given an option of her staying and if not, was she given a choice of where she wanted to go and if she was upset about having to move. She said, I'm not sure who called me or when they called; it sounded like a male. I was told that the Nursing Home was going to be used to house the COVID-19 patients. (Resident #9) has been completely abandoned by her family and I'm all she has now. We've been friends for about [AGE] years now. She had a stroke in December, and she has been crying since then. Since I've not been able to visit her with all this going on, I don't know if this has worsened or not. 9. Resident #11 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Annual MDS with an ARD of 2/7/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 4:02 PM, Resident #11 was interviewed via phone and was asked if she was upset about having to move, was she given a reason for the move, was she given an option to stay and if not, was she given a choice of where she wanted to go. She said, I was upset at first. They told me they were closing down because they were going to be taking care of people with [MEDICAL CONDITION]. She said that she wasn't given an option to stay because they told us everybody had to leave. She also said she was not given a choice of where she wanted to go either. 10. Resident #12 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The significant change MDS with an ARD of 1/4/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/21/2020 at 3:15 PM, Resident #12 was interviewed via phone and was asked if she was upset about having to move, was she given a reason for the move, was she given an option to stay and if not, was she given a choice of where she wanted to go. She said, Yes, I was told about the move, but they let us know the night before. They told us it was because of the [MEDICAL CONDITION] and they were going to start taking people in. I was upset they were going to use that place as a quarantine area. I didn't get an option to stay or where I wanted to go. 11. Resident #13 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The significant change MDS with an ARD of 1/25/20 documented a BIMS score of 9 (8-12 indicates moderate cognitive impairment). a. On 4/1/20 at 3:36 PM, Resident #13 was interviewed via phone and he was asked if he was upset about having to move, was he given a reason for the move, was he given an option to stay and if not, was he given a choice of where he wanted to go. He said, I was upset because I had to move. They didn't tell me why I was moving; they just came and told me I had to move, and I was moved that day. b. On 4/1/20 at 3:11 PM, Resident #13's family was interviewed via phone and she was asked if he was upset about having to move, was she notified prior to him moving, was she told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. She said, Someone from there called me and told me they were moving him to (Facility #2). I can't remember when they called me though. I haven't talked to him since the transfer. They told me that (Facility #1) was a COVID facility and that's why they were notifying people. I wasn't upset because of the reason they were moving him. I knew they couldn't be there with COVID people. 12. Resident #14 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 2/19/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/20 at 3:22 PM, Resident #14 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not, was he given a choice on where to go. He said, My memory is not all that great . I want to say yes, I had a great deal of anxiety when they first told me, and it was rather abrupt, and it was a major stressor. I do remember being a little upset; wasn't to the point that I acted out or anything. I wished more time could have been allotted. The way we moved was like, Hey, pack it up, we got to leave. I was not given an option to stay. To my knowledge no one was given an option to stay. 13. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/15/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/20 at 3:06 PM, Resident #15 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. He said, They told me I was moving because of the overflow from the hospital to make room for people coming from the hospital. Sure, I was upset; they told me I had to move. I wasn't given an option, they said they needed the beds. I was upset, I didn't know what place they were sending me. 14. Resident #16 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 2/15/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 4/1/20 at 12:43 PM, Resident #16 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. He said, I wasn't upset about it, but they didn't give me a notice. I found out I was being moved about 10 minutes prior to the move. II. Non-Sample Selected Resident Interviews: 1. On 3/27/20 at 2:20 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She stated, My sugar had dropped to 31. They (Facility #1) sent me out to (Hospital #1). I stayed there until I was stable; about 3 days, then I was sent to (Facility #6). I thought I was going back to (Facility #1) but they sent me here (Facility #6). I don't know why they sent me here. I think they called my momma after they got me here. I told them (Facility #6) I wanted to talk to my momma because my phone was dead since I didn't have my phone charger with me. After I got my phone charger and charged my phone, I called my momma and told her where I was at. a. At 2:33 PM, surveyor spoke with (Facility #6) Administrator and asked him if and when he notified the above Resident's momma that she was sent here; and not (Facility #1). He said, I talked to her mother the day she got here. They (Facility #1) had not told her that she would not be going back there. 2. On 3/27/20 at 2:32 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She said, I was not told reason I was moving, and I was not given a choice on where I was moving too, and no one came and told me I was going to be moving before they moved me. 3. On 3/27/20 at 2:37 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was he given a choice of where they wanted to go. He said, I was not given an option to stay. No, no reason given either; just told me we had to move. No, not given any options. 4. On 3/27/20 at 3:50 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was he given a choice of where they wanted to go. He said, I don't think they gave me an option to stay. They told us it was because of the flu. 5. On 3/27/20 at 4:44 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was given a choice of where they wanted to go. He said, I was not given a reason for moving. I was upset about having to move. I was not given an option to stay. I was not given a choice of what facility I wanted to go to. 6. On 3/27/20 at 4:46 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She said, I was not given an option to stay. I was not given a choice of what facility I wanted to go to. I was upset about moving because they did it all in one day. The (Certified Nurse Assistant) CNA's told me as they were moving me it was because they were going to be moving peoples with the coronavirus in there. 7. On 3/27/20 at 5:05 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. She said, I was not given an option to stay and I don't think I was given a choice of where I wanted to go. Yes, I was upset about moving. You get in a routine and get secure with it and it gets pulled out from under you. They said I was having to move because they were putting the COVID-19 in there. They told me I was having to move, and they moved me the next day. III. Non-Sampled Resident Family Interviews: 1. On 4/1/20 at 10:15 AM, an interview was conducted via phone with a Non-Sample Selected Residents Family and they were asked if they were upset about their loved one having to move, were they notified prior to them moving and if so when, if they were given an option to stay if not, were they given a choice of where they wanted them to go. They said, I was very upset. They called me late in the evening and told me they were moving her the next day. They picked the Nursing Home and I never had a chance to check it out. I was not given an option of her to stay at (Facility #1). They said she had to go. She was transferred to (Facility #8). We called (Facility #8) that evening as soon as they called, and they accepted her. 2. On 4/1/20 At 10:22 AM, an interview was conducted via phone with a Non-Sample Selected Residents Family and they were asked if they were upset about their loved one having to move, were they notified prior to them moving and if so when, if they were given an option to stay if not, were they given a choice of where they wanted them to go. They said, We were very upset. I was feeling very dissatisfied with the Nursing Home prior to the transfer of the Residents. I had contacted another facility (Facility #9) about transferring my mother. My mother had been at (Facility #1) for 5-plus years. We had been unhappy but kept her there because of the CNA's who had been with her all of these years. We were disappointed with management staff. We were not aware of them getting ready to ship everyone out. Another patient's family member told me. I told her they haven't called us. I called (Facility #1) and asked them what's going on. I asked if they had the coronavirus and I was told no. I told them they knew we were in the process of moving my mother and they said we had to have her out by Thursday. I talked to the facility; I think it was the 17th; then I was panicking. I called the other facility and told them what was going on and how could I expedite. (Facility #1) told me she was going to (Facility #3). They knew we were in the process of going to (Facility #9). They had already sent all of the paperwork to (Facility #9). I kept asking them, Why, why, why are you doing this? I was worried about how my mother was going to react because we haven't been able to visit. The same day I learned they were going to transfer her, I told her please wait, I'm on my way there. When I got there, I was unable to get in. Someone let me in and then they told me you can't come in here. My mother is at (Facility #8). This whole ordeal was a total nightmare. They should have notified us. 3. On 4/1/20 at 11:08 AM, an interview was conducted via phone with a Non-Sample Selected Residents Family and they were asked if they were upset about their loved one having to move, were they notified prior to them moving and if so when, if they were given an option to stay if not, were they given a choice of where they wanted them to go. They said, I got a call from someone at the facility, they left a message. I couldn't completely understand what they were saying. I immediately called back. I think her name was (Licensed Practical Nurse (LPN) #2). They couldn't get her to the phone. I left a message with (Employee #3). I told her I was calling about the message they had left about transferring her. I told her they better not transfer her until I knew where she was going. They did not give me an option of where she was going. Said she was going to one of their sister facility's. They notified me one day in advance. They did not tell me why until I went to get some of her things after she was already transferred. They told us they were going to move all of her things, but they didn't. When we got there, they had 4 of those contractor trash bags full of stuff. When we went and got her things, I was told they were going to be housing COVID patients. It took a week of calling and finally threatening them to take her TV off the wall so I could get it picked up because I wasn't going in there after the COVID patients got there. I talked to (CNA #3) and he said he would let (Maintenance Director) know. Then I talked to the (Business Office Manager, (BOM)) about her account. She suggested I send an email to the Administrator regarding the TV. I had it the next day. My mom didn't throw too much of a fit. She was at (Facility #6) prior to (Facility #1). When someone at (Facility #6) called me, she said she wanted to let me know where my mother was going. I told her she is supposed to be going to (Facility #6). She said she was calling because some of the other Resident families didn't know they were or where they were going. My big thing was I didn't understand the big rush. IV. Policies and Procedures: A. Rapid Response Plan COVID-19 March 13, 2020 (Developed by (Corporation)) documented, Purpose: Out of an abundance of caution and in an effort to contain or mitigate the spread of COVID-19 . Plan: .Contact each resident and resident representative of the designated facilities to obtain permission to temporarily relocate . B. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers Centers of Medicare /and Medicaid (CMS) documented, Resident Transfer/Discharge: .Exceptions: .In 483.10, we are only waiving the requirement, under 483.10(c)(5), that a facility provide advance notification of options relating to the transfer or discharge to another facility. Otherwise all requirement, under 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), and (d), for the written notice of transfer or discharge to be provided before the transfer or discharge. This notice must be provided as soon as practicable . (Corporation) had developed their Rapid Response plan on 3/13/2020 and could have provided sufficient notice as early as 3/13/2020 or immediately thereafter; NOT the day before, day of or after their discharge. .We reminded Office of Long-Term Care (OLTC) facilities that they are responsible for ensuring that any transfers (either within a facility, or to another facility) are conducted in a safe and orderly manner, and that each resident's health and safety is protected . C. The (Facility #1) letter dated 3/17/2020 read (not given and/or sent) to some of the Resident and/or Responsible Party either on 3/17/20, 3/18/20, or 3/19/20 documented, 3/17/2020 . Dear Resident, Family and/or Responsible Party, Due to the illnesses that are occurring with the COVID crisis, we are designating our Facility, (Facility #1) as a COVID-19 facility due to our unique situation of having an isolated building. We do not have any active cases at this point but are planning on this occurring in the near future due to the outbreak. Therefore, we will be moving you (your loved one) to one of our sister facilities: ________ .

Based on observation, record reviews and interviews, the facility failed to ensure residents were informed in writing or verbal communication; in a language they could understand of the need to move from the current facility to another sister facility to prevent potential transmission of the Coronavirus; Failed to ensure the mass transfers was done decent, and in order, with minimum stress, chaos and disruption to minimize mental anguish, emotional distress for all 64 residents. This failed practice resulted in psychological abuse and harm for all 64 residents who resided in the facility during the time of the mass discharges per lists provided by the Regional Director on 3/25/2020 between 11:34 AM and 3:34 PM via emails. The findings are: I. Sample Selected Residents: 1. Resident #1 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/20 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 3/24/2020 at 3:22 PM, spoke with Resident #1's daughter and was asked if she was aware of the reason for her mother's discharge from the facility and when she was notified of her impending discharge and if she was given a choice of which facility she wanted her mother to be discharged to and if she was given an option of her mother staying at the facility and not being discharged . She stated, I found out initially from mother's (Attending Physician #1's) (Advanced Practice Nurse) that the facility where my mother has been for approximately [AGE] years was discharging all of their residents out by the following Monday to their sister facilities. She knew I wanted my mother to go to (Facility #7) so she was nice enough to call me and give me a heads up. She also said she didn't hear from the facility about this until approximately around 10:30 - 11:00 AM on the 19th that they needed approval from (Facility #7) in 5 minutes if they were going to admit her mother or not. She said she immediately called (Facility #7) and told them that (Facility #1) was ready to transfer her mother right then. They (Facility #7) initially told me that all they needed from (Facility #1) was a Pre-Admission and Screening Resident Review (PASARR). She said she then attempted to call (Facility #1) back and never got an answer nor did it ring or give her a busy signal. It would just immediately after dialing just drop the call. She said that was when she called (Facility #7) back and told them of the situation and they told me I'd need to go there and come back to complete admission paperwork and give a deposit to hold the room. She said she immediately went to (Facility #7). Said it was approximately 45 minutes after she spoke to them and while she was there completing paperwork she got another call from (APRN) and asked what was going on at (Facility #1) because they couldn't get anyone there to answer the phone either. She said she then told the lady at (Facility #7) that she needed to go to (Facility #1) and see what was going on. She said she got there around 3:00 PM and her mother was already gone. She asked where they (Facility #1) sent her and they told her (Facility #7) and that's when she became irate and told them No .you didn't send her there (Facility #7) .I just came from there!!! And was screaming at them, Where is my mother? over and over when they finally told her that they had sent her to (Facility #4) since (Facility #7) would not accept her mother. She said she told them that (Facility #7) and herself had been trying to get in touch with them all day to tell them they just needed a (PASARR) and that was when the Administrator and the SSD (Social Service Director) told her no, they had been in contact with (Facility #7) multiple times throughout the day and the conversation became very heated at that point to the point a male (unknown name) shoved her and she fell in the bushes causing scrapes and bruising and the police were called on the scene but she said all she was wanting to do was find out where they sent her mother and why they couldn't get what (Facility #7) needed to admit her mother where she wanted her to go. She said that was when the SSD pushed out the cracked door a post-it-note with (Facility #4) Administrator name and their phone number on it. She said she called (Facility #4) and spoke to the Administrator who was very nice and accommodating and even took his phone to her mother so she could be assured that she was alright. b. On 3/27/2020 at 1:32 PM, Resident #1 was asked via phone interview if she was upset about having to move to another facility. She said, At first I was upset. She was asked if she was given a choice to stay if she wanted to and was also asked if not, was she given a choice of where she wanted to go. She said, No, I was not given an option to stay and no option to go where I wanted to go. c. On 4/2/2020 Resident #1 daughter was interviewed via phone and was asked if her mother received all her personal belongings when she moved. She said, No, her hearing aid and glasses did not go with her. I didn't know that they were not sent with her until (Facility #1) called me to come pick them up the following Monday (3/23/20). I took them to her after I picked them up on Monday. She went from Thursday (3/19/20) until Monday without her hearing aids and her glasses, a total of 4 days. 2. Resident #2 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Quarterly MDS with an ARD of 2/28/20 documented a BIMS score of 13 (13 - 15 indicates cognitively intact). a. On 3/27/2020 at 10:38 AM, Resident #2 was asked via phone interview if she was upset about the move and being discharged to the other facility after 11:00 PM Thursday night. She said, I don't understand why all of us had to move over here. They could have put those people somewhere else. I got moved over her about midnight. I was the last one left in the building at (Facility #1). They said we were being moved because they were going to use that building for the sick people. That new flu going around. They said everybody had to move but we could move back when this was over. I told them they would have to sterilize the building before I'll come back. 3. Resident #3 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Annual MDS with an ARD of 12/25/19 documented a BIMS score of 14 (13-15 indicates cognitively intact). a. On 3/27/2020 at 10:50 AM, Resident #3 was asked via phone interview if she was upset about having to move, if they told her why she was having to move, if they gave her the option of staying and if not was she given a choice of where she wanted to go. She said, We were not given an option to stay. We were told they were closing the Nursing Home down and they were turning it into a Coronavirus home, and we couldn't stay. 4. Resident #4 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Quarterly MDS with an ARD of 2/3/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 11:20 AM, Resident #4 was asked via phone interview if she was upset about the move, was she given an option to stay, if not, was she given a choice of where she wanted to go and if they gave her a reason for making her move. She stated, They told us we had to move because of the coronavirus they were putting people over there with [MEDICAL CONDITION] and I didn't want us to get it; so, I chose to move and not risk getting it. 5. Resident #5 had a [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 1/24/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 11:14 AM, Resident #5 was asked via phone interview if he was upset about having to move, was he given a reason for the move, was given an option to stay and if not was he give a choice of where he wanted to move to. He stated, I was upset about having to move because it came so sudden; no time to prepare for it. I was not given an option; I was told I had to move. They told me it was because of the coronavirus. They were going to use if for people who had [MEDICAL CONDITION]. I was not given a choice of where to move. 6. Resident #6 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Significant Change in Status MDS with an ARD of 1/30/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 11:14 AM, Resident #6 was asked via phone interview if he was upset about the move, was he given a reason for the move, was he given an option to stay and if not, was he given the choice of where he wanted to move to. He said, I was told the night before that I would be moving the next morning around 9 AM. I left actually about 11 - 12. They said the Federal Government was taking the building over and if you had the coronavirus you would go there. They told us that they were told at the last minute and that was the reason for such short notice. I was not given the option to stay and I had a best friend in there, but they split us up. They sent him to (Facility #4) and I'm here (Facility #2). 7. Resident #7 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 12/19/19 documented a BIMS score of 14 (13-15 indicates cognitively intact). a. On 3/27/20 at 2:40 PM, Resident #7) was asked via a phone interview if he was upset about the move, what he was told the reason he was having to move, if he was given an option to stay and if not, was he given a choice of where he wanted to go. He said, When I first was told I had to move, I was upset about moving. They did not notify my family; I did but by the time I notified my family I had already been moved. b. On 4/1/2020 at 3:49 PM, Resident #7 family was interviewed via phone and she was asked if she was notified prior to his move and if so when, if she was told why he had to move, if he was given an option of staying and if not, was he given a choice where he wanted to go. She said, No ma'am, I was not notified. I called him that Wednesday morning and asked if he was getting his baths. He said he was going downtown, and I said downtown where, and I told him to hang up and I was calling up there to see what was going on. I called facility and spoke with the DON (Director of Nursing) and she told me they were moving him to (Facility #6). He was there before going to (Facility #1). She told me they were moving everybody out because getting corona (coronavirus) patients. She said it was such a short notice; nobody knew anything. I was very upset about this. I would have took it better if we had gotten a letter or something and some time so we could better adjust. I don't think (Resident #7) was too happy about leaving. If they had notified me and let me know beforehand, I could have found a place that I wanted him to go. I was given no type of choice; none of us were. When I got his things, I found a paper stuck inside one of the bags that said residents names; where they were going and what time they were going. They called me Friday morning and told me I had to get his things that day. They said there were getting patients with [MEDICAL CONDITION] on Monday. She also said that (Resident #7) wasn't given a chance; no one was given a chance to stay. 8. Resident #9 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Admission MDS with an ARD of 2/12/20 documented a BIMS score of 2 (0-7 indicates severe cognitively impaired). a. On 4/1/2020 at 4:20 PM, a Friend/Responsible Party of Resident #9 was interviewed via phone and was asked if she was notified prior to her being discharged , if she was given a reason for the discharge, if she was given an option of her staying and if not, was she given a choice of where she wanted to go and if she was upset about having to move. She said, I'm not sure who called me or when they called; it sounded like a male. I was told that the Nursing Home was going to be used to house the COVID-19 patients. (Resident #9) has been completely abandoned by her family and I'm all she has now. We've been friends for about [AGE] years now. She had a stroke in December, and she has been crying since then. Since I've not been able to visit her with all this going on, I don't know if this has worsened or not. 9. Resident #11 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The Annual MDS with an ARD of 2/7/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/2020 at 4:02 PM, Resident #11 was interviewed via phone and was asked if she was upset about having to move, was she given a reason for the move, was she given an option to stay and if not, was she given a choice of where she wanted to go. She said, I was upset at first. They told me they were closing down because they were going to be taking care of people with [MEDICAL CONDITION]. She said that she wasn't given an option to stay because they told us everybody had to leave. She also said she was not given a choice of where she wanted to go either. 10. Resident #12 had [DIAGNOSES REDACTED]. She was admitted on [DATE]. The significant change MDS with an ARD of 1/4/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/21/2020 at 3:15 PM, Resident #12 was interviewed via phone and was asked if she was upset about having to move, was she given a reason for the move, was she given an option to stay and if not, was she given a choice of where she wanted to go. She said, Yes, I was told about the move, but they let us know the night before. They told us it was because of the [MEDICAL CONDITION] and they were going to start taking people in. I was upset they were going to use that place as a quarantine area. I didn't get an option to stay or where I wanted to go. 11. Resident #13 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The significant change MDS with an ARD of 1/25/20 documented a BIMS score of 9 (8-12 indicates moderate cognitive impairment). a. On 4/1/20 at 3:36 PM, Resident #13 was interviewed via phone and he was asked if he was upset about having to move, was he given a reason for the move, was he given an option to stay and if not, was he given a choice of where he wanted to go. He said, I was upset because I had to move. They didn't tell me why I was moving; they just came and told me I had to move, and I was moved that day. b. On 4/1/20 at 3:11 PM, Resident #13's family was interviewed via phone and she was asked if he was upset about having to move, was she notified prior to him moving, was she told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. She said, Someone from there called me and told me they were moving him to (Facility #2). I can't remember when they called me though. I haven't talked to him since the transfer. They told me that (Facility #1) was a COVID facility and that's why they were notifying people. I wasn't upset because of the reason they were moving him. I knew they couldn't be there with COVID people. 12. Resident #14 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 2/19/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/20 at 3:22 PM, Resident #14 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not, was he given a choice on where to go. He said, My memory is not all that great . I want to say yes, I had a great deal of anxiety when they first told me, and it was rather abrupt, and it was a major stressor. I do remember being a little upset; wasn't to the point that I acted out or anything. I wished more time could have been allotted. The way we moved was like, Hey, pack it up, we got to leave. I was not given an option to stay. To my knowledge no one was given an option to stay. 13. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/15/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 3/27/20 at 3:06 PM, Resident #15 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. He said, They told me I was moving because of the overflow from the hospital to make room for people coming from the hospital. Sure, I was upset; they told me I had to move. I wasn't given an option, they said they needed the beds. I was upset, I didn't know what place they were sending me. 14. Resident #16 had [DIAGNOSES REDACTED]. He was admitted on [DATE]. The Quarterly MDS with an ARD of 2/15/20 documented a BIMS score of 15 (13-15 indicates cognitively intact). a. On 4/1/20 at 12:43 PM, Resident #16 was interviewed via phone and he was asked if he was upset about having to move, was he notified prior to him moving, was he told the reason for him moving, was he given the option to stay and if not was he given a choice on where to go. He said, I wasn't upset about it, but they didn't give me a notice. I found out I was being moved about 10 minutes prior to the move. II. Non-Sample Selected Resident Interviews: 1. On 3/27/20 at 2:20 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. She stated, My sugar had dropped to 31. They (Facility #1) sent me out to (Hospital #1). I stayed there until I was stable; about 3 days, then I was sent to (Facility #6). I thought I was going back to (Facility #1) but they sent me here (Facility #6). I don't know why they sent me here. I think they called my momma after they got me here. I told them (Facility #6) I wanted to talk to my momma because my phone was dead since I didn't have my phone charger with me. After I got my phone charger and charged my phone, I called my momma and told her where I was at. a. At 2:33 PM, I spoke with (Facility #6) Administrator and asked him if and when he notified the above Resident's momma that she was sent here; not (Facility #1). He said, I talked to her mother the day she got here. They (Facility #1) had not told her that she would not be going back there. 2. On 3/27/20 at 2:32 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. She said, I was not told reason I was moving, and I was not given a choice on where I was moving too and no one came and told me I was going to be moving before they moved me. 3. On 3/27/20 at 2:37 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. He said, I was not given an option to stay. No, no reason given either; just told me we had to move. No, not given any options. 4. On 3/27/20 at 3:50 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. He said, I don't think they gave me an option to stay. They told us it was because of the flu. 5. On 3/27/20 at 4:44 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. He said, I was not given a reason for moving. I was upset about having to move. I was not given an option to stay. I was not given a choice of what facility I wanted to go to. 6. On 3/27/20 at 4:46 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. She said, I was not given an option to stay. I was not given a choice of what facility I wanted to go to. I was upset about moving because they did it all in one day. The (Certified Nurse Assistant) CNA's told me as they were moving me it was because they were going to be moving peoples with the [MEDICAL CONDITION] in there. 7. On 3/27/20 at 5:05 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. She said, I was not given an option to stay and I don't think I was given a choice of where I wanted to go. Yes, I was upset about moving. You get in a routine and get secure with it and it gets pulled out from under you. They said I was having to move because they were putting the COVID-19 in there. They told me I was having to move, and they moved me the next day. III. Non-Sampled Resident Family Interviews 1. On 3/27/20 at 2:20 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She stated, My sugar had dropped to 31. They (Facility #1) sent me out to (Hospital #1). I stayed there until I was stable; about 3 days, then I was sent to (Facility #6). I thought I was going back to (Facility #1) but they sent me here (Facility #6). I don't know why they sent me here. I think they called my momma after they got me here. I told them (Facility #6) I wanted to talk to my momma because my phone was dead since I didn't have my phone charger with me. After I got my phone charger and charged my phone, I called my momma and told her where I was at. a. At 2:33 PM, surveyor spoke with (Facility #6) Administrator and asked him if and when he notified the above Resident's momma that she was sent here; and not (Facility #1). He said, I talked to her mother the day she got here. They (Facility #1) had not told her that she would not be going back there. 2. On 3/27/20 at 2:32 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She said, I was not told reason I was moving, and I was not given a choice on where I was moving too, and no one came and told me I was going to be moving before they moved me. 3. On 3/27/20 at 2:37 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if she was upset about the move, told the reason for the move, was given an option to stay and if not, was he given a choice of where they wanted to go. He said, I was not given an option to stay. No, no reason given either; just told me we had to move. No, not given any options. 4. On 3/27/20 at 3:50 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was he given a choice of where they wanted to go. He said, I don't think they gave me an option to stay. They told us it was because of the flu. 5. On 3/27/20 at 4:44 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was given a choice of where they wanted to go. He said, I was not given a reason for moving. I was upset about having to move. I was not given an option to stay. I was not given a choice of what facility I wanted to go to. 6. On 3/27/20 at 4:46 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not, was she given a choice of where they wanted to go. She said, I was not given an option to stay. I was not given a choice of what facility I wanted to go to. I was upset about moving because they did it all in one day. The (Certified Nurse Assistant) CNAs told me as they were moving me it was because they were going to be moving peoples with the coronavirus in there. 7. On 3/27/20 at 5:05 PM, an interview was conducted via phone with a Non-Sample Selected Resident and was asked if he was upset about the move, told the reason for the move, was given an option to stay and if not was given a choice of where they wanted to go. She said, I was not given an option to stay and I don't think I was given a choice of where I wanted to go. Yes, I was upset about moving. You get in a routine and get secure with it and it gets pulled out from under you. They said I was having to move because they were putting the COVID-19 in there. They told me I was having to move, and they moved me the next day. III. Observations On 3/31/2020 multiple snap shots of the video footage on 3/18/20 and 3/19/20 were received by (Employee #1) via email. They included pictures of multiple large contractor trash bags and plastic and cardboard boxes full of Resident personal belongings piled on top of wheelchairs, serving carts, tables and floor. There were also pictures of clusters of various non-bagged or non-boxed unidentifiable items. Amongst the clutter were some pictures of residents in wheelchairs and/or chairs as well as multiple staff members; including the Maintenance Director. (Photos are available for further details) IV. Corporate and Facility Staff Interviews: a. On 3/20/2020 at 5:16 PM, the Director of the Office of Long-Term Care (OLTC) conducted a phone interview with the Regional Director of (Corporation). She asked what was going on at their (Facility in Little Rock). The State Office had received a general complaint from a family member and the caller informed our office that this facility had transferred all the residents out because of COVID. The Regional Director replied that 53 of 54 were transferred out and the DMS (Division of Medical Service) 702's (Notice of Admission, Discharge, or Transfer from a facility) were completed yesterday. There isn't any COVID. She stated the residents were sent to the sister facilities within 3 days except for 4 families that requested other placements. She stated that they are doing deep cleaning on the facility, will have 1 hall for positive COVID and another hall for presumptive COVID. The Director OLTC made the statement that it would have been a good idea for them to notify the OLTC in advance as to their plan. The Regional Director said that the Corporation wanted to get out in front of this COVID and that they had implemented this in the other stated where they own Nursing Homes. c. On 3/24/2020 at 3:50 PM, spoke to the Administrator via phone and asked her what transpired at her facility last week with discharging all of their residents. She said, I have already spoken to (Director of the OLTC) today but proceeded telling me that last Tuesday (3/17/20) the Regional Director called the DON (Director of Nursing) and herself into her office and proceeded to instruct them to start moving all residents out of the building starting Wednesday (3/18/20) and the building needed to be empty by Friday (3/20/20). She said that the building was going to be a dedicated COVID-19 reception facility and then she assembled all the Department Heads and re-iterated what she had already told her and her DON. On Wednesday at 9:00 AM (Regional Director) and the (Nurse Consultant) came to the facility and began staging people for relocation to sister facilities in Little Rock. Residents were matched with the sister facilities in Little Rock based on their needs. She said the first resident was transferred out on that Wednesday and the last one was sent out by that Thursday night around 11:45 PM. She said on that Friday and over the weekend residents' remaining personal items were taken to their locations. She was asked if the residents were screened for COVID19 before transferring them. She said that their vital signs were taken, and thorough assessments and they did not have any signs/symptoms of COVID-19. She was asked if the residents and/or their Responsible Party were given a choice on their relocation. She said, They were not given a choice on their relocation at first. She said the DON assigned each to go to one of their sister facilities and if a resident and/or their Responsibility Party didn't agree with the facility chosen she accommodated every single alternate request. She went on to say that in doing that she was written up by (Regional Director) for doing that. She said I did not follow process previously discussed prior to the discharges and since 3/17/20 discharges kept changing. She also said that (Regional Director) was present during several irate family member telephone calls demanding alternate facility be arranged and also overheard her conversation with the Ombudsman on the issue and at that point she had no input at all until yesterday when I was written up for not following her directive prior to discharging residents to their sister facilities. She was asked if there were any residents' family upset about having to go to one of their sister facilities if their alternate request was not honored. She said, There was one daughter that wanted her mother to go to (Facility #7) but the SSD spoke with the Admission Coordinator at (Facility #7) on the 19th. They finally told her they would not accept her mother and they did not give a reason. Resident #1 was the 3rd to the last resident transferred and we had no choice but to send her to (Facility #4) due to needing to get everyone out that day. She was asked who and when her staff started notifying residents and/or their families about the move. She said, We set up Guardian Angel rounds for each hall and they were the ones that began notifying resident and/or their families She was asked why the residents and/or their families were not given sufficient written notice of their impending discharge. She said, I was following my superiors' directives. d. On 3/25/2020 at 8:09 AM, placed call to (Regional Director) and asked her what her involvement was in reference to the Resident Mass Discharge from (Facility #1) last week. She said, I was there and helped coordinate which facility residents wanted to go to our Sister Facilities which include: (Facility #6), (Facility #2), (Facility #4) and (Facility #3). She went on to say that there were 4 or 6 who chose to go to other locations that were not one of their sister facilities. She was asked if the residents and/or their Responsible Parties were given a notice and reason for the discharge in writing and if so, how long of a notice did they give them (TRUNCATED)

Based on record review and interviews the facility's Administration failed to ensure residents/ residents representatives received greater than a 24-hour notice before residents were quickly transferred to other nursing facilities to prevent mental anguish and anxiety for all 64 residents transferred on [DATE] and [DATE]. This failed practice affected all 64 residents in the facility per lists provided by the Regional Director on [DATE] between 11:34 AM and 3:34 PM via emails. The findings are: I. Corporate and Administration Interviews: a. On [DATE] at 5:16 PM, the Director of the Office of Long-Term Care (OLTC) conducted a phone interview with the Regional Director of (Corporation). She asked what was going on at the (Facility in Little Rock). The State Office had received a general complaint from a family member and the caller informed our office that this facility had transferred all the residents out because of COVID. The Regional Director replied that 53 of 54 were transferred out and the DMS (Division of Medical Service) 702's (Notice of Admission, Discharge, or Transfer from a facility) were completed yesterday. There isn't any COVID. She stated the residents were sent to the sister facilities within 3 days except for 4 families that requested other placements. She stated that they are doing deep cleaning on the facility, will have 1 hall for positive COVID and another hall for presumptive COVID. The Director OLTC made the statement that it would have been a good idea for them to notify the OLTC in advance as to their plan. The Regional Director said that the Corporation wanted to get out in front of this COVID and that they had implemented this in the other stated where they own Nursing Homes. b. On [DATE] at 3:22 PM, spoke with Resident #1's daughter and was asked if she was aware of the reason for her mother's discharge from the facility and when she was notified of her impending discharge and if she was given a choice of which facility she wanted her mother to be discharged to and if she was given an option of her mother staying at the facility and not being discharged . She stated, I found out initially from mother's (Attending Physician #1's) (Advanced Practice Nurse) that the facility where my mother has been for approximately [AGE] years was discharging all of their residents out by the following Monday to their sister facilities. She knew I wanted my mother to go to (Facility #7) so she was nice enough to call me and give me a heads up. She also said she didn't hear from the facility about this until approximately around 10:30 - 11:00 AM on the 19th that they needed approval from (Facility #7) in 5 minutes if they were going to admit her mother or not. She said she immediately called (Facility #7) and told them that (Facility #1) was ready to transfer her mother right then. They (Facility #7) initially told me that all they needed from (Facility #1) was a Pre-Admission Screening Resident Review (PASRR). She said she then attempted to call (Facility #1) back and never got an answer nor did it ring or give her a busy signal. It would just immediately after dialing just drop the call. She said that was when she called (Facility #7) back and told them of the situation and they told me I'd need to go there and come back to complete admission paperwork and give a deposit to hold the room. She said she immediately went to (Facility #7). Said it was approximately 45 minutes after she spoke to them and while she was there completing paperwork, she got another call from (APRN) and asked what was going on at (Facility #1) because they couldn't get anyone there to answer the phone either. She said she then told the lady at (Facility #7) that she needed to go to (Facility #1) and see what was going on. She said she got there around 3:00 PM and her mother was already gone. She asked where they (Facility #1) sent her and they told her (Facility #7) and that's when she became irate and told them No .you didn't send her there (Facility #7) .I just came from there!!! And was screaming at them, Where is my mother? over and over when they finally told her that they had sent her to (Facility #4) since (Facility #7) would not accept her mother. She said she told them that (Facility #7) and herself had been trying to get in touch with them all day to tell them they just needed a (PSARR) and that was when the Administrator and the SSD (Social Service Director) told her no, they had been in contact with (Facility #7) multiple times throughout the day and the conversation became very heated at that point to the point a male (unknown name) shoved her and she fell in the bushes causing scrapes and bruising and the police were called on the scene but she said all she was wanting to do was find out where they sent her mother and why they couldn't get what (Facility #7) needed to admit her mother where she wanted her to go. She said that was when the SSD pushed out the cracked door a post-it-note with (Facility #4) Administrator name and their phone number on it. She said she called (Facility #4) and spoke to the Administrator who was very nice and accommodating and even took his phone to her mother so she could be assured that she was alright. c. On [DATE] at 3:50 PM, spoke to the Administrator via phone and asked her what transpired at her facility last week with discharging all of their residents. She said, I have already spoken to (Director of the OLTC) today but proceeded telling me that last Tuesday ([DATE]) the Regional Director called the DON (Director of Nursing) and herself into her office and proceeded to instruct them to start moving all residents out of the building starting Wednesday ([DATE]) and the building needed to be empty by Friday ([DATE]). She said that the building was going to be a dedicated COVid-19 reception facility and then she assembled all the Department Heads and re-iterated what she had already told her and her DON. On Wednesday at 9:00 AM (Regional Director) and the (Nurse Consultant) came to the facility and began staging people for relocation to sister facilities in Little Rock. Residents were matched with the sister facilities in Little Rock based on their needs. She said the first resident was transferred out on that Wednesday and the last one was sent out by that Thursday night around 11:45 PM. She said on that Friday and over the weekend residents' remaining personal items were taken to their locations. She was asked if the residents were screened for COVID-19 before transferring them. She said that their vital signs were taken, and thorough assessments and they did not have any signs/symptoms of COVID-19. She was asked if the residents and/or their Responsible Party were given a choice on their relocation. She said, They were not given a choice on their relocation at first. She said the DON assigned each to go to one of their sister facilities and if a resident and/or their Responsibility Party didn't agree with the facility chosen she accommodated every single alternate request. She went on to say that in doing that she was written up by (Regional Director) for doing that. She said I did not follow process previously discussed prior to the discharges and since [DATE] discharges kept changing. She also said that (Regional Director) was present during several irate family member telephone calls demanding alternate facility be arranged and also overheard her conversation with the Ombudsman on the issue and at that point she had no input at all until yesterday when I was written up for not following her directive prior to discharging residents to their sister facilities. She was asked if there were any residents' family upset about having to go to one of their sister facilities if their alternate request was not honored. She said, There was one daughter that wanted her mother to go to (Facility #7) but the SSD spoke with the Admission Coordinator at (Facility #7) on the 19th. They finally told her they would not accept her mother and they did not give a reason. Resident #1 was the 3rd to the last resident transferred and we had no choice but to send her to (Facility #4) due to needing to get everyone out that day. She was asked who and when her staff started notifying residents and/or their families about the move. She said, We set up Guardian Angel rounds for each hall and they were the ones that began notifying resident and/or their families She was asked why the residents and/or their families were not given sufficient written notice of their impending discharge. She said, I was following my superiors' directives. d. On [DATE] at 8:09 AM, placed call to (Regional Director) and asked her what her involvement was in reference to the Resident Mass Discharge from (Facility #1) last week. She said, I was there and helped coordinate which facility residents wanted to go to our Sister Facilities which include: (Facility #6), (Facility #2), (Facility #4) and (Facility #3). She went on to say that there were 4 or 6 who chose to go to other locations that were not one of their sister facilities. She was asked if the residents and/or their Responsible Parties were given a notice and reason for the discharge in writing and if so, how long of a notice did they give them. She said, The staff called them on Tuesday and Wednesday of last week; gave them information over the phone and backed it up in writing that was given to the residents and their Responsible Parties could get a copy of it if they wanted. They were told that they would be having patients come in that were at risk for COVID-19. They were not told that they would admitting patients with COVID-19 because the CDC (Centers for Disease Control) guidelines won't let them admit with a positive COVid19 and currently they have patients from other facilities at the hospital with fever, pneumonia, respiratory issues and if they weren't from one of our facilities we can't admit any of them at this time. She was asked what the urgency was and why they were not given a 30-day written notice. She said, We didn't give them a 30-day notice because none of them were forced to leave and they were all given the option to stay. She said they all decided to go to other facilities and were assured once they got stabilized, they could come back if they wanted to. She went on to say that they had done this same thing in other states, Tennessee, Illinois, Indiana and Kentucky without any issues. She was asked if the Medical Director or the Residents Attending Physicians were involved in this decision. She said, (Medical Director) and his partner were involved via phone and she had bumped into them on a couple of occasions and they were both on board with their decision. She was asked if any of them documented in the Residents Medical Record the reason for the discharges and reason they could not continue to meet their needs. She said, We have not to my knowledge documented such in any of the Residents Medical Records. She was asked if a Discharge Summary was done on each Resident discharged . She said, I think they are working on that now. She was asked how the receiving facilities were made aware of each Residents Medical Care while at their facility along with the medications/treatments/care and condition at time of discharge to ensure continuity of care. She said, Each resident went to their designated facilities with a paper packet including their MARS, (Medication Administration Records) TARS, (Treatment Administration Records) orders and anything else relevant and that their medications went with them and each of them had an armband attached to them with pertinent information. She said the nurses delivered their Narcotics. She was asked if she was aware of any families that were upset because their loved one were not allowed to go to a facility that was not one of their sister facilities. She said, There was one family that was upset because the facility she wanted her mother to go to would not accept her mother. e. On [DATE] at 11:55 AM, the Social Service Director (SSD) was asked via phone what her involvement was in reference to the mass resident discharge that occurred at her facility last week. She said, (Regional Director) came in on the 17th and informed the Dept. Heads that they were going to be a COVID-19 building taking in patients that had been tested positive and were presumptive positive with it as well. We started calling families that day informing them of what she told us to say and to let them know they were going to send them to their sister facilities or to facilities of their choosing. She told us we had to have them all out of there by the 20th. She was asked if she knew why they were given this decision with such a short notice. She said, No, we weren't told why it had to be done in such a short time frame. She was asked if they were given the option to stay at the facility if they did not wish to be sent elsewhere. She said, They were not given that option but there was little resistance; just confusion since they thought by what we told them we already had or would shortly be having residents with COVID-19. She went on to say that they were not forced to leave but they did not want to stay if we were going to admit residents with COVID-19. She was asked if they gave any of the residents and/or their families' written notice. She said, We did not put anything in writing because they were just told to call and inform them of what we were to tell them. She started sending residents out on the 18th and the last one was sent out at 11:45 PM, the night of the 19th. She was asked when and who informed Resident #1 family of the plan to send her mother to one of your sister facilities. She said, I contacted her daughter on the 17th. She was asked if Resident #1 daughter told them that she did not want her mother to go to one of their sister facilities' but wanted her to go elsewhere. She said, She did tell us she wanted her mother to go to (Facility #7) but they would not accept her for whatever reason, so we had to send her to our sister facility; (Facility #4). She was asked if this was all documented. She said, Yes, it was, and I could have access to it per PCC (personal computer chart).She was asked why they told the residents and/or their families that you were going to admit COVID-19 residents when I was told by (Regional Director) earlier that day that you would not be admitting COVID-19 residents due to CDC guidelines their facility could not admit anyone with COVID-19 or Presumptive positive for COVID-19. She said, That had changed since they were first told what they had plans to do and that now they would not be doing what they had told the residents and/or their families the other day. She was asked after they decided not to admit COVID-19 residents did they notify the residents and/or their families to see if they may want to come back. She said, No. f. On [DATE] at 5:46 PM, surveyors entered the facility. The DON was on staff and there was a new admit just a few minutes prior to surveyors arriving. Shortly after entering the facility the DON received a call from the Administrator and after they spoke for a few minutes the Administrator asked to speak to the surveyor. She wanted to know if she needed to come to the facility and she was informed that wasn't necessary and her interview could be conducted over the phone. The Administrator was asked if the Medical Director was involved with the Corporate decision to transfer all the residents and she said, he wasn't informed until it was already happening, and he was upset. The DON was asked if she had anything in writing as to what type of admit she could take and how to care for them, she said she was told that (Facility #1) would admit residents with Upper Respiratory Infections and they would be on the right side of the building and then after 14 days they could go back to the (Corporate Facilities) that they came from but if they want to stay they would be moved to the left side of the building. She was asked if the care of these residents would be any different such as increased monitoring for temperature and O2 (oxygen) saturations and she stated, Yes. The DON looked on her cell phone for an email with instructions from Corporate and said she was sure she had something but was unable to find it right away. She stated she would email it to the surveyors when she found it. At 5:52 PM, the DON was asked what the urgency was to get the residents out and she stated, Corporate came and met with us on that Tuesday and gave us instructions that we were going to be a COVID-19 facility and we were to get all of our current residents discharged by Friday of that week. At the time of the visit the DON was unable to locate any guidance from the facility. The DON was asked to email what guidance she had received on how to care for the residents being admitted . g. On [DATE] at 7:39 PM, an email was received from the DON and it stated, .spoke with (Nurse Consultant) and (Regional Director) and they will be getting me documentation on how the decisions with the Admission Process was made. h. On [DATE] at 8:45 AM, called the Ombudsman to ask her what she knew about all (Facility #1) residents being discharged out of their facility last week and if she had received any complaints from anyone about that. She said, I became aware of what they were doing when the Administrator called me on [DATE] to inform me that they would be discharging all of their current residents to sister facilities because they were going to be a Positive COVID-19 only building and that they would start admitting these patients type of residents from their Sister Facilities. She said she thought that our office (OLTC) had asked them to do this. She said the only Complaints she had received were from one family member of Resident #7 that they had not been informed of his move until a family member of another resident told them about it the day after he was moved. She said she called the Administrator after receiving this complaint and was told by her that her staff had notified all families the day before their resident was moved. She also said that she had received a complaint from an anonymous individual that the facility was throwing away resident belongings. She said she called the Administrator about this also and was told that they had not thrown any of the residents personal items away and in fact was told by a family that they should just toss those things because they didn't want them and if they got thrown away the family had to have done so. She also said the only complaints she received from residents were they didn't understand why their personal belongings weren't being sent with them as they were being sent to other facilities because they were afraid they wouldn't ever get them back. She said she asked the Administrator about this as well and was told that their belongings were taken to the facilities later. That's why I haven't notified the OLTC of all of the complaints I have been receiving surrounding this issue. Like I said, I thought the facility had been in close contact with the OLTC about all of this. i. On [DATE] at 12:10 PM, (Employee #1) called and stated that she was so upset about what happened to their residents that were sent out of their facilities on the 18th and 19th. They were pulled out of their beds and put in their wheelchairs and put out in the hallways lined up like cattle. (Resident #11) was crying and non-sample selected Resident and (Resident #3) were very mad and (Resident #6) was very upset and he went to hospital for [MEDICAL TREATMENT] 3 times a week. Also, (Resident #9) (non-verbal) was so upset she was crying (more than usual), also (Resident #12, #13, #14 and #15) were also upset about the move and (Resident #10) passed away right after the move but I don't know what he died from. j. On [DATE] at 12:45 PM, (Contracted Staff #1) called and reported that he assisted with transporting 8 residents on Wednesday and 4 - 5 residents on Thursday. He said that he had been transporting (Resident #6) previously to [MEDICAL TREATMENT] before he was discharged from that facility. He said that (Resident #6) was appalled and furious about having to move. He also said that since last Thursday all of the residents personal belongings were in trash bags and sitting in the lobby and hallway in front at (Facility #2) which saddened me since so many of these residents that is all they have left to their name and it was tossed about like it was nothing. Seemed as though they weren't thinking or caring about the resident's wellbeing. He went on to say that the only person he currently trusted was the previous Administrator; that they have fired for not lying to us. He said that he was witnessed to families not being told that their loved ones were being moved, patients' belongings in trash bags out in the hallways of (Facility #1) and it appeared that some of the residents whom he transported had not received care before they were sent out. He said that he also heard last Friday the DON and SSD talking about throwing away residents' personal belongings and heard (Nurse Consultant) saying to them We're not taking their things to them and I don't care what you do with them; toss them for all I care. At 1:44 PM, he called back to inform surveyor of the residents he transported and time of transports on the 18th and 19th to (Facility #2). On Wednesday (18th) he gave the following names and times of transport: (Resident #6) at 9:30 AM; (Non-Sampled Selected Resident) at 10:00 AM; (Resident #12) at 11:00 AM; (Resident #4) at 11:30 AM; (Non-Sample Selected Resident) at 12:00 PM; (Non-Sample Selected Resident) at 12:30 PM; (Non-Sample Selected Resident) at 3:00 PM; (Non-Sample Selected Resident) at 4:00 PM. On Thursday (19th) he gave the following names and times of transport: (Resident #14) at 9:30 AM; (Resident #5) at 10:45 AM; (Non-Sample Selected Resident) at 12:30 PM, and (Resident #16) at 2:00 PM. He was asked if he was aware of the last resident being sent out late the night of the 19th. He said, Yes, I can attest to that because they asked me to transport (Resident #2) around 11:00 PM that night but I was already on my way to (out of state) and was not able to do that transfer. k. On [DATE] at 2:00 PM, the DON was called and interviewed by phone. She was asked what her involvement was in the mass discharge of all of their previous residents last Wednesday and Thursday. She said, The (Regional Director) told me and the Administrator that she had received directive from above her that they wanted this facility to be for patients that had gone out to hospitals from sister facilities that went into the hospital with respiratory issues and that we were going to transfer our residents to sister facilities. She was asked why many of the other staff had told the surveyor they were told by Corporate to tell Residents/Families the reason for the discharge was due to facility going to be a COVID-19 facility and were going to start admitting them in the very near future. She said, That was what we were initially told but that has since changed. She was asked after this had changed had they notified their previous residents to give them a choice of returning to the facility. She said, No. She was asked if she knew why the rush was to get their previous residents out with little or no notice. She said, We were told by Corporate on the 17th we had to get them all out by the 20th, but we had them all out by the evening of the 19th. She was asked if they gave the Residents/Families a written discharge notice. She said, There was a letter developed that Tuesday evening on the 17th that was read to the Residents and/or family before sending them out. (I'll send you a copy of it). She said she wasn't sure if they were told they had an option to stay and not be discharged . She was asked if she knew when the first resident was sent out and when the last one was sent out. She said, Our first one was sent out on Wednesday morning around 11:30 AM and the last one was sent out on Thursday around 10:30 PM. She was asked how she ensured that each resident arrived at their designated facilities safely. She said, Unless that facility called to question something about them, she just assumed they arrived safely. She was asked if they discussed moving all of their residents out with their Medical Director and/or Residents Attending Physicians. She said, I'm sure each Physician was contacted prior to their residents going to other facilities by someone here. I'm only certain of (Attending Physician #2) because I spoke with his nurse about all of his residents. She was asked in her professional opinion did she think it was wise they move all their residents to facilities during this pandemic crisis with the COVID-19; since all of us have been told to stay put. She said, I can't give my opinion because I don't have one. l. On [DATE] at 3:19 PM, the Director of the OLTC received a phone call from the Regional Director for (Corporation) who informed that (Regional Personnel #1) would be calling and would be explaining the plans and that she would also provide something in writing regarding how the facility would operate now (post transfer all the residents.) The Regional Director informed that (Regional Personnel #1) was still tweaking this process . m. On [DATE] at 4:11 PM, spoke to LPN #2 via phone. She was asked what her involvement was in the mass discharge of the facility's previous residents on the 18th and 19th. She said, On Tuesday, I believe it was the 17th, (Nurse Consultant) from Corporate came in the building around 9:00 to 10:00 and told all of the Department Heads that we would be moving all of the residents out of this facility within the next 2 days because we are going to be a designated COVID-19 facility. We were given a typed message of what we were to tell the Residents/Families. They should be able to get you a copy of that letter. They also had a list of the residents and where they were going to be transferred to so we could get them lined up awaiting transfer to the various facilities. We all had a certain hall we were assigned to go call the POA's (Power of Attorneys) or tell the residents what was going on. Another staff member and I had the (E) hall. I tried to put in the Residents Progress Notes who I talked to but, I don't know about my partner or any of the other ones what they did or told the residents and/or their families. I have been so upset about all this; spent all weekend crying. They did it in such a way that stripped them (Residents) of their dignity, rights and basically left them in a very fragile emotional state of mind. They were lined up like cattle going to slaughterhouses. They tossed all of their belongings out in the hallways in trash bags and many of the residents saw what was happening to all of their personal belongings. (Resident #8) was sitting at the back with other residents they had lined up awaiting transport. He waved at me and I went back to him and he was unable to talk but was shaking his head; grabbed my arm hanging onto it. I told him it was going to be okay and he would be taken care of. But I felt like I was lying to him trying to make him feel better about what was going on. (Resident #9) is a very depressed resident and has a tendency to cry anyway; she was sitting in her wheelchair with tears running down her face. I tried to console her as well. She is non-verbal most of the time. (Resident #5) was in his room and he asked me, 'Can you tell me where he's going (pointing at his roommate; (Resident #10). He said I'd like to go where he's going because I've always looked after him.' I told him I would check. I did but, they did send them to separate facilities. I was told (Resident #10) expired shortly after the move but I do not know what from. I felt like the DON, SSD could care less and just wanted to get this done. The DON did not come out of her office much at all on the 18th and 19th to help us nor console any of the residents. There was no notice given to anyone and no one was given an option to stay. n. On [DATE] at 4:26 PM, the Director of The Office of Long-Term Care (OLTC) received a call from Regional Personnel #1. She was asked how the decision was made to make (Facility #1) a facility that would take COVID residents. Regional Personnel#1 stated the Corporate Managers met several weeks ago (approximately first week of March) and made the decision that they needed a facility in each of the 8 states in which they own homes to be a receiving facility for COVID positive and presumptive and any Upper Respiratory Infections. They picked (Facility #1) because it was centrally located and had a low census. She was asked if the other states were given the resident a choice to stay and she said yes, there was a man in one of their Illinois facilities wanted to stay and we let him. She was asked what the rush was to transfer the residents out so quickly at (Facility #1) and she replied that she was informed that every resident was notified and agreed and there were not any problems with the facility decision. She was asked if the facility received anything in writing about the type of residents they would accept and how to care for them. She stated that she would send the process/guidance that was provided to the facilities. o. On [DATE] at 2:00 PM, the Chief Operating Officer (COO) was interviewed via phone and was asked what was the hurry to get the residents out of (Facility #1). He said, First the ideal concept was trying to get a handle to COVID admissions. One of the discussions today was that we won't be able to deny admissions with COVID. This was not a directive from anyone. We as a Corporation put this in place for screening and for a place for residents to go. Trying to be pro-active during this COVID-19. We spoke with American Healthcare Association. We are just trying to follow the changes and try to get ahead of this and be pro-active. CMS (Center for Medicare/Medicaid Services) or the State Office were not notified because I was under the impression all residents were in agreement to leave. (Facility #1) has the piped in oxygen and would be the best place to admit the residents whom hospitals won't be able to house. p. On [DATE] at 10:16 AM, the Maintenance Director was interviewed by phone and he was asked what his involvement was when all of the residents were discharged on [DATE] and [DATE]. He said, I was at the facility on the 18th and 19th when our previous residents were all discharged to various facilities. I don't know when or what the residents and families were told the reason for discharge was. I did see staff putting residents' personal belongings in bags, but I think they left them in their rooms not in the hallways. I did hear staff say they were going to trash residents' belongings. I was not up there during the move, so I don't know anything during discharges. The camera goes back 72 hrs. I checked that this morning. I think somebody has been in there messing with it. But we've had storms before in the past and it will shut camera system down. I have not been told to lie to you. The camera system is an old system and I feel like it was the storms last night and this morning were to blame for it appearing that someone had been messing with the system as it has in the past. q. On [DATE] at 2:35 PM, the Director of OLTC was called by (Employee #1) and she informed her that there were three residents that truly did not want to leave the facility and one in particular refused to go, his name is (Resident #13) now at (Facility #2) and went back to his room and was one of the last to go, not sure who talked him into going. (Resident #12) also now at (Facility #2) was another resident that refused to go, and she said, this is my home. (Resident #12) had a private room and it was fixed up very nice. Another resident that was told they would be transferring went to her room and cried and shook her head, she did not want to go and I told her that we are being told that this has to be done but I will make sure you are one of the last ones to leave. She stated that at the time of the residen (TRUNCATED)

Complaint # (AR 085) was substantiated, all, or in part, with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided for management of a suprapubic catheter, as evidenced by failure to ensure an assessment of urinary elimination status was conducted and documented when the resident exhibited signs/symptoms of possible catheter obstruction and failure to ensure nursing staff promptly identified, consulted with the physician and communicated findings to the oncoming shift when there was no measurable urine output, which resulted in a delay in treatment for [REDACTED].#1) of 2 (Residents #1 and #5) sampled residents who had suprapubic catheters. These failed practices resulted in immediate jeopardy, which caused or had the likelihood of causing serious harm, injury or death to Resident #1, who experienced pain related to obstruction of his suprapubic catheter and subsequently required hospitalization for acute kidney injury and urinary tract infection, and had the potential to cause more than minimal harm to 5 residents who had indwelling urinary catheters, according to a list provided by the Administrator on 6/27/19 at 11:10 a.m. The Administrator was informed of the immediate jeopardy condition on 6/26/19 at 3:32 p.m. The findings are: 1. The facility's Catheter Care, Indwelling Catheter Procedure, provided by the Director of Nursing (DON) on 6/26/19 at 11:56 a.m., documented, .Assessment Guidelines: (MONTH) include, but are not limited to: Color, consistency, amount of urine . Equipment: .Measuring device . Documentation Guidelines: Documentation may include: . Any unusual condition or change in condition . Color, amount, consistency and odor of urine . Notification of the physician of any condition change . Intake and output and evaluation of intake and output per facility procedure . 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 6/13/19 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview for Mental Status; required extensive assistance of two plus people for bed mobility and transfer; required extensive assistance of one person for toilet use and personal hygiene; had a urinary ostomy; and was occasionally incontinent of bowel. a. The (MONTH) 2019 Medication Review Report documented, .Irrigate Suprapubic Catheter with 30 ml (milliliters) of Normal Saline if clogged . every 24 hours as needed . Phone Active 04/25/2019 .Monitor Suprapubic Catheter output every shift .Phone Active 04/25/2019 . b. The Resident Plan of Care dated as initiated 10/26/18 documented, .(Resident #1) has Suprapubic Catheter and has a preference of not using leg bag. Prefers only to use Foley bag . will be/remain free from catheter-related trauma through review date Check tubing for kinks each shift. Catheter care as per order Monitor and document output as per facility policy Monitor for s/sx (signs/symptoms) of discomfort on urination and frequency Monitor/document for pain/discomfort due to catheter Monitor/record/report to MD (Medical Doctor) for s/sx UTI (Urinary Tract Infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns . c. A Laboratory Report dated 6/5/19 documented, .Ordered: Chem12 (12-panel chemistry) . Collected: 6/5/19 . Sodium: 141 . Reference Range: 136-145 . Potassium 3.9 . Reference Range: 3.5-5.1 . BUN (Blood Urea Nitrogen): 16 . Reference Range: 7-18 . Creatinine: 1.22 . Reference Range: 0.60-1.3 . d. The (MONTH) 2019 Medication Administration Record [REDACTED].Start Date: 4/25/19 . The following urine output volumes were documented: 6/10/19 on the 7:00 a.m. to 3:00 p.m. (7-3) shift: 500 cubic centimeters (cc) 6/10/19 on the 3:00 p.m. to 11:00 p.m. (3-11) shift: 600 cc 6/10/19 on the 11:00 p.m. to 7:00 a.m. (11-7) shift: 500 cc 6/11/19 on 7-3 shift documented, X with a chart code of 3 6/11/19 on 3-11 shift documented, X with a chart code of 5 6/11/19 on 11-7 shift: 150 cc 6/12/19 on 7-3 shift documented, X with a chart code of 3 6/12/19 on 3-11 shift: 400 cc 6/12/19 on 11-7 shift: 50 cc 6/13/19 on 7-3 shift: 150 cc 6/13/19 on 3-11 shift documented, X with a chart code of 6 6/13/19 on 11-7 shift was left blank. The MAR indicated [REDACTED]=Absent from facility; 5=Hold, see nursing notes; 6=hospitalized . From 6/11/19 through 6/13/19 at 7:38 a.m., there was no documentation in the Nursing Progress Notes that addressed the decreased urine output or indicated an assessment of the resident's urinary status was completed. e. A Progress Note dated 6/13/19 at 7:38 a.m. documented, .Type: Nursing Progress Note Patient alert .Patient f/c (Foley catheter) bag changed and flushed with n/s (normal saline) . f. A Progress Note documented, .Date: 6/13/2019 at 9:30 p.m.Situation: The Change In Condition/s reported on this CIC (Change in Condition) Evaluation are/were: Abdominal pain .Resident/Patient is in the facility for: Long Term Care .Relevant medical history is: Dementia .Code Status: FULL CODE .Abdominal/GI (gastrointestinal) Status Evaluation: Distended abdomen GU ([MEDICAL CONDITION]) / Urine Status Evaluation: Decreased urine output .Lower abdominal pain or tenderness .Pain Status Evaluation: Does the resident/patient have pain? Yes .Nursing observations, evaluation, and recommendations are: Resident was lying in bed quietly, not complaining, but family member was yelling and stating that he said that he was in pain, and that his abdomen was swollen .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send resident out to hospital of choice for eval/tx (evaluation / treatment) of decreased urinary output and abdominal pain/distension .B. New Testing Orders: Other - sent to hospital .C. New Intervention Orders: Other Sent to hospital. Author: (DON electronically signed) (Licensed Practical Nurse (LPN) #2 electronically signed) . This note was dated as created on 6/26/19 at 8:44 a.m., during the complaint investigation survey. g. The Emergency Department (ED) Provider Notes documented, .Date of Service: 6/13/2019 11:25 p.m.History: Chief Complaint: Patient presents with [MEDICAL CONDITION] .Patient reports abdominal pain and diarrhea which onset yesterday. Pt's (Patient's) medical records state he has had no urine output through his Foley .Gastrointestinal: Positive for abdominal pain and diarrhea .[MEDICAL CONDITION]: Positive for dysuria .Physical Exam .Abdominal: There is tenderness in the suprapubic area .Number of [DIAGNOSES REDACTED].Risk of Complications, Morbidity, and/or Mortality: Presenting problems: High; Diagnostic procedures: High; Management options: High .Assessment/Plan: Patient is a [AGE] year-old male that presents (to) emergency department in a nursing home. Patient was sent here due to the fact that patient has had decreased urine output. Patient was noted to have a distended bladder. Patient has a suprapubic Foley . h. A Urology Consultation Report dated 6/14/19 documented, .CT (Computed [NAME]ography) (of) A/P (Abdomen/Pelvis) on 6/13 showed moderate bilateral hydrouretero[DIAGNOSES REDACTED] (defined as: dilatation of the renal pelvis, calyces and ureter caused by the obstruction to free flow of urine from the kidney, leading to progressive atrophy of the renal cortex). No obstructive urinary tract [MEDICATION NAME] are evident. The bladder is distended. Findings are compatible with bladder outlet obstruction with [MEDICAL CONDITION] reflux (defined as: condition in which urine flows backward from the bladder to one or both ureters and sometimes to the kidneys). Currently with suprapubic catheter .16 fr (French) removed and replaced with 20 fr suprapubic catheter with almost immediate return of 2L (liters) yellow urine. Cr (creatinine) 1.37 . The Foley was flushed emergency department with mild improvement in urine return .Physical Exam: . Abdomen: .suprapubic tenderness .GU ([MEDICAL CONDITION]): Suprapubic tenderness, bladder distended .Multiple [MEDICATION NAME] are present in the dependent portion of the urinary bladder. 3. Moderate enlargement of prostate gland. 4. Fecal impaction . Assessment: Chronic suprapubic catheter .[MEDICAL CONDITION] secondary to obstructed suprapubic catheter .bilateral hydro[DIAGNOSES REDACTED] .AKI (acute kidney injury) .Plan: 16 fr suprapubic catheter dc'd (discontinued) and replaced with 20 fr suprapubic catheter using sterile technique. Immediate return of almost 2 liters yellow urine .Continue Foley catheter to drainage .monitor renal function .Plan of care discussed .Suprapubic catheter changed, hydro[DIAGNOSES REDACTED] likely secondary to obstructive suprapubic (catheter). Almost 2 liters drained when catheter changed, continue monthly changes as scheduled . i. An Infectious Diseases Consultation Report dated 6/18/19 documented, .Assessment .male with h/o (history of)[MEDICAL CONDITION](hypertension) [MEDICAL CONDITION] with UTI (urinary tract infection)/urosepsis with AMS (altered mental status) / fever / leukocytosis . j. Hospital Laboratory Reports documented the following pertinent values: 6/14/19 Sodium (no result) with reference range of 136-146, Potassium (no result) with reference range of 3.5-5.5, BUN ( no result) with reference range of 9-21, Creatinine 1.37 with reference range of 0.7-1.4; 6/15/19 Sodium 143, Potassium 3.3, BUN 27, Creatinine 1.42; 6/16/19 Sodium 145, Potassium 3.7, BUN 34, Creatinine 1.40; 6/17/19 Sodium 142, Potassium 3.7, BUN 30, Creatinine 1.04; 6/18/19 Sodium 142, Potassium 4.1, BUN 30, Creatinine 1.01; 6/19/19 Sodium 144, Potassium 4.1, BUN 25, Creatinine .90; 6/19/19 Sodium 144, Potassium 4.1, BUN 25, Creatinine .90; 6/20/19 Sodium 139, Potassium 4.3, BUN 21, Creatinine .80; 6/21/19 Sodium 139, Potassium 4.2, BUN 22, Creatinine .76. k. A facility Laboratory Report dated 6/26/19 documented, .Sodium 139, Potassium 3.3, BUN 19, Creatinine 1.0 . l. On 3/24/19 at 3:42 p.m., the resident was sitting in a wheelchair in the dining room. There was a urinary drainage bag attached to the underside of the wheelchair. The drainage bag contained approximately 150 - 200 cc of light-colored urine. The resident's clinical record documented the drainage bag had been emptied at 3:00 p.m. of 350 cc. m. On 6/25/19 at 2:44 p.m., Licensed Practical Nurse (LPN) #2, who worked the 3:00 a.m. to 11:00 p.m. shift, was asked, Did you take care of (Resident #1) on 6/12/19 and 6/13/19? She stated, Yes. She was asked, Can you describe the events that occurred on 6/12/19 and 6/13/19 concerning his decreased urine output? She stated, I had gotten a text at about 6:30 p.m. or so from (LPN #1) saying he had decreased urine and if I didn't get any more urine then call (Advanced Practice Nurse (APN) #1). The next thing I know I got paged to his room and that I needed to go in because his sister was saying he was in pain. I did an assessment and made the decision to send him out right then because his abdomen was swollen, and the family said he was in pain. She was asked, Did (LPN #1) give you report before she left? She stated, Yeah but she didn't say anything about all that. n. On 6/25/19 at 3:02 p.m., LPN #1 was asked, Did you take care of (Resident #1) on 6/12/19 and 6/13/19? She stated, Yes. She was asked, Can you describe the events that occurred on 6/12/19 and 6/13/19 concerning his decreased urine output? She stated, I came in that morning; I emptied a little bit (urine) and I changed the whole bag. I had told (APN #1) about it and we were pushing fluids. She said to flush it and call her back if we didn't get anything (urine). She was asked, Did you flush the catheter? She stated, Yeah. She was asked, Did you get a return? She stated, I think so .I really cannot remember, but I think a little bit or not .I don't know. When you assumed care of the resident on 6/13/19 at approximately 7:00 a.m., what had you been told in report about his urine output? She stated, Well, the nurse said the catheter had been irritated and she had to put a dressing on it. She was asked, What do you mean 'irritated'? Are you referring to the insertion site? She stated, Yeah, I guess. She was asked, Did she say anything about his urine output decreasing? She stated, No she just said that she put a dressing on it. She was asked, Did she document the output for her shift? She stated, She should have. She was asked, Did you look to see what his output had been for the night of 6/12/19? She stated, I guess not, because I didn't know his there was any problem with the urine. She was asked, What made you change the bag and flush the tubing? She stated, I didn't get any urine the whole day. She was asked, Did you document the interventions and the result? She stated, I have some things that are written down in my own personal notebook and I can bring it to work with me in the morning. She was asked, Did you tell (LPN #2) about the issues with his catheter when you gave her report? She stated, I was in a hurry to leave to go get my kid, so I forgot that part, but I texted her at a little after 3:00 p.m. and told her if there wasn't better urine then call (APN #1). o. On 6/26/19 at 9:38 a.m., LPN #1 was asked, Did you find any notes regarding this resident's condition on 6/12/19 and 6/13/19? She stated, No. I didn't have any, but I remember now that I didn't text (LPN #2) cause I had called her. She was asked, Do you still have any of the communications from that day on your phone? She stated, No, this is a brand-new phone and none of that is on it. She was asked, Can we go over the timeline once more? When did you begin to become concerned about there being no urine in the collection bag? She stated, I don't know really. I actually felt like it would be okay. She was asked, Okay, but you went ahead and called (APN #1) right? She stated, Yeah. She was asked, What did she tell you? She stated, She told me to flush it and if it didn't work then call her back. She was asked, What time did you flush the tubing? She stated, I'm not really sure. She was asked, Did you get any return? She stated, If there was any, then it was not very much. She was asked, How much saline did you use to flush? She stated, 30 cc. She was asked, Did you get the 30 cc back? She stated, I can't remember. She was asked, Was there any improvement? She stated, No. She was asked, The APN asked you to flush and call her back if no improvement. Did you call her back when there was no improvement? She stated, No. I told (LPN #2) to call her if there was no improvement. She was asked, Were you concerned about there being no urine in his collection bag? She stated, I really thought it would be okay. I wasn't that concerned. She was asked, Does the facility have a policy regarding urinary output or do you have just your own guideline of what you are looking for when measuring urine? She stated, It's just my nursing judgement, I guess. She was asked, Have you been trained in this area by the facility? She stated, Not that I can remember. She was asked, Did you report any issues to anyone, other than calling (LPN #2) after you had left on 6/13/19? She stated, I usually tell the DON every time I call the APN. She was asked, Did you tell the DON on 6/13/19? She stated, I can't remember specifically, but it seems like I should have. She was asked, Do you know what an 'X' means when it is in the place of cc of urine measured? She stated, I don't know what the 'X' means. p. On 6/26/19 at 12:15 p.m., APN #1 was asked, Can you tell us about the resident's condition leading up to his transfer secondary to no measurable urine output? She stated, I don't remember being notified of any problems with his catheter. She was asked, When does your group normally get notified by the facility? She stated, With any change, they need to notify us. I do not remember them ever notifying me. I most certainly would have at the very least ordered labs. I feel certain that I would remember a notification of no urine output. q. On 6/26/19 at 2:02 p.m., the DON was asked, When was the first time you were notified of (Resident #1) having decreased or less than measurable urine output? She stated, When we got the records from the hospital is the first time I knew anything about it. She was asked, What have you found out about it since then? She stated, Well, when we started to look into the situation, we could see that the documentation was not very good. She was asked, Have you trained the nurses regarding identifying and reporting less than measurable urine output or what amount of urine to be looking for when measuring urine output? She stated, We have told them they should have at least 30 milliliters during their shift. She was asked, When do they get this information? She stated, We did it when we saw what happened here with (Resident #1). She was asked, Can you outline your investigation into the matter? She stated, I noticed he had zero (urine) out for 7-3. I went back and interviewed the nurses to see if he was complaining of pain, and they said he wasn't. She was asked, Are there other ways of identifying the problem of no urine output? She stated, Yeah, but they usually use the facial expressions with him and his pain because he has a hard time letting us know, but he lets his family know, but not us sometimes. She was asked, When should this situation have been reported to you and/or the APN or MD? She stated, She (LPN #1) called the APN and was told to call her back if there wasn't improvement. She was asked, Did that happen? She stated, I guess. She was informed that the APN does not recall receiving a call or message regarding his decreased urine output. She was asked, Do you know what the 'X' means when used in place of urine output in milliliters She stated, I would have to look it up. She was asked, On 6/11/19, there was an 'X' documented with the code for 'out of facility'. Do you know where he was at that time? She stated she would look it up. She was asked, Are you saying that you in-serviced the nursing staff, including CNAs (Certified Nursing Assistants), regarding what is expected when measuring urine output? She stated, Yes. She was asked to provide the In-service with the sign-in sheets. r. On 6/26/19 at 3:28 p.m., the DON was asked again for the in-service and sign-in sheets. She provided an in-service sheet which documented, Inservice: Foley output, Date: 6/15/2019, Inservice by: (DON) Nursing staff are responsible to notify MD/APN if any resident urine output is less than 30 cc in a 8 hour period. This is a (sic) emergency and shall not wait . Sign indicating you acknowledged the information provided . The form had been signed by 8 nurses. The survey team was able to speak with 5 of the staff members who had signed the form and those staff members reported to the survey team that they had signed the form on 6/26/19. The DON was informed of the need for accurate information to be provided to staff members when conducting in-services, as she had stressed in the in-service the need for urinary output to measure at least 30 milliliters in an 8-hour period and, per nursing standards of practice, should have been at least 30 milliliters per hour. She stated she would re-in-service those staff members who had received incorrect information. She was also asked if she was able to determine if the resident had been out of the facility on 6/11/19 and if so, where had he gone and for how long was he gone? She stated, I can't get that information, because the transport person is not here. s. On 6/26/19 at 3:36 p.m., the Administrator was asked, Had you been notified of the issue with (Resident #1's) decreased urine output? He stated, Not until just now. t. The immediate jeopardy was removed and the scope/severity reduced to G on 6/27/19 at 10:50 a.m. when the facility implemented the following plan of removal: 1.) On 6/26/2019 DON did a 1:1 (one-on-one) in-service with those nurses on shift during the time (Resident #1) had no measurable urinary output to ensure any identified need for immediate notification of physician is done and interventions implemented related to no measurable urine output over multiple shifts. 2.) On 6/26/2019, DON/designee assessed all residents with indwelling catheters to ensure any identified need for immediate notification of physician was done and intervention implemented related to no measurable urine output over multiple shifts, including (Resident #1) with no further negative findings. 3.) On 6/26/2019, DON immediately on notification began in-servicing of current licensed nursing staff on assessment and identification of the need for immediate physician notification and intervention related to no measurable urine output over multiple shifts. DON/designee with continue in-servicing licensed nursing staff prior to starting tour of duty. 4.) DON/designee will monitor using monitoring log all indwelling urinary catheters three times a week for 8 weeks or until compliance is achieved, making corrections as necessary and contacting administrator of all negative findings. 5.) DON/Designee will take all negative findings to the QAPI (Quality Assurance and Performance Improvement) Committee monthly for review and additional recommendations monthly.

Complaint # (AR 570) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding a significant change of condition that involved signs and symptoms of a possible [MEDICAL CONDITION] (stroke) or other neurological event for 1 (Resident #2) of 2 (Residents #1 and #2) case mix residents who had a significant change in condition in the past 30 days. The failed practice resulted in immediate jeopardy (removed), which caused or could have caused serious harm, injury or death to Resident #2, and had the potential to cause more than minimal harm to 24 residents who had a change in condition in the past 30 days, as documented on a list provided by the Director of Nursing (DON) on [DATE] at 3:05 p.m. The facility removed the immediate jeopardy prior to the survey entrance date; however, the current underlying failed practices were not fully corrected. The facility was informed of the removed immediate jeopardy condition on [DATE]. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 13 (,[DATE] indicates cognitively intact) on a brief interview for mental status, had clear speech, was understood by others, had no short or long term memory loss, no signs of [MEDICAL CONDITION], required extensive assistance of one person for transfers, bed mobility, dressing, toileting, personal hygiene and bathing and had functional limitation in range of motion in one lower extremity. a. The Care Plan dated as reviewed / revised on [DATE] documented, (Resident #2) has hypertension and is at risk for complications related to [MEDICAL CONDITION]. Monitor/record use/side effects of medication. Report to MD (Medical Doctor) as necessary . b. A physician order [REDACTED]. A physician order [REDACTED]. A Physician order [REDACTED]. Accuchecks (before meals and after meals) per sliding scale. c. A Hospital Summary dated [DATE] documented the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. d. Nurses' Notes dated [DATE] documented, .Resident arrived earlier part of day. Received patient in bed. Alert and oriented, able to make needs known and understood. No behavior changes noted at this time. Cooperative, no c/o (complaint of) pain or discomfort. Moves extremities (times) 4. Rt. (right) leg [MEDICAL CONDITION], below the knee . e. Daily Skilled Nurses' Notes dated [DATE] documented the resident's blood pressure was ,[DATE] on day shift and ,[DATE] on the evening shift. Daily Skilled Nurses' Notes dated [DATE] documented a day shift blood pressure of ,[DATE]. f. Nurses' Notes dated [DATE] at 11:40 p.m. and signed by Registered Nurse (RN) #1 documented, Awake and anxious; attempting to speak with words not understandable and garbled. Grimacing occ. (occasionally) . Noted mouth dry gave sips of (water) (without) problems (with) swallowing. Reassured pt (patient) freq (frequently) (and) oriented to place (and( situation. Encouraged to relax (and) get some rest. There was no documentation the physician was consulted regarding the change in the resident's condition at this time. g. Daily Skilled Nurse's Notes dated [DATE] at 11:30 p.m. and signed by RN #1 documented, Awake (and) attempting to verbalize (with) speech slurred (and) garbled . denies any pain or being hot or cold. Sips of H2O (water( given to pt. Pt. swallowed H2O (without) prob (problems). Skin warm (and) dry. Respirations are reg (regular) (and) even. No distress . There was no documentation the physician was consulted regarding the changes in the resident's condition at this time. 0030 (12:30 a.m.) Called CNA (Certified Nurse Assistant) (and) RN to room. Attempting to write needs on paper . Denies any pain or needs at this time. No distress noted. HOB (head of bed) ,[DATE] (degrees . There was no documentation the physician was consulted regarding the changes in the resident's condition at this time. 0600 (6:00 a.m.) Meds (medications) attempted to give (with) pt. refusing meds (and) to do Bld (blood) sugar. (No) distress . There was no documentation the physician was consulted regarding the changes in the resident's condition at this time. At 6:20 a.m.: Agitated (and) restless. Refusing to take meds (medications) or get bld (blood) sugar taken too. Explained reasons for her to take her meds. Grimacing but denies any pain. Bed remains in lowest position. There was no documentation the physician was consulted regarding the changes in the resident's condition at this time. h. A Nurses Note dated [DATE] at 7:15 a.m. and signed by RN #2 documented, Patient unable to speak clearly, slurred speech, drooling, left eye drooping, smile even, tongue straight, BUE (bilateral upper extremities) grips good, unable to move BLE (bilateral lower extremities). VS (vital signs) ,[DATE], HR (heart rate) 52, RR (respiratory rate) 15, Temp (temperature) 98.4 degrees, BS (blood sugar) 333. Nurse notified the doctor and received order to send the resident to (local hospital). Family called and message left. Patient was alert, oriented to person and place, (ambulance service) called, emergency room called with report. A period of approximately 8 hours had elapsed, during which the resident repeatedly exhibited signs and symptoms of possible [MEDICAL CONDITION], before the day shift RN (RN #2) arrived for duty, assessed the resident and consulted the physician. i. emergency room Notes dated [DATE] at 8:39 a.m. documented, Patient presents with [MEDICAL CONDITION]. Per report patient had some slurred speech last night unknown the exact time and then when staff awoke this morning she had facial drooping. Physical exam vital signs ,[DATE], pulse 46, temp 97.09, respirations 15, oxygen saturation 99%, left sided facial droop. j. A hospital Cardiology Progress Note dated [DATE] 12:56 p.m. documented, Patient was readmitted over the weekend for acute mental status change and [MEDICAL CONDITION] which is new. Advised to not use BB (Beta Blockers) [MEDICAL CONDITION](Hypertension) in the future and family feels that the other neuro medications might have made her feel that way and was awake and very frail and has right BKA and SR (Sedimentation Rate) and heart rate remains stable in the 60s appear more stable today. BNP (brain natriuretic peptide) 3000. Increased [MEDICATION NAME] to 100 bid (twice daily) to [MEDICAL CONDITION]. Assessment: .[MEDICAL CONDITION] .yes, Uncontrolled hypertension .yes, [MEDICAL CONDITION] .No, Acute or [MEDICAL CONDITION] .yes . 1. [MEDICAL CONDITION], this is not a new problem on review of her chart. Avoid rate related medication on monitor form now, blood pressures are stable. 2. Mental status changes unknown etiology however she is awake and talks 3. CAD ([MEDICAL CONDITION]) previous CABG (Coronary Artery Bypass Graft) she denies chest pain. 4. [MEDICAL CONDITIONS] long term previous lvef (left ventricular ejection fraction) was (less than) 35%, no obvious failure, and now LVEF described near normal and LVH (Left Ventricular Hypertrophy) and moderate [MEDICAL CONDITION] hypertension. 6. Acute on chronic diastolic [MEDICAL CONDITION] . 8. Accelerated hypertension and added [MEDICATION NAME] and [MEDICATION NAME] and avoid BB, [MEDICATION NAME] and other drugs that can cause [MEDICAL CONDITION] and of course cannot use ACEI (angiotensin-converting-enzyme inhibitor) or ARB (Angiotensin II receptor blockers) due to [MEDICAL CONDITION]. BP (Blood Pressure) reasonably better today and heart rate looks better .BNP now 3000. Plan: As outlined above . Visited with the family and discussed the plan from cardiac standpoint of view and also explained the difficult nature of mental status change, which is being addressed by primary team and MRI (Magnetic Resonance Imaging) and CT (Computed Tomography) showing no acute stroke . k. On [DATE] at 8:24 a.m., RN #2 was asked about the condition of the resident on the morning of [DATE] and stated RN #1 told her Resident #2 was having garbled speech at 11:30 p.m. on [DATE] and, .I didn't know about the 5:30 a.m. Nurses Note saying she (the resident) was writing her needs. She (RN #1) didn't tell me about that. I was called at 7:00 a.m. to see the resident and went in to her. She couldn't speak clearly, had slurred speech. I asked her if she was okay and she shook her head no. I checked her blood sugar - it was 333 with her vital signs at ,[DATE], 52, 16, and 98.4 per my notes. I immediately called the doctor and transferred her. l. On [DATE] at 10:40 a.m., the Director of Nursing was asked about Resident #2's change of condition on [DATE] and stated, She (RN #1) should have asked someone familiar with the resident. She is an agency nurse and should not just assume this was her normal (condition), especially with a decline from garbled speech to attempting to write. There is no documentation she called anyone or notified the doctor. You can't just assume it is her normal. m. On [DATE] at 11:30 a.m., CNA #1, who worked with the agency nurse during the night shift on [DATE], was asked about the resident's condition on the night of [DATE]. The CNA stated, I told the nurse that I usually could understand her (resident) and that I couldn't understand her, and I told the nurse about her face, with one side of her face was lower than the other. Later, on [DATE], she (the resident) attempted to write out a message, but wasn't able to. It looked like scribbles. n. On [DATE] at 2:35 p.m., Resident #2 was asked to describe what happened on the night of [DATE] and morning of [DATE] before she was sent to the hospital. Resident #2 stated, They let me lay there from 9:00 p.m. till the next morning. It made me feel bad. I knew everything, but I couldn't talk. The CNA couldn't understand me and kept putting me down in the bed. They didn't do anything for me till the (day shift) CNA came in the next morning. The minute she saw me, she knew what was happening. Resident #2 was asked if she had ever had this type of episode before. Resident #2 stated, I have had this before, back in 2011. It goes away slowly, like it is now. I could have died . Thank God I didn't. I just laid there till that CNA came in that morning. o. Based on the following interviews, as well as the resident's transfer to the hospital on [DATE], the facility removed the immediate jeopardy for Resident #2 and reduced the scope / severity to E on [DATE], prior to the survey entrance date: 1.) On [DATE] at 3:55 p.m., the Administrator and Director of Nursing (DON) were asked if the facility administration had identified any issue with the care provided to Resident #2 on the night of [DATE]. The Administrator stated, Yes, we made an attempt to in-service (RN #1). I sent an e-mail to the (staffing) agency, and she never showed up for the in-service. We identified a problem on Monday ([DATE]), when they did the chart audits that day. That is in our daily start-up meeting. The Administrator also stated RN #1's name had been added to a list of staff who were no longer allowed to work in the facility. 2.) On [DATE] at 4:15 p.m., the Administrator provided a copy of the email she had sent to the staffing agency. The e-mail was dated Tuesday, [DATE], at 1:52 p.m. and documented, Can you please send your nurse that worked ,[DATE] (11:00 p.m. to 7:00 a.m.) for us on ,[DATE] H-hall? No documentation was provided to indicate the facility had assessed / audited other residents who received care from RN #1 or of an ongoing monitoring plan to ensure any further failures related to responding to changes of condition were promptly identified and corrected.

Complaint # (AR 570) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure necessary care and services were promptly provided to address an acute change in condition, as evidenced by failure to ensure the physician was immediately consulted regarding a significant change of condition that involved signs and symptoms of a possible [MEDICAL CONDITION] (stroke) or other neurological event and failure to check vital signs, conduct assessments of the resident's neurological and cardiac status and obtain emergency medical assistance for 1 (Resident #2) of 2 (Residents #1 and #2) case mix residents who had a significant change in condition in the past 30 days. The failed practice resulted in immediate jeopardy (removed), which caused or could have caused serious harm, injury or death to Resident #2, and had the potential to cause more than minimal harm to 24 residents who had a change in condition in the past 30 days, as documented on a list provided by the Director of Nursing (DON) on [DATE] at 3:05 p.m. The facility removed the immediate jeopardy prior to the survey entrance date; however, the current underlying failed practices were not fully corrected. The facility was informed of the removed immediate jeopardy condition on [DATE]. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 13 (,[DATE] indicates cognitively intact) on a brief interview for mental status, had clear speech, was understood by others, had no short or long term memory loss, no signs of [MEDICAL CONDITION], required extensive assistance of one person for transfers, bed mobility, dressing, toileting, personal hygiene and bathing and had functional limitation in range of motion in one lower extremity. a. The Care Plan dated as reviewed / revised on [DATE] documented, (Resident #2) has hypertension and is at risk for complications related to [MEDICAL CONDITION]. Monitor/record use/side effects of medication. Report to MD (Medical Doctor) as necessary . b. A physician order [REDACTED]. A physician order [REDACTED]. c. A Hospital Summary dated [DATE] documented the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. d. Nurses' Notes dated [DATE] documented, .Resident arrived earlier part of day. Received patient in bed. Alert and oriented, able to make needs known and understood. No behavior changes noted at this time. Cooperative, no c/o (complaint of) pain or discomfort. Moves extremities (times) 4. Rt. (right) leg [MEDICAL CONDITION], below the knee . e. Daily Skilled Nurses' Notes dated [DATE] documented the resident's blood pressure was ,[DATE] on day shift and ,[DATE] on the evening shift. Daily Skilled Nurses' Notes dated [DATE] documented a day shift blood pressure of ,[DATE]. f. Nurses' Notes dated [DATE] at 11:40 p.m. and signed by Registered Nurse (RN) #1 documented, Awake and anxious; attempting to speak with words not understandable and garbled. Grimacing occ. (occasionally) . Noted mouth dry gave sips of (water) (without) problems (with) swallowing. Reassured pt (patient) freq (frequently) (and) oriented to place (and( situation. Encouraged to relax (and) get some rest. There was no documentation the physician was consulted regarding the changes in the resident's condition and no neurological and cardiac assessment or vital signs were documented. g. Daily Skilled Nurse's Notes dated [DATE] at 11:30 p.m. and signed by RN #1 documented, Awake (and) attempting to verbalize (with) speech slurred (and) garbled . denies any pain or being hot or cold. Sips of H2O (water( given to pt. Pt. swallowed H2O (without) prob (problems). Skin warm (and) dry. Respirations are reg (regular) (and) even. No distress . There was no documentation the physician was consulted regarding the changes in the resident's condition and no neurological and cardiac assessment or vital signs were documented. 0030 (12:30 a.m.) Called CNA (Certified Nurse Assistant) (and) RN to room. Attempting to write needs on paper . Denies any pain or needs at this time. No distress noted. HOB (head of bed) ,[DATE] (degrees . There was no documentation the physician was consulted regarding the changes in the resident's condition and no neurological and cardiac assessment or vital signs were documented. 0600 (6:00 a.m.) Meds (medications) attempted to give (with) pt. refusing meds (and) to do Bld (blood) sugar. (No) distress . There was no documentation the physician was consulted regarding the changes in the resident's condition and no neurological and cardiac assessment or vital signs were documented. At 6:20 a.m.: Agitated (and) restless. Refusing to take meds (medications) or get bld (blood) sugar taken too. Explained reasons for her to take her meds. Grimacing but denies any pain. Bed remains in lowest position. There was no documentation the physician was consulted regarding the changes in the resident's condition and no neurological and cardiac assessment or vital signs were documented. h. A Nurses Note dated [DATE] at 7:15 a.m. and signed by RN #2 documented, Patient unable to speak clearly, slurred speech, drooling, left eye drooping, smile even, tongue straight, BUE (bilateral upper extremities) grips good, unable to move BLE (bilateral lower extremities). VS (vital signs) ,[DATE], HR (heart rate) 52, RR (respiratory rate) 15, Temp (temperature) 98.4 degrees, BS (blood sugar) 333. Nurse notified the doctor and received order to send the resident to (local hospital). Family called and message left. Patient was alert, oriented to person and place, (ambulance service) called, emergency room called with report. A period of approximately 8 hours had elapsed, during which the resident repeatedly exhibited signs and symptoms of possible [MEDICAL CONDITION], before the day shift RN (RN #2) arrived for duty, assessed the resident and consulted the physician. i. emergency room Notes dated [DATE] at 8:39 a.m. documented, Patient presents with [MEDICAL CONDITION]. Per report patient had some slurred speech last night unknown the exact time and then when staff awoke this morning she had facial drooping. Physical exam vital signs ,[DATE], pulse 46, temp 97.09, respirations 15, oxygen saturation 99%, left sided facial droop. j. A hospital Cardiology Progress Note dated [DATE] 12:56 p.m. documented, Patient was readmitted over the weekend for acute mental status change and [MEDICAL CONDITION] which is new. Advised to not use BB (Beta Blockers) [MEDICAL CONDITION](Hypertension) in the future and family feels that the other neuro medications might have made her feel that way and was awake and very frail and has right BKA and SR (Sedimentation Rate) and heart rate remains stable in the 60s appear more stable today. BNP (brain natriuretic peptide) 3000. Increased [MEDICATION NAME] to 100 bid (twice daily) to [MEDICAL CONDITION]. Assessment: .[MEDICAL CONDITION] .yes, Uncontrolled hypertension .yes, [MEDICAL CONDITION] .No, Acute or [MEDICAL CONDITION] .yes . 1. [MEDICAL CONDITION], this is not a new problem on review of her chart. Avoid rate related medication on monitor form now, blood pressures are stable. 2. Mental status changes unknown etiology however she is awake and talks 3. CAD ([MEDICAL CONDITION]) previous CABG (Coronary Artery Bypass Graft) she denies chest pain. 4. [MEDICAL CONDITIONS] long term previous lvef (left ventricular ejection fraction) was (less than) 35%, no obvious failure, and now LVEF described near normal and LVH (Left Ventricular Hypertrophy) and moderate [MEDICAL CONDITION] hypertension. 6. Acute on chronic diastolic [MEDICAL CONDITION] . 8. Accelerated hypertension and added [MEDICATION NAME] and [MEDICATION NAME] and avoid BB, [MEDICATION NAME] and other drugs that can cause [MEDICAL CONDITION] and of course cannot use ACEI (angiotensin-converting-enzyme inhibitor) or ARB (Angiotensin II receptor blockers) due to [MEDICAL CONDITION]. BP (Blood Pressure) reasonably better today and heart rate looks better .BNP now 3000. Plan: As outlined above . Visited with the family and discussed the plan from cardiac standpoint of view and also explained the difficult nature of mental status change, which is being addressed by primary team and MRI (Magnetic Resonance Imaging) and CT (Computed Tomography) showing no acute stroke . k. On [DATE] at 8:24 a.m., RN #2 was asked about the condition of the resident on the morning of [DATE] and stated RN #1 told her Resident #2 was having garbled speech at 11:30 p.m. on [DATE] and, .I didn't know about the 5:30 a.m. Nurses Note saying she (the resident) was writing her needs. She (RN #1) didn't tell me about that. I was called at 7:00 a.m. to see the resident and went in to her. She couldn't speak clearly, had slurred speech. I asked her if she was okay and she shook her head no. I checked her blood sugar - it was 333 with her vital signs at ,[DATE], 52, 16, and 98.4 per my notes. I immediately called the doctor and transferred her. l. On [DATE] at 10:40 a.m., the Director of Nursing was asked about Resident #2's change of condition on [DATE] and stated, She (RN #1) should have asked someone familiar with the resident. She is an agency nurse and should not just assume this was her normal (condition), especially with a decline from garbled speech to attempting to write. There is no documentation she called anyone or notified the doctor. You can't just assume it is her normal. m. On [DATE] at 11:30 a.m., CNA #1, who worked with the agency nurse during the night shift on [DATE], was asked about the resident's condition on the night of [DATE]. The CNA stated, I told the nurse that I usually could understand her (resident) and that I couldn't understand her, and I told the nurse about her face, with one side of her face was lower than the other. Later, on [DATE], she (the resident) attempted to write out a message, but wasn't able to. It looked like scribbles. n. On [DATE] at 2:35 p.m., Resident #2 was asked to describe what happened on the night of [DATE] and morning of [DATE] before she was sent to the hospital. Resident #2 stated, They let me lay there from 9:00 p.m. till the next morning. It made me feel bad. I knew everything, but I couldn't talk. The CNA couldn't understand me and kept putting me down in the bed. They didn't do anything for me till the (day shift) CNA came in the next morning. The minute she saw me, she knew what was happening. Resident #2 was asked if she had ever had this type of episode before. Resident #2 stated, I have had this before, back in 2011. It goes away slowly, like it is now. I could have died . Thank God I didn't. I just laid there till that CNA came in that morning. o. Based on the following interviews, as well as the resident's transfer to the hospital on [DATE], the facility removed the immediate jeopardy for Resident #2 and reduced the scope / severity to E on [DATE], prior to the survey entrance date: 1.) On [DATE] at 3:55 p.m., the Administrator and Director of Nursing (DON) were asked if the facility administration had identified any issue with the care provided to Resident #2 on the night of [DATE]. The Administrator stated, Yes, we made an attempt to in-service (RN #1). I sent an e-mail to the (staffing) agency, and she never showed up for the in-service. We identified a problem on Monday ([DATE]), when they did the chart audits that day. That is in our daily start-up meeting. The Administrator also stated RN #1's name had been added to a list of staff who were no longer allowed to work in the facility. 2.) On [DATE] at 4:15 p.m., the Administrator provided a copy of the email she had sent to the staffing agency. The e-mail was dated Tuesday, [DATE], at 1:52 p.m. and documented, Can you please send your nurse that worked ,[DATE] (11:00 p.m. to 7:00 a.m.) for us on ,[DATE] H-hall? No documentation was provided to indicate the facility had assessed / audited other residents who received care from RN #1 or of an ongoing monitoring plan to ensure any further failures related to responding to changes of condition were promptly identified and corrected.

Complaint # (AR 562) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a mechanical lift was utilized only by staff who had been trained and checked off on safe and proper use in accordance with manufacturer's instructions. to prevent falls and potential injury for 1 (Resident #1) of 4 (Residents #1, #3, #4 and #5) case mix residents who required the use of a mechanical lift for transfers. The failed practice resulted in past Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was improperly secured in the mechanical lift sling by an agency nurse and subsequently fell out of the sling to the floor during a transfer. The failed practice also had the potential to cause more than minimal harm for 42 residents who required the use of a mechanical lift for transfers, according to a list provided by the Administrator on 10/26/16. The facility was informed of the past Immediate Jeopardy on 10/27/16 at 2:15 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 8/30/16 documented the resident scored 6 (0-7 indicates severely impaired) on the brief interview for mental status, required total assistance of two people for bed mobility and transfers and had functional limitation in range of motion to the lower extremities on both sides. a. The Care Plan with a review date of 8/31/16 documented, (Resident #1) is at risk for fall/injuries r/t (related to) poor safety awareness from dementia, poor balance, right below the knee amputation, and needs assistance with mobility requires a mechanical lift with two person assist with transfers . b. A Nurses Note dated 10/24/16 at 6:35 a.m. and signed by Licensed Practical Nurse (LPN) #2 documented, This nurse was assisting CNA (Certified Nurse Assistant) move patient to wheelchair with hoyer lift. While in motion, the hoyer lift leg strap came off of hoyer lift and patient proceeded to fall. This nurse broke patient's fall before she could completely hit the floor. This nurse eased resident to floor while protecting her head. c. A Resident Incident Report dated 10/24/16 at 6:50 a.m. documented the resident complained of hip pain. The incident occurred in the resident's room and the equipment being used was a hoyer lift during a transfer. The form also documented the resident was sent to the emergency room . 1.) A witness statement dated 10/24/16 at 6:35 a.m. and signed by LPN #2 documented, I was assisting the CNA with getting patient out of bed, the patient was on the lift being moved to her wheelchair and the leg strap on lift pad came off hoyer and patient dropped to floor. I broke her fall going to the floor. 2.) A Witness Statement dated 10/24/16 at 6:35 a.m. and signed by CNA #2 documented, Resident is hoyer lift w/2 (with 2) person assist in room. Nurse on duty with CNA proceeded to follow protocol w/ (with) resident to connect her to mechanical lift. I (CNA #2) connected left side to hoyer, Nurse connected right side. We then began to lift (resident) from bed to transfer to wheelchair w/ nurse on back side assisting w/ turn for resident to be towards me operating the lift. As we are in process of the lift (and) turn, the strap on right side slipped off. I stopped the lift immediately. The resident started rolling out of the (illegible) this time the lift was not secure, the nurse grabbed lift (and) resident to secure her safely to floor to stop resident from pounding on it. She lowered the resident to safety. 3.) A patient Lift In-service Check List dated 9/29/16 and provided by the Administrator on 10/27/16 at 1:26 p.m. documented CNA #2 had been checked off on the use of the Vanderlift II and Drive Lift that were currently being used at the facility; however, there was no documentation that LPN #2 had been trained on the use of the lift prior to the incident involving Resident #1 on 10/24/16. d. A Nurses Note dated 10/24/16 at 6:50 a.m. documented, Fall report to this nurse by staff nurse (and) CNA 0700 (7:00 a.m.). Dr. (Doctor) notified. T.O. (Telephone Order) received to send res (resident) to ER (emergency room ) for evaluation (and) tx (treatment). 0701 (7:01 a.m.) (Emergency Medical Services) called for res transport. 0704 (7:04 a.m.) (LPN #1) on call notified of res transport.0725 (7:25 a.m.) Res left facility via (Emergency Medical Services). e. The hospital ER records dated 10/24/16 documented the following: 1.) XR (x-ray) Chest AP (anterior to posterior view) portable: Impression: Relatively stable chest with probable mild parenchymal scarring at the left lung base . Subtle bunting of the costophrenic angles may be due to pleural fluid or pleural scar no definite pneumothorax identified . A rib series can be obtained if rib fractures are suspected. 2.) XR Shoulder Left AP and Lateral: .Impression: Diffuse osteopenia with no gross fractures or dislocation . 3.) XR Pelvis W (with) Lateral Hip Right: .Impression: No acute fracture is clearly identified . 4.) CT (Computed Tomography) Thoracic Spine WO (without) Contrast; CT Lumbar Spine WO Contrast . Impression: .No acute fracture or traumatic malalignment involving the thoracolumbar spine . 5.) CT Head WO Contrast: Impression: .No acute traumatic intracranial injury or fracture . 6.) CT Cervical Spine WO Contrast: Impression: No acute fracture or traumatic malalignment involving the cervical spine . f. Nurses Notes dated 10/24/16 on the 11:00 p.m. to 7:00 a.m. (11-7) shift documented, .Rec'd (Received) in bed (with) s/r (side rails up) x (times) 2 (and) HOB (head of bed up) all care via staff. Is repositioned (and) turned (every) 2 (hours) for care (and) comfort. Neuro (neurological) (checks within) normal limits. Voices no c/o (complaints of) pain or discomfort from fall. Kept clean and dry. g. On 10/27/16 at 10:00 a.m., the Administrator was asked about the LPN who assisted in the transfer of the resident on 10/24/16 and stated that LPN #2 was not a regular staff member, but was an agency nurse who worked intermittently for the facility. The Administrator stated the LPN had not been trained in the use of the Driver lift by any of the staff. The Administrator was asked, So the nurse was transferring a resident with a piece of equipment that she had not been trained to use? The Administrator stated, Yes, that's correct . We have tried to get ahold of her (indicating LPN #2) to get her to do a re-enactment of the incident, but she won't return any of our phone calls. The Administrator also stated that the agency was supposed to train their nurses, but the facility had recently started checking them off on equipment use themselves, and that after the incident, they re-trained all care staff on the use of the lift. 3. The facility removed the immediate jeopardy and corrected the failed practice on 10/24/16, as follows: a. A Lift Inservice dated 10/24/16, provided by the Director on 10/27/16 at 10:15 a.m., documented facility staff who had been inserviced on the use of the Drive Lift that was used during the transfer of the resident. A list dated from July through October 24, 2016, titled Lift Competency Check offs and hand written at the top right corner most recent lift inservice provided by the Administrator on 10/27/16 at 10:15 a.m. b. An announcement posted by the time clock documented, Attention ALL Staff: If you are agency personnel, or if you have NOT been checked off on the proper use of Mechanical Lifts DO NOT USE a Mechanical Lift Until you have been checked off by (Facility Name) Nursing Management!!!!!! Call facility and ask to speak ADONs (Assistant Directors of Nursing) or Unit Managers and schedule a time to be checked off immediately; or this could result in being removed from the schedule.

Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical well-being for Resident #1. The facility failed to ensure consistent implementation of a physician order [REDACTED].#1) of 5 (Residents #1, #2, #3, #4 and #7) case mix residents who had physician orders [REDACTED].#1, who had swallowing difficulties and a physician order [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 4 (,[DATE] indicates severe impairment) on the Brief Interview for Mental Status, was dependent on staff for eating and had a feeding tube. The Care Area Assessment (CAA) Worksheet dated [DATE] documented, .Reason for Tube Feeding Unable to swallow or to eat food and unlikely to eat within a few days . Prevention of meal-induced hyperemia in resident with [MEDICAL CONDITION] . or other [MEDICAL CONDITION] problems that interfere with eating . a. A (Local Hospital) discharge summary dated [DATE] documented, 71 y/o (year old) female with PMH (past medical history) of [MEDICAL CONDITION], not on 02 (oxygen) . possible stroke with resultant recurrent aspiration s/p (status [REDACTED]. Recently discharged from (City) 2 days ago after presenting with [MEDICAL CONDITION] exacerbation and pneumonia on the 28th. ([DATE]) She required temporary intubation . required a PEG for feeding due to recurrent aspiration . discharged 2 days ago on steroid taper and oral antibiotics . Family reports she has not done well since discharge . worsening non-productive cough . b. A Speech Therapy LP (Speech Language Pathology) Evaluation & Plan of Treatment dated [DATE] documented, .Initial assessment/current level of function (and) underlying impairments factors supporting medical necessity current referral reason for referral: Patient referred to ST (Speech Therapy) due to exacerbation risk for aspiration, risk for weight loss, increased s/s (signs and symptoms) dysphasia and coughing/choking during oral intake placing patient at risk for aspiration . Pre-Swallow Assessment Laryngeal/Pharyngeal Func. (Function) Dry Swallow = (equals) Impaired (Delayed or absent upon the evaluation) . Clinical bedside assessment of swallowing: Neuromuscular/anatomic disorders overall abilities swallowing abilities = Profound/absent - little to no attempts to initiate/ participate (NPO) .Assessment Summary .Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: Aspiration . c. admission orders [REDACTED].NPO (nothing by mouth) bolus [MEDICATION NAME] 1.5 q (every) 4 (hours) . d. A Nurses Note dated [DATE] at (8:45 p.m.) documented, MD (Medical Doctor) ordered chest x-ray to see if aspiration occurred since (resident) was given meds (medications) po (by mouth) and a full lunch tray. (Resident) showing no s/sx (signs and symptoms) of aspiration. X-ray reveals infiltrates in both lower lobes. MD informed of results. New med order for [MEDICATION NAME] 875 mg (milligrams) via (by way of) PEG (percutaneous endoscopic gastrostomy) tube BID (twice daily) X (times) 10 days . e. A Telephone Order dated [DATE] at 3:30 p.m. documented, 1) Clarify NPO, 2) all medications PEG, 3) CXR (chest x-ray) today . f. A Radiology Report dated [DATE] documented, .Conclusion: Slight right lower lobe and modest left lower lobe infiltrate . g. A Telephone Order dated [DATE] at 8:45 p.m. documented, [MEDICATION NAME] 875 mg per peg tube BID for 10 days. h. A Daily Skilled Nurse's Note dated [DATE] documented, (At) approx (approximately) 0743 (7:43 am) CNA (Certified Nursing Assistant) notified this nurse that (resident) rec'd (received) a tray from dietary. This nurse stated, Take the tray out of the room right now. This nurse observed (resident) breathing, displaying anger r/t (related to) tray removal. (Resident) grabbed my hand and wiped her mouth. (No) liquids or food noted in mouth. (At) approx 0800 (8:00 am) CNA called this nurse to the room, upon arrival (resident) was lethargic, cyanotic, clammy and unable to hold her head (up). This nurse checked VS (vital signs), (no) pulse noted, (no) resp (respirations) noted. Code Blue called, 911 notified, CPR (Cardiopulmonary Resuscitation) initiated . APS (Adult Protective Services) notified, Family notified and APN (Advanced Practice Nurse) once in building. 1st (First Responders) and EMS (Emergency Medical Service) arrived, Resident (at) (Local Hospital) in ICU (Intensive Care Unit). A Telephone Order dated [DATE] at 8:00 a.m. documented, 1. Order clarification. Aspirin 81 mg chewable 1 tab (tablet) via peg tube daily. 2. [MEDICATION NAME] 1.5 1 can q (every) 4 (hours) via peg tube. i. An hospital Internal Medicine History and Physical dated [DATE] documented, .History .71 y.o. (year old) female Pt (patient) with hx. (history) of: presented to ED (emergency department) with c/o (complaint of) was supposed to be NPO but was at the breakfast table eating and choked, aspirated and coded. When EMS got there she was in asystole. They got her back in the ER (emergency room ) she is intubated, unresponsive and going to ICU . (Resident expired [DATE]). j. On [DATE] 10:42 a.m., Licensed Practical Nurse (LPN) #2, the charge nurse on the day shift of [DATE], was asked if she had been aware, prior to the resident receiving a meal tray, that the resident had a physician order [REDACTED]. k. On [DATE] at 1:03 p.m., the Director of Nursing (DON) was asked about the Swallow Study conducted on [DATE]. She stated, I never saw this study. She was NPO and only received bolus feedings from the time she came back on [DATE] and was supposed to remain NPO according to the physician orders. What I have (determined) in the investigation, the Dietary Manager went in to put diets into her dietary system. She clicked on regular diet. She had to re-enter everybody's diet, due to there was a dietary system change, and for this resident, she clicked regular diet. When we went from the old system to the new system, to my knowledge no one checked that the correct diets were entered. Through our investigation, we found that the diet had been entered into the new dietary system in error. The DON was then asked if the surveyor could speak to the Dietary Manager. The DON stated, She walked out yesterday. She left after y'all (you all) entered and before the evening meal. l. On [DATE] at 1:41 p.m., CNA #2 was asked if he had worked with Resident #1. He stated, I have been here about 2 months and I worked on C-Hall with her for 2 weeks before she died . She was NPO, not getting anything by mouth. She went to the hospital; this was in September, when she came back from the hospital. She wasn't getting a tray before she went to the hospital, but when she came back, they were giving her a tray. That Friday ([DATE]) she came back (from the hospital), she got a lunch tray. I was thinking in my mind the orders had been changed, and now she was getting a tray with a ticket. On the morning when (LPN #2) was here ([DATE]), she told us she was not supposed to have a tray, but she had already eaten some oatmeal, apples and sausage. (LPN #2) had us take the tray out. She got bad fast and they started CPR. If I had any concerns or questions prior to this incident, I just basically asked around and talked to the nurses. After this, the Administrator told us that we could look in the charts. Now, they have everything in the ADL (Activities of Daily Living) Books. m. On [DATE] at 2:01 p.m., CNA #1 was asked if, prior to [DATE], she was aware that Resident #1 had a physician order [REDACTED]. When she got the tray on Tuesday, I asked 2 nurses. I asked the one that works in the MDS office (LPN #3). She said, 'I'm going to go check' and when she came back, she said, 'If they sent her a tray, give her the tray'. n. On [DATE] at 2:18 p.m., APN #1 was asked about (Resident #1) and she stated, I ordered a chest x-ray on [DATE], because the nurse told me she got a (meal) tray. I checked her; she was fine, and pulse ox (oximeter) was good. She was clear. I think that having the agency nurse and not the regular nurse on the 20th could have contributed to this. o. On [DATE] at 2:43 p.m., Licensed Practical Nurse (LPN) #1 was asked if she was the one who had noted the NPO clarification order on [DATE]. She stated, I noted the order off. I was under the assumption it had been taken care of. All I did was order the x-ray. I should have checked that the dietary communication sheet was done. p. On [DATE] at 2:40 p.m., the Administrator was asked for the Dietary Communication form from [DATE], clarifying the resident was to remain NPO. She stated, There was not one given to dietary. q. On [DATE] at 2:49 p.m., LPN #3 was asked if a CNA had asked her on [DATE] if Resident #1 was supposed to have a tray. She stated, She did come and ask me if she was supposed to get a tray, and I told her I thought she was NPO, but let me check. I told her to check with her nurse, and that was an agency nurse that day. On her admission note from the Friday before, it had NPO and the tube feeding order. I went to find the CNA. I found the hall nurse and she said, 'Yeah, I know I have already taken care of that and wrote a clarification order'. r. The facility removed the immediate jeopardy and corrected the deficient practices on [DATE], when an audit of all dietary orders was completed and the following additional corrective actions were implemented: The Facility Investigation Report (Division of Medical Services (DMS) Form 762) dated [DATE] documented: All other NPO residents were immediately assessed for distress by DON/designee - no negative outcomes noted. Immediate audit of all dietary tray cards from last written order in chart was conducted. In-service all staff on NPO definition and removal guidance completed. In-service all staff on tray card identification completed. In-service for abuse and neglect has been completed. One on one in-service with weekend supervisors requesting they contact the Dietary Manager for all weekend admissions/re- admissions. Daily monitoring of tray cards for four weeks, twice weekly thereafter with all discrepancies to be reported to CEO (Chief Executive Officer)/designee for clarification. Dietary orders in electronic medical records audited ,[DATE]/(16), ,[DATE]/(16), ,[DATE]/(16) - with all discrepancies reported to CEO and DON/designee for clarification and/or correction. Witness statements from staff regarding incident obtained. Unit Managers will continuously monitor all admissions/re - admissions, with weekend supervisors reviewing orders for weekend re-admissions/admissions. NPO signs have been placed over the beds of all NPO residents. CNA sheet (in ADL book) now shows NPO residents and will be updated every Friday by MDS Coordinator. Police, doctor, family and Administrator notified. Resident is currently stable and will be transitioning to general med (medical) floor this week. At this time, we conclude that individual process failure was responsible for this situation. All processes have been corrected. This form was signed by the Administrator and dated for [DATE]. These corrective actions were verified per meal observations, record reviews and interviews conducted by the surveyors on [DATE] through [DATE].

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure a mechanical lift with sensitive manual controls was operated in a way that would prevent a resident from being rapidly dropped into bed and failed to ensure direct care staff who were concerned about the safety or operation of the mechanical lift communicated those concerns to nursing administration and removed the lift from service to prevent potential injury for 1 (Resident #2) of 4 (Residents #2, #3, #5, and #6) case mix residents who required the use of a mechanical lift for transfers. The failed practices resulted in past immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #2, who was rapidly dropped into bed by the mechanical lift and subsequently complained of pain and was diagnosed with [REDACTED]. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 2/28/16 documented the resident scored 5 (0-7 indicates cognitively intact) on the Brief Interview for Mental Status, and was totally dependent on two-plus persons for transfers. a. A Lift/Mobility Evaluation dated 4/18/16 documented, Summary and Plan: Type of lift required - Total Dependent i.e. (such as) Hoyer . Sling size - medium. Number of staff required for lift/transfer - 2. b. A Nurse's Note dated 5/9/16 documented, 3-11 (3:00 p.m. to 11:00 p.m. shift). Upon coming to shift, resident stated that she fell . This nurse went to NS (nurse's station) to inquire if this report had been reported. This nurse finds out that it had already been reported. Later through the shift, resident c/o (complained of) pain to left leg. Family also stated that resident complained of pain to left leg . doctor notified. New order received to obtain x-ray . Tylenol 325 mg (milligrams) 2 tabs (tablets) administered for c/o pain at 8:00 p.m. X-ray result received later through shift. (Physician) notified. New order received to send to ER (emergency room ). DON (Director of Nursing) notified of the above. Family made aware of x-ray results . c. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 5/9/16 documented, At approximately noon on 5/9/16, (Resident #2) alleged to the CNAs (Certified Nursing Assistants) that someone had dropped her after her shower. (Resident #2) acknowledged slight pain to her groin / vaginal area and PRN (as needed) OTC (over the counter) pain reliever was administered. No further pain was reported until approximately 5:00 p.m., when the resident's son attempted to raise the head of the bed; at which time the resident asked him to stop because of a pain in her leg. The nurse was notified, administered a pain reliever, and notified the physician. A stat x-ray was ordered. X-ray showed femur fracture. Resident was then sent to the hospital for further evaluation and treatment. Resident returned with PRN Tylenol as a pain reliever. According to witness statements, mid-morning 5/9/16, resident received shower. Resident is a max (maximum) assist and is transferred from bed to shower bed via (mechanical) lift. Resident was transported to shower room, received shower, and was returned to room. Upon the final transfer to the bed, one CNA notes that the lift had released rapidly, but that the resident landed on the mattress of the bed. All CNAs state resident did not complain or show any signs of pain during any transfer. 1.) A Witness Statement dated 5/9/16 and signed by CNA #1 documented, .After shower, me and (CNA #2) got her (Resident #2) out the shower bed with the manual lift and the lift turn gauge was stuck, had to turn hard and the lift drop a little hard. Then she was complaining someone drop her after we went back to get her up for lunch and resident complain of groin pain. 2.) A Witness Statement dated 5/16/16 and written by CNA #2 documented, .While (CNA #1) assisted me putting her to bed, we used the manual Hoyer lift on her. I guided her body and (CNA #1) pushed the lift. She released it down. We placed her in bed and cleaned her. We went back to get her up for lunch and said she had been dropped and I reported it to the nurse. On 7/12/16 at 12:35 p.m., CNA #2 was asked about the manual Hoyer lift that was utilized for Resident #2's transfer. The CNA stated, The lowering of the resident would depend on how fast you turned the knob. The CNA was asked about the incident on 5/9/16 involving Resident #2 and stated, We did the shower and then took her back to her room. We got ready to put her in bed, and the manual lift did drop too fast. It released too fast. The CNA was asked if she was the person who lowered the resident into bed and stated, No, (CNA #1) did the turning of the knob, but she's on vacation right now. She didn't do nothing wrong. It might depend on how tight the person (who used the lift) before turned it. We came back to get her up for lunch, and that's when she said she had been dropped. I stepped out of the room and told the charge nurse. The CNA was asked if the resident complained of pain when she was lowered into the bed and stated, She did not complain of pain when she dropped down. I was told to do a witness statement and that was the last I heard about it til I came back the next day and they had pulled the lift off the floor. The CNA was asked how long the lift had been lowering residents too fast and stated, Every time I have ever used that lift, if you don't hold that knob, it will release too fast. The CNA was asked if CNA #1 knew that and stated, I'm not sure about that. There were a couple of residents that didn't want that lift used on them because of how fast it lowered. The CNA was asked if she was ever trained on how to use that particular lift and stated, No ma'am, not here. The CNA was asked if she learned how to use it on her own and stated, Basically. I don't even know where that lift came from. 3.) A Witness Statement dated 5/24/16 and written by CNA #3 documented, I have not had any problem or issues reported to me at any time about the manual lift getting stuck. I have had reports of the lift dropping too fast. On 7/12/16 at 2:08 p.m., CNA #3 was asked about her witness statement dated 5/24/16, where she documented that she had received reports of the manual lift dropping too fast. The CNA stated, I was asked about the manual lift and if anybody had said anything about it, so that's when I wrote that. The CNA was asked if she had ever had a problem with that lift and stated, (CNA #4) and I would use it, and she knew that you had to release it really slow, so she was like . 'ok, this thing lowers too fast, so this is what we gonna do'. The CNA was asked if she had received any reports from other CNAs or staff that the lift was lowering residents too fast or not functioning properly and stated, (CNA #4) told me. Well not really reports, but CNAs would be like, 'I ain't using that lift no more, 'cause it comes down too fast'. The CNA was asked if this information had been reported to administration prior to 5/9/16 and stated, Not to my knowledge. d. A hospital Physician Discharge Summary dated 5/10/16 documented, .patient admitted for fall at nursing home. Orthopedic surgery was consulted for evaluation of left femoral neck fracture . she complains of pain to bilateral hips, but left greater than right . she is non-ambulatory and uses a wheelchair at the facility . x-ray pelvis with lat (lateral) left hip - displaced subcapital left femoral neck fracture . valgus impacted left femoral neck fracture . plan for non-operative treatment . e. On 7/12/16 and 7/13/16, direct care staff were asked about the manual lift that had been used by the facility and made the following statements: 1.) On 7/12/13 at 2:31 p.m., CNA #4 stated, We hardly ever used the manual lift, but if the battery was dead on the others, we would use those. The CNA was asked if there were any problems with the functioning of the manual lift and stated, If you guided the resident and released it slow, then everything was OK. If not, well (the CNA did not comment further). The CNA was asked if the lift would lower residents too fast and stated, It would lower them kinda quick. The CNA was asked how quick and stated, I can't say. I never had a problem with it, because I knew how it worked. 2.) On 7/13/16 at 4:25 p.m., CNA #5 stated, I used that lift one time. When I went to lower the resident, it dropped them too fast. I quit using it. It scared me. Anybody could have got hurt with that. I said I would never use it again and I never did. The CNA was asked if she reported the problem to anyone and stated, I reported it to the nurse, but I don't remember who it was, because we have so many agency nurses. I told them I wasn't using that no more because it drops too fast. The CNA was asked if the rate at which a resident was lowered could be controlled, depending on how fast you turned the release knob and stated, No. It went fast as soon as you turned it. The CNA was asked if that was the way that lift was supposed to work and stated, No, I have used manual lifts before and they're not supposed to do that. 3.) On 7/13/16 at 4:36 p.m., CNA #6 was asked if she ever used the manual lift the facility used to have and stated, I think I used that lift about twice. I didn't like it. The CNA was asked why she didn't like it and stated, Because, when you lift a person up, it let them down too fast. The CNA was asked how the lift worked when lowering a resident and stated, I think it was a knob. You twist it, and you can barely be twisting it and it would go whoosh! Too fast. After that second time, I said no. It would drop people. The CNA was asked if this was reported to anyone and stated, The second time I used it, I mentioned it to the nurse. The CNA was asked if the lift was supposed to work that way and stated, No. The CNA was asked if she thought it could hurt a resident and stated, Oh yeah. And it scared them too. I used it on (Resident #6) and she said, 'that let me down too fast'. Then I used it on (Resident #2), and after that, I said I ain't using that no more. f. On 7/12/16 at 3:01 p.m., Resident #6 was asked if she remembered the manual lift that used to be in use at the facility and stated, I remember it. The resident was asked what she remembered about it and stated, It wouldn't release properly, it would let you down too fast. The resident was asked how fast it would lower her and stated, Too fast. It would drop you. The resident was asked if it was a push button release or a knob that was twisted and stated, No, it was a twist knob. If they knew how it worked, it would be okay, but not everybody knew how it worked. She was asked if she had ever been injured because of the lift and the way it worked and stated, No, it didn't hurt me, because the air bed would cushion me, but it was scary. I didn't like it. g. The facility removed the immediate jeopardy and corrected the deficient practices prior to the survey, by taking the following corrective actions: 1.) Documentation provided by the DON on 7/13/16, documented the manual lift was removed from service on 5/9/16 and from the facility 5/10/16. 2.) In-service documentation dated 5/10/16 documented a representative from the equipment company came to the facility and in-serviced staff on the mechanical lifts still in use in the facility. The in-service included what to do if equipment malfunctioned. 3.) Competency check off sheets, which included a return demonstration of mechanical lift operation, were completed on all CNAs and were to be completed for all new nursing employees and quarterly on all nursing staff.

The facility failed to establish and maintain an effective Infection Control Program that provided a safe, sanitary and comfortable environment and helped prevent the development and transmission of disease and infection: A. Based on observation, record review and interview, the facility failed to ensure staff maintained contact isolation precautions to prevent the spread of infection for 1 of 1 (Resident #5) case mix resident who was in contact isolation for a multi-drug resistant Acinetobacter baumannii infection of the percutaneous endogastrostomy insertion site. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to 19 residents residing on the H hall. The facility was notified of the Immediate Jeopardy on 10/29/15 at 2:30 p.m. The findings are: 1. The Centers for Disease Control (CDC) and Prevention web site located at http://www.cdc.gov/HAI/organisms/acinetobacter.html documented, Acinetobacter can be spread to susceptible persons by person-to-person contact or contact with contaminated surfaces . Acinetobacter can live on the skin and may survive in the environment for several days. Careful attention to infection control procedures, such as hand hygiene and environmental cleaning can reduce the risk of transmission . Acinetobacter is often resistant to many commonly prescribed antibiotics . Acinetobacter infection typically occurs in ill patients and can either cause or contribute to death in these patients. 2. Resident #5 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/15 documented the resident had severely impaired cognitive skills for daily decision making per staff assessment for mental status, was totally dependent on the physical assistance of two-plus people for bed mobility, transfers and locomotion on and off the unit, was totally dependent on the physical assistance of one person for dressing, eating, toilet use, personal hygiene and bathing, had an indwelling urinary catheter, was incontinent of bowel, had a feeding tube and had one Stage III pressure ulcer. a. laboratory results dated [DATE] from a hospital laboratory wound culture documented, .few Acinetobacter Baumannii Complex, moderate [MEDICATION NAME] resistant S (Staphylococcus), Aureous, Moderate candida. b. An Admission Order sheet dated 7/16/15 documented, .Isolation Precaution ORSA ([MEDICATION NAME] Resistant Staph (Staphylococcus) Aureous) Peg (percutaneous endoscopic gastrostomy) tube . [MEDICATION NAME] 400 / 5 mg (milligram) / 5 ml (milliliter) susp (suspension). Take 10 ml (800 mg) P/T (per tube) BID (twice daily) (times) 5 days . ORSA peg tube . Bactrim, [MEDICATION NAME] 200-40 mg / 5 ml susp, Take 20 ml / (160 mg) p/t (times) 7 days ORSA peg tube. c. A laboratory Culture and Sensitivity report dated as collected 8/17/15 and reported 8/21/15 documented, .Culture, Wound / Abscess . Source: Wound . Site: PEG Tube Site . Moderate growth Proteus mirabilis . Handwriting on the laboratory report documented, See orders . 8/24/15 . A Physician Telephone Order dated 8/24/15 documented, Clarification order: [MEDICATION NAME] 1 gm (gram) IVPB (Intravenous piggy back) daily (times) 3 days d. A telephone order dated 9/1/15 documented, Re-culture g/t (gastrostomy tube) site to r/o (rule out) ORSA The culture and sensitivity dated 9/5/15 documented Moderate growth of Acinetobacter Baumannii Complex and light growth of [DIAGNOSES REDACTED] Oxytoca. e. A Physician Telephone Order dated 9/6/15 at 4:45 p.m. documented, [MEDICATION NAME] 1 gm IM (intramuscular) (times) 2 days (Monday, Tuesday) . [MEDICATION NAME] 250 mg qd (every day) (times) 5 days . A Physician Telephone Order dated 9/6/15 at 8:00 p.m. documented, D/C (discontinue) [MEDICATION NAME] 1 gm (gram) IM (times) 2 days give [MEDICATION NAME] 1 gm IM (times) 1 now Continue [MEDICATION NAME] 250 mg PT (per tube) qd (times) 5 days . f. The Care Plan dated 10/13/15 documented, Bag and transport used linen according to facility protocol, preventing skin exposure or contamination. CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry . Wash hand immediately after ADLs (activities of daily living), care tasks and activities . Discard in appropriate receptacle and wash hands before leaving room . Resident areas to be thoroughly cleaned using disinfectants. g. A telephone order dated 10/18/15 documented, Clarification: Cleanse [DEVICE] (gastrostomy tube) (with) Dakins, apply dry drsg (dressing) qd on 11-7 (11:00 p.m. to 7:00 a.m.) shift and prn (as needed) h. A telephone order dated 10/22/15 documented, 1) Re-swab to remove isolation . i. The October 2015 physician's orders [REDACTED]. (Order Date) 08/03/2015 .Isolation Precaution ORSA PEG (Percutaneous Endoscopic Gastrostomy) tube . (Order Date) 08/03/2015 and on the same date Physician Order's documented order to j. The August 2015 Infection Control Surveillance Report - Monthly Report of Infections documented Resident #5 peg site inf (infection) . [MEDICATION NAME] 500 q 6 (hours) (times) 10 days The report did not identify the organism causing the infection. As of 10/29/15 at 12:00 p.m., the report did not document isolation of Resident #5, nor did the September and October 2015 reports contain any information on the resident and her isolation status. k. On 10/27/15 at 10:29 a.m., an Isolation sign outside of resident's room documented, 1) Wash hands.6) Wash hands. At this time, Housekeeper #1 donned gown and gloves in the hallway outside of the resident's room, leaving her housekeeping cart in the hallway, she entered the resident's room with a broom and dustpan from her cart. After sweeping the resident's room, she exited with trash in a clear plastic bag, along with the broom and dustpan. She placed all these items on the housekeeping cart without removing her gloves; she reached into her pocket, removed keys and opened her housekeeping cart. She removed a spray bottle containing a light blue liquid and took it into the resident's room and cleaned the handwashing sink. After cleaning the handwashing sink, she took the soiled cleaning cloth and added it to a plastic sack hanging on her cart. She then took keys out of her pocket, opened her cart and returned the spray bottle to the lock box. The Housekeeper then removed her gown and gloves and placed them in the trash on her housekeeping cart. She did not wash her hands prior to leaving the resident's isolation room or after removing her gloves and gown in the hallway. l. On 10/27/15 at 11:00 a.m., Licensed Practical Nurse (LPN) #8 put on a gown and entered Resident #5's room. She washed her hands and donned gloves. She removed a stethoscope from around her neck and placed it on the resident's abdominal area and checked placement of the resident's PEG tube. She then returned the stethoscope over her shoulders and around her neck. After administering medication and a water flush, she disposed of the used medication cups in a clear trash bag. She then wiped the table off with a disposable wipe and threw the wipes in the clear bag of trash. She removed her gloves and gown and added them to the clear bag of trash. Without washing her hands, she exited the room with the bag of trash and put it on the medication cart. The LPN then encountered the housekeeper a few doors down the hall and gave the trash to the housekeeper. The Housekeeper placed the bag of trash in the trash bag on her housekeeping cart. At 11:36 a.m., LPN #8 entered a non-case mix resident's room on the H-Hall, removed her stethoscope from around her neck and without cleaning the stethoscope, used it on the non-case mix resident to check placement of that resident's gastrostomy tube. m. On 10/27/15 at 11:40 a.m., Housekeeper #1 opened the locked door on her housekeeping cart. Inside the locked box were three bottles of spray. She stated the dark blue spray was for windows, the light blue spray was for bathrooms and the other was a smell good spray. All the spray bottles were locked together in the cart with no separation for the bottle that was used in the isolation room. n. On 10/28/15 at 1:58 p.m., LPN #7 entered the resident's room to perform the dressing change to her coccyx, with assistance from Certified Nursing Assistant (CNA) #5. CNA #5 washed her hands under the water, without soap. LPN #7 stated that the soap dispenser did not work. The dispenser had soap in it, but would not dispense soap when hands were placed under it. She stated it needed a battery and they had already reported it. The resident had been incontinent of bowel; CNA #4 assisted to perform incontinent care prior to the resident's dressing change. The LPN and CNA used hand gel on their hands prior to exiting room. o. On 10/29/15 at 11:10 a.m., the soap dispenser in the resident's room did not dispense soap when the surveyor's hands were placed under it. p. On 10/29/15 at 2:05 p.m., an open red bag was in the resident's bathroom and contained trash. There was no sink in the resident's bathroom; the handwashing sink was in the resident's room on a wall. The head of housekeeping stated she put batteries in the dispenser yesterday, but it was not working now. She did not have gloves on when she checked the dispenser. q. A telephone order dated 9/9/15 documented, Re-culture peg tube (after) [MEDICATION NAME] finished. This Culture and Sensitivity was not in the facility until 10/29/15 at 12:30 p.m., when the surveyor requested it. 1) On 10/29/15 at 12:45 p.m., the Assistant Director of Nursing (ADON) was asked who received labs from the laboratory. He said, The floor nurses are responsible for removing labs from fax machine and department heads are too. He was asked, Who is responsible for notifying physician of results of lab? He stated, The floor nurses. He was asked to supply culture results from labs done 9/8/15 for Resident #5. 2) On 10/29/15 at 1:15 p.m., LPN #6 provided the lab results for the 9/8/15 culture and stated, Had to copy it directly from (name of lab). The laboratory report documented, Collected: 09/08/2015 . Reported: 09/11/2015 . Culture, Wound / Abscess . Source: PEG tube site . Heavy Growth Acinetobacter baumannii complex . 3) On 10/29/15 at 2:10 p.m., LPN #6 was asked about the culture dated 9/8/15. She was asked, Is there any documentation where the doctor was made aware of this lab? She stated, Cannot find any documentation. She stated she had contacted the doctor today and he said he did not know why it would need to be re-cultured. She stated she was working on getting an order to re-culture or treat the resident's infection. r. On 10/29/15 at 3:50 p.m., the Advanced Practice Nurse (APN) stated that since it had been so long since the resident's PEG site infection had been cultured, they were going to re-culture the site. s. On 10/30/15 at 1:00 p.m., the Assistant Director of Nursing (ADON) who was in charge of Infection Control was asked, What does your facility infection prevention and control program include? He stated, .Isolation, hand hygiene before and after care, PPE (personal protective equipment) . He was then asked, How does your facility program identify and address infection control issues and monitor staff technique and implementation of isolation precautions? He answered, Skills check-offs. We require them to perform handwashing to evaluate their technique . He was asked, Why was (Resident #5) not placed on the isolation log for September (2015) or October (2015) for isolation precautions? He replied, I'd have to look into it, I don't know . 1) On 10/29/15, personnel files for CNA #14, CNA #15 and CNA 16 were reviewed; there were no skills check off list in any of the three files. 2) On 10/30/15 at 1:50 p.m., a list of 24 CNAs that were employed for one year or greater was obtained from the facility. CNA #5, CNA #7, CNA #9 and CNA #17 through CNA #34 did not have competency check-off lists in their files. 3) On 10/30/15 at 4:20 p.m., LPN #5 was asked Who is responsible for the annual competency check off list and who does the check off list for new hired CNA? The LPN stated that the Director of Nursing was responsible for the annual one and that the new hires were supposed to be checked off by the Lead CNA. She stated that they were to be turned in to her or the DON but they had not had a Lead CNA in a while. t. On 10/29/15, the Immediate Jeopardy was removed, and the scope and severity was lowered to an E when the facility implemented the following plan of removal: 1. Dispenser for hand soap replaced by Maintenance Supervisor 10/29/15 at 14:30 (2:30 p.m.) hrs. (hours) 2. Additional dispenser for hand sanitizing gel placed in room by Maintenance Supervisor at 1445 (2:45 p.m.) hrs. with additional manual hand gel sanitizer placed in room with noted sign Do not Remove from Room. 3. All residents with gastric tubes and Foley catheters are being assessed by ADON and Unit Managers for any signs and symptoms of infection with vital signs obtained with peg tube and Foley care given at time of assessment and will be completed by end of day 10/29/15. 4. Any negative findings: Physician and Family will be notified. With no further negative findings found. Advanced Practice Nurse here to assess residents on 10/29/15 at 1545 (3:45 p.m.) hrs. 5. Housekeeping Supervisor instructed to remove Housekeeping cart from H Hall and deep clean before placing in use at 1510 (3:10 p.m.) hrs. 6. Biohazard containers removed from room by Maintenance Supervisor at 1510 (3:10 p.m.) hrs. 7. Biohazard containers moved from bathroom to inside doorway of room with lids in place at 1530 (3:30 p.m.) hrs. 8. Room (belonging to Resident #5) deep cleaned and hand rails wiped down by Housekeeping Supervisor at 1550 hrs. (3:50 p.m.) 9. One to one re-training initiated by DON for Treatment nurse, LPN, and Housekeeping Supervisor on Personal Protective Equipment and Handwashing on 10/29/15 at 1535 hrs. (3:35 p.m.) 10. In-service / training will be started for all employees prior to start of shift on Personal Protective Equipment and Handwashing. This will be completed by 10/30/15. 11. Dispensers will be checked every shift by nurse and signed on the MAR (medical administration record) flow sheet with any negative findings and corrected immediately. 12. 100 (one-hundred) percent audit of all soap dispensers was completed by Unit Managers and ADON with no additional negative findings found on 10/29/15. 13. The staff will be monitored for handwashing and use of personal protective equipment disposal by DON/Designee: 3 employees per day 5 times per week (times) 4 weeks then 4 per month thereafter with any negative findings corrected immediately. 14. Manual hand sanitizers will be placed in all isolation rooms with label Do Not Remove from Room' as of 10/30/15. B. Based on observation, record review and interview, the facility failed to ensure CNAs maintained clean technique during peri-care for 4 (Residents #1, #2, #4 and #6) of 7 (Resident #1, #2, #5 through #8 and #13) case mix residents who were dependent for incontinent care. The failed practice had the potential to affect 63 resident who were incontinent of bladder and 70 residents who were incontinent of bowel (with a total census of 109), according to the Resident Census and Conditions of Residents form dated 10/29/15. The facility failed to ensure CNAs maintained the catheter bag below the level of the bladder and off the floor to prevent urinary tract infections for 2 (Residents #2 and #9) and failed to ensure catheter care was provided after an incontinent episode to prevent urinary tract infections for 2 (Resident #2 and #13) of 4 (Resident #2, #5, #8 and #13) case mix residents with Foley Catheters. These failed practices had the potential to affect 13 residents with Foley Catheters, as per a list provided by the Administrator on 10/30/15 at 1:15 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. An MDS with an ARD of 10/5/15 documented the resident scored 6 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was totally dependent on one person for bed mobility, transfers, locomotion on and off of the unit, dressing, eating, toilet use, personal hygiene and bathing, had limitation in range of motion of an upper extremity on one side and was always incontinent of bowel and bladder. a. The resident's Care Plan dated 10/05/15 documented on multiple problems .Administer/give medication as ordered . Check nail length and trim and clean on bath day and as necessary . resident is totally dependent on (times) 1 staff for personal hygiene and oral care . Anticipate and meet needs . bath/shower 3 (times) weekly and as necessary . report any changes to the nurse . b. On 10/28/15 at 2:45 p.m., CNA #1 performed peri care. CNA #1 failed to wash her hands prior to starting peri care. The CNA donned gloves, then while providing peri care, went from the resident to an open container of wipes multiple times without changing gloves. When asked at what point during peri care are gloves considered dirty, CNA #1 answered, .after touching the resident . The CNA was asked, Are you supposed to go into the wipes container with dirty gloves? CNA #1 covered her face and stated, .Oh, no! . 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/15 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS); required total assistance of one person physical assist for bed mobility, dressing, toilet use, and personal hygiene; required total assistance of 2 plus persons physical assist for transfer; had a urinary catheter and was always incontinent of bowel. On 10/27/15 at 10:20 a.m., CNA #10 and CNA #13 provided incontinent care. CNA #10, after cleaning the resident's abdominal crease and catheter tubing, began to cleanse the resident's buttocks with bowel movement noted. The CNA continued to remove clean wipes from the container with her soiled gloves. At the last, the CNA cleansed the dressing on the pressure ulcer with a wipe saturated with bowel movement, wiping under the upturned side of the dressing in an attempt to remove fecal matter from under the dressing. 3. Resident #2 had a [DIAGNOSES REDACTED]. a. The Plan of Care updated 10/13/15 did not address any problems related to incontinence of bowel. b. On 10/27/15 at 4:55 p.m., LPN #7 and CNA #3 entered the room to perform incontinent care. The resident had been incontinent of bowel. The resident was turned to the left side and CNA #3 used her soiled gloves to get clean wipes from the clean container. After the incontinent care was complete, CNA #3 rolled up the soiled incontinent pad and laid it on the clean blanket at the foot of the bed. c. The Plan of care updated 10/13/15 identified a problem of, (name of resident) is at risk for complications related to Catheter secondary to Urinary Retention with interventions that included . Position catheter bag and tubing below the level of the bladder and away from entrance room door. d. On 10/27/15 at 12:40 p.m., the resident was in bed. The catheter tubing was up over the side rail and above the level of the bladder. e. On 10/27/15 at 4:55 p.m., LPN #7 and CNA #3 entered the room to perform incontinent care. The resident was incontinent of bowel. The CNA did not perform catheter care after this incontinent episode. At 5:05 p.m., CNA #3 moved the catheter bag from one side of the bed to the other by lifting it up to her shoulders and over the bed. 4. Resident #6 had [DIAGNOSES REDACTED]. An MDS with an ARD of 9/18/15 documented the resident scored 9 (8-12 indicates moderate cognitive impairment) on the BIMS and required extensive to total assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene and bathing. a. On 10/27/15 at 4:19 p.m., CNA #2 provided peri care for the resident who had been incontinent of bladder. CNA #2 did not wash her hands prior to initiating care. CNA #2, after initiating incontinent care, did not change her gloves at any time, going from the resident to the wipes package and back to the resident multiple times. When the peri care was completed, CNA #2 took the resident to the dining room without washing her hands. b. On 10/27/15 at 4:33 p.m., CNA #2 was asked, At what time after beginning Peri Care are your gloves considered dirty? She stated, .After beginning, touching the resident . The CNA was asked, Are you supposed to go into the wipes container with dirty gloves? She stated .No . She was asked, Do you know what you did? She stated, .yeah, I thought about that, but it was too late . 5. A document titled Catheter Care, Urinary, received from the Administrator on 10/30/15 at 1:15 p.m. documented, . Maintaining Unobstructed Urine Flow . The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from lowing back into the urinary bladder . Routine hygiene is appropriate . Be sure the catheter tubing and drainage bag are kept off the floor . a. Resident #9 had [DIAGNOSES REDACTED]. An MDS with an ARD of 10/13/15 documented the resident scored 7 (0-7 indicates severe cognitive impairment) on the BIMS, required extensive assistance of 1 person for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing and had an indwelling urinary catheter. 1) Physicians orders dated 10/12/15 documented, .Place Foley Catheter x (times) 14 days (to clear skin breakdown) . 2) On 10/27/15 at 6:35 p.m., the resident's Foley Catheter bag was dragging on the floor with approximately 2 inches of fold over. 3) On 10/28/15 at 8:19 a.m., the resident was observed sitting in the day room in his wheel chair, his Foley Catheter bag was touching the floor. 4) On 10 28/15 at 11:55 a.m., CNA #1 transferred the resident from the whirlpool seat to his wheel chair while holding the Foley Catheter bag at her waist level, approximately shoulder level to the resident. The resident's Foley Catheter was positioned over the waist band of his pajama bottoms and was attached to the underside of his wheel chair. b. Resident # 13 had [DIAGNOSES REDACTED]. An Admission MDS with ARD of 8/20/15 documented the resident had severe impaired cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent for all activities of daily living, had an indwelling urinary catheter and was incontinent of bowel. 1) An undated care plan copied 10/28/15 had an admission date of [DATE] and documented, .check resident every two hours and assist with toileting as needed . provide pericare after each incontinent episode . the resident will be / remain free from catheter-related trauma . 2) Policy and Procedure entitled Perineal care received on 10/30/15 at 1:15 p.m. from the Administrator documented, .9. b. (1) Separate labia and wash area downward from front to back.If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches . 3) An Admission Order sheet dated 10/13/15 documented, Section B: [DIAGNOSES REDACTED]. 4) On 10/27/15 at 3 p.m., LPN # 9 donned gloves and wiped stool from the resident's buttocks with disposable wipes. When the buttocks were wiped cleaned, LPN #9 placed a clean brief on the resident without performing peri care to the labia or cleaning the Foley catheter tube. 5) On 10/28/15 at 10:35 a.m., LPN 6 was asked, Do you expect your staff to do Foley care after a resident has had a BM (bowel movement)? She replied, Yes. She was then asked, Why is that important? She replied, Because it can get up in there and cause a urinary tract infection or sepsis. C. Based on observations, record review and interview, the facility failed to ensure reusable equipment, the glucose monitoring device, was disinfected before and after use for 1 (Resident #25) of 6 (Residents #2, #7, #8, #18, #23 and #25) case mix residents who received Capillary Blood Glucose (CBG) testing. This failed practice had the potential to affect 30 residents who received CBG testing, according a list provided by Licensed Practical Nurse (LPN) #12 on 10/30/15. The findings are: Resident #25 had a [DIAGNOSES REDACTED]. a. On 10/28/15 at 5:41 p.m., the resident had a reading of 108 mg/dl. b. On 10/28/15 at 5:42 p.m., LPN #2 did not disinfect the glucose monitoring device after use. c. On 10/28/15 at 5:42 p.m., LPN #2 cleaned the glucose monitoring device after use with alcohol. The surveyor asked LPN #2, What are you doing? The LPN #2 stated, Cleaning this machine. The surveyor asked, What are you using? LPN #2 said, Alcohol and placed the glucose monitoring device into the top drawer. d. On 10/30/15 at 12:07 p.m., LPN #4 was asked, What does the facility use for cleaning the glucose machine? LPN #4 got into the medication cart and provided the Clorox Healthcare Germicidal Wipe, One-Step Cleaner and Disinfectant. D. Based on observation, the facility failed to ensure soiled cloths and dressings were not left in 1 (E-Hall) of 5 whirlpool / bathing rooms and biohazardous waste was contained in the biohazard room on F-Hall. The failed practice had the potential to affect 16 resident who lived on E-Hall and 13 residents who lived on the F-Hall, according to the Daily Census lists provided by LPN #12 on 10/29/15. The findings are: 1. On 10/30/15 at 10:00 a.m., the Whirlpool room on E-Hall had a soiled washcloth laying on the upper edge and the area that supported the lower extension had a dark substance splattered on it. A cardboard box with a red trash bag that was opened with dirty gloves and a discarded feeding tube visible in the F Hall-Biohazard Room. 2. On 10/30/15 at 10:05 a.m., the Maintenance Supervisor picked a soiled dressing up off of the floor of the whirlpool room on E-Hall with his pliers and placed it in an unlined non biohazard waste receptacle.

Based on observation, record review and interviews, Nursing Administration failed to ensure an effective infection control program was established and maintained to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection as evidenced by: Nursing Administration failed to ensure staff maintained contact isolation precautions to prevent the spread of infection for 1 of 1 (Resident #5) case mix resident who was in contact isolation for a multi-drug resistant Acinetobacter baumannii infection of the percutaneous endogastrostomy insertion site The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to 19 residents residing on the H hall. The facility was notified of the Immediate Jeopardy on 10/29/15 at 2:30 p.m. Nursing Administration failed to ensure that CNAs/LPNs maintained clean during peri-care for 4 (Residents #1, #2, #4 and #6) of 7 (Resident #1, #2, #5 through #8 and #13) case mix residents who were dependent for incontinent care. The failed practice had the potential to affect 63 resident who were incontinent of bladder and 70 residents who were incontinent of bowel (with a total census of 109), according to the Resident Census and Conditions of Residents form dated 10/29/15. Nursing Administration failed to ensure CNAs/LPNs maintained the catheter bag below the level of the bladder and off the floor to prevent urinary tract infections for 2 (Resident #2 and #9) of 4 (Resident #s 2, 5, 8 and 13) case mix residents with Foley Catheter and failed to ensure catheter care was provided after an incontinent episode to prevent urinary tract infections for 2 (Resident #2 and #13) of 4 (Resident #s 2, 5, 8 and #13) case mix resident with Foley Catheters. These failed practices had the potential to affect 13 residents currently residing in the facility with Foley Catheters as per a list provided by the Administrator on 10/30/15 at 1:15 p.m. Nursing Administration failed to ensure reusable equipment, the glucose monitoring device, was disinfected before and after use for 1 (Resident #25) of 4 (Resident #5, #18, #23 and #25) case mix residents who received CBG (Capillary Blood Glucose) testing. This practice had the potential to affect 30 residents that received CBG (Capillary Blood Glucose) testing, according to the DON (Director or Nursing) on 10/30/15. The findings are: 1. The Director of Nurses job description obtained from the facility on 10/30/15 at 5:15 p.m., documented: Set resident care standards in accordance with accepted current standards of care to provide high quality care to residents, Supervise and manage all aspects of the nursing department and assess, direct and supervise residents' care needs. 2. Resident #5 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/15 documented the resident had severely impaired cognitive skills for daily decision making per staff assessment for mental status, was totally dependent on the physical assistance of two-plus people for bed mobility, transfers and locomotion on and off the unit, was totally dependent on the physical assistance of one person for dressing, eating, toilet use, personal hygiene and bathing, had an indwelling urinary catheter, was incontinent of bowel, had a feeding tube and had one Stage III pressure ulcer. a. laboratory results dated [DATE] from a hospital laboratory wound culture documented, .few Acinetobacter Baumannii Complex, moderate [MEDICATION NAME] resistant S (Staphylococcus), Aureous, Moderate candida. b. An Admission Order sheet dated 7/16/15 documented, .Isolation Precaution ORSA ([MEDICATION NAME] Resistant Staph (Staphylococcus) Aureous) Peg (percutaneous endoscopic gastrostomy) tube . [MEDICATION NAME] 400 / 5 mg (milligram) / 5 ml (milliliter) susp (suspension). Take 10 ml (800 mg) P/T (per tube) BID (twice daily) (times) 5 days . ORSA peg tube . Bactrim, [MEDICATION NAME] 200-40 mg / 5 ml susp, Take 20 ml / (160 mg) p/t (times) 7 days ORSA peg tube. c. A laboratory Culture and Sensitivity report dated as collected 8/17/15 and reported 8/21/15 documented, .Culture, Wound / Abscess . Source: Wound . Site: PEG Tube Site . Moderate growth Proteus mirabilis . Handwriting on the laboratory report documented, See orders . 8/24/15 . A Physician Telephone Order dated 8/24/15 documented, Clarification order: [MEDICATION NAME] 1 gm (gram) IVPB (Intravenous piggy back) daily (times) 3 days d. A telephone order dated 9/1/15 documented, Re-culture g/t (gastrostomy tube) site to r/o (rule out) ORSA The culture and sensitivity dated 9/5/15 documented Moderate growth of Acinetobacter Baumannii Complex and light growth of [DIAGNOSES REDACTED] Oxytoca. e. A Physician Telephone Order dated 9/6/15 at 4:45 p.m. documented, [MEDICATION NAME] 1 gm IM (intramuscular) (times) 2 days (Monday, Tuesday) . [MEDICATION NAME] 250 mg qd (every day) (times) 5 days . A Physician Telephone Order dated 9/6/15 at 8:00 p.m. documented, D/C (discontinue) [MEDICATION NAME] 1 gm (gram) IM (times) 2 days give [MEDICATION NAME] 1 gm IM (times) 1 now Continue [MEDICATION NAME] 250 mg PT (per tube) qd (times) 5 days . f. The Care Plan dated 10/13/15 documented, Bag and transport used linen according to facility protocol, preventing skin exposure or contamination. CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry . Wash hand immediately after ADLs (activities of daily living), care tasks and activities . Discard in appropriate receptacle and wash hands before leaving room . Resident areas to be thoroughly cleaned using disinfectants. g. A telephone order dated 10/18/15 documented, Clarification: Cleanse [DEVICE] (gastrostomy tube) (with) Dakins, apply dry drsg (dressing) qd on 11-7 (11:00 p.m. to 7:00 a.m.) shift and prn (as needed) h. A telephone order dated 10/22/15 documented, 1) Re-swab to remove isolation . i. The October 2015 physician's orders [REDACTED]. (Order Date) 08/03/2015 .Isolation Precaution ORSA PEG (Percutaneous Endoscopic Gastrostomy) tube . (Order Date) 08/03/2015 and on the same date Physician Order's documented order to j. The August 2015 Infection Control Surveillance Report - Monthly Report of Infections documented Resident #5 peg site inf (infection) . [MEDICATION NAME] 500 q 6 (hours) (times) 10 days The report did not identify the organism causing the infection. As of 10/29/15 at 12:00 p.m., the report did not document isolation of Resident #5, nor did the September and October 2015 reports contain any information on the resident and her isolation status. k. On 10/27/15 at 10:29 a.m., an Isolation sign outside of resident's room documented, 1) Wash hands.6) Wash hands. At this time, Housekeeper #1 donned gown and gloves in the hallway outside of the resident's room, leaving her housekeeping cart in the hallway, she entered the resident's room with a broom and dustpan from her cart. After sweeping the resident's room, she exited with trash in a clear plastic bag, along with the broom and dustpan. She placed all these items on the housekeeping cart without removing her gloves; she reached into her pocket, removed keys and opened her housekeeping cart. She removed a spray bottle containing a light blue liquid and took it into the resident's room and cleaned the handwashing sink. After cleaning the handwashing sink, she took the soiled cleaning cloth and added it to a plastic sack hanging on her cart. She then took keys out of her pocket, opened her cart and returned the spray bottle to the lock box. The Housekeeper then removed her gown and gloves and placed them in the trash on her housekeeping cart. She did not wash her hands prior to leaving the resident's isolation room or after removing her gloves and gown in the hallway. l. On 10/27/15 at 11:00 a.m., Licensed Practical Nurse (LPN) #8 put on a gown and entered Resident #5's room. She washed her hands and donned gloves. She removed a stethoscope from around her neck and placed it on the resident's abdominal area and checked placement of the resident's PEG tube. She then returned the stethoscope over her shoulders and around her neck. After administering medication and a water flush, she disposed of the used medication cups in a clear trash bag. She then wiped the table off with a disposable wipe and threw the wipes in the clear bag of trash. She removed her gloves and gown and added them to the clear bag of trash. Without washing her hands, she exited the room with the bag of trash and put it on the medication cart. The LPN then encountered the housekeeper a few doors down the hall and gave the trash to the housekeeper. The Housekeeper placed the bag of trash in the trash bag on her housekeeping cart. At 11:36 a.m., LPN #8 entered a non-case mix resident's room on the H-Hall, removed her stethoscope from around her neck and without cleaning the stethoscope, used it on the non-case mix resident to check placement of that resident's gastrostomy tube. m. On 10/27/15 at 11:40 a.m., Housekeeper #1 opened the locked door on her housekeeping cart. Inside the locked box were three bottles of spray. She stated the dark blue spray was for windows, the light blue spray was for bathrooms and the other was a smell good spray. All the spray bottles were locked together in the cart with no separation for the bottle that was used in the isolation room. n. On 10/28/15 at 1:58 p.m., LPN #7 entered the resident's room to perform the dressing change to her coccyx, with assistance from Certified Nursing Assistant (CNA) #5. CNA #5 washed her hands under the water, without soap. LPN #7 stated that the soap dispenser did not work. The dispenser had soap in it, but would not dispense soap when hands were placed under it. She stated it needed a battery and they had already reported it. The resident had been incontinent of bowel; CNA #4 assisted to perform incontinent care prior to the resident's dressing change. The LPN and CNA used hand gel on their hands prior to exiting room. o. On 10/29/15 at 11:10 a.m., the soap dispenser in the resident's room did not dispense soap when the surveyor's hands were placed under it. p. On 10/29/15 at 2:05 p.m., an open red bag was in the resident's bathroom and contained trash. There was no sink in the resident's bathroom; the handwashing sink was in the resident's room on a wall. The head of housekeeping stated she put batteries in the dispenser yesterday, but it was not working now. She did not have gloves on when she checked the dispenser. q. A telephone order dated 9/9/15 documented, Re-culture peg tube (after) [MEDICATION NAME] finished. This Culture and Sensitivity was not in the facility until 10/29/15 at 12:30 p.m., when the surveyor requested it. 1) On 10/29/15 at 12:45 p.m., the Assistant Director of Nursing (ADON) was asked who received labs from the laboratory. He said, The floor nurses are responsible for removing labs from fax machine and department heads are too. He was asked, Who is responsible for notifying physician of results of lab? He stated, The floor nurses. He was asked to supply culture results from labs done 9/8/15 for Resident #5. 2) On 10/29/15 at 1:15 p.m., LPN #6 provided the lab results for the 9/8/15 culture and stated, Had to copy it directly from (name of lab). The laboratory report documented, Collected: 09/08/2015 . Reported: 09/11/2015 . Culture, Wound / Abscess . Source: PEG tube site . Heavy Growth Acinetobacter baumannii complex . 3) On 10/29/15 at 2:10 p.m., LPN #6 was asked about the culture dated 9/8/15. She was asked, Is there any documentation where the doctor was made aware of this lab? She stated, Cannot find any documentation. She stated she had contacted the doctor today and he said he did not know why it would need to be re-cultured. She stated she was working on getting an order to re-culture or treat the resident's infection. r. On 10/29/15 at 3:50 p.m., the Advanced Practice Nurse (APN) stated that since it had been so long since the resident's PEG site infection had been cultured, they were going to re-culture the site. s. On 10/30/15 at 1:00 p.m., the Assistant Director of Nursing (ADON) who was in charge of Infection Control was asked, What does your facility infection prevention and control program include? He stated, .Isolation, hand hygiene before and after care, PPE (personal protective equipment) . He was then asked, How does your facility program identify and address infection control issues and monitor staff technique and implementation of isolation precautions? He answered, Skills check-offs. We require them to perform handwashing to evaluate their technique . He was asked, Why was (Resident #5) not placed on the isolation log for September (2015) or October (2015) for isolation precautions? He replied, I'd have to look into it, I don't know . 1) On 10/29/15, personnel files for CNA #14, CNA #15 and CNA 16 were reviewed; there were no skills check off list in any of the three files. 2) On 10/30/15 at 1:50 p.m., a list of 24 CNAs that were employed for one year or greater was obtained from the facility. CNA #5, CNA #7, CNA #9 and CNA #17 through CNA #34 did not have competency check-off lists in their files. 3) On 10/30/15 at 4:20 p.m., LPN #5 was asked Who is responsible for the annual competency check off list and who does the check off list for new hired CNA? The LPN stated that the Director of Nursing was responsible for the annual one and that the new hires were supposed to be checked off by the Lead CNA. She stated that they were to be turned in to her or the DON but they had not had a Lead CNA in a while. t. On 10/29/15, the Immediate Jeopardy was removed, and the scope and severity was lowered to an E when the facility implemented the following plan of removal: 1. Dispenser for hand soap replaced by Maintenance Supervisor 10/29/15 at 14:30 (2:30 p.m.) hrs. (hours) 2. Additional dispenser for hand sanitizing gel placed in room by Maintenance Supervisor at 1445 (2:45 p.m.) hrs. with additional manual hand gel sanitizer placed in room with noted sign Do not Remove from Room. 3. All residents with gastric tubes and Foley catheters are being assessed by ADON and Unit Managers for any signs and symptoms of infection with vital signs obtained with peg tube and Foley care given at time of assessment and will be completed by end of day 10/29/15. 4. Any negative findings: Physician and Family will be notified. With no further negative findings found. Advanced Practice Nurse here to assess residents on 10/29/15 at 1545 (3:45 p.m.) hrs. 5. Housekeeping Supervisor instructed to remove Housekeeping cart from H Hall and deep clean before placing in use at 1510 (3:10 p.m.) hrs. 6. Biohazard containers removed from room by Maintenance Supervisor at 1510 (3:10 p.m.) hrs. 7. Biohazard containers moved from bathroom to inside doorway of room with lids in place at 1530 (3:30 p.m.) hrs. 8. Room (belonging to Resident #5) deep cleaned and hand rails wiped down by Housekeeping Supervisor at 1550 hrs. (3:50 p.m.) 9. One to one re-training initiated by DON for Treatment nurse, LPN, and Housekeeping Supervisor on Personal Protective Equipment and Handwashing on 10/29/15 at 1535 hrs. (3:35 p.m.) 10. In-service / training will be started for all employees prior to start of shift on Personal Protective Equipment and Handwashing. This will be completed by 10/30/15. 11. Dispensers will be checked every shift by nurse and signed on the MAR (medical administration record) flow sheet with any negative findings and corrected immediately. 12. 100 (one-hundred) percent audit of all soap dispensers was completed by Unit Managers and ADON with no additional negative findings found on 10/29/15. 13. The staff will be monitored for handwashing and use of personal protective equipment disposal by DON/Designee: 3 employees per day 5 times per week (times) 4 weeks then 4 per month thereafter with any negative findings corrected immediately. 14. Manual hand sanitizers will be placed in all isolation rooms with label Do Not Remove from Room' as of 10/30/15. 2. Resident #1 had [DIAGNOSES REDACTED]. An MDS with an ARD of 10/5/15 documented the resident scored 6 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was totally dependent on one person for bed mobility, transfers, locomotion on and off of the unit, dressing, eating, toilet use, personal hygiene and bathing, had limitation in range of motion of an upper extremity on one side and was always incontinent of bowel and bladder. a. The resident's Care Plan dated 10/05/15 documented on multiple problems .Administer/give medication as ordered . Check nail length and trim and clean on bath day and as necessary . resident is totally dependent on (times) 1 staff for personal hygiene and oral care . Anticipate and meet needs . bath/shower 3 (times) weekly and as necessary . report any changes to the nurse . b. On 10/28/15 at 2:45 p.m., CNA #1 performed peri care. CNA #1 failed to wash her hands prior to starting peri care. The CNA donned gloves, then while providing peri care, went from the resident to an open container of wipes multiple times without changing gloves. When asked at what point during peri care are gloves considered dirty, CNA #1 answered, .after touching the resident . The CNA was asked, Are you supposed to go into the wipes container with dirty gloves? CNA #1 covered her face and stated, .Oh, no! . 3. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/15 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS); required total assistance of one person physical assist for bed mobility, dressing, toilet use, and personal hygiene; required total assistance of 2 plus persons physical assist for transfer; had a urinary catheter and was always incontinent of bowel. On 10/27/15 at 10:20 a.m., CNA #10 and CNA #13 provided incontinent care. CNA #10, after cleaning the resident's abdominal crease and catheter tubing, began to cleanse the resident's buttocks with bowel movement noted. The CNA continued to remove clean wipes from the container with her soiled gloves. At the last, the CNA cleansed the dressing on the pressure ulcer with a wipe saturated with bowel movement, wiping under the upturned side of the dressing in an attempt to remove fecal matter from under the dressing. 4. Resident #2 had a [DIAGNOSES REDACTED]. a. The Plan of Care updated 10/13/15 did not address any problems related to incontinence of bowel. b. On 10/27/15 at 4:55 p.m., LPN #7 and CNA #3 entered the room to perform incontinent care. The resident had been incontinent of bowel. The resident was turned to the left side and CNA #3 used her soiled gloves to get clean wipes from the clean container. After the incontinent care was complete, CNA #3 rolled up the soiled incontinent pad and laid it on the clean blanket at the foot of the bed. c. The Plan of care updated 10/13/15 identified a problem of, (name of resident) is at risk for complications related to Catheter secondary to [MEDICAL CONDITION] with interventions that included . Position catheter bag and tubing below the level of the bladder and away from entrance room door. d. On 10/27/15 at 12:40 p.m., the resident was in bed. The catheter tubing was up over the side rail and above the level of the bladder. e. On 10/27/15 at 4:55 p.m., LPN #7 and CNA #3 entered the room to perform incontinent care. The resident was incontinent of bowel. The CNA did not perform catheter care after this incontinent episode. At 5:05 p.m., CNA #3 moved the catheter bag from one side of the bed to the other by lifting it up to her shoulders and over the bed. 5. Resident #6 had [DIAGNOSES REDACTED]. An MDS with an ARD of 9/18/15 documented the resident scored 9 (8-12 indicates moderate cognitive impairment) on the BIMS and required extensive to total assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene and bathing. a. On 10/27/15 at 4:19 p.m., CNA #2 provided peri care for the resident who had been incontinent of bladder. CNA #2 did not wash her hands prior to initiating care. CNA #2, after initiating incontinent care, did not change her gloves at any time, going from the resident to the wipes package and back to the resident multiple times. When the peri care was completed, CNA #2 took the resident to the dining room without washing her hands. b. On 10/27/15 at 4:33 p.m., CNA #2 was asked, At what time after beginning Peri Care are your gloves considered dirty? She stated, .After beginning, touching the resident . The CNA was asked, Are you supposed to go into the wipes container with dirty gloves? She stated .No . She was asked, Do you know what you did? She stated, .yeah, I thought about that, but it was too late . 6. A document titled Catheter Care, Urinary, received from the Administrator on 10/30/15 at 1:15 p.m. documented, . Maintaining Unobstructed Urine Flow . The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from lowing back into the urinary bladder . Routine hygiene is appropriate . Be sure the catheter tubing and drainage bag are kept off the floor . a. Resident #9 had [DIAGNOSES REDACTED]. An MDS with an ARD of 10/13/15 documented the resident scored 7 (0-7 indicates severe cognitive impairment) on the BIMS, required extensive assistance of 1 person for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing and had an indwelling urinary catheter. 1) Physicians orders dated 10/12/15 documented, .Place Foley Catheter x (times) 14 days (to clear skin breakdown) . 2) On 10/27/15 at 6:35 p.m., the resident's Foley Catheter bag was dragging on the floor with approximately 2 inches of fold over. 3) On 10/28/15 at 8:19 a.m., the resident was observed sitting in the day room in his wheel chair, his Foley Catheter bag was touching the floor. 4) On 10 28/15 at 11:55 a.m., CNA #1 transferred the resident from the whirlpool seat to his wheel chair while holding the Foley Catheter bag at her waist level, approximately shoulder level to the resident. The resident's Foley Catheter was positioned over the waist band of his pajama bottoms and was attached to the underside of his wheel chair. b. Resident # 13 had [DIAGNOSES REDACTED]. An Admission MDS with ARD of 8/20/15 documented the resident had severe impaired cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent for all activities of daily living, had an indwelling urinary catheter and was incontinent of bowel. 1) An undated care plan copied 10/28/15 had an admission date of [DATE] and documented, .check resident every two hours and assist with toileting as needed . provide pericare after each incontinent episode . the resident will be / remain free from catheter-related trauma . 2) Policy and Procedure entitled Perineal care received on 10/30/15 at 1:15 p.m. from the Administrator documented, .9. b. (1) Separate labia and wash area downward from front to back.If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches . 3) An Admission Order sheet dated 10/13/15 documented, Section B: [DIAGNOSES REDACTED]. 4) On 10/27/15 at 3 p.m., LPN # 9 donned gloves and wiped stool from the resident's buttocks with disposable wipes. When the buttocks were wiped cleaned, LPN #9 placed a clean brief on the resident without performing peri care to the labia or cleaning the Foley catheter tube. 5) On 10/28/15 at 10:35 a.m., LPN 6 was asked, Do you expect your staff to do Foley care after a resident has had a BM (bowel movement)? She replied, Yes. She was then asked, Why is that important? She replied, Because it can get up in there and cause a urinary tract infection [MEDICAL CONDITION]. 7. Resident #25 had a [DIAGNOSES REDACTED]. a. On 10/28/15 at 5:41 p.m., the resident had a reading of 108 mg/dl. b. On 10/28/15 at 5:42 p.m., LPN #2 did not disinfect the glucose monitoring device after use. c. On 10/28/15 at 5:42 p.m., LPN #2 cleaned the glucose monitoring device after use with alcohol. The surveyor asked LPN #2, What are you doing? The LPN #2 stated, Cleaning this machine. The surveyor asked, What are you using? LPN #2 said, Alcohol and placed the glucose monitoring device into the top drawer. d. On 10/30/15 at 12:07 p.m., LPN #4 was asked, What does the facility use for cleaning the glucose machine? LPN #4 got into the medication cart and provided the Clorox Healthcare Germicidal Wipe, One-Step Cleaner and Disinfectant.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure planned interventions to prevent falls were consistently implemented for 1 (Resident #4) of 1 case mix resident who was care planned for an intervention of a winged mattress to prevent falls. This failed practice resulted in a pattern of actual harm to Resident #4, who fell and sustained a fractured right femur and had the potential cause more than minimal harm to 6 residents who were care planned for a winged mattress as documented on a list provided by the Administrator on 9/26/13 at 9:00 a.m. The findings are: 1. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/13 documented the resident scored 5 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); required supervision with no support for transfer, limited assist with one person physical assist for walking in the room and corridor, supervision without support for toilet use; extensive assist with one person physical assist for personal hygiene, not steady, only able to stablize with staff assistance with walking and turning around; and had two falls with no injury since prior assessment. a. The Nurse's Notes dated 6/25/13 documented: "2239 (10:39 p.m.) Summons to room by CNA (Certified Nurse Assistant). (Resident) lying on back in bathroom, denies pain, full AROM (active range of motion) in all extremities, (No) bruising noted to back, assisted off floor per staff, ... will cont (continue) to be monitored per nursing staff." b. A Fall Investigation Form dated 6/26/13 documented: "... 1. What intervention was implemented after the fall? Inserviced staff to toilet (Resident) per facility policy (Q 2 (hours) (and) PRN (as needed) to prevent unassisted transfers. ... Conclusions: ... (Resident) ambulated to bathroom unassisted (and) fell . ... Fall Committee Review/Recommendations: Will be placed on B (and) B program, winged mattress will be placed when order received." This was signed by the Director of Nursing (DON). The Active Physician order [REDACTED]. "... W/C alarm while in W/C - all shifts everyday 2/1/13, 2/19/13, 8/1/13." " ... Apply bed alarm to alert staff with unassisted transfers to prevent falls - all shifts everyday11/3/12, 2/19/13, 8/1/13..." There were no orders for a winged mattress documented. c. The Care Plan dated 7/12/13 documented: "... (Resident #4) is at risk for falls/injuries r/t (related to) Medication usage, Previous or History of Falls, Poor safety awareness from dementia, Unsteady Gait, and Needed assistance with mobility. ... Interventions: ... Frequent monitoring and anticipation of needs if resident is unable to or forgets to use call light. ... Personal alarm at all times to alert staff of unsafe/unassisted transfers, ... Pressure sensitive alarm to bed to alert staff of unsafe/unassisted transfers" with hand written notes in intervention column that documented, "6/9/13 Offer toilet Q (every) 2 (hours) ... 6/19/13 Offer toilet Q 1 (hour) when awake. 6/26/13 winged mattress." d. The Nurse's Notes dated 8/10/13 at 0730 (7:30 a.m.) documented: "While I was going to another resident room around 0515 (5:15 a.m.), I heard bed alarm sounding, went to check on resident, resident observed sitting upright position on the floor, supporting self (with) the bed, asking for help, ...". Neurochecks were documented and the xray report was negative for fracture. There was no documentation of a winged matress in use as planned. e. A Fall Investigation Form dated 8/12/13 documented: "... 1. What intervention was implemented after the fall? Assist resident to bathroom Q 2 hrs (hours). ... Conclusion: ... Transferring self (without) assist, did not call for help. ... 11. Was resident referred to P.T. (Physical Therapy)? Yes. 12. Was resident referred to O.T. Occupational Therapy? Yes. ... Fall Committee Review/Recommendations: Put on B (and) B program. Offer toilet Q 2 (hours). ..." No documentation of a screening from Physical or Occupational Therapy was found near this date and there was no documentation of a winged mattress in use. 1) On 9/25/13 at 1:29 p.m., Physical Therapist #1 stated that Resident #4 had been screened due to a fall around 8/12/13 but had been on therapy recently and was non-compliant so did not treat. The Physical Therapist provided a Therapy Screen Form with Resident's name and no date. There was a yellow sticky note that documented, "(Physical Therapist #1) screened pt (patient) on 8/12 (secondary to) fall..." There was no documentation of the screening results. 2) The care plan contained a hand written notation in the intervention column: "8/12/13 B (and) B (bowel and bladder) program." f. The Nurse's Notes dated 9/2/13 documented: "0615 (6:15 a.m.) ... was observed on floor on (right) side when I walked into ... room. ... Patient assist to bed after assessment (with) ROM. C/O (complains of) hurting on (right) side. ...". This entry was signed by Licensed Practical Nurse (LPN) #1. There was no documentation that the resident had been on a winged mattress. The Final Radiology Report dated 9/2/13 documented: "... Findings: There is a new acute, impacted and medially angulated fracture through the right femoral neck. ... Impression: 1. Acute right femoral neck fracture as described. ...". g. A Fall Investigation Form dated 9/2/13 documented: "... 1. What intervention was implemented after the fall? Yes. 2. Care Plan must be updated with a new intervention. Will update when pt. (patient) returns from hospital. ... Conclusion: ... Patient very confused and forgetful, to wait for help or use C/L (call light). ... Supervisor Report: 2. If so, what was the injury and how was it treated? Acute right femoral neck FX (fracture). ... 11. Was resident referred to P.T. (Physical Therapy)? No. 12. Was resident referred to O.T. Occupational Therapy? No. Will refer when return from hospital. ... Fall Committee Review/Recommendations: 9/3/13 Will update on return from hospital. 9/13/13 Upon return from hospital resident in low bed, fall mats on both sides of bed. W/C and bed alarms. Will keep resident at nurses station if not in bed and will keep out of room if (up) in W/C." This entry was signed by the DON. There was no documentation of the resident being on a winged mattress. The care plan contained a hand written notation in the intervention column: "9/20/13 low bed, fall mat both sides of bed, falling star program, bed alarm, w/c (wheelchair) alarm, when up in w/c keep out of room, keep at nurses station..." h. The Nurse's Notes from 6/25/13 through 9/25/13 were reviewed and there was no documentation regarding a winged mattress being placed on the resident's bed. i. On 9/23/13 at 3:20 p.m. room (E#) had one bed in it with a regular matress with no covers on it. At 3:25 p.m., Resident #4 was in a room on G hall in a low bed with 1/2 side rails up on both sides of the bed and with mats on both sides of the beds. There was no winged mattress on the resident's bed. LPN #2 reported Resident #4 had been in another room (E#) but was moved. j. On 9/24/13 at 5:00 p.m., the resident was in a low bed with mats on either side of the bed with the bed alarm on. The resident was not on a winged mattress. k. On 9/25/13 at 9:50 a.m., this Surveyor and the DON went to the resident's room and found the resident was in a low bed with the bed alarm on, mats on either side of the bed, but not on a winged mattress. The DON was asked why the resident was not on a winged matress. The DON stated, "Maybe it didn't get transferred over when she was moved when she got back from the hospital." l. On 9/25/13 at 10:50 a.m. CNA #1 who was a Restorative CNA (RNA), was asked if she was responsible for making sure interventions to prevent falls were in place. She stated, "We are responsible for making sure, like if they order a bed or chair alarm, that we place it on and make sure it is working." She stated that Maintenence put the winged mattresses on. When asked if Resident #4 ever had a winged mattress on. She stated, "No, She was on E hall on a regular mattress before she came back from the hospital." On 9/25/13 at 11:30 a.m., CNA #2 who cared for the resident was interviewed, and stated that he was aware of the resident having alarms, but not aware of Resident #4 ever having a winged mattress. On 9/25/13 at 11:31 a.m., LPN #4 was interviewed and was asked what interventions to prevent falls that Resident #4 had in place. The LPN stated, "I know she is a fall risk, has a bed/chair alarm, if up in wheel chair to keep at nurses station, and to keep bed in low position. I'm not aware of her ever having a winged mattress." m. On 9/25/13 at 11:35 a.m., the DON stated that she had gotten a winged mattress out of the resident's previous room and was having it put on the resident's bed. When the DON was asked if the mattress was from room E-(#), she stated, "From E-10 (not room that resident was in prior to move to G hall)." The DON was asked who was responsible to ensure interventions to prevent falls were implemented. She stated, "Myself and the Unit Manager at the time, but now I don't have any Unit Managers. I gave the Unit Manager, (LPN #3), the task to place the winged mattress on (Resident #4)'s bed, because I had ordered some and actually gave her the mattress to put on the bed." The DON was asked if she had made sure the LPN had put the mattress on the bed. The DON stated, "I can't remember. (LPN #3) is no longer working here." She was asked if she had found documentation of when the mattress was placed on the bed. She stated, "No." n. On 9/25/13 at 11:52 a.m., CNA #3 was interviewed and stated that she had been off recently, but before the resident went to the hospital the resident had never had a winged mattress. o. On 9/25/13 at 12:20 p.m., a winged mattress had been placed on the resident's bed on G hall. p. On 9/25/13 at 12:30 p.m., the Admninistrator was informed that the intervention of a winged mattress care planned on 8/26/13 was not observed on the resident's bed until today at 12:20 p.m. The Administrator stated that he knew it was not a winged matress, when the resident returned on 9/13/13... because he had thrown the mattress out after the resident went to the hospital again, because it was ruined. q. On 9/25/13 at 3:27 p.m. LPN #3, who no longer worked at the facility, was interviewed by telephone. She was asked if Resident #4 had a winged mattress. She stated, "I had a CNA on the 3-11 shift put the mattress on. Didn't actually see them put it on but I know it was there because I made the bed several times when the girls were busy. I think it was put on soon after it was an intervention. Don't remember the exact day. I don't know when it was taken off. She went to the hospital before I left, but wasn't back when I left." 1) On 9/25/13 at 4:00 p.m., CNA #4 was interviewed and stated, "I never was asked to put a winged matress on (Resident #4)'s bed. The resident has moved to a new hall. I did take care of her in June and July and she never has had a winged mattress." 2) On 9/25/13 at 4:03 p.m., CNA #5 was interviewed and stated, "I never was asked to put a winged mattress on the Resident's bed. She did have a bed and a chair alarm. She has not had a winged mattress since I have been here."

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility failed to ensure a hemostat and replacement [MEDICAL CONDITION] kit were present to maintain a patent airway in case of accidental dislodgement for 2 of 2 (Residents # 1 and #2) case mix residents in the facility who had a [MEDICAL CONDITION]. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 1 who had a recent [MEDICAL CONDITION] procedure on 7/12/13, and had the potential to cause more than minimal harm to 1 other resident in the facility who had a [MEDICAL CONDITION] according to the listing received from the Director of Nurse on 8/3/13. The facility was notified of the Immediate Jeopardy condition on 7/30/13 at 5:32 p.m. The facility also failed to ensure [MEDICAL CONDITION] (trach) care was provided using sterile technique and included cleaning of [MEDICAL CONDITION] to prevent possible infections for 2 of 2 (Residents # 1 and #2) case mix residents who [MEDICAL CONDITION]. The facility failed to ensure the correct inner cannula was used [MEDICAL CONDITION] for 1 (Resident # 2) of 2 (Residents # 1 and #2) case mix residents who [MEDICAL CONDITION]. The facility failed to ensure water was present in the humidifier to humidify oxygen administered [MEDICAL CONDITION] for 1 (Resident # 2) of 2 (Residents # 1 and #2) case mix residents with a physician order for [REDACTED]. The findings are: 1. The "Best Practices: A Guide to Excellence in Nursing Care" published in 2003 by Lippincott, Williams and Wilkins page 353" documented: "... For emergency [MEDICAL CONDITION] replacement: Sterile tracheal [MEDICATION NAME] or sterile hemostat, sterile obturator that fits the [MEDICAL CONDITION] in use, two extra sterile tubes and obturators in the appropriate size, suction equipment and supplies. Keep these supplies in full view in the patient's room at all times, for easy access in case of emergency. Consider taping an emergency sterile [MEDICAL CONDITION] in a sterile wrapper to the head of the bed for easy access in an emergency ..." The facility's policy "[MEDICAL CONDITION] Care ..." documented: " ...Special Considerations: Keep appropriate equipment at the patient's bedside for immediate use in an emergency ... Consult the doctor about first-aid measures you can use for your [MEDICAL CONDITION] patient should an emergency occur. Follow your facility's policy for what to do if a [MEDICAL CONDITION] is expelled or if the inner cannula becomes blocked ..." This "policy" provided by the facility is from Lippincott's "Nursing Procedures Sixth Edition" published by Lippincott Williams and Wilkins 2013 pages 718 through 722. 2. The facility's policy "[MEDICAL CONDITION] Care ..." documented:"Preparation of equipment: Perform hand hygiene and gather all equipment and supplies in the patient's room. For [MEDICAL CONDITION] cannula and stoma care ... Open the waterproof trash bag and place it next to you so that you can avid reaching across the sterile field or the patient'[MEDICATION NAME] discarding soiled items. Establish a sterile field near the patient's bed (usually on the over bed table) and place equipment and supplies on it. Pour normal saline solution or sterile water into one the sterile solution containers; then pour normal saline solution or sterile water into the second sterile container for rinsing. For inner-cannula care, you may use a third sterile solution container to hold the gauze pads and cotton-tipped applicators saturated with normal saline solution. Hydrogen peroxide is no longer recommended for cleaning inner cannulas or [MEDICAL CONDITION] sites. If you'll be replacing the disposable inner cannula, open the package containing the new inner cannula while maintaining sterile technique ... Implementation: ... Perform hand hygiene and put on gloves ... Hyperoxygenate the patient for at least 1 minute and then perform deep oropharyngeal suctioning to remove accumulated secretions from above the cuff and prevent pooled secretions from descending into the trachea ... For [MEDICAL CONDITION] cannula and stoma care: ... Discard gloves, perform hand hygiene, and put on sterile gloves. With your non dominant hand, remove any humidification or ventilation device. Using sterile technique, suction the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation ... With your non dominant hand, reconnect the patient to the humidifier or ventilator, if necessary. Remove the patient's [MEDICAL CONDITION] dressing; inspect it for drainage and then discard it. Remove and discard your gloves and perform hand hygiene. ... Caring for a disposable inner cannula: Perform hand hygiene and put on sterile gloves. Using your dominant hand, remove the patient's inner cannula. ... Pick up the new inner cannula, touching only the outer locking portion. Insert the cannula into the [MEDICAL CONDITION] and following the manufacturer's instructions, lock it securely. Replace any humidification ... device. Cleaning the stoma and outer cannula: Perform hand hygiene and put on sterile gloves. With your dominant hand, moisten a sterile gauze pad with the normal saline solution or sterile water. Squeeze out the excess liquid to prevent accidental aspiration. Then wipe the patient's neck under the [MEDICAL CONDITION] flanges and [MEDICATION NAME] tapes. Assess the site for redness, swelling and drainage, which may indicate infection. ... Use a cotton-tipped applicator and a gauze pad to clean the stoma site and the tube's flanges. Wipe only once with each applicator or gauze pad and then discard it to prevent contamination of a clean area with a soiled applicator or pad. ... Dry the area thoroughly with additional sterile gauze pads; then apply a new sterile [MEDICAL CONDITION] dressing..." This "policy" provided by the facility is from Lippincott's "Nursing Procedures Sixth Edition" published by Lippincott Williams and Wilkins 2013 pages 718 through 722. 3. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/26/13 documented the resident scored a 0 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, received oxygen therapy, and required suctioning and [MEDICAL CONDITION] care. a. The (Hospital) medical records received from the Director of Nurses on 8/2/13 documented: "Surgical Operative Note: ... Date Performed: 7/12/13. Pre Procedure Diagnosis: [REDACTED]. ... Procedure: 1. Percutaneous [MEDICAL CONDITION] (#8 Shiley)..." The facility intake form dated 7/16/13 documented "... Additional Information:[MEDICAL CONDITION]# 8 Shiley ... [MEDICAL CONDITION] kits ... (Oxygen) at 6 liters [MEDICAL CONDITION], humidified air." The (Medical Equipment Supplier) delivery ticket dated 7/19/13 documented a suction machine,[MEDICAL CONDITION], canisters with tubing and ambu bag were delivered on 7/19/13. There was no documentation of sterile hemostats or a [MEDICAL CONDITION] for a # 8 [MEDICAL CONDITION] on this date. b. The Admission Data Collection Form dated 7/19/13 at 5:30 p.m. documented, "... Respiratory: ... Cough: ... Productive cough, describe: yellow thick [MEDICAL CONDITION] ... Special Treatments and Procedures: FIO2 (at) 28%. Oxygen: 7 L (liters) ... Suctioning: X ..." c. The admission orders [REDACTED]. The physician orders dated 7/19/13 through 7/30/13 at 6:10 p.m. did not include physician orders for oxygen, humidification, [MEDICAL CONDITIONS]. d. The Care Plan dated 7/29/13 documented, "Focus: Resident is at risk for breathing difficulties (related to) [MEDICAL CONDITION] ... Interventions: Administer and monitor effectiveness of respiratory treatments as ordered ... Monitor resident's O2 (oxygen) saturation as needed and titrate (oxygen) to keep resident's O2 saturation (equal to) or (greater than) 90% as ordered ... [MEDICAL CONDITION] as ordered..." e. On 7/30/13 at 3:02 p.m., Licensed Practical Nurse (LPN) # 1 and this surveyor observed Resident # 1 on initial rounds. [MEDICAL CONDITION] that were in sight in the resident's room included an ambu bag, suction catheter kit, suction machine with canister and extension tubing, and humidifier. Resident # 1 was noted to have four sutures present attaching [MEDICAL CONDITION] to Resident # 1's neck. At 4:12 p.m. LPN # 1 and LPN # 3, the resident's charge nurse on TCU (Transitional Care Unit) was asked: "Do you have any residents with trachs on this unit?" LPNs # 1 and # 3 stated, "(Resident # 1)." LPNs # 1 and # 3 were asked: "Can you show me a replacement trach, obturator, and hemostats that you would use in case [MEDICAL CONDITION] dislodged?" LPN # 1 and # 3 entered Resident # 1's room, searched the bed side table (drawer and both shelves of the cabinet area under the drawer), and searched the built in drawers between the closets. LPN # 1 found a box with three sterile Shiley size 8 disposable inner cannulas in the third drawer down from the top drawer of the built in drawers. LPN # 1 and 3 were asked: "Where are the [MEDICAL CONDITION], obturator, and hemostats?" LPN # 1 stated, "We don't have that." LPN # 1 was asked: "Have you ever had them?" LPN # 1 stated, "No." LPN # 1 and # 3 were asked: "What supplies for trachs are at the nursing station/med room?" LPN # 1 stated, "I'll have to go get a key." LPN # 1 returned in two minutes with a key and opened the door to the med room on B hall/TCU (Transitional Care Unit). Inside the med room there were two boxes with 10 each Shiley # 8 disposable inner cannulas, extension suction tubing, canisters with lids,[MEDICAL CONDITION] kits, and suction catheter kits. LPN # 1 was asked: "Do you see any [MEDICAL CONDITION], obturators or hemostats?" LPN # 1 stated, "No." LPN # 2 entered the med room and stated she was the charge nurse for the Nursing Center halls (halls A through D). LPN # 1 and # 2 were asked: "Do you know what size and kind [MEDICAL CONDITION](Resident # 1) has?" LPN # 1 stated, "Other than the inner cannula, no." LPN # 1 and 2 were asked: "Is there another storage area [MEDICAL CONDITION]?" LPN # 1 and # 2 stated, "Central Supply." This surveyor and both nurses entered Central Supply at 4:20 p.m. The [MEDICAL CONDITION] were present in Central Supply: 14 Fr (French) suction catheter kits, humidifier bottles, oxygen tubing,[MEDICAL CONDITION] kits, sterile water, 2 boxes with 10 count per box [MEDICATION NAME] size 8 disposable inner cannulas and 4 boxes with 10 count per box of Shiley # 8 disposable inner cannulas. There were no [MEDICAL CONDITION], obturators, or hemostats. LPN # 1 and 2 were asked: "If a resident dislodges [MEDICAL CONDITION] do you do?" LPN # 1 stated, "I don't know that's never happened." LPN # 2 stated, "Maintain airway, get a replacement kit and put [MEDICAL CONDITION]." LPN # 2 was asked "Where do you go to find the [MEDICAL CONDITION]?" LPN # 2 stated, "Not in here." LPN # 2 was asked, "How are you going to maintain the airway?" LPN # 2 stated, "Call 911." At 4:25 p.m., the Director of Nurses (DON) was asked: "If a resident dislodges a trach, what is your staff to do?" The DON stated, "Attempt to put it back in. The DON was asked, "The same one?" The DON stated, "No. A new one. All the residents with trachs have a [MEDICAL CONDITION] the bedside." The DON was asked, "Can you come with me to (Resident # 1's) room to find one?" The DON stated, "Yes, but can I stop at Central Supply and check there first?" The DON and this surveyor went to Central Supply. The DON looked [MEDICAL CONDITION] and then stated, "There's none here." The DON and this surveyor left Central Supply at 4:29 p.m. and went to Resident # 1's room. The DON removed the clear plastic bag with the ambu bag inside it from the top of the light fixture. The DON stated, "Not here." The DON searched the bed side table (drawer and both shelves of the cabinet area under the drawer), and searched the built in drawers between the closets. The DON stated, "I don't see one but I will call and get one right away." The DON was asked, "Do you see an obturator or hemostats?" The DON stated, "No." The DON was asked, "How long has this resident been here?" The DON stated, "Two to three weeks." The DON went to the resident's chart and reviewed the face sheet. The DON stated, "Since 7/19/13." At 7:00 p.m. the Administrator was asked, "Who [MEDICAL CONDITION]?" The Administrator stated, "The nurses are supposed to let us know what supplies they need." The Administrator was asked, "What is your intake process, are they able to determine at intake [MEDICAL CONDITION] a resident will need prior to admission?" The Administrator stated, "Sure, we'll inservice the DON, ADON (Assistant Director of Nurses) and Admission (Coordinator) to [MEDICAL CONDITION] before a resident arrives." f. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 7/30/13 at 7:10 p.m. when the facility implemented the following Plan of Removal: Identification: 1) This failed practice had the potential to affect 2 residents that have trachs. Assessments: 2) ADON (Assistant Director of Nurses)/designee assessed both resident for signs and symptoms related to negative outcomes due to [MEDICAL CONDITION] not available, with no negative findings. On 7/30/13 upon notification of the deficient practice DON (Director of Nurses) ordered [MEDICAL CONDITION] resident and hung hemostats on the resident's wall above the bed. Once [MEDICAL CONDITION] delivered, it will be hung above the resident's bed. Resident's physician was notified by DON of the failed practice related [MEDICAL CONDITION] not available. Training: 3) On 7/30/13 at 6:00 p.m., DON/Designee started an on-going in-service to licensed staff that upon admission,[MEDICAL CONDITION] are to have: emergency [MEDICAL CONDITION] replacement kit: sterile tracheal [MEDICATION NAME] or sterile hemostat, sterile obturator that fits the [MEDICAL CONDITION] in use, extra sterile [MEDICAL CONDITION] and obturators in the appropriate size, suction equipment and supplies. Licensed staff will be inserviced before the start of their shift. Licensed staff that is on FMLA, Vacation, out sick or newly hired will be in-serviced before the start of their shift. DON/ADON/Admissions Coordinator were in-serviced on 7/30/13 at 7:10 p.m. on having all supplies in the facility prior to admission. This is to include [MEDICAL CONDITION]. Monitoring: 4) DON/Designee will [MEDICAL CONDITION] in the rooms daily x (times) 3 weeks. Monitoring supplies with be placed on the MAR (Medication Administration Record) for the nurse to sign off (every) shift. Care Keeper Rounds will be incorporated to [MEDICAL CONDITION] 5 days a week. Any negative findings will be corrected immediately and the DON will report to the monthly QAA (Quality Assessment and Assurance) meeting for further recommendations. g. On 8/2/13 at 2:05 p.m., the DON presented (name) medical equipment supplier invoices from 6/19/13 through 7/31/13. On 7/30/13 the medical equipment supplier delivered a replacement # 8 cannula low pressure tube. This was the only documented invoice for a [MEDICAL CONDITION] in this time frame. h. On 7/30/13 at 3:02 p.m., on 7/31/13 at 8:12 a.m., 9:35 a.m., 10:13 a.m., 12:45 p.m., 1:00 p.m., 3:40 p.m. and 4:05 p.m., and on 8/1/13 at 9:18 a.m. and 11:00 a.m., Resident # 1 was noted to have four sutures present attaching [MEDICAL CONDITION] to Resident # 1's neck. Oxygen was administered [MEDICAL CONDITION] at 7 liters a minute and a humidifier was at 28%. i. On 7/31/13 at 12:50 p.m.,[MEDICAL CONDITION] supplies were noted on the nursing station desk. Licensed Practical Nurse (LPN) # 4 was asked, "Who is going to [MEDICAL CONDITION]?" LPN # 4 stated, "I'll do it." LPN # 4 was asked, "Doesn't (LPN # 6) [MEDICAL CONDITION] as the resident's charge nurse today?" LPN # 4 stated, "I'm relieving her, she'll do it if she's back in time." LPN # 4 then left the unit. At 12:55 p.m. the Nurse Consultant stated, "We have switched nurses and I have started retraining them. (LPN # 6) moved to another unit and I'm training her." LPN # 4 entered the nursing unit and walked toward the nursing station desk area. At 1:00 p.m., LPN # 4 [MEDICAL CONDITION] from the nursing station desk area and took them into Resident # 1's room. The Assistant Director of Nurses (ADON) also entered Resident # 1's room to assist [MEDICAL CONDITION]. The ADON washed her hands and put on gloves. LPN # 4 placed the suction catheter kit,[MEDICAL CONDITION] kit, neck band, q-tips, Normal Saline bottle, sterile inner cannula, Hydrogen Peroxide bottle, and a bottle of alcohol gel on a clean towel set up on Resident # 1's over bed table. There was a box of clean gloves next to the clean towel. LPN # 4 used alcohol gel on her hands then opened [MEDICAL CONDITION] kit. LPN # 4 placed the sterile drape on the resident's upper chest area, removed the tray from the kit, and filled one of two tubs built into the tray with normal saline. LPN # 4 opened the suction catheter kit. LPN # 4 used alcohol gel on her hands, put on clean gloves and unhooked [MEDICAL CONDITION] while leaving it in place over [MEDICAL CONDITION]. LPN # 4 removed her gloves and opened the new sterile inner cannula. LPN # 4 put on sterile gloves, suctioned Resident # 1 and placed the upper part of the suction catheter, including the tip, curled up inside the sterile suction catheter tray. LPN # 4 poured normal saline and hydrogen peroxide into the second tub of [MEDICAL CONDITION] tray. As LPN # 4 removed a pair of clean gloves from the box of clean gloves, the suction catheter was pulled out of the sterile suction catheter tray touching the outside of the box of clean gloves then landing on the clean field. LPN # 4 put on clean gloves. LPN # 4 cleaned around the edge of the [MEDICAL CONDITION] where the [MEDICAL CONDITION] and cleaned the upper side of [MEDICAL CONDITION]. Resident # 1 still had 4 sutures present attaching [MEDICAL CONDITION] to her neck. LPN # 4 did not clean [MEDICAL CONDITION] site or the bottom side of [MEDICAL CONDITION]. LPN # 4 used alcohol gel on her hands and put on clean gloves. LPN # 4 picked up the inner cannula with her clean (not sterile) gloves by holding the inner cannula with the thumb and second finger and placing the first finger on the back side (curved area) of the clear plastic of the inner cannula which contaminated the inner cannula. LPN # 4 used the first (pointer) finger to push the inner cannula into the outer cannula. LPN # 4 then locked the inner cannula into the outer cannula of the trach. LPN # 4 then suctioned Resident # 1 two times using the contaminated suction catheter. LPN # 4 reconnected [MEDICAL CONDITION], removed the sterile field, picked up trach, took her gloves off, and put alcohol gel on her hands. During [MEDICAL CONDITION] procedure the ADON gave LPN # 4 directions but did not stop LPN # 4 when she contaminated the suction catheter or the inner cannula, nor did the ADON direct LPN # 4 to clean [MEDICAL CONDITION] site. LPN # 4 was asked, "Where all did you clean when you cleaned the white area (flange) of the outer cannula?" LPN # 4 stated, "The top and under the outer trach." LPN # 4 was asked, "[MEDICAL CONDITION] a clean or a sterile procedure?" LPN # 4 stated "Clean." LPN # 4 was asked, "Did you have on clean gloves when the inner cannula was replaced?" LPN # 4 stated, "Yes." LPN # 4 was asked, "How did you hold onto the inner cannula?" LPN demonstrated how she held the inner cannula and stated, "Thumb and middle finger (second finger) on the white outside area and first finger on the inner cannula to steady it." LPN # 4 demonstrated her first finger was approximately 1/2 inch beyond her thumb and "middle finger." LPN # 4 was asked, "When were you trained [MEDICAL CONDITION]?" LPN # 4 stated, "Two months ago." LPN # 4 was asked, "Do you [MEDICAL CONDITION] often?" LPN # 4 stated, "No." LPN # 4 was asked, "How often do you [MEDICAL CONDITION]?" LPN # 4 stated, "Counting today, twice." LPN # 4 was asked, "Why is it a clean and not a sterile procedure?" LPN # 4 stated, "Here we don't have sterile gloves." LPN # 4 was asked, "Were the purple gloves inside the wrapper from the [MEDICAL CONDITION] sterile?" LPN # 4 stated, "Yes, they came in a closed container." LPN # 4 was asked, "What did you take the inner cannula out of?" LPN # 4 stated, "A sterile container." LPN # 4 was asked, "When you touched the inner cannula with clean gloves, what did you do to the inner cannula?" LPN # 4 stated, "Contaminated it." j. On 8/2/13 at 11:40 a.m. the Director of Nurses (DON) was asked to review Resident # 1's physician orders. The DON was asked "Can you find any oxygen orders?" The DON stated, "No." The DON was asked, "She's (Resident) been observed with humidified oxygen at 7 liters per minute, is that a problem?" The DON stated, "Yes." The DON was asked, "Can you find any directions to change the [MEDICAL CONDITION] or [MEDICAL CONDITION] for (Resident # 1)?" The DON stated, "None on the 7/18/13 TAR (Treatment Administration Record)." The DON was asked, "Find any orders [MEDICAL CONDITION] or changes of the [MEDICAL CONDITION]?" The DON stated, "No." The DON was asked, "Did you know (Resident # 1) still has sutures in her trach?" The DON stated "No." The DON was asked, "How long do you normally leave sutures in?" The DON stated "Seven to ten days." The DON was asked, "Do you know what date [MEDICAL CONDITION] put in?" The DON stated "No, I'll see what I can find." 4. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/25/13 documented the resident was comatose, was totally dependent for activities of daily living, received oxygen therapy, suctioning and [MEDICAL CONDITION] (trach) care. a. The undated admission intake form documented "... Possible (discharge) Date: 6/17/13 ...Admit (Diagnoses): ... [MEDICAL CONDITION] ... Trach/Size: Collar # 8 [MEDICATION NAME]" b. The medical equipment supplier delivery ticket dated 6/17/13 documented sterile water,[MEDICAL CONDITION], jet nebulizer and an ambu bag were delivered on 6/17/13. There was no documentation of sterile hemostats or a [MEDICAL CONDITION] for a # 8 Shiley [MEDICAL CONDITION] on this date. c. The Care Plan dated 6/27/13 documented, "Focus: Resident is at risk for breathing difficulties (related to) pneumonia, [MEDICAL CONDITION] ... Interventions: ... Provide oral/trach suctioning as needed ..." d. The admission orders ... [MEDICAL CONDITION](as needed). Cool [MEDICAL CONDITION] 28% (with) humidified (oxygen) (at) 2 (liters) [MEDICAL CONDITION] Clean outside [MEDICAL CONDITIONS] (twice a day) (and) (as needed) on 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m..." e. On 7/30/13 at 4:30 p.m., the Assistant Director of Nurses (ADON) was asked to [MEDICAL CONDITION] in Resident # 2's room. The ADON found disposable inner cannulas size 8, suction catheters,[MEDICAL CONDITIONS] kit, and an ambu bag. There were no hemostats or obturator located in the resident's room. The ADON stated, "I do not see any hemostats at this time." The ADON was asked "Did you see an obturator ..." The ADON stated, "I don't see an obturator." f. On 7/30/13 at 5:10 p.m., the medication room for halls E, F, G, and H, (the med room for Resident # 2) was observed [MEDICAL CONDITION]. There were [MEDICAL CONDITION] kits and 6 suction catheter kits present in the med room. g. On 7/30/13 at 5:42 p.m., the Director of Nurses (DON) placed a package of hemostats on the wall above Resident # 2's head. The DON showed this surveyor a [MEDICAL CONDITION] that was in a built in drawer by the closet which contained an obturator. h. On 7/31/13 at 10:50 a.m. LPN # 9, the resident's charge nurse on this date, was asked, "When [MEDICAL CONDITION] done?" LPN # 9 stated, "Every four hours." LPN # 9 was asked, "When are you going to do it?" LPN # 9 stated, "I don't. (LPN # 1) does." LPN # 9 was asked,"Why does (LPN # 1) do it?" LPN # 9 stated, "I'm usually passing pills." i. On 8/1/13 at 9:30 a.m., approximately 1 inch of water was noted in Resident # 2's humidifier bottle. At 1:05 p.m. and 3:10 p.m., the humidifier bottle was empty of water. j. On 8/1/13 at 3:10 p.m., LPN #4 and LPN #6 stated they were going to [MEDICAL CONDITION]. LPN #6 [MEDICAL CONDITION] supplies on an over bed table at the nursing station. The supplies included a suction catheter kit, a Shiley # 8 disposable inner cannula, [MEDICAL CONDITION] kits, packages 4 by 4's, a large package of 2 x 2's, a box of opened clean gloves. LPN #6 pushed the over bed table from the nursing station to Resident # 2's room. LPN #4 and #6 put on isolation gowns, mask, gloves and foot covers prior to entering Resident # 2's room. LPN # 6 set up a clean field, opened the suction catheter kit, [MEDICAL CONDITION] kit, poured Hydrogen Peroxide into one of the two tubs built into [MEDICAL CONDITION] tray, added normal saline to this tray and then poured normal saline into another tray. LPN # 6 removed her gloves, used alcohol gel on her hands, put on one glove and then turned to turn on the suction machine. LPN #6 stated, "I'm not sure how to turn this on, they are all different." LPN #4 provided directions to LPN #6 regarding where the switch was to turn on the suction machine. LPN #6 turned on the suction machine with her ungloved hand. LPN #6 removed her glove and used alcohol gel on her hands. LPN #6 put on sterile gloves, picked up the sterile suction catheter and suctioned Resident # 2. LPN #6 then removed the suction catheter from the extension suction tubing and removed her sterile gloves. LPN #6 discarded the suction catheter and gloves. LPN #6 put on clean gloves from the box of gloves, picked up a 4 by 4 and started toward the resident'[MEDICAL CONDITION] the 4 x 4. LPN #6 stopped, removed her gloves, used alcohol gel on her hands, picked up the sterile drape and held in it her hand while putting on sterile gloves on the opposite hand. LPN #6 then changed hands holding the sterile drape and put a sterile glove on the other hand. LPN #6 contaminated the sterile field when touching it with her hands then contaminated her sterile gloves by holding the contaminated drape in her gloved hands. LPN #6 put the drape across the resident's upper chest and touched the outside locking portion of [MEDICAL CONDITION]. LPN #6 removed her "sterile" gloves, used alcohol gel, and then put on clean gloves from the box of gloves. LPN #4 used clean gloves to clean the upper side of [MEDICAL CONDITION], using a sterile 4 x 4 wet with a solution of one half Hydrogen Peroxide and one half normal saline. LPN #6 used a total of four 4 x 4's wiping a quarter area of the upper flange with each wipe and changing gloves and 4 x 4's after each wipe. LPN #6 put on clean gloves from the box of gloves and removed the inner cannula. After hand hygiene, LPN #6 put on clean gloves and used a sterile 4 by 4 wet with one half Hydrogen Peroxide and one half normal saline to clean the locking mechanism on the [MEDICAL CONDITION]. LPN #6 never cleaned [MEDICAL CONDITION] site or the bottom side of [MEDICAL CONDITION] where secretions can accumulate. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley # 8 disposable inner cannula. LPN #6 attempted to insert the Shiley #8 curved inner cannula into a straight Shiley #[MEDICATION NAME] cannula. LPN #6 stated, "It will not go" and requested LPN #4 to get another inner cannula. LPN # 4 returned with another Shiley # 8 curved inner cannula. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley #8 curved disposable inner cannula. LPN #6 attempted to insert the Shiley # 8 curved inner cannula into a straight Shiley # [MEDICATION NAME] cannula a second time. This surveyor suggested to the LPNs that they stop and check the type [MEDICAL CONDITION] #2 had. At 3:55 p.m., LPN # 6 was asked, "What kind [MEDICAL CONDITION] he have, can you look at the replacement box or [MEDICAL CONDITION] tell?" LPN # 6 stated, "It says XLT. I got the wrong kind of inner cannula. I followed the doctor's orders and brought what it said." There was no physician order that specified the type or size of trach. At 4:05 p.m., LPN # 4 entered Resident # 2's room with a Shiley #[MEDICATION NAME] inner cannula. LPN #4 opened the inner cannula package. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley #[MEDICATION NAME] inner cannula and touched the outside of the clear plastic inner tube with her clean gloves, contaminating the inner cannula. LPN #6 inserted the disposable inner cannula into the [MEDICAL CONDITION]. On completion [MEDICAL CONDITION] LPN #6 was asked, "Did you know the humidifier was empty?" LPN #6 stated, "No." LPN # 6 was asked, "You checked the humidifier when?" LPN # 6 did not respond. LPN #4 and #6 looked in the resident's room for sterile water to fill the humidifier and stated there was no water in the room to fill the humidifier bottle. k. On 8/1/13 at 4:17 p.m. LPN #6 was asked, "You've worked how many times on TCU in the last month?" LPN #6 stated, "Six times." LPN #6 was asked, "Prior to yesterday did you have [MEDICAL CONDITION]?" LPN #6 stated, "Yes, five to six years ago in (Town)." LPN #6 was asked, "Any (training) here?" LPN #6 stated, "No." LPN #6 was asked, "How many times have you [MEDICAL CONDITION] in the last month?" LPN # 6 stated, "Every shift I worked on TCU." LPN #6 was asked, "[MEDICAL CONDITION] a clean or sterile procedure?" LPN # 6 stated, "It's clean in a long term care facility." LPN #6 was asked, "Is that what they taught you yesterday?" LPN #6 stated, "No, just the steps and what to do if it came out. I was on a med cart and they told me what to do." LPN #6 was asked, "Did you do any return demonstration?" LPN #6 stated, "No, I told them what I'd do, the steps." LPN #6 was asked, "Did you know your clean gloves contaminated the inner cannula on (Resident # 2)?" LPN #6 stated, "No, I had on clean gloves and it's a clean procedure." l. On 8/2/13 at 11:40 a.m., the DON was asked to review the TARs dated 7/29/13 for Resident # 2. The DON was asked, "Can you find directions [MEDICAL CONDITION] or cannula changes?" The DON stated, "Clean outside [MEDICAL CONDITIONS] (twice a day) is the only thing there." The DON was asked, "What does that mean?" The DON stated, "I couldn't tell you. By reading it, it says just clean the outside of [MEDICAL CONDITION] about the inside." The DON was asked, "Are staff to clean [MEDICAL CONDITION]?" The DON stated, "Yes." The DON was asked, "Can you tell by looking at the TARs what the system is [MEDICAL CONDITION]?" The DON stated, "No." The DON was asked, "What should happen [MEDICAL CONDITION]?" The DON stated, "Wash hands, masks and gloves on, etc., get supplies ready -[MEDICAL CONDITION], inner cannula, another nurse with me, hyperoxygenate the resident." The DON was asked "All residents get [MEDICATION NAME]?" The DON stated, "Yes, then I would take out the disposable inner cannula, clean the

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review, and interview, Nursing Administration failed to ensure a hemostat and replacement [MEDICAL CONDITION] kit were present to maintain a patent airway in case of accidental dislodgement for 2 of 2 (Resident # 1 and #2) case mix residents in the facility who had a [MEDICAL CONDITION]. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 1 who had a recent [MEDICAL CONDITION] procedure on 7/12/13, and had the potential to cause more than minimal harm to 1 other resident in the facility who had a [MEDICAL CONDITION] according to the listing received from the Director of Nurse on 8/3/13. The facility was notified of the Immediate Jeopardy condition on 7/30/13 at 5:32 p.m. Nursing Administration also failed to ensure: [MEDICAL CONDITION] (trach) care was provided in a sterile manner and included cleaning of [MEDICAL CONDITION] to prevent possible infections for 2 of 2 (Residents # 1 and #2) case mix residents who [MEDICAL CONDITION]. The correct inner cannula was used [MEDICAL CONDITION] for 1 (Resident # 2) of 2 (Residents # 1 and #2) case mix residents who [MEDICAL CONDITION]. Water was present in the humidifier to humidify oxygen administered [MEDICAL CONDITION] for 1 (Resident # 2) of 2 (Residents # 1 and #2) case mix residents with a physician order for [REDACTED]. The findings are: 1. The facility's "Job Description Director of Nursing" documented: "...Essential Duties and Responsibilities: Ensures and oversees implementation of all (corporate name) nursing services and standards ... Responsible for the development and maintenance of nursing service objectives and standards of nursing practice ... Oversees and ensures that all tasks and responsibilities of the Nursing Services Department are in compliance with State and Federal guidelines. Maintains current knowledge and understanding of the same ..." 2. The "Best Practices: A Guide to Excellence in Nursing Care" published in 2003 by Lippincott, Williams and Wilkins page 353" documented: "... For emergency [MEDICAL CONDITION] replacement: Sterile tracheal [MEDICATION NAME] or sterile hemostat, sterile obturator that fits the [MEDICAL CONDITION] in use, two extra sterile tubes and obturators in the appropriate size, suction equipment and supplies. Keep these supplies in full view in the patient's room at all times, for easy access in case of emergency. Consider taping an emergency sterile [MEDICAL CONDITION] in a sterile wrapper to the head of the bed for easy access in an emergency ..." The facility's policy "[MEDICAL CONDITION] Care ..." documented: " ...Special Considerations: Keep appropriate equipment at the patient's bedside for immediate use in an emergency ... Consult the doctor about first-aid measures you can use for your [MEDICAL CONDITION] patient should an emergency occur. Follow your facility's policy for what to do if a [MEDICAL CONDITION] is expelled or if the inner cannula becomes blocked ..." This "policy" provided by the facility is from Lippincott's "Nursing Procedures Sixth Edition" published by Lippincott Williams and Wilkins 2013 pages 718 through 722. 3. The facility's policy "[MEDICAL CONDITION] Care ..." documented:"Preparation of equipment: Perform hand hygiene and gather all equipment and supplies in the patient's room. For [MEDICAL CONDITION] cannula and stoma care ... Open the waterproof trash bag and place it next to you so that you can avid reaching across the sterile field or the patient'[MEDICATION NAME] discarding soiled items. Establish a sterile field near the patient's bed (usually on the over bed table) and place equipment and supplies on it. Pour normal saline solution or sterile water into one the sterile solution containers; then pour normal saline solution or sterile water into the second sterile container for rinsing. For inner-cannula care, you may use a third sterile solution container to hold the gauze pads and cotton-tipped applicators saturated with normal saline solution. Hydrogen peroxide is no longer recommended for cleaning inner cannulas or [MEDICAL CONDITION] sites. If you'll be replacing the disposable inner cannula, open the package containing the new inner cannula while maintaining sterile technique ... Implementation: ... Perform hand hygiene and put on gloves ... Hyperoxygenate the patient for at least 1 minute and then perform deep oropharyngeal suctioning to remove accumulated secretions from above the cuff and prevent pooled secretions from descending into the trachea ... For [MEDICAL CONDITION] cannula and stoma care: ... Discard gloves, perform hand hygiene, and put on sterile gloves. With your non dominant hand, remove any humidification or ventilation device. Using sterile technique, suction the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation ... With your non dominant hand, reconnect the patient to the humidifier or ventilator, if necessary. Remove the patient's [MEDICAL CONDITION] dressing; inspect it for drainage and then discard it. Remove and discard your gloves and perform hand hygiene. ... Caring for a disposable inner cannula: Perform hand hygiene and put on sterile gloves. Using your dominant hand, remove the patient's inner cannula. ... Pick up the new inner cannula, touching only the outer locking portion. Insert the cannula into the [MEDICAL CONDITION] and following the manufacturer's instructions, lock it securely. Replace any humidification ... device. Cleaning the stoma and outer cannula: Perform hand hygiene and put on sterile gloves. With your dominant hand, moisten a sterile gauze pad with the normal saline solution or sterile water. Squeeze out the excess liquid to prevent accidental aspiration. Then wipe the patient's neck under the [MEDICAL CONDITION] flanges and [MEDICATION NAME] tapes. Assess the site for redness, swelling and drainage, which may indicate infection. ... Use a cotton-tipped applicator and a gauze pad to clean the stoma site and the tube's flanges. Wipe only once with each applicator or gauze pad and then discard it to prevent contamination of a clean area with a soiled applicator or pad. ... Dry the area thoroughly with additional sterile gauze pads; then apply a new sterile [MEDICAL CONDITION] dressing..." This "policy" provided by the facility is from Lippincott's "Nursing Procedures Sixth Edition" published by Lippincott Williams and Wilkins 2013 pages 718 through 722. 4. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/26/13 documented the resident scored a 0 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, received oxygen therapy, and required suctioning and [MEDICAL CONDITION] care. a. The (Hospital) medical records received from the Director of Nurses on 8/2/13 documented: "Surgical Operative Note: ... Date Performed: 7/12/13. Pre Procedure Diagnosis: [REDACTED]. ... Procedure: 1. Percutaneous [MEDICAL CONDITION] (#8 Shiley)..." The facility intake form dated 7/16/13 documented "... Additional Information:[MEDICAL CONDITION]# 8 Shiley ... [MEDICAL CONDITION] kits ... (Oxygen) at 6 liters [MEDICAL CONDITION], humidified air." The (Medical Equipment Supplier) delivery ticket dated 7/19/13 documented a suction machine,[MEDICAL CONDITION], canisters with tubing and ambu bag were delivered on 7/19/13. There was no documentation of sterile hemostats or a [MEDICAL CONDITION] for a # 8 [MEDICAL CONDITION] on this date. b. The Admission Data Collection Form dated 7/19/13 at 5:30 p.m. documented, "... Respiratory: ... Cough: ... Productive cough, describe: yellow thick [MEDICAL CONDITION] ... Special Treatments and Procedures: FIO2 (at) 28%. Oxygen: 7 L (liters) ... Suctioning: X ..." c. The admission orders [REDACTED]. The physician orders dated 7/19/13 through 7/30/13 at 6:10 p.m. did not include physician orders for oxygen, humidification, [MEDICAL CONDITIONS]. d. The Care Plan dated 7/29/13 documented, "Focus: Resident is at risk for breathing difficulties (related to) [MEDICAL CONDITION] ... Interventions: Administer and monitor effectiveness of respiratory treatments as ordered ... Monitor resident's O2 (oxygen) saturation as needed and titrate (oxygen) to keep resident's O2 saturation (equal to) or (greater than) 90% as ordered ... [MEDICAL CONDITION] as ordered ..." e. On 7/30/13 at 3:02 p.m., Licensed Practical Nurse (LPN) # 1 and this surveyor observed Resident # 1 on initial rounds. [MEDICAL CONDITION] that were in sight in the resident's room included an ambu bag, suction catheter kit, suction machine with canister and extension tubing, and humidifier. Resident # 1 was noted to have four sutures present attaching [MEDICAL CONDITION] to Resident # 1's neck. At 4:12 p.m. LPN # 1 and LPN # 3, the resident's charge nurses on TCU (Transitional Care Unit) were asked: "Do you have any residents with trachs on this unit?" LPNs # 1 and # 3 stated, "(Resident # 1)." LPNs # 1 and # 3 were asked: "Can you show me a replacement trach, obturator, and hemostats that you would use in case [MEDICAL CONDITION] dislodged?" LPN # 1 and # 3 entered Resident # 1's room, searched the bed side table (drawer and both shelves of the cabinet area under the drawer), and searched the built in drawers between the closets. LPN # 1 found a box with three sterile Shiley size 8 disposable inner cannulas in the third drawer down from the top drawer of the built in drawers. LPN # 1 and 3 were asked: "Where are the [MEDICAL CONDITION], obturator, and hemostats?" LPN # 1 stated, "We don't have that." LPN # 1 was asked: "Have you ever had them?" LPN # 1 stated, "No." LPN # 1 and # 3 were asked: "What supplies for trachs are at the nursing station/med room?" LPN # 1 stated, "I'll have to go get a key." LPN # 1 returned in two minutes with a key and opened the door to the med room on B hall/TCU (Transitional Care Unit). Inside the med room there were two boxes with 10 each Shiley # 8 disposable inner cannulas, extension suction tubing, canisters with lids,[MEDICAL CONDITION] kits, and suction catheter kits. LPN # 1 was asked: "Do you see any [MEDICAL CONDITION], obturators or hemostats?" LPN # 1 stated, "No." LPN # 2 entered the med room and stated she was the charge nurse for the Nursing Center halls (halls A through D). LPN # 1 and # 2 were asked: "Do you know what size and kind [MEDICAL CONDITION](Resident # 1) has?" LPN # 1 stated, "Other than the inner cannula, no." LPN # 1 and 2 were asked: "Is there another storage area [MEDICAL CONDITION]?" LPN # 1 and # 2 stated, "Central Supply." This surveyor and both nurses entered Central Supply at 4:20 p.m. The [MEDICAL CONDITION] were present in Central Supply: 14 Fr (French) suction catheter kits, humidifier bottles, oxygen tubing,[MEDICAL CONDITION] kits, sterile water, 2 boxes with 10 count per box [MEDICATION NAME] size 8 disposable inner cannulas and 4 boxes with 10 count per box of Shiley # 8 disposable inner cannulas. There were no [MEDICAL CONDITION], obturators, or hemostats. LPN # 1 and 2 were asked: "If a resident dislodges [MEDICAL CONDITION] do you do?" LPN # 1 stated, "I don't know that's never happened." LPN # 2 stated, "Maintain airway, get a replacement kit and put [MEDICAL CONDITION]." LPN # 2 was asked "Where do you go to find the [MEDICAL CONDITION]?" LPN # 2 stated, "Not in here." LPN # 2 was asked, "How are you going to maintain the airway?" LPN # 2 stated, "Call 911." At 4:25 p.m., the Director of Nurses (DON) was asked: "If a resident dislodges a trach, what is your staff to do?" The DON stated, "Attempt to put it back in. The DON was asked, "The same one?" The DON stated, "No. A new one. All the residents with trachs have a [MEDICAL CONDITION] the bedside." The DON was asked, "Can you come with me to (Resident # 1's) room to find one?" The DON stated, "Yes, but can I stop at Central Supply and check there first?" The DON and this surveyor went to Central Supply. The DON looked [MEDICAL CONDITION] and then stated, "There's none here." The DON and this surveyor left Central Supply at 4:29 p.m. and went to Resident # 1's room. The DON removed the clear plastic bag with the ambu bag inside it from the top of the light fixture. The DON stated, "Not here." The DON searched the bed side table (drawer and both shelves of the cabinet area under the drawer), and searched the built in drawers between the closets. The DON stated, "I don't see one but I will call and get one right away." The DON was asked, "Do you see an obturator or hemostats?" The DON stated, "No." The DON was asked, "How long has this resident been here?" The DON stated, "Two to three weeks." The DON went to the resident's chart and reviewed the face sheet. The DON stated, "Since 7/19/13." At 7:00 p.m. the Administrator was asked, "Who [MEDICAL CONDITION]?" The Administrator stated, "The nurses are supposed to let us know what supplies they need." The Administrator was asked, "What is your intake process, are they able to determine at intake [MEDICAL CONDITION] a resident will need prior to admission?" The Administrator stated, "Sure, we'll inservice the DON, ADON (Assistant Director of Nurses) and Admission (Coordinator) to [MEDICAL CONDITION] before a resident arrives." f. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 7/30/13 at 7:10 p.m. when the facility implemented the following Plan of Removal: Identification: 1) This failed practice had the potential to affect 2 residents that have trachs. Assessments: 2) ADON (Assistant Director of Nurses)/designee assessed both resident for signs and symptoms related to negative outcomes due to [MEDICAL CONDITION] not available, with no negative findings. On 7/30/13 upon notification of the deficient practice DON (Director of Nurses) ordered [MEDICAL CONDITION] resident and hung hemostats on the resident's wall above the bed. Once [MEDICAL CONDITION] delivered, it will be hung above the resident's bed. Resident's physician was notified by DON of the failed practice related [MEDICAL CONDITION] not available. Training: 3) On 7/30/13 at 6:00 p.m., DON/Designee started an on-going in-service to licensed staff that upon admission,[MEDICAL CONDITION] are to have: emergency [MEDICAL CONDITION] replacement kit: sterile tracheal [MEDICATION NAME] or sterile hemostat, sterile obturator that fits the [MEDICAL CONDITION] in use, extra sterile [MEDICAL CONDITION] and obturators in the appropriate size, suction equipment and supplies. Licensed staff will be inserviced before the start of their shift. Licensed staff that is on FMLA, Vacation, out sick or newly hired will be in-serviced before the start of their shift. DON/ADON/Admissions Coordinator were in-serviced on 7/30/13 at 7:10 p.m. on having all supplies in the facility prior to admission. This is to include [MEDICAL CONDITION]. Monitoring: 4) DON/Designee will [MEDICAL CONDITION] in the rooms daily x (times) 3 weeks. Monitoring supplies with be placed on the MAR (Medication Administration Record) for the nurse to sign off (every) shift. Care Keeper Rounds will be incorporated to [MEDICAL CONDITION] 5 days a week. Any negative findings will be corrected immediately and the DON will report to the monthly QAA (Quality Assessment and Assurance) meeting for further recommendations. g. On 8/2/13 at 2:05 p.m., the DON presents (name) medical equipment supplier invoices from 6/19/13 through 7/31/13. On 7/30/13 the medical equipment supplier delivered a replacement # 8 cannula low pressure tube. This was the only documented invoice for a [MEDICAL CONDITION] in this time frame. h. On 7/30/13 at 3:02 p.m., on 7/31/13 at 8:12 a.m., 9:35 a.m., 10:13 a.m., 12:45 p.m., 1:00 p.m., 3:40 p.m. and 4:05 p.m., and on 8/1/13 at 9:18 a.m. and 11:00 a.m., Resident # 1 was noted to have four sutures present attaching [MEDICAL CONDITION] to Resident # 1's neck. Oxygen was administered [MEDICAL CONDITION] at 7 liters a minute and a humidifier was at 28%. i. On 7/31/13 at 12:50 p.m.,[MEDICAL CONDITION] supplies were noted on the nursing station desk. Licensed Practical Nurse (LPN) # 4 was asked, "Who is going to [MEDICAL CONDITION]?" LPN # 4 stated, "I'll do it." LPN # 4 was asked, "Doesn't (LPN # 6) [MEDICAL CONDITION] as the resident's charge nurse today?" LPN # 4 stated, "I'm relieving her, she'll do it if she's back in time." LPN # 4 then left the unit. At 12:55 p.m. the Nurse Consultant stated, "We have switched nurses and I have started retraining them. (LPN # 6) moved to another unit and I'm training her." LPN # 4 entered the nursing unit and walked toward the nursing station desk area. At 1:00 p.m., LPN # 4 [MEDICAL CONDITION] from the nursing station desk area and took them into Resident # 1's room. The Assistant Director of Nurses (ADON) also entered Resident # 1's room to assist [MEDICAL CONDITION]. The ADON washed her hands and put on gloves. LPN # 4 placed the suction catheter kit,[MEDICAL CONDITION] kit, neck band, q-tips, Normal Saline bottle, sterile inner cannula, Hydrogen Peroxide bottle, and a bottle of alcohol gel on a clean towel set up on Resident # 1's over bed table. There was a box of clean gloves next to the clean towel. LPN # 4 used alcohol gel on her hands then opened [MEDICAL CONDITION] kit. LPN # 4 placed the sterile drape on the resident's upper chest area, removed the tray from the kit, and filled one of two tubs built into the tray with normal saline. LPN # 4 opened the suction catheter kit. LPN # 4 used alcohol gel on her hands, put on clean gloves and unhooked [MEDICAL CONDITION] while leaving it in place over [MEDICAL CONDITION]. LPN # 4 removed her gloves and opened the new sterile inner cannula. LPN # 4 put on sterile gloves, suctioned Resident # 1 and placed the upper part of the suction catheter, including the tip, curled up inside the sterile suction catheter tray. LPN # 4 poured normal saline and hydrogen peroxide into the second tub of [MEDICAL CONDITION] tray. As LPN # 4 removed a pair of clean gloves from the box of clean gloves, the suction catheter was pulled out of the sterile suction catheter tray touching the outside of the box of clean gloves then landing on the clean field. LPN # 4 put on clean gloves. LPN # 4 cleaned around the edge of the [MEDICAL CONDITION] where the [MEDICAL CONDITION] and cleaned the upper side of [MEDICAL CONDITION]. Resident # 1 still had 4 sutures present attaching [MEDICAL CONDITION] to her neck. LPN # 4 did not clean [MEDICAL CONDITION] site or the bottom side of [MEDICAL CONDITION]. LPN # 4 used alcohol gel on her hands and put on clean gloves. LPN # 4 picked up the inner cannula with her clean (not sterile) gloves by holding the inner cannula with the thumb and second finger and placing the first finger on the back side (curved area) of the clear plastic of the inner cannula which contaminated the inner cannula. LPN # 4 used the first (pointer) finger to push the inner cannula into the outer cannula. LPN # 4 then locked the inner cannula into the outer cannula of the trach. LPN # 4 then suctioned Resident # 1 two times using the contaminated suction catheter. LPN # 4 reconnected [MEDICAL CONDITION], removed the sterile field, picked up trach, took her gloves off, and put alcohol gel on her hands. During [MEDICAL CONDITION] procedure the ADON gave LPN # 4 directions but did not stop LPN # 4 when she contaminated the suction catheter or the inner cannula, nor did the ADON direct LPN # 4 to clean [MEDICAL CONDITION] site. LPN # 4 was asked, "Where all did you clean when you cleaned the white area (flange) of the outer cannula?" LPN # 4 stated, "The top and under the outer trach." LPN # 4 was asked, "[MEDICAL CONDITION] a clean or a sterile procedure?" LPN # 4 stated "Clean." LPN # 4 was asked, "Did you have on clean gloves when the inner cannula was replaced?" LPN # 4 stated, "Yes." LPN # 4 was asked, "How did you hold onto the inner cannula?" LPN demonstrated how she held the inner cannula and stated, "Thumb and middle finger (second finger) on the white outside area and first finger on the inner cannula to steady it." LPN # 4 demonstrated her first finger was approximately 1/2 inch beyond her thumb and "middle finger." LPN # 4 was asked, "When were you trained [MEDICAL CONDITION]?" LPN # 4 stated, "Two months ago." LPN # 4 was asked, "Do you [MEDICAL CONDITION] often?" LPN # 4 stated, "No." LPN # 4 was asked, "How often do you [MEDICAL CONDITION]?" LPN # 4 stated, "Counting today, twice." LPN # 4 was asked, "Why is it a clean and not a sterile procedure?" LPN # 4 stated, "Here we don't have sterile gloves." LPN # 4 was asked, "Were the purple gloves inside the wrapper from the [MEDICAL CONDITION] sterile?" LPN # 4 stated, "Yes, they came in a closed container." LPN # 4 was asked, "What did you take the inner cannula out of?" LPN # 4 stated, "A sterile container." LPN # 4 was asked, "When you touched the inner cannula with clean gloves, what did you do to the inner cannula?" LPN # 4 stated, "Contaminated it." j. On 8/2/13 at 11:40 a.m. the Director of Nurses (DON) was asked to review Resident # 1's physician orders. The DON was asked "Can you find any oxygen orders?" The DON stated, "No." The DON was asked, "She's (Resident) been observed with humidified oxygen at 7 liters per minute, is that a problem?" The DON stated, "Yes." The DON was asked, "Can you find any directions to change the [MEDICAL CONDITION] or [MEDICAL CONDITION] for (Resident # 1)?" The DON stated, "None on the 7/18/13 TAR (Treatment Administration Record)." The DON was asked, "Find any orders [MEDICAL CONDITION] or changes of the [MEDICAL CONDITION]?" The DON stated, "No." The DON was asked, "Did you know (Resident # 1) still has sutures in her trach?" The DON stated "No." The DON was asked, "How long do you normally leave sutures in?" The DON stated "Seven to ten days." The DON was asked, "Do you know what date [MEDICAL CONDITION] put in?" The DON stated "No, I'll see what I can find." 5. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/25/13 documented the resident was comatose, was totally dependent for activities of daily living, received oxygen therapy, suctioning and [MEDICAL CONDITION] (trach) care. a. The undated admission intake form documented "... Possible (discharge) Date: 6/17/13 ...Admit (Diagnoses): ... [MEDICAL CONDITION] ... Trach/Size: Collar # 8 [MEDICATION NAME]" b. The medical equipment supplier delivery ticket dated 6/17/13 documented sterile water,[MEDICAL CONDITION], jet nebulizer and an ambu bag were delivered on 6/17/13. There was no documentation of sterile hemostats or a [MEDICAL CONDITION] for a # 8 Shiley [MEDICAL CONDITION] on this date. c. The Care Plan dated 6/27/13 documented, "Focus: Resident is at risk for breathing difficulties (related to) pneumonia, [MEDICAL CONDITION] ... Interventions: ... Provide oral/trach suctioning as needed ..." d. The admission orders ... [MEDICAL CONDITION](as needed). Cool [MEDICAL CONDITION] 28% (with) humidified (oxygen) (at) 2 (liters) [MEDICAL CONDITION] Clean outside [MEDICAL CONDITIONS] (twice a day) (and) (as needed) on 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m..." e. On 7/30/13 at 4:30 p.m., the Assistant Director of Nurses (ADON) was asked to [MEDICAL CONDITION] in Resident # 2's room. The ADON found disposable inner cannulas size 8, suction catheters,[MEDICAL CONDITIONS] kit, and an ambu bag. There were no hemostats or obturator located in the resident's room. The ADON stated, "I do not see any hemostats at this time." The ADON was asked "Did you see an obturator ..." The ADON stated, "I don't see an obturator." f. On 7/30/13 at 5:10 p.m., the medication room for halls E, F, G, and H, (the med room for Resident # 2) was observed [MEDICAL CONDITION]. There were [MEDICAL CONDITION] kits and 6 suction catheter kits present in the med room. g. On 7/30/13 at 5:42 p.m., the Director of Nurses (DON) placed a package of hemostats on the wall above Resident # 2's head. The DON showed this surveyor a [MEDICAL CONDITION] that was in a built in drawer by the closet which contained an obturator. h. On 7/31/13 at 10:50 a.m. LPN # 9, the resident's charge nurse on this date, was asked, "When [MEDICAL CONDITION] done?" LPN # 9 stated, "Every four hours." LPN # 9 was asked, "When are you going to do it?" LPN # 9 stated, "I don't. (LPN # 1) does." LPN # 9 was asked,"Why does (LPN # 1) do it?" LPN # 9 stated, "I'm usually passing pills." i. On 8/1/13 at 9:30 a.m., approximately 1 inch of water was noted in Resident # 2's humidifier bottle. At 1:05 p.m. and 3:10 p.m., the humidifier bottle was empty of water. j. On 8/1/13 at 3:10 p.m., LPN #4 and LPN #6 stated they were going to [MEDICAL CONDITION]. LPN #6 [MEDICAL CONDITION] supplies on an over bed table at the nursing station. The supplies included a suction catheter kit, a Shiley # 8 disposable inner cannula, [MEDICAL CONDITION] kits, packages 4 by 4's, a large package of 2 x 2's, a box of opened clean gloves. LPN #6 pushed the over bed table from the nursing station to Resident # 2's room. LPN #4 and #6 put on isolation gowns, mask, gloves and foot covers prior to entering Resident # 2's room. LPN # 6 set up a clean field, opened the suction catheter kit, [MEDICAL CONDITION] kit, poured Hydrogen Peroxide into one of the two tubs built into [MEDICAL CONDITION] tray, added normal saline to this tray and then poured normal saline into another tray. LPN # 6 removed her gloves, used alcohol gel on her hands, put on one glove and then turned to turn on the suction machine. LPN #6 stated, "I'm not sure how to turn this on, they are all different." LPN #4 provided directions to LPN #6 regarding where the switch was to turn on the suction machine. LPN #6 turned on the suction machine with her ungloved hand. LPN #6 removed her glove and used alcohol gel on her hands. LPN #6 put on sterile gloves, picked up the sterile suction catheter and suctioned Resident # 2. LPN #6 then removed the suction catheter from the extension suction tubing and removed her sterile gloves. LPN #6 discarded the suction catheter and gloves. LPN #6 put on clean gloves from the box of gloves, picked up a 4 by 4 and started toward the resident'[MEDICAL CONDITION] the 4 x 4. LPN #6 stopped, removed her gloves, used alcohol gel on her hands, picked up the sterile drape and held in it her hand while putting on sterile gloves on the opposite hand. LPN #6 then changed hands holding the sterile drape and put a sterile glove on the other hand. LPN #6 contaminated the sterile field when touching it with her hands then contaminated her sterile gloves by holding the contaminated drape in her gloved hands. LPN #6 put the drape across the resident's upper chest and touched the outside locking portion of [MEDICAL CONDITION]. LPN #6 removed her "sterile" gloves, used alcohol gel, then put on clean gloves from the box of gloves. LPN #4 used clean gloves to clean the upper side of [MEDICAL CONDITION], using a sterile 4 x 4 wet with a solution of one half Hydrogen Peroxide and one half normal saline. LPN #6 used a total of four 4 x 4's wiping a quarter area of the upper flange with each wipe and changing gloves and 4 x 4's after each wipe. LPN #6 put on clean gloves from the box of gloves and removed the inner cannula. After hand hygiene, LPN #6 put on clean gloves and used a sterile 4 by 4 wet with one half Hydrogen Peroxide and one half normal saline to clean the locking mechanism on the [MEDICAL CONDITION]. LPN #6 never cleaned [MEDICAL CONDITION] site or the bottom side of [MEDICAL CONDITION] where secretions can accumulate. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley # 8 disposable inner cannula. LPN #6 attempted to insert the Shiley #8 curved inner cannula into a straight Shiley #[MEDICATION NAME] cannula. LPN #6 stated, "It will not go" and requested LPN #4 to get another inner cannula. LPN # 4 returned with another Shiley # 8 curved inner cannula. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley #8 curved disposable inner cannula. LPN #6 attempted to insert the Shiley # 8 curved inner cannula into a straight Shiley # [MEDICATION NAME] cannula a second time. This surveyor suggested to the LPNs that they stop and check the type [MEDICAL CONDITION] #2 had. At 3:55 p.m., LPN # 6 was asked, "What kind [MEDICAL CONDITION] he have, can you look at the replacement box or [MEDICAL CONDITION] tell?" LPN # 6 stated, "It says XLT. I got the wrong kind of inner cannula. I followed the doctor's orders and brought what it said." There was no physician order that specified the type or size of trach. At 4:05 p.m., LPN # 4 entered Resident # 2's room with a Shiley #[MEDICATION NAME] inner cannula. LPN #4 opened the inner cannula package. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley #[MEDICATION NAME] inner cannula and touched the outside of the clear plastic inner tube with her clean gloves, contaminating the inner cannula. LPN #6 inserted the disposable inner cannula into the [MEDICAL CONDITION]. On completion [MEDICAL CONDITION] LPN #6 was asked, "Did you know the humidifier was empty?" LPN #6 stated, "No." LPN # 6 was asked, "You checked the humidifier when?" LPN # 6 did not respond. LPN #4 and #6 looked in the resident's room for sterile water to fill the humidifier and stated there was no water in the room to fill the humidifier bottle. k. On 8/1/13 at 4:17 p.m. LPN #6 was asked, "You've worked how many times on TCU in the last month?" LPN #6 stated, "Six times." LPN #6 was asked, "Prior to yesterday did you have [MEDICAL CONDITION]?" LPN #6 stated, "Yes, five to six years ago in (Town)." LPN #6 was asked, "Any (training) here?" LPN #6 stated, "No." LPN #6 was asked, "How many times have you [MEDICAL CONDITION] in the last month?" LPN # 6 stated, "Every shift I worked on TCU." LPN #6 was asked, "[MEDICAL CONDITION] a clean or sterile procedure?" LPN # 6 stated, "It's clean in a long term care facility." LPN #6 was asked, "Is that what they taught you yesterday?" LPN #6 stated, "No, just the steps and what to do if it came out. I was on a med cart and they told me what to do." LPN #6 was asked, "Did you do any return demonstration?" LPN #6 stated, "No, I told them what I'd do, the steps." LPN #6 was asked, "Did you know your clean gloves contaminated the inner cannula on (Resident # 2)?" LPN #6 stated, "No, I had on clean gloves and it's a clean procedure." l. On 8/2/13 at 11:40 a.m., the DON was asked to review the TARs dated 7/29/13 for Resident # 2. The DON was asked, "Can you find directions [MEDICAL CONDITION] or cannula changes?" The DON stated, "Clean outside [MEDICAL CONDITIONS] (twice a day) is the only thing there." The DON was asked, "What does that mean?" The DON stated, "I couldn't tell you. By reading it, it says just clean the outside of [MEDICAL CONDITION] about the inside." The DON was asked, "Are staff to clean [MEDICAL CONDITION]?" The DON stated, "Yes."

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility Quality Assessment and Assurance (QA&A) Committee failed to identify quality deficiencies in order to implement corrective actions as evidenced by the facility failures to: Ensure a hemostat and replacement [MEDICAL CONDITION] kit were present to maintain a patent airway in case of accidental dislodgement for 2 of 2 (Resident # 1 and #2) case mix residents in the facility who had a [MEDICAL CONDITION]. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 1 who had a recent [MEDICAL CONDITION] procedure on 7/12/13, and had the potential to cause more than minimal harm to 1 other resident in the facility who had a [MEDICAL CONDITION] according to the listing received from the Director of Nurse on 8/3/13. The facility was notified of the Immediate Jeopardy condition on 7/30/13 at 5:32 p.m. Ensure [MEDICAL CONDITION] (trach) care was provided in a sterile manner and included cleaning of [MEDICAL CONDITION] to prevent possible infections for 2 of 2 (Residents # 1 and #2) case mix residents who [MEDICAL CONDITION]. Ensure the correct inner cannula was used [MEDICAL CONDITION] for 1 (Resident # 2) of 2 (Residents # 1 and #2) case mix residents who [MEDICAL CONDITION]. Ensure water was present in the humidifier to humidify oxygen administered [MEDICAL CONDITION] for 1 (Resident # 2) of 2 (Residents # 1 and #2) case mix residents with a physician order for [REDACTED]. The findings are: 1. The facility's "Job Description Administrator" documented "... Essential Duties and Responsibilities: ... Directs, coordinates, facilitates and evaluates the performance of the facility's department directors and other members of the administrative team. ... Serves as chairperson of the Performance Improvement and Assurance committee and facilities the operation of the Quality Assurance program in accordance with facility policy and Federal regulation ..." On 8/2/13 at 9:50 a.m. the Administrator was asked, "Describe your formal method to identify issues which require QA (Quality Assurance) Committee actions." The Administrator stated, "Care Keeper rounds ... we look at severity of issues, how long, ongoing, etc. It is a case by case." 2. The "Best Practices: A Guide to Excellence in Nursing Care" published in 2003 by Lippincott, Williams and Wilkins page 353" documented: "... For emergency [MEDICAL CONDITION] replacement: Sterile tracheal [MEDICATION NAME] or sterile hemostat, sterile obturator that fits the [MEDICAL CONDITION] in use, two extra sterile tubes and obturators in the appropriate size, suction equipment and supplies. Keep these supplies in full view in the patient's room at all times, for easy access in case of emergency. Consider taping an emergency sterile [MEDICAL CONDITION] in a sterile wrapper to the head of the bed for easy access in an emergency ..." The facility's policy "[MEDICAL CONDITION] Care ..." documented: " ...Special Considerations: Keep appropriate equipment at the patient's bedside for immediate use in an emergency ... Consult the doctor about first-aid measures you can use for your [MEDICAL CONDITION] patient should an emergency occur. Follow your facility's policy for what to do if a [MEDICAL CONDITION] is expelled or if the inner cannula becomes blocked ..." This "policy" provided by the facility is from Lippincott's "Nursing Procedures Sixth Edition" published by Lippincott Williams and Wilkins 2013 pages 718 through 722. 3. The facility's policy "[MEDICAL CONDITION] Care ..." documented:"Preparation of equipment: Perform hand hygiene and gather all equipment and supplies in the patient's room. For [MEDICAL CONDITION] cannula and stoma care ... Open the waterproof trash bag and place it next to you so that you can avid reaching across the sterile field or the patient'[MEDICATION NAME] discarding soiled items. Establish a sterile field near the patient's bed (usually on the over bed table) and place equipment and supplies on it. Pour normal saline solution or sterile water into one the sterile solution containers; then pour normal saline solution or sterile water into the second sterile container for rinsing. For inner-cannula care, you may use a third sterile solution container to hold the gauze pads and cotton-tipped applicators saturated with normal saline solution. Hydrogen peroxide is no longer recommended for cleaning inner cannulas or [MEDICAL CONDITION] sites. If you'll be replacing the disposable inner cannula, open the package containing the new inner cannula while maintaining sterile technique ... Implementation: ... Perform hand hygiene and put on gloves ... Hyperoxygenate the patient for at least 1 minute and then perform deep oropharyngeal suctioning to remove accumulated secretions from above the cuff and prevent pooled secretions from descending into the trachea ... For [MEDICAL CONDITION] cannula and stoma care: ... Discard gloves, perform hand hygiene, and put on sterile gloves. With your non dominant hand, remove any humidification or ventilation device. Using sterile technique, suction the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation ... With your non dominant hand, reconnect the patient to the humidifier or ventilator, if necessary. Remove the patient's [MEDICAL CONDITION] dressing; inspect it for drainage and then discard it. Remove and discard your gloves and perform hand hygiene. ... Caring for a disposable inner cannula: Perform hand hygiene and put on sterile gloves. Using your dominant hand, remove the patient's inner cannula. ... Pick up the new inner cannula, touching only the outer locking portion. Insert the cannula into the [MEDICAL CONDITION] and following the manufacturer's instructions, lock it securely. Replace any humidification ... device. Cleaning the stoma and outer cannula: Perform hand hygiene and put on sterile gloves. With your dominant hand, moisten a sterile gauze pad with the normal saline solution or sterile water. Squeeze out the excess liquid to prevent accidental aspiration. Then wipe the patient's neck under the [MEDICAL CONDITION] flanges and [MEDICATION NAME] tapes. Assess the site for redness, swelling and drainage, which may indicate infection. ... Use a cotton-tipped applicator and a gauze pad to clean the stoma site and the tube's flanges. Wipe only once with each applicator or gauze pad and then discard it to prevent contamination of a clean area with a soiled applicator or pad. ... Dry the area thoroughly with additional sterile gauze pads; then apply a new sterile [MEDICAL CONDITION] dressing..." This "policy" provided by the facility is from Lippincott's "Nursing Procedures Sixth Edition" published by Lippincott Williams and Wilkins 2013 pages 718 through 722. 4. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/26/13 documented the resident scored a 0 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, received oxygen therapy, and required suctioning and [MEDICAL CONDITION] care. a. The (Hospital) medical records received from the Director of Nurses on 8/2/13 documented: "Surgical Operative Note: ... Date Performed: 7/12/13. Pre Procedure Diagnosis: [REDACTED]. ... Procedure: 1. Percutaneous [MEDICAL CONDITION] (#8 Shiley)..." The facility intake form dated 7/16/13 documented "... Additional Information:[MEDICAL CONDITION]# 8 Shiley ... [MEDICAL CONDITION] kits ... (Oxygen) at 6 liters [MEDICAL CONDITION], humidified air." The (Medical Equipment Supplier) delivery ticket dated 7/19/13 documented a suction machine,[MEDICAL CONDITION], canisters with tubing and ambu bag were delivered on 7/19/13. There was no documentation of sterile hemostats or a [MEDICAL CONDITION] for a # 8 [MEDICAL CONDITION] on this date. b. The Admission Data Collection Form dated 7/19/13 at 5:30 p.m. documented, "... Respiratory: ... Cough: ... Productive cough, describe: yellow thick [MEDICAL CONDITION] ... Special Treatments and Procedures: FIO2 (at) 28%. Oxygen: 7 L (liters) ... Suctioning: X ..." c. The admission orders [REDACTED]. The physician orders dated 7/19/13 through 7/30/13 at 6:10 p.m. did not include physician orders for oxygen, humidification, [MEDICAL CONDITIONS]. d. The Care Plan dated 7/29/13 documented, "Focus: Resident is at risk for breathing difficulties (related to) [MEDICAL CONDITION] ... Interventions: Administer and monitor effectiveness of respiratory treatments as ordered ... Monitor resident's O2 (oxygen) saturation as needed and titrate (oxygen) to keep resident's O2 saturation (equal to) or (greater than) 90% as ordered ... [MEDICAL CONDITION] as ordered ..." e. On 7/30/13 at 3:02 p.m., Licensed Practical Nurse (LPN) # 1 and this surveyor observed Resident # 1 on initial rounds. [MEDICAL CONDITION] that were in sight in the resident's room included an ambu bag, suction catheter kit, suction machine with canister and extension tubing, and humidifier. Resident # 1 was noted to have four sutures present attaching [MEDICAL CONDITION] to Resident # 1's neck. At 4:12 p.m. LPN # 1 and LPN # 3, the resident's charge nurses on TCU (Transitional Care Unit) were asked: "Do you have any residents with trachs on this unit?" LPNs # 1 and # 3 stated, "(Resident # 1)." LPNs # 1 and # 3 were asked: "Can you show me a replacement trach, obturator, and hemostats that you would use in case [MEDICAL CONDITION] dislodged?" LPN # 1 and # 3 entered Resident # 1's room, searched the bed side table (drawer and both shelves of the cabinet area under the drawer), and searched the built in drawers between the closets. LPN # 1 found a box with three sterile Shiley size 8 disposable inner cannulas in the third drawer down from the top drawer of the built in drawers. LPN # 1 and 3 were asked: "Where are the [MEDICAL CONDITION], obturator, and hemostats?" LPN # 1 stated, "We don't have that." LPN # 1 was asked: "Have you ever had them?" LPN # 1 stated, "No." LPN # 1 and # 3 were asked: "What supplies for trachs are at the nursing station/med room?" LPN # 1 stated, "I'll have to go get a key." LPN # 1 returned in two minutes with a key and opened the door to the med room on B hall/TCU (Transitional Care Unit). Inside the med room there were two boxes with 10 each Shiley # 8 disposable inner cannulas, extension suction tubing, canisters with lids,[MEDICAL CONDITION] kits, and suction catheter kits. LPN # 1 was asked: "Do you see any [MEDICAL CONDITION], obturators or hemostats?" LPN # 1 stated, "No." LPN # 2 entered the med room and stated she was the charge nurse for the Nursing Center halls (halls A through D). LPN # 1 and # 2 were asked: "Do you know what size and kind [MEDICAL CONDITION](Resident # 1) has?" LPN # 1 stated, "Other than the inner cannula, no." LPN # 1 and 2 were asked: "Is there another storage area [MEDICAL CONDITION]?" LPN # 1 and # 2 stated, "Central Supply." This surveyor and both nurses entered Central Supply at 4:20 p.m. The [MEDICAL CONDITION] were present in Central Supply: 14 Fr (French) suction catheter kits, humidifier bottles, oxygen tubing,[MEDICAL CONDITION] kits, sterile water, 2 boxes with 10 count per box [MEDICATION NAME] size 8 disposable inner cannulas and 4 boxes with 10 count per box of Shiley # 8 disposable inner cannulas. There were no [MEDICAL CONDITION], obturators, or hemostats. LPN # 1 and 2 were asked: "If a resident dislodges [MEDICAL CONDITION] do you do?" LPN # 1 stated, "I don't know that's never happened." LPN # 2 stated, "Maintain airway, get a replacement kit and put [MEDICAL CONDITION]." LPN # 2 was asked "Where do you go to find the [MEDICAL CONDITION]?" LPN # 2 stated, "Not in here." LPN # 2 was asked, "How are you going to maintain the airway?" LPN # 2 stated, "Call 911." At 4:25 p.m., the Director of Nurses (DON) was asked: "If a resident dislodges a trach, what is your staff to do?" The DON stated, "Attempt to put it back in. The DON was asked, "The same one?" The DON stated, "No. A new one. All the residents with trachs have a [MEDICAL CONDITION] the bedside." The DON was asked, "Can you come with me to (Resident # 1's) room to find one?" The DON stated, "Yes, but can I stop at Central Supply and check there first?" The DON and this surveyor went to Central Supply. The DON looked [MEDICAL CONDITION] and then stated, "There's none here." The DON and this surveyor left Central Supply at 4:29 p.m. and went to Resident # 1's room. The DON removed the clear plastic bag with the ambu bag inside it from the top of the light fixture. The DON stated, "Not here." The DON searched the bed side table (drawer and both shelves of the cabinet area under the drawer), and searched the built in drawers between the closets. The DON stated, "I don't see one but I will call and get one right away." The DON was asked, "Do you see an obturator or hemostats?" The DON stated, "No." The DON was asked, "How long has this resident been here?" The DON stated, "Two to three weeks." The DON went to the resident's chart and reviewed the face sheet. The DON stated, "Since 7/19/13." At 7:00 p.m. the Administrator was asked, "Who [MEDICAL CONDITION]?" The Administrator stated, "The nurses are supposed to let us know what supplies they need." The Administrator was asked, "What is your intake process, are they able to determine at intake [MEDICAL CONDITION] a resident will need prior to admission?" The Administrator stated, "Sure, we'll inservice the DON, ADON (Assistant Director of Nurses) and Admission (Coordinator) to [MEDICAL CONDITION] before a resident arrives." f. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 7/30/13 at 7:10 p.m. when the facility implemented the following Plan of Removal: Identification: 1) This failed practice had the potential to affect 2 residents that have trachs. Assessments: 2) ADON (Assistant Director of Nurses)/designee assessed both resident for signs and symptoms related to negative outcomes due to [MEDICAL CONDITION] not available, with no negative findings. On 7/30/13 upon notification of the deficient practice DON (Director of Nurses) ordered [MEDICAL CONDITION] resident and hung hemostats on the resident's wall above the bed. Once [MEDICAL CONDITION] delivered, it will be hung above the resident's bed. Resident's physician was notified by DON of the failed practice related [MEDICAL CONDITION] not available. Training: 3) On 7/30/13 at 6:00 p.m., DON/Designee started an on-going in-service to licensed staff that upon admission,[MEDICAL CONDITION] are to have: emergency [MEDICAL CONDITION] replacement kit: sterile tracheal [MEDICATION NAME] or sterile hemostat, sterile obturator that fits the [MEDICAL CONDITION] in use, extra sterile [MEDICAL CONDITION] and obturators in the appropriate size, suction equipment and supplies. Licensed staff will be inserviced before the start of their shift. Licensed staff that is on FMLA, Vacation, out sick or newly hired will be in-serviced before the start of their shift. DON/ADON/Admissions Coordinator were in-serviced on 7/30/13 at 7:10 p.m. on having all supplies in the facility prior to admission. This is to include [MEDICAL CONDITION]. Monitoring: 4) DON/Designee will [MEDICAL CONDITION] in the rooms daily x (times) 3 weeks. Monitoring supplies with be placed on the MAR (Medication Administration Record) for the nurse to sign off (every) shift. Care Keeper Rounds will be incorporated to [MEDICAL CONDITION] 5 days a week. Any negative findings will be corrected immediately and the DON will report to the monthly QAA (Quality Assessment and Assurance) meeting for further recommendations. g. On 8/2/13 at 2:05 p.m., the DON presents (name) medical equipment supplier invoices from 6/19/13 through 7/31/13. On 7/30/13 the medical equipment supplier delivered a replacement # 8 cannula low pressure tube. This was the only documented invoice for a [MEDICAL CONDITION] in this time frame. h. On 7/30/13 at 3:02 p.m., on 7/31/13 at 8:12 a.m., 9:35 a.m., 10:13 a.m., 12:45 p.m., 1:00 p.m., 3:40 p.m. and 4:05 p.m., and on 8/1/13 at 9:18 a.m. and 11:00 a.m., Resident # 1 was noted to have four sutures present attaching [MEDICAL CONDITION] to Resident # 1's neck. Oxygen was administered [MEDICAL CONDITION] at 7 liters a minute and a humidifier was at 28%. i. On 7/31/13 at 12:50 p.m.,[MEDICAL CONDITION] supplies were noted on the nursing station desk. Licensed Practical Nurse (LPN) # 4 was asked, "Who is going to [MEDICAL CONDITION]?" LPN # 4 stated, "I'll do it." LPN # 4 was asked, "Doesn't (LPN # 6) [MEDICAL CONDITION] as the resident's charge nurse today?" LPN # 4 stated, "I'm relieving her, she'll do it if she's back in time." LPN # 4 then left the unit. At 12:55 p.m. the Nurse Consultant stated, "We have switched nurses and I have started retraining them. (LPN # 6) moved to another unit and I'm training her." LPN # 4 entered the nursing unit and walked toward the nursing station desk area. At 1:00 p.m., LPN # 4 [MEDICAL CONDITION] from the nursing station desk area and took them into Resident # 1's room. The Assistant Director of Nurses (ADON) also entered Resident # 1's room to assist [MEDICAL CONDITION]. The ADON washed her hands and put on gloves. LPN # 4 placed the suction catheter kit,[MEDICAL CONDITION] kit, neck band, q-tips, Normal Saline bottle, sterile inner cannula, Hydrogen Peroxide bottle, and a bottle of alcohol gel on a clean towel set up on Resident # 1's over bed table. There was a box of clean gloves next to the clean towel. LPN # 4 used alcohol gel on her hands then opened [MEDICAL CONDITION] kit. LPN # 4 placed the sterile drape on the resident's upper chest area, removed the tray from the kit, and filled one of two tubs built into the tray with normal saline. LPN # 4 opened the suction catheter kit. LPN # 4 used alcohol gel on her hands, put on clean gloves and unhooked [MEDICAL CONDITION] while leaving it in place over [MEDICAL CONDITION]. LPN # 4 removed her gloves and opened the new sterile inner cannula. LPN # 4 put on sterile gloves, suctioned Resident # 1 and placed the upper part of the suction catheter, including the tip, curled up inside the sterile suction catheter tray. LPN # 4 poured normal saline and hydrogen peroxide into the second tub of [MEDICAL CONDITION] tray. As LPN # 4 removed a pair of clean gloves from the box of clean gloves, the suction catheter was pulled out of the sterile suction catheter tray touching the outside of the box of clean gloves then landing on the clean field. LPN # 4 put on clean gloves. LPN # 4 cleaned around the edge of the [MEDICAL CONDITION] where the [MEDICAL CONDITION] and cleaned the upper side of [MEDICAL CONDITION]. Resident # 1 still had 4 sutures present attaching [MEDICAL CONDITION] to her neck. LPN # 4 did not clean [MEDICAL CONDITION] site or the bottom side of [MEDICAL CONDITION]. LPN # 4 used alcohol gel on her hands and put on clean gloves. LPN # 4 picked up the inner cannula with her clean (not sterile) gloves by holding the inner cannula with the thumb and second finger and placing the first finger on the back side (curved area) of the clear plastic of the inner cannula which contaminated the inner cannula. LPN # 4 used the first (pointer) finger to push the inner cannula into the outer cannula. LPN # 4 then locked the inner cannula into the outer cannula of the trach. LPN # 4 then suctioned Resident # 1 two times using the contaminated suction catheter. LPN # 4 reconnected [MEDICAL CONDITION], removed the sterile field, picked up trach, took her gloves off, and put alcohol gel on her hands. During [MEDICAL CONDITION] procedure the ADON gave LPN # 4 directions but did not stop LPN # 4 when she contaminated the suction catheter or the inner cannula, nor did the ADON direct LPN # 4 to clean [MEDICAL CONDITION] site. LPN # 4 was asked, "Where all did you clean when you cleaned the white area (flange) of the outer cannula?" LPN # 4 stated, "The top and under the outer trach." LPN # 4 was asked, "[MEDICAL CONDITION] a clean or a sterile procedure?" LPN # 4 stated "Clean." LPN # 4 was asked, "Did you have on clean gloves when the inner cannula was replaced?" LPN # 4 stated, "Yes." LPN # 4 was asked, "How did you hold onto the inner cannula?" LPN demonstrated how she held the inner cannula and stated, "Thumb and middle finger (second finger) on the white outside area and first finger on the inner cannula to steady it." LPN # 4 demonstrated her first finger was approximately 1/2 inch beyond her thumb and "middle finger." LPN # 4 was asked, "When were you trained [MEDICAL CONDITION]?" LPN # 4 stated, "Two months ago." LPN # 4 was asked, "Do you [MEDICAL CONDITION] often?" LPN # 4 stated, "No." LPN # 4 was asked, "How often do you [MEDICAL CONDITION]?" LPN # 4 stated, "Counting today, twice." LPN # 4 was asked, "Why is it a clean and not a sterile procedure?" LPN # 4 stated, "Here we don't have sterile gloves." LPN # 4 was asked, "Were the purple gloves inside the wrapper from the [MEDICAL CONDITION] sterile?" LPN # 4 stated, "Yes, they came in a closed container." LPN # 4 was asked, "What did you take the inner cannula out of?" LPN # 4 stated, "A sterile container." LPN # 4 was asked, "When you touched the inner cannula with clean gloves, what did you do to the inner cannula?" LPN # 4 stated, "Contaminated it." j. On 8/2/13 at 11:40 a.m. the Director of Nurses (DON) was asked to review Resident # 1's physician orders. The DON was asked "Can you find any oxygen orders?" The DON stated, "No." The DON was asked, "She's (Resident) been observed with humidified oxygen at 7 liters per minute, is that a problem?" The DON stated, "Yes." The DON was asked, "Can you find any directions to change the [MEDICAL CONDITION] or [MEDICAL CONDITION] for (Resident # 1)?" The DON stated, "None on the 7/18/13 TAR (Treatment Administration Record)." The DON was asked, "Find any orders [MEDICAL CONDITION] or changes of the [MEDICAL CONDITION]?" The DON stated, "No." The DON was asked, "Did you know (Resident # 1) still has sutures in her trach?" The DON stated "No." The DON was asked, "How long do you normally leave sutures in?" The DON stated "Seven to ten days." The DON was asked, "Do you know what date [MEDICAL CONDITION] put in?" The DON stated "No, I'll see what I can find." 5. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/25/13 documented the resident was comatose, was totally dependent for activities of daily living, received oxygen therapy, suctioning and [MEDICAL CONDITION] (trach) care. a. The undated admission intake form documented "... Possible (discharge) Date: 6/17/13 ...Admit (Diagnoses): ... [MEDICAL CONDITION] ... Trach/Size: Collar # 8 [MEDICATION NAME]" b. The medical equipment supplier delivery ticket dated 6/17/13 documented sterile water,[MEDICAL CONDITION], jet nebulizer and an ambu bag were delivered on 6/17/13. There was no documentation of sterile hemostats or a [MEDICAL CONDITION] for a # 8 Shiley [MEDICAL CONDITION] on this date. c. The Care Plan dated 6/27/13 documented, "Focus: Resident is at risk for breathing difficulties (related to) pneumonia, [MEDICAL CONDITION] ... Interventions: ... Provide oral/trach suctioning as needed ..." d. The admission orders ... [MEDICAL CONDITION](as needed). Cool [MEDICAL CONDITION] 28% (with) humidified (oxygen) (at) 2 (liters) [MEDICAL CONDITION] Clean outside [MEDICAL CONDITIONS] (twice a day) (and) (as needed) on 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m..." e. On 7/30/13 at 4:30 p.m., the Assistant Director of Nurses (ADON) was asked to [MEDICAL CONDITION] in Resident # 2's room. The ADON found disposable inner cannulas size 8, suction catheters,[MEDICAL CONDITIONS] kit, and an ambu bag. There were no hemostats or obturator located in the resident's room. The ADON stated, "I do not see any hemostats at this time." The ADON was asked "Did you see an obturator ..." The ADON stated, "I don't see an obturator." f. On 7/30/13 at 5:10 p.m., the medication room for halls E, F, G, and H, (the med room for Resident # 2) was observed [MEDICAL CONDITION]. There were [MEDICAL CONDITION] kits and 6 suction catheter kits present in the med room. g. On 7/30/13 at 5:42 p.m., the Director of Nurses (DON) placed a package of hemostats on the wall above Resident # 2's head. The DON showed this surveyor a [MEDICAL CONDITION] that was in a built in drawer by the closet which contained an obturator. h. On 7/31/13 at 10:50 a.m. LPN # 9, the resident's charge nurse on this date, was asked, "When [MEDICAL CONDITION] done?" LPN # 9 stated, "Every four hours." LPN # 9 was asked, "When are you going to do it?" LPN # 9 stated, "I don't. (LPN # 1) does." LPN # 9 was asked,"Why does (LPN # 1) do it?" LPN # 9 stated, "I'm usually passing pills." i. On 8/1/13 at 9:30 a.m., approximately 1 inch of water was noted in Resident # 2's humidifier bottle. At 1:05 p.m. and 3:10 p.m., the humidifier bottle was empty of water. j. On 8/1/13 at 3:10 p.m., LPN #4 and LPN #6 stated they were going to [MEDICAL CONDITION]. LPN #6 [MEDICAL CONDITION] supplies on an over bed table at the nursing station. The supplies included a suction catheter kit, a Shiley # 8 disposable inner cannula, [MEDICAL CONDITION] kits, packages 4 by 4's, a large package of 2 x 2's, a box of opened clean gloves. LPN #6 pushed the over bed table from the nursing station to Resident # 2's room. LPN #4 and #6 put on isolation gowns, mask, gloves and foot covers prior to entering Resident # 2's room. LPN # 6 set up a clean field, opened the suction catheter kit, [MEDICAL CONDITION] kit, poured Hydrogen Peroxide into one of the two tubs built into [MEDICAL CONDITION] tray, added normal saline to this tray and then poured normal saline into another tray. LPN # 6 removed her gloves, used alcohol gel on her hands, put on one glove and then turned to turn on the suction machine. LPN #6 stated, "I'm not sure how to turn this on, they are all different." LPN #4 provided directions to LPN #6 regarding where the switch was to turn on the suction machine. LPN #6 turned on the suction machine with her ungloved hand. LPN #6 removed her glove and used alcohol gel on her hands. LPN #6 put on sterile gloves, picked up the sterile suction catheter and suctioned Resident # 2. LPN #6 then removed the suction catheter from the extension suction tubing and removed her sterile gloves. LPN #6 discarded the suction catheter and gloves. LPN #6 put on clean gloves from the box of gloves, picked up a 4 by 4 and started toward the resident'[MEDICAL CONDITION] the 4 x 4. LPN #6 stopped, removed her gloves, used alcohol gel on her hands, picked up the sterile drape and held in it her hand while putting on sterile gloves on the opposite hand. LPN #6 then changed hands holding the sterile drape and put a sterile glove on the other hand. LPN #6 contaminated the sterile field when touching it with her hands then contaminated her sterile gloves by holding the contaminated drape in her gloved hands. LPN #6 put the drape across the resident's upper chest and touched the outside locking portion of [MEDICAL CONDITION]. LPN #6 removed her "sterile" gloves, used alcohol gel, then put on clean gloves from the box of gloves. LPN #4 used clean gloves to clean the upper side of [MEDICAL CONDITION], using a sterile 4 x 4 wet with a solution of one half Hydrogen Peroxide and one half normal saline. LPN #6 used a total of four 4 x 4's wiping a quarter area of the upper flange with each wipe and changing gloves and 4 x 4's after each wipe. LPN #6 put on clean gloves from the box of gloves and removed the inner cannula. After hand hygiene, LPN #6 put on clean gloves and used a sterile 4 by 4 wet with one half Hydrogen Peroxide and one half normal saline to clean the locking mechanism on the [MEDICAL CONDITION]. LPN #6 never cleaned [MEDICAL CONDITION] site or the bottom side of [MEDICAL CONDITION] where secretions can accumulate. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley # 8 disposable inner cannula. LPN #6 attempted to insert the Shiley #8 curved inner cannula into a straight Shiley #[MEDICATION NAME] cannula. LPN #6 stated, "It will not go" and requested LPN #4 to get another inner cannula. LPN # 4 returned with another Shiley # 8 curved inner cannula. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley #8 curved disposable inner cannula. LPN #6 attempted to insert the Shiley # 8 curved inner cannula into a straight Shiley # [MEDICATION NAME] cannula a second time. This surveyor suggested to the LPNs that they stop and check the type [MEDICAL CONDITION] #2 had. At 3:55 p.m., LPN # 6 was asked, "What kind [MEDICAL CONDITION] he have, can you look at the replacement box or [MEDICAL CONDITION] tell?" LPN # 6 stated, "It says XLT. I got the wrong kind of inner cannula. I followed the doctor's orders and brought what it said." There was no physician order that specified the type or size of trach. At 4:05 p.m., LPN # 4 entered Resident # 2's room with a Shiley #[MEDICATION NAME] inner cannula. LPN #4 opened the inner cannula package. After hand hygiene, LPN #6 put on clean gloves and picked up the Shiley #[MEDICATION NAME] inner cannula and touched the outside of the clear plastic inner tube with her clean gloves, contaminating the inner cannula. LPN #6 inserted the disposable inner cannula into the [MEDICAL CONDITION]. On completion [MEDICAL CONDITION] LPN #6 was asked, "Did you know the humidifier was empty?" LPN #6 stated, "No." LPN # 6 was asked, "You checked the humidifier when?" LPN # 6 did not respond. LPN #4 and #6 looked in the resident's room for sterile water to fill the humidifier and stated there was no water in the room to fill the humidifier bottle. k. On 8/1/13 at 4:17 p.m. LPN #6 was asked, "You've worked how many times on TCU in the last month?" LPN #6 stated, "Six times." LPN #6 was asked, "Prior to yesterday did you have [MEDICAL CONDITION]?" LPN #6 stated, "Yes, five to six years ago in (Town)." LPN #6 was asked, "Any (training) here?" LPN #6 stated, "No." LPN #6 was asked, "How many times have you [MEDICAL CONDITION] in the last month?" LPN # 6 stated, "Every shift I worked on TCU." LPN #6 was asked, "[MEDICAL CONDITION] a clean or sterile procedure?" LPN # 6 stated, "It's clean in a long term care facility." LPN #6 was asked, "Is that what they taught you yesterday?" LPN #6 stated, "No, just the steps and what to do if it came out. I was on a med cart and they told me what to do." LPN #6 was asked, "Did you do any return demonstration?" LPN #6 stated, "No, I told them what I'd do, the steps." LPN #6 was asked, "Did you know your clean gloves contaminated the inner cannula on (Resident # 2)?" LPN #6 stated, "No, I had on clean gloves and it's a clean procedure." l. On 8/2/13 at 11:40 a.m., the DON was asked to review the TARs dated 7/29/13 for Resident # 2. The DON was asked, "Can you find directions [MEDICAL CONDITION] or cannula changes?" The DON stated, "Clean outside of