Every finding on record at The Green House Cottages of Belle Meade

Based on observations, interviews, and record reviews, the facility failed to ensure hands were washed between residents while serving dinner, and to ensure utensils were not used after contamination during meal preparation for one of one puree meal observed. The findings include: 1) During an observation on 07/28/2025 at 4:55 PM, Certified Nurse Aide (CNA) #5 and CNA #6 were observed passing trays with gloves on. CNA #5 retrieved a plate from a resident room while wearing gloves. She then took a plate to another resident room without removing gloves or performing hand hygiene. CNA #5 came out of this room, again without performing hand hygiene or removing gloves, and went to the dining room. In the dining room, CNA #5 removed her gloves and started feeding a resident without washing or sanitizing her hands. During an observation on 07/28/2025 at 5:10 PM, CNA #4 touched a coffee cup a resident had drank from with her gloved hands. She did not remove her gloves or sanitize her hands before continuing to pass out dinner plates. During an interview on 07/30/2025 at 4:15 PM, CNA #4 indicated she should always wash her hands and keep hand sanitizer in her pockets. CNA #4 indicated she wore gloves and was supposed to change her gloves every time she passed a plate. She stated she should have taken her gloves off and washed her hands before passing any residents their plates. During a phone interview on 07/31/2025 at 5:19 AM, CNA #5 indicated she usually washed her hands and used hand sanitizer when she was serving meals. She stated that she used gloves to serve the dinner meal on 07/29/2025 because CNA #6 used gloves. CNA #5 indicated she should have removed her gloves after she came out of a resident's room, and before continuing to pass meal plates. She also indicated her gloves should have been removed to prevent the spread of germs since things are touched while in the resident's room. During an interview on 07/30/2025 at 4:25 PM, CNA # 6 stated, “I should wash my hands constantly and apply sanitizer while serving the residents their meals.” She indicated she did not change gloves after passing plates to the residents on 07/29/2025, or before going to the next resident. She indicated she usually kept the same gloves on the entire time she was passing out plates. During an interview on 07/31/2025 at 9:25 AM, Dietary Manger (DM) #7 indicated staff should wash their hands before they pass the residents plates out, and between each resident. She indicated she would start an in-service for handwashing immediately. During an interview on 07/31/2025 at 12:52 PM, the Administrator indicated that staff should wash their hands between serving each resident. He indicated that if they touch any of the residents' items such as a cup, they should wash their hands before passing more trays. A review of a handwashing policy indicated that handwashing was important because your hands can transfer pathogens to food. The policy indicated that your hands should be washed before putting on gloves and at the start of a new task. 2) During an observation on 07/30/2025 at 3:04 PM, CNA #1 used a food processor to prepare food for residents on modified diets CNA #1 obtained a spatula from the drawer and mixed the puree mix with the spatula. The spatula was then placed on the counter, which had not been cleaned prior to meal service. CNA #1 added chicken broth to the blender and mixed. CNA #1 picked up the spatula and mixed the food with the spatula. CNA #1 removed the blender and poured the mixture into a bowl. CNA #1 then used the spatula to remove the mixture from the bottom of the blender. During an observation on 07/30/2025 at 3:22 PM, CNA #1 washed, rinsed, and sanitized the spatula and a #8 scoop. CNA #1 then placed the spatula and #8 scoop on the counter next to the sink, which had not been cleaned and did not have a barrier. During an observation on 07/30/2025 at 3:39 PM, on three separate occurrences, CNA #1 laid the spatula on the unclean counter next to the blender, mixed the meat in the blender and stirred the meat with the unclean spatula. CNA #1 completed the puree, poured the meat mixture into a warming container, and used the spatula to remove the meat from the bottom of the blender. During an interview on 07/30/2025 at 4:22 PM, CNA #1 confirmed the counters had not been cleaned and a barrier should have been placed prior to placing the utensils on the counter. CNA #1 confirmed the utensils should not have been used after contamination. During an interview on 07/30/2025 at 4:23 PM, Dietary Manager #7 confirmed the counters had not been cleaned and a barrier should have been placed prior to placing the utensils on the counter. DM confirmed the spatula and #8 scoop were contaminated.

Based on interview and record review, the facility failed to ensure an as needed psychotropic medication was reviewed and updated every 14 days for one (Resident #137) of five residents reviewed. The findings include: A review of Resident #137's Order Summary Report revealed the facility admitted the resident on 02/28/2024. Resident #137 had an order for an antianxiety medication to be given every 24 hours as needed for anxiety, ordered on 04/05/2024. A review of Resident #137's quarterly Minimum Data Set, with an Assessment Reference Date of 06/17/2025, revealed the resident had a Brief Interview for Mental Status score of 06, which indicated the resident had severe cognitive impairment. A review of Resident #137's Care Plan initiated 02/20/2025, indicated to administer an anti-anxiety medication as ordered by the physician. A review of Resident # 137's Medication Administration Record dated 08/01/2025 - 08/31/2025, indicated an as needed antianxiety medication was started on 04/05/2024, and discontinued 08/01/2025. A review of Resident #137's Pharmacy MRR [Medication Regimen Review], signed date 05/26/2025, indicated to continue the medication past 14 days. The medication review indicated that the resident had periods of anxiety, and it was in Resident #137's best interest to continue the medication.A review of Resident #137's Pharmacy MRR [Medication Regimen Review], dated 07/28/2025, did not indicate if the medication should be continued and was not signed by the attending physician or the DON.During an interview on 07/31/2025 at 3:43 PM, the Nurse Practitioner indicated Resident #137's as needed antianxiety medication should be reviewed every 14 days. During an interview on 07/31/2025 at 3:47 PM, the Director of Nursing indicated she did not know the order for antianxiety medication had to be rewritten every 14 days. During an interview on 08/01/2025 at 10:30 AM, Licensed Practical Nurse #3 indicated Resident #137 had an anxiety medication ordered as needed. She then indicated she was not sure when the medication should be renewed, that some medications were renewed every seven or 14 days. During an interview on 08/01/2025 at 12:01 PM, the Medical Director (MD) indicated he did not change the as needed medications when he reviewed them. He indicated he was not aware that as needed medications should be reviewed and updated every 14 days. The MD then indicated that Resident #137's as needed medication were being reviewed. If the practitioner believed the medication should extend beyond 14 days the rationale should be documented in the medical record and the duration should be documented.

Based on record reviews, observation, interviews, and facility policy review, the facility failed to ensure personal protective equipment (PPE) was disposed of before walking out of one (Resident #4) of one resident’s room that was on Enhanced Barrier Precautions (EBP). The findings include: A review of Resident #4’s Order Listing Report revealed a revised order dated 07/19/2025, for an IV [intravenous] antibiotic related to a right hip incision infection. A review of Resident #4’s admission Minimum Data Set, with an Assessment Reference Date of 07/10/2025, revealed the resident had a Brief Interview for Mental Status score of 14, which indicated Resident #4 was cognitively intact. A review of Resident #4’s Care Plan revised 07/22/2025, indicated EBP were required related to a medical device used to drain urine directly from the kidney. The Care Plan also indicated to wear disposable gloves and gowns when providing high contact care. During an observation on 07/30/2025 at 2:12 PM, Registered Nurse (RN) #8, and RN #9 put on gowns, sanitized their hands, and put on gloves. A bandage dated 07/29/2025 was observed to Resident #4's right hip. The bag of a medical device to drain urine directly from the kidney was observed on the bed. RN #9 looked behind the door in Resident #4's room to get supplies, and the supply organizer did not have any PPE. RN #9 left Resident #4's room with her gown and gloves on and went into the supply closet to get more gowns and gloves. She came back into the room with a box of gloves. She indicated that she threw her gown away in a garbage can in the hall. During an interview on 07/30/2025 at 2:31 PM, RN #8 indicated that the supplies should be stored behind the door for residents on EBP. She also indicated she should not have left the room with a gown and gloves on because of transmission of different bacteria. During an interview on 07/30/2025 at 2:43 PM, RN #9 indicated the supplies for EBP should be stored inside the room. RN #9 also indicated that PPE should always be discarded before leaving a resident’s room because used PPE could have had drainage on it, or it could have been exposed to another resident. During an interview on 07/30/2025 at 3:00 PM, RN #9 indicated she should have taken her gown and gloves off before exiting the room. During an interview on 07/30/2025 at 3:08 PM, RN #8 indicated RN #9 should have taken her gown and gloves off before exiting the room. A policy titled “Infection Prevention and Control” indicate the infection control program was designed to provide a safe, sanitary, and comfortable environment to prevent transmission of diseases and infections.

Based on observations, record review, document review, and interviews, the facility failed to ensure staff followed a resident's care plan, as evidenced by Resident #1 sliding off the side of the bed while 1 staff assisted with dressing, despite the care plan indicating the need for 2 staff, for 1 (Resident # 1) sampled resident. The failed practice resulted in noncompliance at the level of immediate jeopardy (IJ), which caused major injury to Resident # 1, who was at high risk for falls. It was determined the facility's non-compliance 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 State Operations Manual, Appendix PP, 483.25 Accidents and Hazards (to provide appropriate and sufficient supervision to each resident to prevent an avoidable accidents) at a scope and severity of J. The IJ began on 12/12/2024 at 7:15am, when Resident #1 was being assisted with getting dressed by 1 staff person, when the staff person sat the resident up on the side of the bed while waiting for the 2nd staff person to come help, at which point the resident slid to the floor, resulting in hospitalization , a broken femur, and surgical repair of the injury. The Administrator, Assistant Administrator, and Nurse Consultant were notified of the immediate jeopardy on 12/18/2024 at 1:53 PM. A Plan of Removal (POR) was requested. The POR was accepted by the State Survey Agency (SSA) on 12/19/2024 at 9:23am. The findings are: A review of an Admission Record indicated the facility admitted Resident #1 with medical diagnosis of dementia, unspecified severity, without behavioral, psychotic, or mood disturbances, and anxiety. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/2024 revealed Resident # 1 scored 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS) and exhibited the need for maximum (max) assistance with dressing their upper body. Review of Resident # 1's Care Plan, initiated 11/27/2023, revealed the resident's usual performance is requiring max assistance with Activities of Daily Living (ADLs) related to cognitive impairment, incontinent of bowel and bladder, wheelchair for mobility, and required a mechanical lift for transfers. Resident is dependent of 2 staff with upper body dressing. Care Plan initiated 8/17/2023 and revised on 10/15/2024 indicated resident was at risk for falls and had a history of falls. A review of a nursing Progress Note, dated 12/12/2024 at 07:15am, revealed Resident #1 had fallen off the bed and into the floor, landing on her left side, after a Certified Nursing Assistant (CNA) had the resident sit on the side of the bed in order to assist dressing upper body. The progress note indicated resident was complaining of pain in left hip. An Incident and Accident (I & A) was completed, Advanced Practice Registered Nurse (APRN) was notified, and x-rays were ordered. Family and Administrator were also notified. A review of a nursing Progress Note, dated 12/12/2024 at 10:18pm, revealed Resident #1 was hospitalized . A review of a nursing Progress Note, dated 12/16/2024 at 7:03pm, revealed Resident # 1 returned to the facility earlier that day at 4:45pm with oxygen being administered at two liters due to blood oxygen levels not staying at normal range, a catheter due to urinary retention, a prescription for Norco due to the resident groaning in pain, and a surgical site to left hip where the femur had been surgically repaired. A review of Administrator's Internal Investigation, dated 12/12/2024 following the incident involving resident #1, in-services were provided to facility staff pertaining to, Following Care Plans, How to read a Kardex, and How to operator a mechanical lift. (A Kardex is a brand name for an informational filing system that is used as a quick reference for nurses. It's a desktop file system that gives a brief overview of each patient and is updated every shift.) A review of a witness statement within investigation packet dated 12/13/2024 by CNA #1 indicated that she sat the resident up on the side of the bed, and then went and asked another CNA for help. CNA #1 stated that the resident tried to stand up and fell to the floor. A review of a witness statement within the investigation packet dated 12/12/2024 by Licensed Practical Nurse (LPN) #3 indicated that CNA #1 had Resident #1 sitting on the side of the bed, which was raised to hip level, lift pad placed in wheelchair, and lift wasn't inside the resident's room. LPN #3 stated in the witness statement that it appeared as though CNA #1 was attempting a transfer by herself without using the lift. A review of a witness statement dated 12/12/2024 by CNA #2 indicated that CNA #1 had come into the room where CNA #2 was at and asked for help. CNA #2 stated that she would be right there to help as soon as she could. CNA #1 returned to the room where CNA #2 was a few minutes later and stated that the resident had fallen into the floor. CNA #2 stated that upon entry to Resident #1's room, the lift pad was in the resident's chair instead of on the bed and the lift was located outside the room in the hallway and it appeared as though CNA #1 had attempted to transfer the resident by herself rather than using the lift with the assistance of another staff. In an interview on 12/18/2024 at 08:33am with LPN #3, she confirmed that she was familiar with Resident #1 and their care plan, conducted weekly body audits, Braden scales, and assessments. LPN #3 confirmed she was working the day Resident #1 fell and that it was CNA #2 that reported the fall. LPN #3 stated that staff received in-services following the incident and that Resident #1 already had fall mats in place and was unsure if anything was added as an intervention. LPN #3 stated that changes in resident's care are communicated verbally. LPN #3 confirmed that staff receive retraining and in-services on falls, lifts, and transfers as needed and that the [NAME] house always has 3 staff on duty. In an interview on 12/18/2024 at 08:41am with CNA #2, she confirmed that all the CNAs work closely together but she has never witnessed an incident due to abuse or neglect of a resident. CNA #2 did not think that any injury occurred due to low staffing and staff mannerisms are always professional. CNA #2 stated that in order to find out changes in a resident's care, needs, or interventions, they look at the Cardex. CNA #2 stated that she is familiar with Resident #1's care and that she was working the day the resident fell . CNA #2 said that CNA #1 had come in the room where she was working and asked for help. CNA #2 told CNA #1 that she would be in there as soon as she could but before she could get in there, CNA #1 came and told her that Resident #1 had fallen off the bed and was in the floor. CNA #2 called the nurse, and that Resident #1 was complaining that her left hip was hurting. CNA #2 said that resident was a 1 person assist with dressing and 2-person using a lift for transfer but since the incident, she is a 2 person assist with all Activities of Daily Living (ADL's). CNA #2 said she feels like there is enough staff during the day but due to some of the dementia residents having sundowner's syndrome, she wishes there were more staff at night. (Sundowning, or sundown syndrome, is a neurological phenomenon wherein people with delirium or some form of dementia experience increased confusion and restlessness beginning in the late afternoon and early evening.) In an interview on 12/18/2024 at 08:53am with CNA #1, CNA #1 confirmed that the Cardex is where information about resident's care, needs, and interventions were found. CNA #1 stated that she was familiar with Resident #1's care and on the morning that the resident slid out of bed, CNA #1 had just given her a bed bath and was dressing resident's upper body when she sat her up on the side of the bed and the resident tried to stand up and fell . CNA #1 stated that there were only 2 CNAs working the [NAME] house that morning and she had gone to get CNA #2 to help get resident dressed. CNA #1 said she feels like there needs to always be 3 CNAs in the house. CNA #1 stated that staff receive monthly check offs on lifts and transfers as well as quarterly in-services on patient care. On 12/18/2024 at 12:30pm, in a 2nd interview with CNA #1, CNA #1 stated that Resident #1's bed at the time of the incident was lowered all the way down, as far as it could go, maybe just a little bit higher. CNA #1 said that the resident's feet were touching the floor. On 12/18/2024 at 12:36pm in a 2nd interview with CNA #2, CNA #2 confirmed that the position of Resident #1's bed at the time of the incident was upper thigh to possibly waist high. CNA #2 confirmed that resident's feet could not have touched the floor and that the bed should have been in the lowest position. Removal Plan: On 12/13/2024, the Interdisciplinary Team changed resident #1 upper body dressing assistance from 1 staff assist to 2 staff assist. When resident #1 returned to the facility on [DATE], staff was educated of Resident #1 changing from a 1 person assist to 2-person assist with upper body dressing ADL. On 12/18/2024 at 3:08 p.m., the Administrator was notified of an immediate jeopardy level deficiency of alleged failure to provide adequate supervision and assistance to prevent accidents by failing to ensure resident assisted with Activities of Daily Living (ADLs) with the number of staff members required according to the resident's assessed needs. On 12/18/2024, the Administrator/Designee immediately initiated an in-service for all direct care staff for following the care plan for ADLs, specifically dressing. All direct care staff will be in-serviced as they report for shift. On 12/18/2024, the Director of Nursing/designee physically assessed all 12 residents who need 2-person assistance with dressing assistance with the potential for neglect with no negative findings. Minimum Data Set (MDS) Coordinators immediately began reviewing all resident ADL care plans for accuracy. Any care plans that required updates were completed immediately. Completion date of 12/18/2024 Director of Nursing/Designee monitored ADL care by observation of 6 residents to ensure staff is following care plan for ADL assistance to prevent accidents. This was initiated and completed on 12/18/2024 with no negative findings. Administrator/Designee will provide a binder to each cottage identifying residents who require 2 persons assist with ADLs. Completion date of 12/18/2024. On 12/19/2024, the Director of Nursing/designee initiated an in-service for all direct care staff that bed height is appropriate for resident and staff during dressing ADLs. All corrections were completed on 12/19/2024. The Plan of Correction (POC) was accepted on 12/19/2024 @ 9:23am. Onsite Verification: On 12/13/2024, the Interdisciplinary Team changed Resident #1 upper body dressing assistance from 1 staff assist to 2 staff assist. When Resident #1 returned to the facility on [DATE], staff was educated of Resident #1 changing from a 1 person assist to 2 person assist with upper body dressing ADL. On 12/18/2024, the Administrator/Designee immediately initiated an in-service for all direct care staff for following the care plan for ADLs, specifically dressing. All direct care staff will be in-serviced as they report for shift. On 12/19/2024, the Director of Nursing/Designee initiated an in-service for all direct care staff that bed height is appropriate for resident and staff during dressing ADLs. On 12/18/2024, the Director of Nursing/Designee physically assessed all 12 residents who need 2-person assistance with dressing assistance with the potential for neglect with no negative findings. Minimum Data Set (MDS) Coordinators immediately began reviewing all resident ADL care plans for accuracy. Any care plans that required updates were completed immediately. Completion date of 12/18/2024 Director of Nursing/Designee monitored ADL care by observation of 6 residents to ensure staff is following care plan for ADL assistance to prevent accidents. This was initiated and completed on 12/18/2024 with no negative findings. Administrator/Designee will provide a binder to each cottage identifying residents who require 2- person assist with ADLs. Completion date of 12/18/2024. All corrections were completed on 12/19/2024. The Immediate Jeopardy (IJ) was removed on 12/19/2024 at 9:23am after the survey team performed onsite verification that the Plan of Removal (POR) had been implemented. Onsite verification of the Removal Plan began on 12/18/2024 when the facility's Interdisciplinary Team changed Resident #1's upper body assistance during dressing from 1 staff assist to 2-person assist. The survey team reviewed the education in-service trainings that were provided to staff regarding resident's change in care from 1 staff assist to 2 staff assist, in-service trainings for all direct care staff on following resident's care plans for ADLs, using appropriate bed height while performing ADLs, Minimum Data Sets (MDS) for accuracy and completion of resident's requiring 2-person assist with ADLs, nursing monitoring logs ensuring care plans were being followed, and binder in cottage containing resident's identified as being 2-person assist with ADLs. A total of 7 staff were interviewed, including 1 administrator, 1 assistant administrator, 1 director of nursing, 1 licensed practical nurse, and 3 certified nursing assistants, to verify that training had been provided regarding residents requiring 2-person assistance with ADLs for dressing, appropriate bed height while providing care, lifts and transfers, following care plans and looking for changes in resident's care plans.

Based on observation and interview, the facility failed to ensure the nurse completed hand sanitation before and after giving a resident medication and before giving another resident medication. The findings are: 1. On 04/23/2024 at 8:25 am, observed Licensed Practical Nurse (LPN) #1 begin to administer medication to a resident without sanitizing hands, come out of the resident's room to the medication cart and began to pull medications and administer medications to the next resident. There was a medication missing for the resident and LPN #1 had to go to another cottage to the e-kit and get the medication. LPN #1 returned to the cottage and administered the medication without sanitizing hands. 2. On 04/23/2024 at 8:48 am, LPN #1 was asked to explain what should be done before starting to give a resident medication. LPN #1 said, sanitize my hands. LPN #1 was asked what should be done after giving medication to a resident and before giving another resident medication. LPN #1 said, sanitize hands. LPN #1 was asked what should be done after leaving this cottage and going to another cottage and returning then giving a medication? LPN #1 said, sanitize my hands. LPN #1 was asked to explain the importance of sanitizing hands before and after resident interaction. LPN #1 said, it spreads germs to other residents. 3. On 04/24/2024 at 1:21 pm, the Director of Nursing (DON) was asked what should a nurse do before and after and in between giving medications. The DON said, sanitize their hands. The DON was asked who is responsible for making sure that staff are trained in proper handwashing and infection control. The DON said, myself or a designee. The DON was asked to explain the importance of sanitizing hands in between residents. The DON said, it could spread infection. 4. On 04/24/2024 at 2:11 pm, an Inservice received from the Administrator titled, Medication Administration-Annually documented, .BE Careful on Order Entry!!! .Always keep in mind infection control-wash hands often and per guidelines .

Based on observation, interview, and record review, the facility failed to provide a meaningful program of activities for 5 (Residents #4, #10, #66, #80, and #120) sampled residents and failed to ensure the activity program was designed to meet the individual activity needs, interests, and abilities of each resident. The findings are: 1. On 04/22/2024 at 11:15 AM, the Surveyor entered Cottage 2 and observed that there were no activities taking place. There was no activity calendar observed in the common area or in the resident rooms. 2. On 04/22/2024 at 1:00 AM, the Surveyor entered Cottage 900 as the residents were having lunch. There was no activity calendar observed in the common area. Resident #66 and Resident #10 were observed at the head of the table. Resident #66 identified a lack of activities as her area of dissatisfaction. Resident #10 concurred that activities are not held on a regular basis and that boredom is a daily burden. 3. On 04/22/2024 at 2:08 PM, the Surveyor observed in Cottage #2, no activities were being conducted. 4. On 04/22/2024 at 2:17 PM, the Surveyor observed in Cottage #3, no activities were being conducted. 5. On 04/23/2024 at 8:30 AM, CNA #3 was asked if there was an activity calendar. CNA #3 reported that the Activity Director provides a calendar, but does not specify the exact activities, that the cottages decide what they are going to do each day. CNA #3 provided a copy of the (Facility Name) Times, April 2024. The calendar provided had notes of interest each day but doesn't provide specifics. 6. On 04/23/2024 at 10:11 am, the Surveyor observed in Cottage #2, no activities were being conducted. 7. On 04/23/2024 at 10:16 am, the Surveyor observed in Cottage #3, no activities were being conducted. 8. On 04/23/2024 at 2:19 pm, the Surveyor asked CNA #1 in Cottage #3 if the residents in this cottage received activities. CNA #1 said, not very often, they want us to do them, and we don't have the time to. The Activity Director never comes and does them or even helps. 9. On 04/23/2024 at 2:20 PM, Cottage #600 was observed to be engaged in no activities. 10. On 04/24/2024 at 8:42 AM, the Activity Director was to describe how activities were provided on campus. The Activity Director reported that she puts out a newsletter each month as a guide, however the elders in each cottage decide what activities are carried out. The Activity Director continued to describe self-directed past times as examples of what was being referred to as activities. She continued to describe how she will occasionally complete an event, however the staff in the cottages are responsible for the day-to-day completion of activities and for recording the attendance in (Facility Computer Software). At 8:46 AM, the Administrator joined the meeting. The Administrator confirmed that he had discussed with the AD her need confirm activity completion in the cottages. 11. On 04/24/2024 at 11:24 AM, CNA #3 was asked if Cottage 2 had activities daily. CNA #3 replied no we don't, but once a week a resident's daughter does come in and call bingo for us. 12. On 4/22/2024 at 10:10 AM, Resident #120 was asked about her participation in activities. Resident #120 stated, What activities. We watch television. a. On 04/23/2024 at 10:01 AM, Resident #120 stated, We never have activities. There were no activity calendars in the rooms or located in the common area. 13. On 04/22/2024 at 11:34 AM, during initial rounds, Resident #80 was sitting in the dayroom with a family member. Resident #80 said we don't have activities around here and we need something to do. The Surveyor observed no activities happening at the time. a. Review of Resident #80's Care Plan initiated on: 07/17/2023 and revised on 11/17/2023 documented, .[Resident #80] was a very sociable person . The following activities are important me: Likes to talk with friends and family as much as possible. The following activities are important me: gardening, visiting with [family members], watching tv .participate in group activities at least twice weekly, keeping self-busy with self-directed activities at other times .needs reminders for the time and place of group activities. Invite to religious activities .Remind me of upcoming activities so I can choose to attend if I want to. Allow me to make suggestions on activities that I prefer .Allow or encourage me to assist with activities if I am able. Stop by for friendly or 1:1 visits 1-2 times a week. Invite to activities that involve food and drink . 14. On 04/22/2024 at 11:52 AM, Resident #4 was asked if he attended activities. Resident #4 stated, We have had no activities. a. On 04/23/2024 at 09:15 AM, Resident #4 was observed in bed and stated, I wish we had activities. We never have them. Are you going to help us get some? b. Review of Resident #4's Care Plan dated 03/12/2019 documented, .Honor my customary routine for preferred activities, bathing, dressing, snacks . Provide emotional support to me and my family to assist with the transition into a long-term care setting. Revision on: 03/21/2019 . 15. On 04/23/2024 from 9:15 AM to 10:30 AM, the residents sat in the dayroom, dining room or in their bedroom. There were no activities observed. There were no activity calendars in the rooms or located in the common area. 16.On 04/23/2024 at 10:35 AM, Resident #80 stated, Did you come to make sure we will get an activity. 17. On 04/23/2024 from 1:00 PM to 2:30 PM, the residents sat in the day room, dining room or in their bedroom. There were no activities. 18. On 04/23/2024 at 2:15 PM, Certified Nursing Assistant (CNA) #5 was asked when activities occurred. CNA #5 stated, We have Bingo on Wednesdays. CNA #5 was asked if this was the only activity that occurs all week. CNA #5 stated, We are planning on sitting on the front porch and planting seeds and eating melon, but we haven't done that yet. CNA #5 was asked what activities were offered on 04/22/2024 and 04/23/2024. CNA #5 stated, None. 19. On 04/23/2024, from 9:15 AM to 10:30 AM, the residents in [NAME] Hall sat in the dayroom, dining room, therapy, or in their bedroom. There were no activities observed. 20. On 04/23/2024 from 1:00 PM to 2:30 PM, the residents residing in [NAME] Hall, sat in the day room, dining room, in therapy, or in their bedroom. There were no activities. 21. On 04/24/2024 at 08:45 AM, CNA # 6 was asked to name the activities offered or provided on [NAME] Hall for the residents for 4/22/24 and 4/24/24. CNA #6 stated, Sitting and listening to music. They have church on Sundays by watching it on television. CNA #6 was asked for logs on who attends the activities. CNA #6 stated, We don't write the names down. CNA's #7 and #8 confirmed that there were no activities occurring. 22.On 04/23/2024 at 01:30 PM, CNA #9 was asked about activities on [NAME] Hall. CNA #9 stated, We didn't have any on Monday [04/22/2024] and Tuesday they sat and chit chatted. They are going to play dominoes Wednesday [94/24/24]. CNA #9 was asked to explain the importance of activities. CNA #9 stated, Because they can socialize with each other and maybe come out of their rooms. There were residents in wheelchairs and recliners in front of the television asleep. 23. On 4/23/24 at 10:11 AM, the Nurse Consultant provided a form titled, ACTIVITY PROGRAMS, which documented, .The Nursing Facility provides an ongoing program of Resident/Elder activities/meaningful engagements. Activities will be varied in nature and should be designed to meet the individual needs, interests, and limitations of Residents/Elders .with the elder's request . These activities should provide meaningful engagement, mental, social, and spiritual stimulation .Residents/Elders will be informed of the events with the opportunity to participate. A calendar of events should be posted throughout the facility in obvious places or easily accessible to Residents/Elders. The calendar should reflect the actual activities . 46868 24. On 4/22/2024 at 10:10 AM, Resident #120 was asked about her participation in activities. Resident #120 stated, What activities. We watch television. a. On 04/23/2024 at 10:01 AM, Resident #120 stated, We never have activities. There were no activity calendars in the rooms or located in the common area. 25. On 04/22/2024 at 11:34 AM, during initial rounds, Resident #80 was sitting in the dayroom with a family member. Resident #80 said we don't have activities around here and we need something to do. The Surveyor observed no activities happening at the time. a. Review of Resident #80's Care Plan initiated on: 07/17/2023 and revised on 11/17/2023 documented, .[Resident #80] was a very sociable person . The following activities are important me: Likes to talk with friends and family as much as possible. The following activities are important me: gardening, visiting with [family members], watching tv .participate in group activities at least twice weekly, keeping self-busy with self-directed activities at other times .needs reminders for the time and place of group activities. Invite to religious activities .Remind me of upcoming activities so I can choose to attend if I want to. Allow me to make suggestions on activities that I prefer .Allow or encourage me to assist with activities if I am able. Stop by for friendly or 1:1 visits 1-2 times a week. Invite to activities that involve food and drink . 26. On 04/22/2024 at 11:52 AM, Resident #4 was asked if he attended activities. Resident #4 stated, We have had no activities. a. On 04/23/2024 at 09:15 AM, Resident #4 was observed in bed and stated, I wish we had activities. We never have them. Are you going to help us get some? b. Review of Resident #4's Care Plan dated 03/12/2019 documented, .Honor my customary routine for preferred activities, bathing, dressing, snacks . Provide emotional support to me and my family to assist with the transition into a long-term care setting. Revision on: 03/21/2019 . 27. On 04/23/2024 from 9:15 AM to 10:30 AM, the residents sat in the dayroom, dining room or in their bedroom. There were no activities observed. There were no activity calendars in the rooms or located in the common area. 28. On 04/23/2024 at 10:35 AM, Resident #80 stated, Did you come to make sure we will get an activity. 29. On 04/23/2024 from 1:00 PM to 2:30 PM, the residents sat in the day room, dining room or in their bedroom. There were no activities. 30. On 04/23/2024 at 2:15 PM, Certified Nursing Assistant (CNA) #5 was asked when activities occurred. CNA #5 stated, We have Bingo on Wednesdays. CNA #5 was asked if this was the only activity that occurs all week. CNA #5 stated, We are planning on sitting on the front porch and planting seeds and eating melon, but we haven't done that yet. CNA #5 was asked what activities were offered on 04/22/2024 and 04/23/2024. CNA #5 stated, None. 31. On 04/23/2024, from 9:15 AM to 10:30 AM, the residents in [NAME] Hall sat in the dayroom, dining room, therapy, or in their bedroom. There were no activities observed. 32. On 04/23/2024 from 1:00 PM to 2:30 PM, the residents residing in [NAME] Hall, sat in the day room, dining room, in therapy, or in their bedroom. There were no activities. 33. On 04/24/2024 at 08:45 AM, CNA # 6 was asked to name the activities offered or provided on [NAME] Hall for the residents for 4/22/24 and 4/24/24. CNA #6 stated, Sitting and listening to music. They have church on Sundays by watching it on television. CNA #6 was asked for logs on who attends the activities. CNA #6 stated, We don't write the names down. CNA's #7 and #8 confirmed that there were no activities occurring. 34.On 04/23/2024 at 01:30 PM, CNA #9 was asked about activities on [NAME] Hall. CNA #9 stated, We didn't have any on Monday [04/22/2024] and Tuesday they sat and chit chatted. They are going to play dominoes Wednesday [94/24/24]. CNA #9 was asked to explain the importance of activities. CNA #9 stated, Because they can socialize with each other and maybe come out of their rooms. There were residents in wheelchairs and recliners in front of the television asleep. 35. On 4/23/24 at 10:11 AM, the Nurse Consultant provided a form titled, ACTIVITY PROGRAMS, which documented, .The Nursing Facility provides an ongoing program of Resident/Elder activities/meaningful engagements. Activities will be varied in nature and should be designed to meet the individual needs, interests, and limitations of Residents/Elders .with the elder's request . These activities should provide meaningful engagement, mental, social, and spiritual stimulation .Residents/Elders will be informed of the events with the opportunity to participate. A calendar of events should be posted throughout the facility in obvious places or easily accessible to Residents/Elders. The calendar should reflect the actual activities .

Based on observation and interview, the facility failed to ensure pureed food was smooth items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The findings are: On 04/24/2024 at 11:10 AM, a divided plate containing pureed chicken fettucine, pureed bread and peaches was observed on the counter in the kitchen. Each item was observed to contain particles of food that had not been completely blended. Certified Nursing Assistant (CNA) #1 who prepared the meal was asked to describe the consistency of the items on the plate. CNA #1 described how she could see the particles of food, however despite continuing to blend the items for an extended period of time the processor would not provide a smooth consistency. The peaches were described as runny; however, CNA #1 verbalized her expectations that they would thicken as they sat because thickener had been added. On 04/23/2024 at 8:30 AM, the plate contained pureed eggs, pureed sausage/biscuit combination and pureed super cereal which is oatmeal with brown sugar, white sugar, and butter. CNA #2 who was assisting the resident was asked to describe the consistency of the food. CNA #2 verbalized her understanding that pureed food was to be the consistency of baby food, although she did not feel that this food looked like what she had provided for her children. Description continued as thick, but you can still see pieces of the original food in the mixture. On 04/24/2024 at 12:50 PM, the Dietary Manager (DM) was asked to describe the desired consistency of pureed food. The DM described pudding thick food that won't go through your fork as the goal for a pureed product. When examining the two meals provided, the DM and Clinical Manager both confirmed that the items were grainy and not smooth with the bread being too thick and gummy. On 04/24/2024 at 1:08 PM, the Consultant confirmed that the facility did not have a policy concerning specialized diets, specifically pureed food.

Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with personal hygiene was regularly offered to have fingernails cleaned to maintain good grooming and hygiene for 1 (Resident #47) sampled resident. The findings are: 1. On 04/22/2024 at 11:08 am, observed Resident #47 with 0.5 inch long fingernails with a brown substance under the nails on both hands. 2. On 04/23/2024 at 9:18 am, observed Resident #47 with 0.5 inch long painted nails with brown substance under nails on both hands. 3. On 04/24/2024 at 3:31 pm, Certified Nursing Assistant (CNA) #4 was asked who was responsible for making sure fingernails were cleaned and trimmed. CNA #4 replied, The CNA is, unless they are diabetic or on blood thinner, then the nurses do it. The Surveyor asked, When do you perform nailcare. CNA #4 replied, On their shower days or whenever we see that they need them cleaned or trimmed. 4. During record review, Resident #47's Care Plan with an initiated date of 03/09/2024 noted Resident #47 required supervision with bathing. The care plan did not address fingernail care. 5. Review of Resident #47's bathing task sheet noted Resident #47 received a shower on 04/11/2024, 04/15/2024, 04/18/2024, 14/20/2024 and 04/23/2024 and refused on 04/22/2024.

Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee put forth good faith attempts to correct, monitor, and reassess its own quality deficiencies for proper respiratory care for residents who were on oxygen therapy. The findings are: 1. The Quality Assurance and Performance Improvement (QAPI) Plan undated, the Facility assessment dated [DATE], and the Quality Assessment and Assurance (QAA) Committee list provided by the Assistant Administrator on 01/30/23 at 1:04 PM documented, .Those in attendance varies occasionally but normally includes the Administrator, Director of Nursing, the Infection Control/Wound Nurse, the Campus Educator, The Assistant Director of Nursing, the MDS [Minimum Data Set] Coordinators, and the Medical Director at least Quarterly . a. On 02/01/23 at 10:30 AM, the Surveyor asked the Administrator if the facility had an updated Facility Assessment as the one provided to the Surveyors was dated 12/31/21. The Administrator stated, No, I am over a month behind in doing that. It is the most current. 2. On 02/02/23 at 9:30 PM, the Surveyor reviewed the current survey's findings and noted three care areas with deficiencies that were patterns for the facility. a. F689 was cited on the 2020, and 2021 annual surveys. b. F695 was cited on the 2018, 2020, and 2021 annual surveys. c. F880 was cited on the 2019, 2020, and 2021 annual surveys. 3. On 02/03/23 at 12:41 PM, the Surveyor asked the Administrator how often QAA meetings were held. The Administrator stated, We do them at least once a quarter, but we try to do them every other month based on what is going on. The Surveyor asked what members were required to attend. The Administrator stated, Medical Director, DON [Director of Nursing], me [Administrator], and that is all that is required, but we also have our MDS [Minimum Data Set Coordinator], Infection Control, and sometimes we have Dietary, or a CNA [Certified Nursing Assistant] join. The Surveyor asked if she was aware of the pattern areas of deficiencies the facility had from 2018 to 2021. The Administrator stated, We had F880 for quite a while, but we haven't had it in a while. Let me look. The F880 we have had twice, but we have not had any others and we have resolved those. The Surveyor stated the current team had found three of the same pattern deficiency care areas of respiratory care, accidents and hazards, and infection control. The Administrator stated, Oh. The Surveyor asked how long a deficiency listed on the 2567 was tracked after it was received. The Administrator stated, Umm, we do it for at least 3 months regularly, and after that if we feel it has gotten better, then we do it every quarter, and then we try to follow it for the next year until the next survey. The Surveyor asked how the facility tracked the progress of compliance. The Administrator stated, Through our QAA meetings and department head meetings every morning. We have consultants that oversee each area, and they are in our buildings always once a month sometimes more, and once issues arise. We have company meetings at least twice a year. Our company has QAPI meetings quarterly and they review all the consultant reports and our QAA minutes, they review those.

Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator, freezer and dry storage areas, were sealed or covered and stored in accordance with the manufacturer's instructions; expired food items were promptly removed from stock; staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; ice machines were maintained in clean and sanitary condition; and hot foods were maintained at or above 135 degrees Fahrenheit (F.) while awaiting service to prevent potential food borne illness for residents who received meals from 11 (Cottages #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) of 11 kitchens. These failed practices had the potential to affect 118 residents who received meals from the 11 affected kitchens (total census:119), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 10:57 AM, the following observations were made in Cottage #6: a. The following items were on a shelf in the refrigerator: i) One opened container of cottage cheese with an expiration date of [DATE]. ii) One bag of tortilla chips with an expiration date of [DATE]. b. The following item was on a shelf in the Storage Room: i) One bag of rippled potato chips with an expiration date of [DATE]. c. The following seasoning containers were in a kitchen cabinet without an opened date on the containers: i) Garlic Powder ii) Mediterranean Style Ground Oregano iii) Ground Cinnamon iv) Paprika v) Black Pepper vi) Ground Nutmeg vii) Poultry Seasoning viii) Ground Thyme ix) Rubbed Sage x) Chili Powder xi) Lemon and Pepper Seasoning xii) Ground Mustard xiii) Shake Barbeque Seasoning xiv) Mediterranean Style Ground Oregano xv) Ground Cayenne Pepper xvi) Onion Powder xvii) Ground Cumin d. On [DATE] at 7:27 AM, Certified Nursing Assistant (CNA) #13 turned on the hand washing sink faucet, rinsed the blender with hot water only, no soap or sanitizer. She then, turned off the faucet contaminating her hand. At 7:29 AM, She removed gloves from the glove box and placed them on her hands contaminating the gloves. At 7:30 AM, she picked up a sausage patty and placed it into the blender to be pureed. The Surveyor immediately stopped her and asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. e. On [DATE] at 7:53 AM, CNA #13 was ready to serve the plate of pureed food to the resident. The Surveyor asked CNA #13 to check the temperature of the pureed food items. CNA #18 checked the food temperatures with the following results: i) Pureed eggs - 70 degrees F. ii) Pureed sausage - 55 degrees F. iii) Pureed french toast - 65 degrees F. iv) Pureed oatmeal - 60 degrees F. After preparing the breakfast meal, the Surveyor asked CNA #13, What should you have done before serving the meal to the residents? She stated, Check the temperature. f. The temperatures of the food awaiting meal service were tested and read by CNA #1 with the following results: i) Regular scrambled eggs - 90 degrees F. ii) Sausage - 105 degrees F. iii) Oatmeal - 110 degrees F. 2. On [DATE] at 11:13 AM, the following observations were made in Cottage #7: a. The following items were on a shelf in the Storage Room: i) One 5 pound bag of grits with an expiration date of [DATE]. ii) One 8 count bag of hamburger buns had no opened or received date. iii) One 4 count bag of hamburger buns had no received date. iv) One 12 count bag of hot dog buns had no received date. b. The following seasoning containers and/or items were in a kitchen cabinet without an opened date on the containers: i). Garlic Powder ii). Shake Barbeque Seasoning iii). Ground Cinnamon. iv). Black Pepper. v). Ground Nutmeg. vi). Ground Paprika. vii). Poultry Seasoning. viii). Ground Thyme. ix). Rubbed Sage. x). Chili Powder. xi). Lemon and Pepper Seasoning xii). Ground Mustard xiii). Mediterranean Style Ground Oregano xiv). Ground Cayenne Pepper xv). Onion Powder. xvi). Ground Cumin xvii). One opened 16 ounce (oz) bottle of dry Grated Parmesans Cheese c. On [DATE] at 11:28 AM, the following were on a shelf in the refrigerator/freezer: i) One container of cottage cheese was in the refrigerator located in the Storage Room with an expiration date of [DATE]. ii) One 32-ounce (oz) carton of half and half with no opened date on the carton. iii) One 5-pound container of sour cream with no opened date on the container. iv) Three bags of chimichangas were in the freezer with no received date on the bags. v) One 5-pound container of strawberry topping was in the freezer with no received date on the container. d. On [DATE] at 11:30 AM, the bottom of the ice scoop holder on top of the ice machine had a wet brown residue on it. The ice scoop was stored in the scoop holder directly on the residue. The Surveyor asked the Dietary Manager to wipe the brown residue at the bottom of the scope holder. She did so, and the brown residue easily transferred to the tissue. The Surveyor asked, How often do you clean the ice scoop holder and who uses the ice from the machine? She stated, They should clean it daily. They used it to fill beverages served to the residents at mealtimes. The Surveyor asked the Dietary Manager to describe what was on the tissue. She stated, It was dirty and has brown rusty residue. e. On [DATE] at 11:34 AM, the following were in the Kitchen cabinet: i) One opened box of corn starch not covered or sealed. ii) One opened box of classic plain iodized salt not covered. f. In the Kitchen refrigerator there was one opened 10 oz. bottle of sugar free syrup on a shelf with no opened date on the bottle. 3. On [DATE] at 11:38 AM, the following observations were made in Cottage #8: a. CNA #10 pushed a utility cart that contained beverages towards the Dining Room. She opened the refrigerator and removed a pitcher of tea and placed it on the counter. Without washing her hands, she picked up a glass by the rim and poured tea in it. She then picked up other glasses that contained beverages to be served to the residents for lunch and placed them on the table. b. On [DATE] at 11:40 AM, the ice machine metal panel, which was in contact with the ice before it dropped into the ice collector had a wet black residue on it. The Surveyor asked the Dietary Supervisor to wipe the black residue off the section where the ice forms. She did so, and the black residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor, How often do you clean the ice machine and who uses the ice from the machine? She stated, They should clean it once it a week. They use it to fill beverages served to the residents at mealtimes. The Surveyor asked her to describe what was observed. She stated, It was dirty and has black wet debris. c. On [DATE] at 11:47 AM, the following were on a shelf in the Storage Room: i) One 8 count bag of hamburger buns had an expiration date of [DATE]. d. The following seasoning containers/items were in a kitchen cabinet without an opened date on the container and/or were not covered: i) Garlic Powder ii) Shake Barbeque Seasoning iii) Ground Cinnamon iv) Black Pepper v) Ground Nutmeg vi) Ground Paprika vii) Poultry Seasoning viii) Ground Thyme ix) Rubbed Sage x) Chili Powder xi) Lemon and Pepper Seasoning xii) Ground Mustard xiii) Mediterranean Style Ground Oregano ix) Ground Cayenne Pepper xv) Onion Powder xvi) Ground Cumin xvii) One opened box of classic plain Salt was not covered. e. On [DATE] at 1:23 PM, in the freezer there was one 5-pound bag of strawberry topping on a shelf with no received date on the bag. 4. On [DATE] at 12:05 PM, the following observations were made in Cottage #5. a. The following seasoning containers/items were in a kitchen cabinet without an opened date on the container: i) Garlic Powder. ii) Shake Barbeque Seasoning. iii) Ground Cinnamon. iv) Paprika. v) Black Pepper. vi) Ground Nutmeg. vii) Poultry Seasoning. vii) Ground Thyme. ix) Rubbed Sage. x) Chili Powder. xi) Lemon and Pepper Seasoning. xii) Ground Mustard. xiii) Mediterranean Style Ground Oregano. xiv) Ground Cayenne Pepper. xv) Onion Powder. xvi) Ground Cumin. xvii) One bottle (Brand) Popcorn. xviii) One 16 oz. dry grated parmesan cheese. b. In the refrigerator there was one 5-pound container of strawberry topping on a shelf with no received date on the container. c. On [DATE] at 11:17 AM, CNA #12 used a #8 scoop to place 2 servings of cut green beans into a blender, pureed, and then poured onto a divided plate. The consistency of the pureed cut green beans was not smooth. There were pieces of beans visible in the mixture. d. On [DATE] at 11:27 AM, CNA #12 turned on the hand washing sink faucet and washed the blender. She turned off the faucet. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to use in pureeing food items to be served to the residents for lunch. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 5. On [DATE] at 12:12 PM, the following observations were made in Cottage #2: a. CNA #11 opened a drawer and removed an alcohol pad. She gave it to CNA #21. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. At 12:15 PM, she used her contaminated gloved hand to pick up slices of cornbread from a pan and placed them on the serving plate to be served to the residents for lunch. At 1:37 PM, the Surveyor asked CNA #11, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. b. On [DATE] at 1:40 PM, the following seasoning containers/items were in a kitchen cabinet without an opened date on the containers: i) Garlic Powder ii) Shake Barbeque Seasoning iii) Ground Cinnamon iv) Paprika v) Black Pepper vi) Ground Nutmeg vii) Poultry Seasoning viii) Ground Thyme ix) Rubbed Sage x) Chili Powder xi) Lemon and Pepper Seasoning xii) Ground Mustard xiii) Mediterranean Style Ground Oregano xiv) Ground Cayenne Pepper xv) Onion Powder c. On [DATE] at 1:49 PM, there was an opened 4 count bag of hamburger buns on a bread rack with no opened date. d. On [DATE] at 11:50 AM, the following were in the refrigerator: i) 5 crates, that contained 30 eggs each of pasteurized eggs were in the bottom of the refrigerator with no received dates on the crates. ii) One individual sealed super donut with no received date on the seal. iii) One pack of 4 sugar free jello was with no received date. e. On [DATE] at 11:55 PM, the following observations were made in the freezer: i) Two 3 pound packages of spinach with no received date. ii) One opened quart container of vanilla ice cream with no opened date on the container. f. On [DATE] at 1:58 PM, the following were on a shelf in the refrigerator in the Storage Room: i) One opened bottle of ranch dressing with no opened date on the bottle. ii) One container of pickles with no opened date. 6. On [DATE] at 12:33 PM, the following observations were made in Cottage #10: a. The following were in the freezer/refrigerator: i) One opened container of vanilla ice cream was on a shelf in the freezer with no opened date on the container. ii) One opened bottle of zesty Italian dressing was on a shelf in the refrigerator with no opened date on the bottle. iii) One opened bottle of honey mustard dressing was on a shelf in the refrigerator with no opened date on the bottle. iv) One opened bottle of thousand island was on a shelf in the refrigerator with no opened date on the bottle. v) One opened bottle of ranch dressing was on a shelf in the refrigerator with no opened date on the bottle. b. The following seasoning containers were in a kitchen cabinet without an opened date on the containers: i) Garlic Powder ii) Shake Barbeque Seasoning iii) Ground Cinnamon iv) Paprika v) Black Pepper vi) Ground Nutmeg vii) Poultry Seasoning viii) Ground Thyme ix) Rubbed Sage x) Chili Powder xi) Lemon and Pepper Seasoning xii) Ground Mustard xiii) Mediterranean Style Ground Oregano xiv) Ground Cayenne Pepper xv) Onion Powder c. One opened, partially used bottle of reconstituted lemon juice was in a kitchen cabinet. The manufacturer's instructions on the bottle documented, Refrigerate after opening. The Surveyor asked CNA #17 what the lemon juice was used for. She stated, We use it in sweet tea served to the residents and we use it for baking pies. d. Five cans of chicken noddle soup were on a shelf in the Storage Room with no received dates on the cans. e. One opened box of cornstarch was in a cabinet with no opened date on the box. 7. On [DATE] at 12:40 PM, the following observations were made in Cottage #1: a. One can of baking powder was in a cabinet with an expiration date of [DATE]. b. On [DATE] at 12:45 PM, one bag of biscuits with sausage was on a shelf in the freezer. They were discolored. The Surveyor asked the Dietary Supervisor to describe the appearance of biscuits with sausage. She stated, It looks like freezer burn. c. On [DATE] at 12:49 PM, the following observations were made in the Storage Room: i) One twelve count bag of hot dog buns with no received date on the bag. ii) One twelve count bag of hamburger buns with no received date on the bag. iii) One bag of crispy round tortilla chips with an expiration date of [DATE]. d. The following seasoning containers in a kitchen cabinet were not covered and/or did not have an opened date on the containers: i) Garlic Powder ii) Shake Barbeque Seasoning iii) Ground Cinnamon iv) Paprika v) Black Pepper vi) Ground Nutmeg vii) Poultry Seasoning viii) Ground Thyme ix) Rubbed Sage x) Chili Powder xi) Lemon and Pepper Seasoning Salt xii) Ground Mustard xiii) Mediterranean Style Ground Oregano xiv) Ground Cayenne Pepper xv) Onion Powder xvi) One container of creole seasoning was not covered and did not have an opened date on the container. e. On [DATE] at 1:00 PM, the metal section of the ice machine where the ice forms before dropping into the ice collector had a wet black residue on it. The Surveyor asked the Dietary Supervisor to wipe the black residue off the section where ice forms. She did so, and the black residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor How often do you clean the ice machine and who uses the ice from the machine? She stated, They should clean it once weekly. They use it to fill beverages served to the residents at mealtimes. The Surveyor asked her to describe what was observed. She stated, It was black wet residue f. On [DATE] at 9:00 AM, the temperature of the food items when checked by CNA #15 were as follows: i) Scrambled eggs - 120 degrees F. ii) Pureed sausage - 120 degrees F. g. On [DATE] at 11:16 AM, CNA #16 opened the oven door with her bare hand, contaminating her hand. She removed 8 chicken strips from a pan in the oven with a tong and placed them on the cutting board. Without washing her hands, she used a knife to slice the chicken strips. She then used the same contaminated hand to pick up slices of chicken strips. When she was about to place them into a blender, she was immediately stopped, and the Surveyor asked, What should you have done after touching dirty objects and before handling food items? She stated, I should have washed my hands. 8. On [DATE] at 1:00 PM, the following observations were made in Cottage #11: a. The metal section of the ice machine where the ice forms before dropping into the ice collector had a wet black residue on it. The Surveyor asked the Dietary Supervisor to wipe the black residue off the section where ice forms. She did so, and the black residue easily transferred to the tissue. The Surveyor asked, How often do you clean the ice machine and who uses the ice from the machine? She stated, They should clean it once weekly. They use it to fill beverages served to the residents at mealtimes. The Surveyor asked the Dietary Supervisor to describe what was observed. She stated, It was black wet residue b. On [DATE] at 11:16 AM CNA #16 opened the oven door with her bare hand, contaminating her hand. She then removed 8 chicken strips from a pan in the oven with a tong and placed them on the cutting board. Without washing her hands, she used a knife to slice the chicken strips, then used the same contaminated hand to pick up slices of the chicken strips. When she was about to place them into a blender, the Surveyor immediately stopped her and asked, What should you have done after touching dirty objects and before handling food items? She stated, I should have washed my hands. 9. On [DATE] at 2:03 PM, the following observations were made in Cottage #3: a. Two containers of opened baking powder were in the kitchen cabinet with no opened on the containers. b. One opened 5-pound container of baking powder double active was in the cabinet with an expiration date of [DATE]. c. One opened 24 oz. bottle of butter pancake and waffle syrup was on a shelf in the storage room with no opened date on the bottle. d. One opened bottle of lemon juice was on a shelf in the refrigerator with no opened date on the bottle. e. One opened bottle of sweet relish was on a shelf in the refrigerator with no opened date on the bottle. f. One opened 32 oz. container of chopped garlic was on a shelf in the refrigerator with no opened date on the bottle. 10. On [DATE] at 2:14 PM, the following observations were made in Cottage #9: a. The following seasoning containers/items were in a kitchen cabinet without an opened date on the containers: i) Italian Seasoning ii) Parley Flakes iii) Ground Cinnamon iv) Paprika v) Black Pepper vi) Ground Nutmeg vii) Poultry Seasoning viii) Ground Thyme ix) Rubbed Sage x) Chili Powder xi) Lemon and Pepper Seasoning Salt xii) Ground Mustard xiii) Mediterranean Style Ground Oregano xiv) Ground Cayenne Pepper xv) Onion Powder xvi) Garlic Powder xvii) One opened 32 oz. bottle of light corn syrup xviii) One opened box of corn starch. xix) One opened 12 oz. bottle of honey. xx) One opened 16 oz. container of baking soda. b. One 5 lb. container of baking powder was inside the kitchen cabinet with an expiration date of [DATE]. c. On [DATE] at 2:21 PM, the following observations were made in the refrigerator and the Storage Room: i) One opened carton of half and half was on a shelf in the refrigerator with no opened date on the carton. ii) One gallon of whole milk and one gallon of 2% milk were on a shelf in the refrigerator with no opened dates on the containers. iii) Two bags of bread were on a shelf in the Storage Room with no received dates on the bags. iv) One eight count bag of hamburger buns was on shelf in the Storage Room with no received date on the bag. d. On [DATE] at 10:47 AM, CNA #19 was wearing gloves. She opened the refrigerator door, removed a ziplock bag that contained biscuits and placed it on the counter. She then, turned on the stove and without changing gloves and washing her hands, she removed biscuits from the bag and placed them in a pan to be baked and served to the residents for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 11. On [DATE] at 2:30 PM, the following observations were made in Cottage #4: a. The following seasoning containers/items were in a kitchen cabinet without an opened date on the containers: i) Onion Powder ii) Garlic Powder iii) Ground Black Pepper iv) Ground Cinnamon v) Poultry Seasoning vi) Parsley Flakes vii) Light Chili Powder viii) Cayenne Pepper b. On [DATE] at 2:32 PM, one 5-pound container of grits was on a shelf in the Storage Room with an expiration date of [DATE]. c. On [DATE] at 2:34 PM, the following items were on a shelf in the refrigerator with no opened dates on the containers: i) One gallon of milk. ii) One bottle of mayo. iii) One bottle of sweet relish. d. On [DATE] at 2:36 PM, the following observations were made in the freezer and the Storage Room: i) Three boxes of hot pockets were on a shelf in the freezer with no received or opened dates on the boxes. ii) One bag of bread was on the shelf in the Storage Room with no received date. iii) One opened 36 oz. bottle of syrup was on a shelf in the Storage Room with no opened date on the bottle. e. On [DATE] at 2:40 PM, the following observations were made on a shelf in the refrigerator: i) One 24 oz. container of cottage cheese with an expiration date of [DATE]. ii) One opened bottle of ranch dressing with no opened date on the bottle. iii) One opened bottle of thousand island with no opened date on the bottle. iv) One opened bottle of Italian dressing with no opened date on the bottle. v) One opened bottle of lemon juice with no opened date on the bottle. 12. The facility policy titled, Handwashing and Glove Usage in Food Service, provided by the Administrator on [DATE] at 3:21 PM documented, .When Food Handlers must wash their hands: .After leaving and returning to the kitchen/prep area. After touching anything else such as dirty equipment, work surfaces or cloths .

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected an active diagnosis for 1 (Resident #27) of 10 (Residents #3, #11, #16 #27, #30, #57, #60, #69, #108 and #109) sampled residents who had Physician Orders for Insulin; 1 (Resident #59) of 12 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170 and #370) sampled residents who had Physician Orders for oxygen therapy and 1 (Resident #74) of 1 sampled resident who had Physician Orders for Hospice services. This failed practice had the potential to affect all 117 residents according to the Census and Conditions of Residents provided by the Administrator on 01/31/22 at 10:03 am. The findings are: 1. Resident #27 had diagnoses of Vascular Dementia, Chronic Pain, Presence of Prosthetic Heart Valve and Atherosclerotic Heart Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and received insulin(s) injection one day of the seven day look back period. a. The Physician Order dated 10/07/22 documented, .NovoLog Solution 100 UNIT/ML [milliliter] (Insulin Aspart), Inject as per sliding scale: if 201-250 = 1; 251-300 = 2; 301-350 = 3; 351- 400 = 4; 401-450 = 5; 451-500 = 6, subcutaneously before meals for per sliding scale for diabetes . b. The Progress Note dated 10/8/2022 at 11:23 pm documented, .Elder resting in bed with eyes closed. Respirations even and nonlabored. No s/s [signs/symptoms] pain or distress at this time. Elder continues on N.O. [New Order] Humalog sliding scale. No adverse reactions noted related to new order of Humalog . c. The Care Plan with a revision date 01/06/23 did not address that Resident #27 had a diagnosis of Diabetes or received sliding scale Insulin. d. On 02/03/23 at 7:14 am, the Surveyor asked Licensed Practical Nurse (LPN) #7 if Resident #27 had a diagnosis of Diabetes and used Insulin. She stated, Yes. The Surveyor asked if that was important information to have on the Care Plan. She stated, Honestly I don't know. I think that would be something the office would need more than me. I don't use the Care Plans I use the Medication Admission Record [MAR]. e. On 02/03/23 at 7:36 am, the Surveyor asked the Assistant Director of Nursing (ADON), Who is responsible for the completion of the Minimum Data Set? She stated, The MDS Coordinators. The Surveyor asked if a Diabetes diagnosis and Insulin use as ordered by the Physician, should be addressed on the Care Plan. She stated, Yes. The Surveyor asked what the potential consequences of the omission could be. She stated, The Care Plan gets into the specifics of how to take care of that resident. It goes further than the Physician Orders to tell you what to do for that resident, such as assessing the feet, skin integrity, high and low blood sugars, etc. [etcetera] f. On 02/03/23 at 9:23 am, the Surveyor asked the MDS Coordinator what his job duties were. He stated I'm the business part of nursing. I look into the care of the residents, document the progress, or decline and try to find the best outlook for them. Example, therapy or whatever can help them the most. The Surveyor asked, What are the possible complications of not identifying the resident's health concerns upon admission? He stated, The Care Plan helps us take care of residents. The Surveyor asked, What problems could arise if the Care Plans are not updated? He stated, The resident may not get the care that they need. The Surveyor asked if a diagnosis of diabetes and the use of insulin for a resident as ordered by the physician should be addressed on the Care Plan. He stated, Yes. The Surveyor asked what the potential consequences of the omission could be. He stated, The outlook for their care. g. The facility policy titled, Resident/Elder Assessment and Comprehensive Care Plan Procedure ., provided by the Administrator on 02/03/23 at 7:44 am documented, 1 . Comprehensive assessments describe the Resident/Elder's capability to perform daily life functions and significant impairment . to provide appropriate care and services for each Resident/Elder . 3 . The comprehensive assessment shall include all information specified in the State-approved Resident/Elder assessment instrument [RAI] and all other evaluations and assessments completed by health care professionals . 2. Resident #59 had diagnoses of Unspecified Dementia and Immunodeficiency. The Quarterly MDS with ARD of 11/20/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a BIMS and did not receive oxygen therapy. a. The Physician's Order dated 09/16/22 documented, .Oxygen at 2 liters per minute via nasal cannula prn [as needed] shortness of breath . every shift . b. The Medication Administration Record (MAR) for November 2022 documented the oxygen tubing was changed on 11/6/22, 11/13/22, and on 11/20/22 and oxygen was used 16 days of the 20 days prior to the MDS being completed. c. The Care Plan with a revision date of 11/27/22 did not address oxygen therapy. d. On 01/30/23 at 12:03 PM, Resident #59's oxygen (O2) concentrator was set at 4 lpm (liters per minute). e. On 01/31/23 at 2:32 PM, Resident #59's O2 concentrator was set at 4 lpm. f. On 02/01/23 at 3:20 PM, the Surveyor accompanied LPN #4 to Resident #59's room and asked LPN #4 what her O2 was set at. LPN#4 stated, Hers is at 4 lpm. The Surveyor asked what the Physician Order was. LPN #4 stated, I need to look it up. The Surveyor accompanied LPN #4 to her computer, and she stated, Oh, it's supposed to be at 2 [lpm]. I will get that adjusted today. g. On 02/03/23 at 8:56 AM, the Surveyor asked MDS Coordinator #1 to pull up Resident #59's last MDS completed. MDS Coordinator #1 pulled up the MDS dated [DATE]. The Surveyor asked what was marked for oxygen in Section O. The MDS Coordinator stated, It says No. The Surveyor asked MDS Coordinator #1 to pull up Resident #59's MAR for November 2022 and asked what the oxygen use showed prior to the MDS date. MDS Coordinator #1 stated, It should have been marked Yes. That can be corrected. I can correct that today. h. The Long Term Care Facility Resident Assessment Instrument (RAI) RAI Version 3.0 Manual Page O-3 documented, .O0100,C Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP, CPAP) here. This item may be coded if the resident placed or removes his/her own oxygen mask, cannula . 3. Resident #74 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Dementia. The Quarterly MDS with an ARD of 12/13/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a BIMS and did not receive Hospice care. a. The Physician Orders dated 07/12/22 documented, .Admit to Hospice . b. The Care Plan with a revision date of 09/15/22 documented, .I have elected Hospice Services . Consult with physician regarding Hospice care for me in the facility as needed . Work cooperatively with hospice team to ensure my spiritual, emotional, intellectual, physical, and social needs are met . c. On 02/02/23 at 3:10 pm, the Surveyor asked MDS Coordinator #1 if the hospice services should be documented in Section O of the Quarterly MDS with ARD of 12/13/22. He stated, Yes, it could have very well been just hitting the wrong box . d. On 02/23/23 at 3:21 pm, the Administrator provided a document that documented, .[Facility] does not have a MDS Policy and Procedure. We utilize the RAI manual for direction . e. The Long Term Care Facility Resident Assessment Instrument (RAI) Version 3.0 Manual Page O-5 documented, .Special Treatments, Procedures, and Programs . O0100K, Hospice care. Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions . 43262 46032

Based on observation, interview, and record review, the facility failed to ensure the doors to the laundry rooms in 6 (Cottages #2, #3, #4, #5, #9 and #11) cottages were locked to prevent the potential of an injury to residents/elders, failed to ensure electrical cords were safely secured out of water for 1 (Cottage #1) to prevent the potential of injury and/or fire and failed to ensure dryer lint traps were appropriately maintained in 6 (Cottages #2, #3, #4, #9, #10 and #11) of 11 (Cottages #1, 2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) cottages to prevent the potential for a fire. The findings are: 1. On 01/30/23 at 11:56 AM, the following were in Cottage #2: a. The door to the Laundry Room was unlocked. b. The dryer contained a load of white towels and in and around the lint trap there was 1/4 to 1/2 inch thick grey and pink lint buildup in and under the lint trap. c. The Surveyor asked Certified Nursing Assistant (CNA) #3 if the door should be locked. CNA #3 stated it should have been. The Surveyor asked CNA #3 how often the dryer lint traps were cleaned. CNA #3 stated, Umm, we are supposed to do it daily, but it probably should be after each load. The Surveyor asked CNA #3 what the possible outcome could be from lint build up. CNA #3 stated, It's a fire hazard. 2. On 01/30/23 at 2:23 PM, the following were in Cottage #1: a. There was water was pooled in the floor of the Laundry Room, the water was discolored with a pinkish red thick substance around the edges. b. There were electrical cords in the water. The cords were plugged into a 4 outlet box. One of the cords was plugged into a box labeled, 'Storm Medical Equipment'. 3. On 02/01/23 at 2:32 PM, the following were in Cottage #4: a. The doors to the Laundry Room were unlocked. The Surveyor asked CNA #2 if the doors should be unlocked. CNA #2 stated, No they should not. b. There was 1/2 inch of lint in the filter and approximately one handful of lint under the filter of the dryer. The Surveyor asked CNA #2 when the dryer lint traps were cleaned. CNA #2 stated, Every time you put a new load in. The Surveyor asked CNA #2 to describe the lint and how much was in the trap. CNA #2 stated, I'm not sure, but it's more than a couple of loads. The Surveyor asked what the possible outcome could be. CNA #2 stated, A fire. 4. On 02/01/23 at 2:39 PM, the following were in Cottage #5: a. The doors to the Laundry Room were unlocked. The Surveyor asked CNA #6 if the laundry doors should be locked. CNA #6 stated, Yes. 5. On 02/01/23 at 2:47 PM, the following were in Cottage #9: a. The doors to the Laundry Room were unlocked. The Surveyor asked CNA #5 if the doors should be unlocked. CNA #5 stated, They are supposed to be locked. b. There was 1/4 inch of lint in the filter and approximately two handfuls of lint under the filter of the dryer. The Surveyor asked how often the lint traps were cleaned. CNA #5 stated, Daily. The Surveyor asked what could happen with the lint built up as it was in the trap. CNA#5 stated, Maybe a fire. 6. On 02/01/23 at 2:52 PM, the following were in Cottage #3: a. The doors to the Laundry Room were unlocked. The Surveyor asked CNA #7 if the doors should be unlocked. CNA #7 stated, They need to be locked. b. There was 1/2 inch of lint in the filter and one to two handfuls of lint under the filter of the dryer. The Surveyor asked CNA #7 how often the lint traps were cleaned. CNA #7 stated, After every load. The Surveyor showed CNA #7 the lint under the trap and CNA #7 stated, I did not know that opened. The Surveyor asked what a possible outcome was if with the lint built up as it was. CNA #7 stated, It could cause a fire most definitely. 7. On 02/01/23 at 3:01 PM, the following were in Cottage #10: a. The lint trap in the dryer was full. The Surveyor asked how often the lint trap was cleaned. CNA #8 stated, After each load. The Surveyor showed CNA #8 the area below the lint trap and asked him to scoop out the lint. CNA #8 scooped out 2 handfuls of lint. CNA #8 stated, I did not know that came out. The Surveyor asked what could happen with the lint built up that thick. CNA #8 stated, A fire. We do not want that. 8. On 02/01/23 at 3:09 PM, the following were in Cottage #11: a. The doors to the Laundry Room were unlocked. The Surveyor asked CNA #9 if the doors should be unlocked. The CNA #9 stated, No, they should not be unlocked. There should not be any unlocked doors. b. The lint trap to the dryer was overflowing. The Surveyor showed CNA #9 the lint trap and the lint in the area below the lint trap. CNA #9 stated, I did not know lint could build up under there. 9. On 02/01/23 at 3:38 PM, the Surveyor asked the Maintenance Supervisor to accompany the Surveyors to Cottage #1's Laundry Room. The door was unlocked. The Surveyor asked the Maintenance Supervisor if it should be locked. The Maintenance Supervisor shook his head and said, Yes, all doors need to be locked. The Surveyor asked about the water puddles on the floor that the electrical cords were touching. The Maintenance Supervisor stated, I can zip-tie them up, so they do not touch the floor. I do not know where the water is coming from. I think it is from under the wall. The Surveyor asked the possible outcome of having the cords touching the water on the floor. The Maintenance Supervisor stated, It could short out the refrigerator, or phones, or the outlet and it could ground out. The Surveyor asked if it was a safety issue. The Maintenance Supervisor stated, There is a GFI [Ground Fault Circuit Interrupter] breaker, but the Elders could get in here because the door was not locked. The Surveyor asked about a cord coming from a box with the label that documented, Storm Medical equipment and asked what it controlled. The Maintenance Supervisor stated, I am not completely sure, but I think it controls the door locks. The Surveyor asked if it was a safety issue if the door locks are shorted out and do not work on the doors at a secure cottage. The Maintenance Supervisor stated, Yes, that would be a big problem. 10. On 02/01/23 at 4:06 PM, the Surveyor asked the Administrator and the Assistant Administrator if the laundry room doors should be locked. The Administrator stated, Yes, unless there is somebody currently in it. The Surveyor asked how often the lint traps should be emptied. The Administrator stated, They do the front ones at least daily and more often when needed. The Surveyor asked if the CNAs received training on using the dryers and cleaning the lint traps. The Administrator stated, Yes, they do. We obviously did not train them enough on the traps. I heard about the amount in some of them. The Surveyor asked who was responsible for ensuring the lint traps did not build up. The Administrator stated, It's on me. The Surveyor asked what the outcome could be if the lint traps built up. The Administrator stated, Well, a fire possibly. The Surveyor requested the manufacturer and model of the dryers in each cottage and the Manufacturer instructions regarding the lint traps. 11. On 02/02/23 at 12:49 PM, the Assistant Administrator provided a list of dryer manufacturers and model numbers and the corresponding lint trap instructions. a. The list documented Cottages #1, #2, #3, #4, #9, #10, and #11 had (Brand) dryers with the model (number). The manufacturer lint filter instructions documented, .The lint filter is located at the front of the dryer in the lower part of the door opening. Clean the lint filter before drying each load. Remove lint filter cover, clean lint filter, and replace cover. Annually remove lint filter and screw, to vacuum the duct under it .

Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) was administered at the physician ordered flow rate for 4 (Residents #21, #34, #59 and #66); failed to obtain a Physicians Order for 2 (Resident #170 and #370) who received oxygen therapy; failed to ensure oxygen tubing was dated for 1 (Resident #170), and failed to ensure CPAP (Continuous Positive Airway Pressure) mask, updraft masks and nebulizer mouthpieces were properly stored when not in use to prevent the potential for cross contamination and respiratory infections for 3 (Residents #21, #37 and #370) of 13 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170, #370 and #371) sampled residents who received updrafts and/or oxygen therapy or used a CPAP machine as documented on a list provided by the Assistant Director of Nursing (ADON) on 02/03/23 at 8:32 AM. The findings are: 1. Resident #59 had diagnoses of Unspecified Dementia and Immunodeficiency. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and did not receive oxygen therapy. a. The Physician's Order dated 09/16/22 documented, .Oxygen at 2 liters per minute via nasal cannula PRN [as needed] Shortness of Breath . every shift . b. On 01/30/23 at 12:03 PM, Resident #59 was lying in bed with O2 at 4 LPM (liters per minute) via nasal cannula (NC). c. On 01/31/23 at 2:32 PM, Resident #59 was lying in bed with O2 at 4 LPM via NC. d. On 02/01/23 at 3:20 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #4 to Resident #59's room. The Surveyor asked LPN #4 what Resident #59's O2 was set at. LPN #4 stated, Hers is at 4 LPM. The Surveyor asked, What is the Physicians Order for? LPN #4 stated, I need to look it up. After looking on the computer she stated, Oh, it's supposed to be at 2 [LPM]. I will get those adjusted today. The Surveyor asked how often O2 concentrators should be checked. LPN #4 stated, Technically at least a glance at it when we are in there [Resident's room]. The Surveyor asked, What could happen if the O2 flow rate was not followed accurately? LPN #4 stated, Well, if it's not high enough then there's a risk of their sats [saturation rate] dropping. If it's too high, they can be getting too much oxygen which could be a problem too. The Surveyor asked if the Physicians Orders should be followed. LPN #4 stated, Yes. 2. Resident #66 had a diagnosis of Chronic Respiratory Failure with Hypoxia. The Annual MDS with an ARD of 11/02/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a BIMS and did not receive oxygen therapy. a. The Physicians Order dated 09/16/23 documented, .Oxygen at 3 liters per minute via nasal cannula PRN Shortness of Breath .every shift . b. On 01/30/23 at 12:09 PM, Resident #66 was lying in bed with O2 at 2.25 LPM via nasal cannula. c. On 01/31/23 at 2:34 PM, Resident #66 was lying in bed with O2 at 2.25 LPM via NC. d. On 02/01/23 at 3:13 PM, the Surveyor accompanied LPN #4 to Resident #66's room and asked LPN #4 what Resident #66's O2 was set at. LPN #4 stated, It's at 2 LPM. The Surveyor asked what the Physician's Order stated. LPN #4 stated, I do not know. I will have to look it up. After looking on the computer, she stated, It's supposed to be at 3 [LPM]. 3. Resident #21 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Vascular Dementia. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/22/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and received oxygen therapy. a. The Physician's Order dated 09/16/22 documented, .Oxygen at 3 liters per minute via nasal cannula PRN [as needed] Shortness of Breath . every shift . b. The Care Plan with a revision date of 12/23/22 documented, .DX [Diagnosis] of COPD with risk for complications . Administer oxygen and updrafts as ordered . May self-administer updraft tx [treatment] after setup. Nurse to determine time, set up medication, store medication and clean machine . c. On 01/30/23 at 12:07 PM, Resident #21 was lying in bed with O2 at 2.25 LPM via nasal cannula. An updraft mask was lying on the bedside table not in a bag. d. On 01/31/23 at 2:35 PM, Resident #21 was lying in bed with eyes closed with O2 at 4 LPM via NC. An updraft mask, and nebulizer mouthpiece was lying on the bedside table not in a bag. e. On 02/01/23 at 3:16 PM, the Surveyor accompanied LPN #4 to Resident #21's room. The Surveyor asked LPN #4 what Resident #21's O2 was set at. LPN #4 stated, It's at 4 liters per minute. The Surveyor asked what the Physicians Order was for Resident #21's oxygen. LPN #4 stated, I will have to look it up too. After looking on the computer, LPN #4 stated, It's also supposed to be at 3 [LPM]. 4. Resident #34 had a diagnosis of COPD. The Admission MDS with an ARD of 01/15/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS and received oxygen therapy. a. The Physicians Order dated 01/13/23 documented, .May have oxygen 2 LPM via N/C [nasal cannula] as needed every shift oxygen therapy . b. The Care Plan with a revision date of 01/20/23 documented, .I have DX [diagnosis] of COPD with risk for complications including exacerbation of COPD, Pneumonia, Respiratory Distress . Administer Oxygen and Updrafts as ordered . c. On 01/30/23 at 11:22 AM, Resident #34's O2 concentrator was on running at 4.5 liters, and the nasal cannula (NC) was lying across the O2 concentrator not in bag. d. On 01/31/23 at 1:44 PM, Resident #34 in his wheelchair with the O2 at 4 liters via NC. e. On 02/01/23 at 3:51 PM, Resident #34 was in his room visiting with a visitor with O2 at 4 liters via NC. f. On 02/02/23 at 10:51 AM, the Surveyor asked LPN #2, Do you know what Resident #34's O2 is ordered to be set on? LPN #2 stated, No. The Surveyor asked if she knew what his O2 was set on right now. LPN #2 said, No. The Surveyor asked if she would go into Resident #34's room. LPN #2 said, Yes. The Surveyor asked LPN #2 what his O2 was set on. She said, Four, I thought it was on 2 LPM. LPN#2 turned it down, as the resident was not using it at this time. The Surveyor and LPN #2 went back to her computer and checked the order. LPN #2 said, It states 2 liters as needed. He is known to turn the O2 up when he wants. The Surveyor asked, That means you all keep an eye on him and his concentrator? LPN #2 said, Yes. 5. Resident #37 had diagnoses of Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia, Acute Pulmonary Edema, and COPD. The Quarterly MDS with an ARD of 01/02/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and received oxygen therapy. a. The Physicians Order dated 09/30/22 documented, .Oxygen at 3 liters per minute via nasal cannula PRN Shortness of Breath every shift . b. The Care Plan with a revision date 10/10/22 documented, .I am at risk for Pulmonary edema related to chronic respiratory failure . I have to use oxygen for my SOB [Shortness of Breath] . Administer oxygen to me as ordered . c. On 01/30/23 at 4:12 PM, Resident #37 was not in his room. The 02 concentrator was on and running at 3 liters. The NC was lying on the floor not in a bag. d. On 02/01/23 at 3:17 PM, Resident #37 was lying in bed with his eyes closed with O2 at 3 liters via NC. e. On 02/02/23 at 11:07 AM, the Surveyor asked Certified Nursing Assistant (CNA) #2, On Monday, when I entered the residents' room the NC was on the floor. What should have been done with the NC? CNA #2 said, It should have been put in the bag connected to the O2 concentrator. The Surveyor asked, Why, should the NC be put in the bag? CNA #2 said, So it doesn't get dirty. The Surveyor asked, Why, do we not want it to get dirty? CNA #2 stated, I'm not sure? The Surveyor said, To protect the resident from infections. 6. Resident #170 had diagnoses of COPD and Vascular Dementia. The Admission MDS with an ARD of 01/27/23 documented the resident had modified independence in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and received oxygen therapy. a. The February 2023 Physicians Order did not contain an order for oxygen therapy. b. On 01/30/23 at 12:33 PM, Resident #170 was lying in bed asleep with O2 at 2 LPM via NC. The O2 tubing was not dated. c. On 01/31/23 at 2:17 PM, Resident #170 was lying in bed with O2 at 1.75 LPM via NC. The O2 tubing was not dated. d. On 02/01/23 at 3:24 PM, the Surveyor accompanied LPN #5 to Resident #170's room and asked what Resident #170's O2 flow rate was set at. LPN #5 stated, It's at 2 [LPM]. The Surveyor asked what the Physicians Order was for Resident #170's oxygen. LPN #5 stated, I will check. After looking on the computer, LPN #5 stated I don't see any oxygen orders. I don't know who put it [O2] in there. It shows she was on O2 in the hospital, but there are no transfer orders for the oxygen, so she should not be on any. The Surveyor asked when the O2 flow rate should be checked. LPN #5 stated, Every shift. The Surveyor asked when Resident #170 was admitted . LPN #5 stated, The 25th. The Surveyor asked how many shifts that would be. LPN #5 stated, Approximately fourteen. 7. Resident #370 had diagnoses of Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia, Dependence on Respiratory (ventilator) Status, and Other Sleep Apnea. The Quarterly MDS with an ARD of 01/02/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and received oxygen therapy and did not require BiPAP/CPAP. a. The February 2023 Physicians Orders did not contain orders for oxygen therapy or CPAP use. b. The Care Plan with a revision date of 01/27/23 did not address oxygen therapy or CPAP use. c. On 01/30/23 at 10:31 AM, Resident #370 was sitting in her recliner in her room without her O2 on. Resident #370 stated she uses her O2 at night on 4 liters, it hooks up to the CPAP. The CPAP nose piece was lying on the bed, not in the bag. d. On 01/31/23 at 10:31 AM, Resident #370 was sitting in her recliner in her room. The CPAP nose piece was lying on the bed, not in the bag. e. On 02/01/23 at 3:11 PM, Resident #370 had just returned to her room from therapy. The CPAP nose piece was lying on her bed, not in a bag. f. The Surveyor accompanied CNA #6 to Resident #370's room. The Surveyor asked CNA #6, Why is the CPAP nose piece lying on the bed, where should it be stored, and should it be in a bag? CNA #6 said, I don't know. I am not allowed to touch anything that has to do with the O2. g. The Surveyor accompanied LPN #1 to Resident #370's room. The Surveyor asked LPN #1 if the CPAP nose piece should be on the resident's bed. LPN #1 said, No, it is supposed to be in a bag, we have talked about that. The Surveyor asked, Why should the nose piece be put in a bag? LPN #1 said, For sanitary reasons. The Surveyor asked, What can happen if it gets dirty? LPN #1 stated, It could cause an infection. 8. On 02/01/23 at 4:01 PM, the Surveyor asked the DON how often O2 concentrator flow rates should be checked. The DON stated, Every shift and on the MARs [Medication Administration Records]. The Surveyor asked if a resident did not have a Physicians Order for O2, should the resident have had oxygen being administered the last 3 days. The DON stated, No, they should only get a moment or so of oxygen without an order after a fall or something if we are worried about the elder and have called the APRN [Advanced Practice Registered Nurse]. The Surveyor asked if the LPNs were to find a resident with O2 being administered without an order who do they call. The DON stated, They can call the APRN or the after-hours number they all have access to. The Surveyor asked if 3 or more days was too long to go without a Physicians Order. The DON stated, Yes, and I will have to investigate when the O2 was started, but yes, 3 days is too long. 9. The facility policy titled, Oxygen Administration, provided by the Administrator on 02/02/23 at 9:49 AM documented, .to administer oxygen safely to the Resident/Elder when insufficient oxygen is being carried by the blood to the tissues . 1. Check physician's order for liter flow and method of administration . 11. At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier and assess Resident/Elder's respirations to determine further need for oxygen therapy . 9. Humidifier should be labeled with date and time changed . 46723

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets, 22 residents who received mechanical soft diets, and 74 residents who received regular diets (total census:117), according to the Diet List provided by the Dietary Supervisor on 02/01/23. The findings are: 1. On 02/01/23 the facility's menu for breakfast provided by the Dietary Supervisor at 4:52 PM documented the residents on mechanical soft diets and on regular diets were to receive 3/4 cup of cereal. The residents on pureed diets were to receive a #8 scoop of pureed french toast. 2.On 02/01/23, the following observations were made during breakfast in Cottage #6: a. At 7:43 AM, Certified Nursing Assistant (CNA) #13 used a #10 scoop, (equivalent to 2/5 cup) to serve oatmeal to the residents who received mechanical soft diets and regular diets, instead of 3/4 cup as specified on the menu. b. At 7:48 AM, CNA #13 placed half a slice of french toast into a blender, added whole milk, pureed, and then poured it into a divided plate to be served to a resident on a pureed diet. The menu specified, the residents on pureed diets were to receive a #8 scoop of pureed french toast. c. On 02/02/23 at 12:41 PM, the Surveyor asked CNA #13 how much french toast the resident on a pureed diet received. She stated, I used a half a slice of French toast. I should have used one slice. I was in a hurry. 3. On 02/02/23 at 10:40 AM, the menu for the noon meal documented for the residents on mechanical soft diets to receive a #8 scoop of ground fried chicken. a. On 02/02/23 at 11:43 AM, during the serving of the noon meal in Cottage #9, CNA #19 used a #16 scoop (Blue) which is equivalent to 1/4 cup to serve a single portion of ground chicken to the residents who received mechanical soft diets. The menu specified for the residents who received mechanical soft diets to receive a #8 scoop of mechanical soft chicken each. At 12:44 PM, the Surveyor asked CNA #19, What scoop size did you use to serve the mechanical soft chicken and how many servings did you give to each resident? She stated, I used a #16 scoop, and I gave a serving each. The Surveyor asked, What scoop should you have used? She stated, I should have used a #8 scoop. That was my mistake.

Based on observation, record review, and interview, the facility to ensure food was prepared by methods that maintained the flavor and encouraged good nutritional intake for residents who received regular diets, mechanical soft diets, and pureed diets for 1 of 1 meal observed. This failed practice had the potential to affect 5 residents who received regular diets and 5 residents who required mechanical soft diets in Cottage #2 according to lists provided by the Dietary Supervisor on 02/01/23. The findings are: 1. On 01/30/23 at12:31 PM, in Cottage #2, the bottom of the cornbread was burnt. Certified Nursing Assistant (CNA) #11 removed the burnt area and served the top part of the cornbread to the residents. At 1:37 PM, the Surveyor asked CNA #11 to describe the appearance of the cornbread served to the residents. She stated, It was baked from another cottage and sent to us. The bottom was burnt. I had to remove the bottom part of the cornbread and I served the top part to the residents. 2. On 02/01/23 at 7:36 AM, CNA #13 placed one sausage patty into a blender, added whole milk and pureed. She poured the pureed sausage in a divided plate. The consistency of the pureed sausage was runny. 3. On 02/01/23 at 12:23 PM CNA #15 placed 12 crackers and whole milk into a blender, pureed and scooped the mixture into two bowls. The appearance of the pureed crackers was thick. At 12:26 PM, CNA #14 was asked to describe the appearance of the pureed crackers. She stated, Too thick.

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets in Cottage #1, #2, #5 and #6 as documented on a list provided by the Dietary Supervisor on 02/02/23 at 4:52 PM. The findings are: 1. On 1/30/2023 at 12:05 PM in Cottage #5, the following pureed food items were served to the resident on a pureed diet: a. Pureed cornbread was served to the resident. The consistency of the pureed cornbread was not smooth. There were pieces of cornbread visible in the mixture. b. Pureed seasoned cut green beans served to the resident were runny and the pureed chicken and dumplings was not smooth. There were pieces of chicken in the mixture. The Surveyor asked the Dietary Supervisor to describe the consistency of the food items served to the resident. She stated, Pureed cut green beans were too runny. Pureed chicken and dumplings have pieces of meat in it and pureed cornbread has pieces of cornbread in it. 2. On 2/01/23 at 7:36 AM, in Cottage #6, during breakfast preparation, CNA #13 placed one sausage patty into a blender, added whole milk and pureed. She poured the pureed sausage on a divided plate. The consistency of the pureed sausage was runny. 3.The following observations were made in Cottage #1 during lunch preparation on 02/01/23: a. At 12:00 PM, Certified Nursing Assistant (CNA) #15 placed one baked potato into a blender, added salt, butter, thickener, milk, and pureed. She poured the pureed potato on a plate. The consistency of the pureed potato was not smooth. There were lumps visible in the mixture. b. At 12:07 PM, CNA #15 used a #8 scoop to place 2 servings of cut green beans into a blender and pureed. She poured the pureed cut green beans on a plate. The consistency of the pureed cut green beans was not smooth. There were pieces cut green beans of visible in the mixture. c. At 12:12 PM, CNA #15 used a #6 scoop to place 2 servings of chili into a blender and pureed. She poured the pureed chili on the same plate. There were pieces of meat visible in the mixture.

Based on observation, interview, and record review, the facility failed to ensure standard infection control precautions were followed for 1 (Resident #60) of 10 (Residents #11, #27, #57, #60, #66, #69, #75, #95, #96 and #108) sampled residents who had Physician Orders for Accucheck Glucose Monitoring and failed to ensure transmission-based precautions were followed for 1 (Resident #78) of 1 sampled resident who was on contact and droplet precautions. This failed practice had the potential to affect all 117 residents according to the Census and Conditions of Residents provided by the Administrator on 01/31/22 at 10:03 AM. The findings are: 1. On 02/01/22 at 11:29 AM, Licensed Practical Nurse (LPN) #6 obtained an accucheck glucose reading on Resident #76. LPN #6 then entered Resident #60's room and obtained an accucheck glucose reading using the same glucometer used on Resident #76 without cleaning the glucometer between residents. a. The Surveyor asked LPN #6 if the same glucometer was used for multiple residents. LPN #6 stated, Yes, and I messed up, I didn't clean it. b. On 02/02/23 at 3:20 PM, the Surveyor asked the Director of Nursing (DON) if it was appropriate to use the same glucometer for multiple residents and not clean it between residents. The DON stated, No, it's not. I have already started an Inservice. c. The facility policy and procedure titled, Blood Glucose Monitoring, provided by the Administrator on 02/02/23 at 9:49 AM documented, .Procedure .6.Cleanse the equipment with a disinfectant wipe between use on other residents . 2. Resident #78 was admitted to the facility on [DATE] and had diagnoses of Atherosclerotic Heart Disease, Chronic Systolic Congestive Heart Failure, and Personal History of Covid-19. The Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was not on isolation for an active infection. a. On 01/30/23 at 12:51 PM, Resident #78 had droplet and contact isolation signage on the door of the room and a cart with supplies by the door. Certified Nursing Assistant (CNA) #4 and CNA #5 entered Resident #78's room with no isolation gowns, face shields, or shoe covers in use. The door to the room was open and the Surveyor observed CNA #5 with only gloves and a regular isolation mask removed a biohazard bag of trash and took it out of the room. The Surveyor asked Assistant Director of Nursing (ADON) #2 what Resident #78 was in isolation for. ADON #2 stated, COVID-19, we do contact and droplet isolation for that. The Surveyor asked if she was aware (CNA #4) and (CNA #5) were in an isolation room without proper personal protective equipment in use. ADON #2 looked in the open doorway of Resident #78's room and observed CNA #4 still in room without proper protection. b. On 01/30/23 at 1:15 PM, CNA #4 and CNA #5 were interviewed. The Surveyor asked CNA #4 and CNA #5 what precautions should be used for Resident #78's isolation. CNA #4 stated, The full gamut gown, gloves, mask, face shield, shoe covers. You caught me. CNA #5 stated, She has had 2 negative tests 2 days in a row. We thought she was going to be taken off isolation. c. On 02/01/23 at 3:57 PM, the Surveyor asked the Administrator for COVID-19 testing and results for Resident #78. The Administrator provided the test dates and stated Resident #78 had a test completed on 01/22/23 due to symptoms and was positive and that she was in her 90 day window from a positive test on 12/05/22. d. The facility policy and procedure titled, COVID-19 Guidance, provided by the Administrator on 01/30/23 at 2:36 PM documented, .8. HCP [Health Care Providers] who enters the room of a resident with suspected or confirmed SARS-CoV-2 [Coronavirus COVID-19] infection should adhere to standard precautions and use a NIOSH [National Institute for Occupational Safety and Health] approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection .

Based on observation, record review, and interview, the facility failed to ensure individualized comprehensive Care Plans were implemented to meet the resident's medical and nursing needs, to promote continuity of care for 2 (Residents #27 and #69) of 10 (Residents #3, #11, #16, #27, #30, #57, #60, #69, #108 and #109) sampled residents on Insulin and 1 (Resident #69) of 12 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170 and #370) sampled residents who had Physician Orders for oxygen (O2) therapy. This failed practice had the potential to affect all 117 residents according to the Census List provided by the Administrator on 01/30/23 at 10:15 am. The findings are: 1. Resident #27 had diagnoses of Vascular Dementia, Chronic Pain, Presence of Prosthetic Heart Valve and Atherosclerotic Heart Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and received insulin(s) injection one day of the seven day look back period. a. The Physician Order dated 10/07/22 documented, .NovoLog Solution 100 UNIT/ML [milliliter] (Insulin Aspart), Inject as per sliding scale: if 201-250 = 1; 251-300 = 2; 301-350 = 3; 351-C400 = 4; 401-450 = 5; 451-500 = 6, subcutaneously before meals for per sliding scale for diabetes . b. The Progress Note dated 10/8/2022 at 23:45 (11:23) pm documented, .Elder resting in bed with eyes closed. Respirations even and nonlabored. No s/s pain or distress at this time. Elder continues on N.O. [New Order] Humalog sliding scale. No adverse reactions noted related to new order of Humalog. c. The Care Plan with a revision date 01/06/23 did not address that Resident #27 had a diagnosis of Diabetes or received sliding scale Insulin. d. On 02/03/23 at 7:14 am, the Surveyor asked Licensed Practical Nurse (LPN) #7 if Resident #27 had a diagnosis of Diabetes and used Insulin. She stated, Yes. The Surveyor asked if that was important information to have on the Care Plan. She stated, Honestly I don't know. I think that would be something the office would need more than me. I don't use the Care Plans I use the Medication Admission Record [MAR]. e. On 02/03/23 at 7:36 am, the Surveyor asked the Assistant Director of Nursing (ADON), Who is responsible for the completion of the Minimum Data Set? She stated, The MDS Coordinators. The Surveyor asked if a Diabetes diagnosis and Insulin use as ordered by the Physician, should be addressed on the Care Plan. She stated, Yes. The Surveyor asked what the potential consequences of the omission could be. She stated, The Care Plan gets into the specifics of how to take care of that resident. It goes further than the Physician Orders to tell you what to do for that resident, such as assessing the feet, skin integrity, high and low blood sugars, etc. [etcetera] f. On 02/03/23 at 9:23 am, the Surveyor asked the MDS Coordinator what his job duties were. He stated I'm the business part of nursing. I look into the care of the residents, document the progress, or decline and try to find the best outlook for them. Example, therapy or whatever can help them the most. The Surveyor asked, What are the possible complications of not identifying the resident's health concerns upon admission? He stated, The Care Plan helps us take care of residents. The Surveyor asked, What problems could arise if the Care Plans are not updated? He stated, The resident may not get the care that they need. The Surveyor asked if a diagnosis of diabetes and the use of insulin for a resident as ordered by the physician should be addressed on the Care Plan. He stated, Yes. The Surveyor asked what the potential consequences of the omission could be. He stated, The outlook for their care. 2. Resident #69 had diagnoses of Atherosclerotic Heart Disease, Personal History of Transient Ischemic Attack and Cerebral Infarction without Residual Deficits and Dependence on Supplemental Oxygen. The Quarterly MDS with an ARD of 11/20/22 documented the resident scored 8 (8-12 indicates moderately cognitively intact) on a BIMS and received oxygen therapy. a. The January 2023 Physicians Orders did not contain an order for oxygen therapy. b. The Care Plan with a revision date of 02/22/22 did not address the diagnosis of Dependence on Supplemental Oxygen, oxygen therapy, the need to change and date the O2 tubing, the humidifier, or the need to remove, clean and replace the O2 concentrator filter while in use. c. On 01/30/23 at 12:00 pm, Resident #69 was lying in bed, with O2 at 2 liters via nasal cannula (n/c). The Surveyor asked Resident #69 if he wore his O2 all the time. He stated, Not all the time, just when I'm in bed. d. On 01/30/23 at 12:00 pm, Resident #69 was lying in bed, with O2 at 2 liters via nasal cannula (n/c). The Surveyor asked Resident #69 if he wore his O2 all the time. He stated, Not all the time, just when I'm in bed. e. On 02/02/23 at 2:45 pm, the Surveyor asked Licensed Practical Nurse (LPN) #7 if Resident #69 used O2. She stated, Not all the time, he does wear it when he is in bed. 3. On 02/03/23 at 07:27 am, the Surveyor asked the Assistant Director of Nursing (ADON) who was responsible for the completion of the Minimum Data Set. She stated, Our MDS Coordinators. The Surveyor asked if O2 ordered by the physician should be addressed on the Care Plan. She stated, Yes. The Surveyor asked what the potential consequences of the omission of O2 on the Care Plan could be. She stated, The Care Plan is what we tell the staff to follow along with the Physician Orders, to know the flow rate, when to clean, change tubing, just general information about the O2. 4. On 02/03/23 at 9:23 am, the Surveyor asked the MDS Coordinator what his job duties were. He stated I'm the business part of nursing. I look into the care of the residents, document the progress, or decline and try to find the best outlook for them. Example, therapy or whatever can help them the most. The Surveyor asked, What are the possible complications of not identifying the resident's health concerns upon admission? He stated, The Care Plan helps us take care of residents. The Surveyor asked, What problems could arise if the Care Plans are not updated? He stated, The resident may not get the care that they need. The Surveyor asked if O2 use as ordered by the physician should be addressed on the Care Plan. He stated, Yes. The Surveyor asked what the potential consequences of the omission could be. He stated, The outlook for their care. 5. The facility policy titled, Resident/Elder Assessment and Comprehensive Care Plan Procedure ., provided by the Administrator on 02/03/23 at 7:44 am documented, .1 .Comprehensive assessments describe the Resident/Elder's capability to perform daily life functions and significant impairment .to provide appropriate care and services for each Resident/Elder . 3 .The comprehensive assessment shall include all information specified in the State-approved Resident/Elder assessment instrument [RAI] and all other evaluations and assessments completed by health care professionals . 6. The Long Term Care Facility Resident Assessment Instrument (RAI) version 3.0 Manuel Chapter 3 Section I, Active Diagnosis, documented, .1. Identify diagnoses . Medical record sources for physician dx [diagnosis] include progress notes .2. Determine whether diagnoses are active .

Based on interview, and record review, the facility failed to ensure COVID-19 vaccinations were provided to eligible residents in a timely manner who consented to the immunization for 1 (Resident #67) and documented accurately in the immunization records consents and declinations for COVID-19 vaccinations for 1 (Resident #75) of 5 (Residents #14, #32, #67, #75 and #108) sampled residents whose COVID-19 immunizations were reviewed. This failed practice had the potential to affect all 117 residents who resided in the facility as documented on the Resident Matrix provided by the Minimum Data Set (MDS) Coordinator #2 on 01/30/23. The findings are: 1.On 02/01/23 at 9:25 PM, a review of the COVID-19 Consents and Immunization records showed Resident #67 had a signed consent for the COVID-19 vaccination dated 8/15/22. There was no documentation that Resident #67 received the vaccination. a. On 02/02/23 at 3:10 PM, the Surveyor asked the Human Resource Assistant (HRA) to pull up the Immunization Consent Form for Resident #67 to see which vaccines Resident #67 had consent to. The HRA stated, All three. The Surveyor asked the HRA to show whether or not Resident #67 had received them. The HRA stated, She hasn't had the COVID. The Surveyor asked if Resident #67 should have received it. The HRA stated, Yes. The Surveyor asked, How long after the resident has signed the consent form should they have to wait to receive the vaccination? The HRA stated, I couldn't say, I don't administer them. b. On 02/02/23 at 3:13 PM, the Surveyor asked the Director of Nursing (DON) to pull up the Immunization Consent Form for Resident #67. She did. The Surveyor asked if Resident #67 consented to the COVID-19 Vaccine. The DON stated, Yes. The Surveyor asked the DON if Resident #67 had received the vaccine. The DON stated, They have not. The Surveyor asked how soon the resident should expect to receive the vaccination after they signed the consent. The DON stated, Pretty soon. 2. On 02/01/23 at 9:25 PM, the Surveyor found no signed consent or declination in Resident #75's electronic record. a. On 02/02/23 at 2:50 PM, the Surveyor asked the HRA to pull up the COVID-19 vaccine consent or declination for Resident #75. The HRA pulled up the Immunization Consent/Declination page and stated, It's not on there. The Surveyor asked her to pull up Resident #75's immunization list and asked if Resident #75 had been given the COVID-19 vaccine. The HRA stated, It says COVID was refused? The Surveyor asked if she could locate the documentation for the declination. The HRA stated, I'm not finding the refusal. The Surveyor asked if the resident should be asked about their immunization preferences. The HRA stated, Yes. b. On 02/02/23 at 2:58 PM, the Assistant Director of Nursing (ADON) provided the Declination form dated 08/13/21 for Resident #75. The Surveyor asked the HRA if the declination should be in the electronic records. The HRA stated, Yes. 3. On 02/02/23 at 3:18 PM, the Surveyor asked the Administrator how soon after signing a COVID-19 vaccination consent should a resident receive the immunization. The Administrator stated, I don't know, within a month. The Surveyor asked if a resident signed a consent in August, if she should have received it by now. The Administrator stated, Oh yes, I don't know why they haven't. 4. The facility policy titled, COVID-19 Moderna Vaccination Delivery for Nursing Home Administration, provided by the Administrator on 01/31/23 at 12:15 PM, did not address a timeframe as to when COVID-19 vaccinations were administered.

Based on observation, record review and interview, the facility failed to ensure an individualized comprehensive Care Plan was implemented to meet the resident's medical and nursing needs and promote continuity of care for 1 (Resident #69) of 12 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170 and #370) sampled residents whose Care Plan was reviewed. This failed practice had the potential to affect all 117 residents who had Care Plans according to the Census list provided by the Administrator on 01/30/23 at 10:15 am. The findings are: 1. Resident #69 had diagnoses of Atherosclerotic Heart Disease, Personal History of Transient Ischemic Attack and Cerebral Infarction without Residual Deficits and Dependence on Supplemental Oxygen (O2). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/22 documented the resident scored 8 (8-12 indicates moderately cognitively intact) on a Brief Interview of Mental Status (BIMS) and received oxygen therapy. a. The January 2023 Physicians Orders did not contain an order for oxygen therapy. b. The Care Plan with a revision date of 02/22/22 did not address the diagnosis of Dependence on Supplemental Oxygen, oxygen therapy, the need to change and date the O2 tubing, the humidifier, or the need to remove, clean and replace the O2 concentrator filter while in use. c. On 01/30/23 at 12:00 pm, Resident #69 was lying in bed, with O2 at 2 liters via nasal cannula (n/c). The Surveyor asked Resident #69 if he wore his O2 all the time. He stated, Not all the time, just when I'm in bed. d. On 02/02/23 at 2:45 pm, the Surveyor asked Licensed Practical Nurse (LPN) #7 if Resident #69 used O2. She stated, Not all the time, he does wear it when he is in bed. e. On 02/03/23 at 7:27 am, the Surveyor asked the Assistant Director of Nursing (ADON) who was responsible for the completion of the Minimum Data Set. She stated, Our MDS Coordinators. The Surveyor asked if O2 ordered by the physician should be addressed on the Care Plan. She stated, Yes. The Surveyor asked what potential consequences of the omission of O2 not being on the Care Plan could be. She stated, The Care Plan is what we tell the staff to follow along with the Physician Orders, to know the flow rate, when to clean, change tubing, just general information about the O2. f. On 02/03/23 at 9:23 am, the Surveyor asked the MDS Coordinator what his job duties were. He stated, I'm the business part of nursing. I look into the care of the residents, document the progress, or decline and try to find the best outlook for them. Example, therapy or whatever can help them the most. The Surveyor asked, What are the possible complications of not identifying the resident's health concerns upon admission? He stated, The Care Plan helps us take care of residents. The Surveyor asked, What problems could arise if the Care Plans are not updated? He stated, The resident may not get the care that they need. The Surveyor asked if O2 use as ordered by the physician should be addressed on the Care Plan. He stated, Yes. The Surveyor asked what the potential consequences of the omission could be. He stated, The outlook for their care. g. The facility policy titled, Resident/Elder Assessment and Comprehensive Care Plan Procedure ., provided by the Administrator on 02/03/23 at 7:44 am documented, .1.Comprehensive assessments describe the Resident/Elder's capability to perform daily life functions and significant impairment .to provide appropriate care and services for each Resident/Elder . 3 .The comprehensive assessment shall include all information specified in the State-approved Resident/Elder Assessment Instrument [RAI] and all other evaluations and assessments completed by health care professionals . h. The Long Term Care Facility Resident Assessment Instrument (RAI) version 3.0 Manuel Chapter 3 Section I, Active Diagnosis, documented, .1. Identify diagnoses .Medical record sources for physician dx [diagnosis] include progress notes .2. Determine whether diagnoses are active .

Complaint # (AR 369) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a resident was free from neglect, as evidenced by failure of a direct care staff member to remove a resident from the whirlpool prior to ending her shift and leaving the facility, to prevent injury for 1 (Resident #1) of 3 (Residents #1, #3 and #4) case mix residents who resided in the 400 cottage and used the whirlpool. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was found unresponsive with a temperature of 104.2 degrees Fahrenheit and required hospitalization after being left unattended in the whirlpool, and had the potential to cause more than minimal harm to 5 residents who resided in the 400 cottage and used the whirlpool, as documented on a list provided by the Administrator on 8/18/17. The facility removed the Immediate Jeopardy and corrected the failed practices on 8/11/17, prior to the survey. The Administrator was informed of the past immediate jeopardy condition on 8/18/17 at 1:55 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/21/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for bathing, bed mobility, transfer, locomotion and toilet use, and had unsteady balance. a. The Plan of Care dated 7/21/17 documented, Decline in ADLs (activities of daily living) related to S/P (status [REDACTED]. (Resident #1) likes to take whirlpools and enjoys soaking in whirlpool . b. The 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 8/11/17 documented, .Date and Time of Incident: 8/11/2017 Time: 10:15 PM. Date and Time of Discovery: 8/11/2017 Time: 10:15 PM . Section II Complete Description of Incident At 10:48 pm on 8/11/2017, Administrator received a phone call from (Director of Nursing (DON)) to inform me of the following set of circumstances: CNA (Certified Nursing Assistant #2) came on duty at 10:00 p.m. on 8/11/17 and during report she was told by CNA, (CNA #1), that resident (Resident #1) was in the whirlpool. (CNA #2) states she told (CNA #1) and her partner (CNA #3) to get him out of the whirlpool while she, (CNA #2) and the other 2-10 (2:00 p.m.-10:00 p.m.) CNA, (CNA #4), went to put another resident to bed. At that point, (CNA #2) noticed water in the floor in front of the spa room and upon entering saw (Resident #1) was still in the whirlpool. She summoned for help, while staying with the resident and the LPN (Licensed Practical Nurse) (LPN #1) came and they opened the whirlpool door and got (Resident #1) out. (LPN #1) reports that (Resident #1) was not verbally responding, but was breathing and opening his eyes. He was transported to the local hospital by the EMS (Emergency Medical Services) ambulance and was admitted overnight for observation. On-coming LPN, (LPN #2), spoke with the hospital around 11:00 p.m. and was told that (Resident #1) was stable but being kept in observation through the night. At 4:00 a.m. (LPN #2) spoke to a nurse at the hospital and was told that (Resident #1) was up and talking and drinking ginger ale. (Resident #1) did return to the campus on 8/12/2017 around 4:15 p.m. with orders to follow up with nursing home physician and no negative outcomes related to the incident. The Administrator interviewed (Resident #1) at approximately 8 pm on 8/12/2017 in his room. He was lying in bed, head covered (which is normal) listening to the TV. Administrator asked him about the incident on 8/11/2017 and he said that the girl checked on him 'several times', he told her each time he 'was fine' and was 'enjoying the whirlpool' and the next thing he knew 'he was in the emergency room .' He stated he was fine now but that 'he didn't get any sleep up there' and was tired. Resident did appear to be his normal self, had no fears or concerns about the incident but did ask 'would he still be able to use the whirlpool again'. He was told he would be able to use the whirlpool again but related to his current medical condition he would no longer be allowed to use the whirlpool without staff present during the whirlpool. (Resident #1) is a 15 out of 15 on his BIMS scores and is very cable of making decisions and able to request help. His call light was in reach in the whirlpool and staff made frequent checks while he was bathing himself. The hospital reported the incident to Adult Protective Services and Office of Long Term Care (OLTC) as neglect. (Resident #1) frequently bathes himself with minimal supervision and uses the call light when needed while staff make frequent rounds on resident. During this bathing experience (Resident #1) did become lethargic with a low pulse ox (oxygen level). As reported by ER (emergency room ) visit records, normal CXR (chest x-ray) and breath sounds, (Resident #1) was never submerged as reported by ER. Section III Findings and Actions Taken (CNA #1) was called back to the campus by (DON) and (LPN #3 MDS/guide) and guide over the Cottage that (Resident #1) resides, who both arrived before the ambulance did. (CNA #1) was interviewed by DON, MDS Nurse / Guide for the house and Administrator. She states she checked on (Resident #1) at least 3 times and the third time the tub was empty and he had the water running and he was wetting his mouth. (CNA #1) states she informed the on-coming CNA, (CNA #2) that he was in the whirlpool and she left . c. An Office of Long Term Care (OLTC) Witness Statement dated 8/11/17 and signed by CNA #1 documented, I put him (Resident #1) in the tub around 8:30 / 9 pm. I put the chair by the tub with his clothes. He told me he could do it on his own so he can relax. I showed him where the call light was and made sure he was ok (okay). I went by in there to give him a clean underwear, asked if he was ok, which he gave the ok, after a while I checked back on him in which he had the jets on relaxing I asked if he was ok, he stated yes, after so long I checked on him again, he didn't have any water in the tub but the water was running for him to wet his mouth, asked if he was ok he said 'Yep.' I told another CNA he was still in there. She said ok then I went home. The other CNAs was (CNA #3 and CNA #4) with me tonight. d. An OLTC Witness Statement form dated 8/11/17 by CNA #2 documented, When I (CNA #2) got here, I was getting report when (CNA #1) said (Resident #1) was in the whirlpool. I told her and (CNA #3) to get him out. (CNA #4) asked me if I would help get (another resident) to bed, so me and her and (another CNA) went and put her to bed. When we came out, everyone (from 2:00 p.m. to 10:00 p.m. shift) was gone and then (CNA #3) went home. That when (CNA #5) came in and ask me if I could go look at (other cottage's) dishwasher, it was smoking. I told her to stay here, I was going to go look and that when I seen (sic) water, I ran in the whirlpool room and (Resident #1) was in the whirlpool. The water was running and he had half of his head lying on the side of the tub but the water was overflowing in mouth. I tried to hold him up and yelled for the nurse. Then we open the whirlpool door and got him out the call light was hanging behind tub but still could be reach by hand. e. An OLTC Witness Statement form dated 8/11/17 by LPN #1 documented, This nurse was called to the whirlpool room at 2215 (10:15 p.m., a period of over 1 hour after CNA #1 stated she placed the resident in the tub) by CNAs. R (Resident) was found in whirlpool (with) it overflowing. R was not verbally responsive but was breathing and opening eyes. We opened the whirlpool and tried to stimulate and dry him off. I told the CNAs to get vital signs and I went and called (LPN #5) and APN (Advanced Practice Nurse). f. An OLTC Witness Statement form dated 8/11/17 by LPN #2 documented, (At) 1030p (10:30 p.m.) (LPN #1) off-going nurse from the (400 Cottage) house stating there was an emergency (with) (Resident #1). We ran to (400 house) house. Upon entering, water was in the floor coming out of whirlpool room. Upon entering CNA (CNA #6) and nurse (LPN #1) were in (with) R in whirlpool. We moved R to the floor. Temp 104.2 Ax (axillary). Covered (with) cold rags, rolled to left side. (LPN #5) stated she was unable to obtain a blood pressure. O2 (oxygen) sat (saturation) 64%. O2 applied. R breathing opening eyes, (and) grunting. EMTs (emergency medical technicians) arrived (and) took R via ambulance (at) 1050p (10:50 p.m.). This nurse notified (Resident #1's family) at 10:53 p.m. g. An OLTC Witness Statement form dated 8/11/17 by CNA #6 documented, I (CNA #6) came over to the (400 House) to talk to (CNA #2) about the schedule when it was a convenient time. (CNA #4) had asked (CNA #2) for help to lay (another resident) down and (CNA #2) told (CNA #1) and (CNA #3) to get (Resident #1) out of the whirlpool. After leaving, we were walking toward the front door and (CNA #2) glanced over and noticed water on the floor by the whirlpool room. She yelled for help, I ran over and seen (Resident #1) body bobbing in the water, the head was above. Water was on and running over the tub. I yelled for (LPN #1) the nurse to come fast. (CNA #2) opened the tub door. We tried multiple times to get him to respond. I stayed with him while nurses called everyone and until ambulance got here. Call light was found behind the tub but was still in reach for him to reach and set off. h. An OLTC Witness Statement form dated 8/12/17 by CNA #3 documented, In between the hours of 8 (and) 9, I witnessed (CNA #1) and (Resident #1) going into the shower room to give (Resident #1) a bath, I was sitting at the table. (CNA #1) left (Resident #1) in the whirlpool and was checking on him three times, about 30 mins (minutes) in between. I heard a noise and told (CNA #1) it sounded like he was getting out, she went to check on him and said he was fine. When (CNA #2) came in for shift change, (CNA #1) told her that (Resident #1) was still in the whirlpool; I did not hear (CNA #2) tell (CNA #1) to get him out. I was speaking with (CNA #4) and getting all the trash together. i. An OLTC Witness Statement form dated 8/13/17 by CNA #4 documented, On Friday around 8:30/9:00 p (CNA #1) put (Resident #1) into the whirlpool. I ask maybe 10 minutes later have she checked on (Resident #1). She then get up to check on him. He's still soaking she said. About 15 minutes later I then ask her is he out the whirlpool she gets up and came back with the same thing he's still soaking after 10p-6a (10:00 p.m. to 6:00 a.m.) shift came in I left around 10:30 pm b/c (because) I was finished with my dutys (sic) when I left at 10:30 pm I wasn't aware that (CNA #1) never got him out the whirlpool. j. An Event Investigation Report dated 8/11/17 and written by LPN #1 documented, Person Involved (Resident #1) . Date of Incident 8/11/17 Time of Incident 2215 (10:15 p.m.) Location of Incident . Whirlpool . Document an exact description of the incident/accident and circumstances surrounding it. This nurse was called to the whirlpool room at 2215 by CNAs. R was found in whirlpool (with) it overflowing. R was not verbally responsive but was breathing and would open eyes. We opened the whirlpool and tried to stimulate and dry him off. I told the CNAs to get vital signs and I called (LPN #5) and (APN). Skin tear noted to upper mid back and (right) shoulder. k. An Interventions Evaluations form dated 8/11/17 at 11:37 p.m. documented, R taken to (local hospital) ER by ambulance at 2250 (10:50 p.m.) . 8/11/17 Late entry 0023 (12:23 a.m.) I was called to the whirlpool room by the CNAs. R was found in the whirlpool room by the CNAs, water was running over. R was verbally unresponsive. R was breathing. We emptied the whirlpool and started drying R off and trying to stimulate him. He opened his eyes and grunted. O2 was 65. Temp 104.4. Pulse was 58. I called (APN) at 2224 (10:24 p.m.) and was ordered to call ambulance . ambulance called at 2229 (10:29 p.m.). l. The ambulance Patient Care Report dated 8/11/17 documented, Chief Complaint/Response. This crew responded to a call for a [AGE] year old male that was dispatched by 911 for unresponsive . The Chief complaint for the patient is Unresponsive . The general impression of the patient was unresponsive . Upon arrival of the scene at Cottage #4 the crew was escorted to the spa room. Patient . was found lying next to the whirlpool tub. He was lying in about 2 inches of standing water throughout the floor with a wet towel/blanket underneath him. Staff stated they had come in and found him unresponsive in the whirlpool and had gotten him out and placed him onto the floor. Initial assessment revealed his skin was hot to the touch. I asked how long he had been in the whirlpool and the nursing home staff did not know how long he had been inside the whirlpool or who had put him in there. They stated they did not know how he got there. Several nursing home staff members assisted the crew in pulling him out of the room and into the adjoining area where the ambulance cot was. Upon moving the patient we noted a large amount of feces underneath him and assisted staff in cleaning him up. Staff and crew jointly placed patient on the stretcher and the crew loaded him into the ambulance. Patient did start to show signs of improvement just prior to arriving at the ER. He began to respond more to verbal stimuli and try to respond verbally, although it was incomprehensible . m. The hospital Emergency Department (ED) physician notes dated 8/11/17 documented, .History of Present Illness Chief Complaint: Fever and weakness. This started just prior to arrival and is still present (better) . At its maximum, severity described as severe. When seen in the ED, severity described as moderate . The report from the NH (Nursing Home) is that the patient remained in a step-in type one person whirlpool tub for about 1.5 hours. The patient was removed from the tub unresponsive, temperature 104.2, HR (heart rate) 58, and experienced an uncontrolled loose BM (bowel movement). He was eventually aroused but was weak and lethargic beyond his normal baseline. EMS was called to transport to the ER . Review of Systems: The patient has had high measured temperature of 104.2 . Physical Exam Vital Signs: Temp: 38 C (Celsius) (equals temperature of 100.4 Fahrenheit . Appearance: Lethargic . Neuro: Altered mental status: lethargic. Patient slow to respond. Eyes open to voice. Best verbal response: disoriented . n. A hospital Nursing Progress Notes dated 8/11/17 at 11:10 p.m. documented, (Facility Name) called . asked about certain times that patient was placed in whirlpool. Informed that times were uncertain and that patient could have been there for approx. (approximately) 2 hours . o. A hospital physician short stay note dated 8/11/17 documented, .Chief Complaint: Mental status change, got too hot. History of Present Illness: He was in a whirlpool bath hot tub for a few hours, apparently was forgotten by the nursing home staff. They pulled him out and his temperature was 104.2 and had some mental status changes including that of mental status depressed. He was transported via EMS, wet. On arrival to the ER, 100.4, no distress. Mental status had returned to baseline after about an hour of observation. EMS called it a near drowning but it seems that this was a small contained hot tub and his head did not go under water. He's seen this morning in ICU (Intensive Care Unit) .He is awake, alert, oriented (times) 3 and in currently no distress.Patient apparently, when he gets too hot, has done this before . IMPRESSION: Depressed mental status secondary to probable hyperthermia. Hyperthermia, unintentional due to hot tub . being careful not to get over heated and unmonitored, especially in whirlpool bath . p. A Nursing Note dated 8/12/17 at 11:00 p.m. written by LPN #2 documented, (At) 2230 (10:30 p.m.) (LPN #1) came to get me from the (facility cottage name), he stated I was needed in the (400 Cottage). Upon entering there was water out in the floor. Upon entering whirlpool room observed R in whirlpool, CNAs (and) nurse (LPN #1) present. R was breathing. We lowered R to the floor, he was verbally unresponsive, pulse present. Rolled R to (left) side, instructed CNAs to get me cold towels. During this time I was talking to R, he would open his eyes (and) grunt. Cold towels placed over R. Lung fields noted (with) crackles. O2 sat between 64% (and) 68%. Temp 104.2 Ax. (LPN #5) brought oxygen to room, placed on R. Still talking (with) R asking him to keep opening eyes, which he would do. Temp rechecked, 102.7 Ax. EMTs arrived. R transferred to gurney, ambulance left (with) R (at) 2250 (10:50 p.m.). This nurse notified (Resident #1's family member) (at) 2253 (10:53 p.m.) Administration aware (and) present. q. An Intervention Evaluation note written by LPN #1 at 8/12/17 at 6:29 p.m. documented, R returned to facility by (facility) transportation (at) 1615 (4:15 p.m.). r. On 8/17/17 at 4:50 p.m., CNA #2 was asked what event had occurred with Resident #1 on 8/11/17 and CNA #2 stated, I came in on 10-6 (10:00 p.m. to 6:00 a.m. shift). When (I) came on, he was in the whirlpool. The CNA was asked if she knew the resident was in the whirlpool and stated, . (CNA #1) told me he was in the whirlpool. The CNA was asked CNA #1 told her this and stated, A little before 10 (p.m.). The CNA was asked if she was on duty at that time and stated, Yes, just came on duty. I told her (CNA #2) she needed to get him out, because I'm the only one here at night. After I told her, me and (CNA #4) had to put (other resident's name) to bed. When we came out of the room, there was no one left. The CNA was asked what she meant by, no one left and stated, (CNA #3 name) and (CNA #1 name). They wasn't (sic) out here. The CNA was asked if she had seen those CNAs again after that and stated, No, the other CNA (CNA #5's name) came in the door and said that (another cottage's) washing machine was smoking or steaming, and that's when I looked over there and saw water coming out under the door. The CNA was asked which door and stated, The whirlpool room . I ran over there, opened the door and (Resident #1) was lying in there. I yelled for help. He was in the tub with water, his head lying on top of the tub. CNA #2 accompanied the surveyor to the whirlpool room and demonstrated how the resident was found in the whirlpool tub. The whirlpool was a walk-in type, with a wide door, and the CNA opened the door, sat on the whirlpool seat and placed her head on the top right edge of the tub. The door was positioned lower than the top edges of the tub. The CNA stated The door was closed, and he was lying here like this. The CNA was asked if the resident's head was out of the water and stated, Yes, the water was going over (side of tub). The CNA was asked if the water was going over the door and stated Yes, I straightened him up and held his head. (CNA #5 and CNA #6) came and (LPN #1), the nurse, and (LPN #5), nurse. They were right here immediately. He was breathing. He would open his eyes; he moaned. (We) opened the door (to the whirlpool), and (LPN #2 and LPN #1) held him. They got (LPN #2) from the other building. Me, (CNA #6, and LPN #5) got him and laid him on the floor and nurses started working on him, sternal rubs, had him on his side. The CNA was asked if residents can get in the spa room by themselves and stated Not anymore, we didn't have a policy, but we do now. The CNA was asked what the policy was and stated, You (residents) have 15 minutes with somebody (staff) in there with you. The CNA was asked if this was for every resident and stated, For everybody. They in-serviced us right after that. Before, they could go in there with a CNA, but if they ask for privacy, you leave, but in and out. They said we can stand outside the door with it cracked where we can hear. The CNA was asked if a resident can now be left in the whirlpool and the CNA stated, No, that's what the in-service told us. s. On 8/17/17 at 7:55 p.m., LPN #1 was asked what occurred with Resident #1 on 8/11/17 and stated, I had already given report to (LPN #2) and I heard the CNA who just came and the other CNA (CNA #6) I heard her say I need a nurse by whirlpool room. I ran. I heard her say they left (Resident #1) in the whirlpool. I think she meant the CNAs on my shift, (CNA #1) and another, new male CNA. The LPN was asked if she was aware that Resident #1 was in the whirlpool and stated, No, I was aware he was supposed to get a bath sometime on my shift. I just know there are some residents who get a bath. To my knowledge, I didn't know he had gone to the whirlpool. The LPN was asked if staff were to be with a resident when in the whirlpool and stated, My understanding, they were supposed to stay with him or near, to give him some privacy. The LPN was asked if she had seen the resident go into the whirlpool room and stated, No. LPN #1 was asked, When was the last time you had seen the resident that shift? She stated, About 7:15 p.m., when I gave him his medicine . When asked for further details about the incident, the LPN stated, When I walked in, (CNA #2 and CNA #6) were standing next to the whirlpool with (Resident #1). First thing I checked was to make sure he was breathing, he would open his eyes. When I touched him, he opened his eyes, so she (CNA #2) opened door after I held him in place. From there I called (LPN #5) and we started getting vitals. (LPN #5) was there, and (another LPN), (LPN #5) relief. So both got there and when they got there, I called (APN). (APN) said get a set of vitals and text, and if unresponsive, send to ER . ran and got (LPN #2). As soon as I got off the phone with (APN), I called the ambulance. Ambulance arrived approximately 10:50 or 11:00 p.m. I believe I called ambulance at 10:29 . We got vitals, (LPN #2) told me she checked pulse ox, they told me I'm pretty sure I wrote on it, it was 68. I was getting paperwork together. LPN #1 was asked where CNA #1 was during this incident and stated, She had clocked out and went home, or at least was off campus. I didn't see her after that. LPN #1 was asked if the CNA should have left the resident unattended in the whirlpool and stated, No, obviously not, I guess you could say. The LPN was then asked if CNA staff were supposed to leave the facility after assisting a resident into the whirlpool and stated, No I would say not. The LPN was asked how many CNA staff members were in the cottage on the night shift and stated, There's just one on nights. t. On 8/18/17 at 10:32 a.m., LPN #2 was asked what had occurred on 8/11/17 when Resident #1 had an incident. The LPN stated, I was in the (another cottage) at 10:30 (p.m.) and (LPN #1) came and got me and said we had an emergency . I ran in; as soon as I got in the whirlpool room, I said, 'is he breathing?' (LPN #5) said 'yes'. At that point, he (resident) was sitting in the whirlpool; we lifted him out of the whirlpool, and I listened to his lungs. I asked for cold towels, his skin was very warm, temp (temperature) was 104 axillary. His pulse ox was 64 to 68. I said '(LPN #5) go get oxygen'. She brought oxygen and put it on. He responded, not answered, but with his eyes, and he would grunt. I rechecked temp and blood pressure. We were unable to get the blood pressure. We tried a manual cuff. The EMTs got here. We sent him to the ER. They left at 10:50, and I notified the family at 10:53 p.m. Pulse I believe was 58. The LPN was asked if the blood pressure was audible when she attempted to check it with a manual cuff. The LPN stated, No. u. On 8/18/17 at 10:45 a.m., CNA #1 was asked what time the resident was taken to the whirlpool on the date of the incident and stated, I want to say maybe 8:30 or 9ish. I didn't look at my watch. The CNA was asked if she had remained with the resident in the whirlpool tub room and stated, He asked for me to step out and get underwear, and I gave him privacy. I came back and handed him the underwear on a chair. The CNA was asked what time she ended her shift and left the building. CNA #1 stated, About 10:05, or a little after. The CNA was asked if the resident was still in the whirlpool tub when she left the building and stated, Yes, and I told the CNA coming on that he was still in the whirlpool. CNA #1 was asked if the resident should have been left in the whirlpool tub when she left work for the day and stated, No, I shouldn't have. The CNA was asked how many CNAs worked the night shift in the cottage and stated, Evening there's (sic) 3, and nights there's (sic) 1. v. On 8/18/17 at 4:52 p.m., the Administrator was asked if the CNA should have gotten the resident out of the whirlpool prior to ending her shift and leaving the building. He stated, Oh yes. The Administrator was asked if CNA staff should ever leave a resident who requires extensive ADL assistance unattended in the whirlpool. The Administrator stated, No. w. On 8/18/17 at 5:00 p.m., the Director of Nursing (DON) was asked if CNA #1 should have gotten the resident out of the whirlpool tub prior to leaving the building. The DON stated, Absolutely. The DON was asked if the CNA staff should ever leave a resident who requires extensive ADL assistance unattended in the whirlpool. The DON stated, No. x. The facility removed the immediate jeopardy and corrected the failed practices on 8/11/17, as evidenced by the following: 1.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities dated 8/11/17, Section III - Findings and Actions Taken, documented, .(CNA #1) was asked to write a statement and was suspended until the investigation was completed. On 8/15/2017 (CNA #1) was terminated. (LPN #3 MDS Nurse / Guide) immediately went to each cottage and in-serviced all staff on duty on 3 things: (1) No one is to be left in the whirlpool unattended. (2) No one is to be in the whirlpool for more than 15 minutes and (3) The on-coming and off going staff are to do rounds on every resident in the cottage before the off going staff leave the premises. (LPN #2) did the same in-service with all oncoming staff at 6 am on 8/12/17, (LPN #2) did the in-service with all oncoming staff at 2:00 p.m. on 8/12/17 and (LPN #3 / Guide) did the in-service with all oncoming staff at 10:00 pm on 8/12/17. The in-service has been done at every shift change and will continue until all staff have received the in-service. All new hires will be in-serviced during the orientation prior to working in the cottages. DON/designee will monitor 3 times a week for 4 weeks and weekly thereafter to ensure compliance. Any negative findings will be reported to Administrator and corrective actions taken immediately . CNA #1's time sheet documented the CNA clocked out on 8/11/17 at 10:06 p.m. and did not return to duty after that date. 2.) An in-service form dated 8/11/17 documented, .Do not leave anyone in whirlpool unsupervised. No Elder should be left in W/P (whirlpool) more than 15 minutes. Everyone should be doing rounds (with) oncoming shift. The form was signed by all licensed and direct care nursing staff who worked on 8/11/17, then all oncoming staff on 8/12/17, 8/13/17, 8/15/17, and 8/20/17. An In-service Education Report dated 8/18/17 to the hospice agency staff documented, 1. No elder is to be left in the whirlpool longer than 15 minutes. There is a timer on the wall by the light switch. 2. No elder is to be left in the whirlpool unattended, for resident privacy staff / responsible person can stand outside the door with the door partially opened so they can be heard in case of an emergency. 3.) A revision to the resident's Plan of Care dated 8/12/17 documented, Provide supervision while in W/P (whirlpool) and do not exceed over 15 min (minutes). 4.) On 8/18/17 at 10:32 a.m., LPN #2 was asked if there had been any in-services since the incident and stated, We had a whirlpool in-service that entails that no one can leave a resident alone in the whirlpool . It (in-service) started that night (8/11/17), for everyone. The LPN was asked if any residents had been left unattended in the whirlpool since the staff in-servicing was completed and stated, No. 5.) On 8/18/17 at 2:50 p.m., Resident #6 was asked, Does staff assist with your bathing and stay with you? She stated, Yes. 6.) On 8/18/17, the Administrator provided documentation of monitoring of whirlpool baths in all cottages, initiated on 8/12/17. No further negative findings had been identified as of this date.

Complaint # (AR 369) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure adequate supervision was provided to a resident during a whirlpool bath, as evidenced by failure of a direct care worker to remove the resident from the whirlpool prior to ending her shift and leaving the facility, to prevent injury for 1 (Resident #1) of 3 (Residents #1, #3 and #4) case mix residents who resided in the 400 cottage and used the whirlpool. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was found unresponsive with a temperature of 104.2 degrees Fahrenheit and required hospitalization after being left unattended in the whirlpool, and had the potential to cause more than minimal harm to 5 residents who resided in the 400 cottage and used the whirlpool, as documented on a list provided by the Administrator on 8/18/17. The facility removed the Immediate Jeopardy and corrected the failed practices on 8/11/17, prior to the survey. The Administrator was informed of the past immediate jeopardy condition on 8/18/17 at 1:55 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/21/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for bathing, bed mobility, transfer, locomotion and toilet use, and had unsteady balance. a. The Plan of Care dated 7/21/17 documented, Decline in ADLs (activities of daily living) related to S/P (status [REDACTED]. (Resident #1) likes to take whirlpools and enjoys soaking in whirlpool . b. The 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 8/11/17 documented, .Date and Time of Incident: 8/11/2017 Time: 10:15 PM. Date and Time of Discovery: 8/11/2017 Time: 10:15 PM . Section II Complete Description of Incident At 10:48 pm on 8/11/2017, Administrator received a phone call from (Director of Nursing (DON)) to inform me of the following set of circumstances: CNA (Certified Nursing Assistant #2) came on duty at 10:00 p.m. on 8/11/17 and during report she was told by CNA, (CNA #1), that resident (Resident #1) was in the whirlpool. (CNA #2) states she told (CNA #1) and her partner (CNA #3) to get him out of the whirlpool while she, (CNA #2) and the other 2-10 (2:00 p.m.-10:00 p.m.) CNA, (CNA #4), went to put another resident to bed. At that point, (CNA #2) noticed water in the floor in front of the spa room and upon entering saw (Resident #1) was still in the whirlpool. She summoned for help, while staying with the resident and the LPN (Licensed Practical Nurse) (LPN #1) came and they opened the whirlpool door and got (Resident #1) out. (LPN #1) reports that (Resident #1) was not verbally responding, but was breathing and opening his eyes. He was transported to the local hospital by the EMS (Emergency Medical Services) ambulance and was admitted overnight for observation. On-coming LPN, (LPN #2), spoke with the hospital around 11:00 p.m. and was told that (Resident #1) was stable but being kept in observation through the night. At 4:00 a.m. (LPN #2) spoke to a nurse at the hospital and was told that (Resident #1) was up and talking and drinking ginger ale. (Resident #1) did return to the campus on 8/12/2017 around 4:15 p.m. with orders to follow up with nursing home physician and no negative outcomes related to the incident. The Administrator interviewed (Resident #1) at approximately 8 pm on 8/12/2017 in his room. He was lying in bed, head covered (which is normal) listening to the TV. Administrator asked him about the incident on 8/11/2017 and he said that the girl checked on him 'several times', he told her each time he 'was fine' and was 'enjoying the whirlpool' and the next thing he knew 'he was in the emergency room .' He stated he was fine now but that 'he didn't get any sleep up there' and was tired. Resident did appear to be his normal self, had no fears or concerns about the incident but did ask 'would he still be able to use the whirlpool again'. He was told he would be able to use the whirlpool again but related to his current medical condition he would no longer be allowed to use the whirlpool without staff present during the whirlpool. (Resident #1) is a 15 out of 15 on his BIMS scores and is very cable of making decisions and able to request help. His call light was in reach in the whirlpool and staff made frequent checks while he was bathing himself. The hospital reported the incident to Adult Protective Services and Office of Long Term Care (OLTC) as neglect. (Resident #1) frequently bathes himself with minimal supervision and uses the call light when needed while staff make frequent rounds on resident. During this bathing experience (Resident #1) did become lethargic with a low pulse ox (oxygen level). As reported by ER (emergency room ) visit records, normal CXR (chest x-ray) and breath sounds, (Resident #1) was never submerged as reported by ER. Section III Findings and Actions Taken (CNA #1) was called back to the campus by (DON) and (LPN #3 MDS/guide) and guide over the Cottage that (Resident #1) resides, who both arrived before the ambulance did. (CNA #1) was interviewed by DON, MDS Nurse / Guide for the house and Administrator. She states she checked on (Resident #1) at least 3 times and the third time the tub was empty and he had the water running and he was wetting his mouth. (CNA #1) states she informed the on-coming CNA, (CNA #2) that he was in the whirlpool and she left . c. An Office of Long Term Care (OLTC) Witness Statement dated 8/11/17 and signed by CNA #1 documented, I put him (Resident #1) in the tub around 8:30 / 9 pm. I put the chair by the tub with his clothes. He told me he could do it on his own so he can relax. I showed him where the call light was and made sure he was ok (okay). I went by in there to give him a clean underwear, asked if he was ok, which he gave the ok, after a while I checked back on him in which he had the jets on relaxing I asked if he was ok, he stated yes, after so long I checked on him again, he didn't have any water in the tub but the water was running for him to wet his mouth, asked if he was ok he said 'Yep.' I told another CNA he was still in there. She said ok then I went home. The other CNAs was (CNA #3 and CNA #4) with me tonight. d. An OLTC Witness Statement form dated 8/11/17 by CNA #2 documented, When I (CNA #2) got here, I was getting report when (CNA #1) said (Resident #1) was in the whirlpool. I told her and (CNA #3) to get him out. (CNA #4) asked me if I would help get (another resident) to bed, so me and her and (another CNA) went and put her to bed. When we came out, everyone (from 2:00 p.m. to 10:00 p.m. shift) was gone and then (CNA #3) went home. That when (CNA #5) came in and ask me if I could go look at (other cottage's) dishwasher, it was smoking. I told her to stay here, I was going to go look and that when I seen (sic) water, I ran in the whirlpool room and (Resident #1) was in the whirlpool. The water was running and he had half of his head lying on the side of the tub but the water was overflowing in mouth. I tried to hold him up and yelled for the nurse. Then we open the whirlpool door and got him out the call light was hanging behind tub but still could be reach by hand. e. An OLTC Witness Statement form dated 8/11/17 by LPN #1 documented, This nurse was called to the whirlpool room at 2215 (10:15 p.m., a period of over 1 hour after CNA #1 stated she placed the resident in the tub) by CNAs. R (Resident) was found in whirlpool (with) it overflowing. R was not verbally responsive but was breathing and opening eyes. We opened the whirlpool and tried to stimulate and dry him off. I told the CNAs to get vital signs and I went and called (LPN #5) and APN (Advanced Practice Nurse). f. An OLTC Witness Statement form dated 8/11/17 by LPN #2 documented, (At) 1030p (10:30 p.m.) (LPN #1) off-going nurse from the (400 Cottage) house stating there was an emergency (with) (Resident #1). We ran to (400 house) house. Upon entering, water was in the floor coming out of whirlpool room. Upon entering CNA (CNA #6) and nurse (LPN #1) were in (with) R in whirlpool. We moved R to the floor. Temp 104.2 Ax (axillary). Covered (with) cold rags, rolled to left side. (LPN #5) stated she was unable to obtain a blood pressure. O2 (oxygen) sat (saturation) 64%. O2 applied. R breathing opening eyes, (and) grunting. EMTs (emergency medical technicians) arrived (and) took R via ambulance (at) 1050p (10:50 p.m.). This nurse notified (Resident #1's family) at 10:53 p.m. g. An OLTC Witness Statement form dated 8/11/17 by CNA #6 documented, I (CNA #6) came over to the (400 House) to talk to (CNA #2) about the schedule when it was a convenient time. (CNA #4) had asked (CNA #2) for help to lay (another resident) down and (CNA #2) told (CNA #1) and (CNA #3) to get (Resident #1) out of the whirlpool. After leaving, we were walking toward the front door and (CNA #2) glanced over and noticed water on the floor by the whirlpool room. She yelled for help, I ran over and seen (Resident #1) body bobbing in the water, the head was above. Water was on and running over the tub. I yelled for (LPN #1) the nurse to come fast. (CNA #2) opened the tub door. We tried multiple times to get him to respond. I stayed with him while nurses called everyone and until ambulance got here. Call light was found behind the tub but was still in reach for him to reach and set off. h. An OLTC Witness Statement form dated 8/12/17 by CNA #3 documented, In between the hours of 8 (and) 9, I witnessed (CNA #1) and (Resident #1) going into the shower room to give (Resident #1) a bath, I was sitting at the table. (CNA #1) left (Resident #1) in the whirlpool and was checking on him three times, about 30 mins (minutes) in between. I heard a noise and told (CNA #1) it sounded like he was getting out, she went to check on him and said he was fine. When (CNA #2) came in for shift change, (CNA #1) told her that (Resident #1) was still in the whirlpool; I did not hear (CNA #2) tell (CNA #1) to get him out. I was speaking with (CNA #4) and getting all the trash together. i. An OLTC Witness Statement form dated 8/13/17 by CNA #4 documented, On Friday around 8:30/9:00 p (CNA #1) put (Resident #1) into the whirlpool. I ask maybe 10 minutes later have she checked on (Resident #1). She then get up to check on him. He's still soaking she said. About 15 minutes later I then ask her is he out the whirlpool she gets up and came back with the same thing he's still soaking after 10p-6a (10:00 p.m. to 6:00 a.m.) shift came in I left around 10:30 pm b/c (because) I was finished with my dutys (sic) when I left at 10:30 pm I wasn't aware that (CNA #1) never got him out the whirlpool. j. An Event Investigation Report dated 8/11/17 and written by LPN #1 documented, Person Involved (Resident #1) . Date of Incident 8/11/17 Time of Incident 2215 (10:15 p.m.) Location of Incident . Whirlpool . Document an exact description of the incident/accident and circumstances surrounding it. This nurse was called to the whirlpool room at 2215 by CNAs. R was found in whirlpool (with) it overflowing. R was not verbally responsive but was breathing and would open eyes. We opened the whirlpool and tried to stimulate and dry him off. I told the CNAs to get vital signs and I called (LPN #5) and (APN). Skin tear noted to upper mid back and (right) shoulder. k. An Interventions Evaluations form dated 8/11/17 at 11:37 p.m. documented, R taken to (local hospital) ER by ambulance at 2250 (10:50 p.m.) . 8/11/17 Late entry 0023 (12:23 a.m.) I was called to the whirlpool room by the CNAs. R was found in the whirlpool room by the CNAs, water was running over. R was verbally unresponsive. R was breathing. We emptied the whirlpool and started drying R off and trying to stimulate him. He opened his eyes and grunted. O2 was 65. Temp 104.4. Pulse was 58. I called (APN) at 2224 (10:24 p.m.) and was ordered to call ambulance . ambulance called at 2229 (10:29 p.m.). l. The ambulance Patient Care Report dated 8/11/17 documented, Chief Complaint/Response. This crew responded to a call for a [AGE] year old male that was dispatched by 911 for unresponsive . The Chief complaint for the patient is Unresponsive . The general impression of the patient was unresponsive . Upon arrival of the scene at Cottage #4 the crew was escorted to the spa room. Patient . was found lying next to the whirlpool tub. He was lying in about 2 inches of standing water throughout the floor with a wet towel/blanket underneath him. Staff stated they had come in and found him unresponsive in the whirlpool and had gotten him out and placed him onto the floor. Initial assessment revealed his skin was hot to the touch. I asked how long he had been in the whirlpool and the nursing home staff did not know how long he had been inside the whirlpool or who had put him in there. They stated they did not know how he got there. Several nursing home staff members assisted the crew in pulling him out of the room and into the adjoining area where the ambulance cot was. Upon moving the patient we noted a large amount of feces underneath him and assisted staff in cleaning him up. Staff and crew jointly placed patient on the stretcher and the crew loaded him into the ambulance. Patient did start to show signs of improvement just prior to arriving at the ER. He began to respond more to verbal stimuli and try to respond verbally, although it was incomprehensible . m. The hospital Emergency Department (ED) physician notes dated 8/11/17 documented, .History of Present Illness Chief Complaint: Fever and weakness. This started just prior to arrival and is still present (better) . At its maximum, severity described as severe. When seen in the ED, severity described as moderate . The report from the NH (Nursing Home) is that the patient remained in a step-in type one person whirlpool tub for about 1.5 hours. The patient was removed from the tub unresponsive, temperature 104.2, HR (heart rate) 58, and experienced an uncontrolled loose BM (bowel movement). He was eventually aroused but was weak and lethargic beyond his normal baseline. EMS was called to transport to the ER . Review of Systems: The patient has had high measured temperature of 104.2 . Physical Exam Vital Signs: Temp: 38 C (Celsius) (equals temperature of 100.4 Fahrenheit . Appearance: Lethargic . Neuro: Altered mental status: lethargic. Patient slow to respond. Eyes open to voice. Best verbal response: disoriented . n. A hospital Nursing Progress Notes dated 8/11/17 at 11:10 p.m. documented, (Facility Name) called . asked about certain times that patient was placed in whirlpool. Informed that times were uncertain and that patient could have been there for approx. (approximately) 2 hours . o. A hospital physician short stay note dated 8/11/17 documented, .Chief Complaint: Mental status change, got too hot. History of Present Illness: He was in a whirlpool bath hot tub for a few hours, apparently was forgotten by the nursing home staff. They pulled him out and his temperature was 104.2 and had some mental status changes including that of mental status depressed. He was transported via EMS, wet. On arrival to the ER, 100.4, no distress. Mental status had returned to baseline after about an hour of observation. EMS called it a near drowning but it seems that this was a small contained hot tub and his head did not go under water. He's seen this morning in ICU (Intensive Care Unit) .He is awake, alert, oriented (times) 3 and in currently no distress.Patient apparently, when he gets too hot, has done this before . IMPRESSION: Depressed mental status secondary to probable hyperthermia. Hyperthermia, unintentional due to hot tub . being careful not to get over heated and unmonitored, especially in whirlpool bath . p. A Nursing Note dated 8/12/17 at 11:00 p.m. written by LPN #2 documented, (At) 2230 (10:30 p.m.) (LPN #1) came to get me from the (facility cottage name), he stated I was needed in the (400 Cottage). Upon entering there was water out in the floor. Upon entering whirlpool room observed R in whirlpool, CNAs (and) nurse (LPN #1) present. R was breathing. We lowered R to the floor, he was verbally unresponsive, pulse present. Rolled R to (left) side, instructed CNAs to get me cold towels. During this time I was talking to R, he would open his eyes (and) grunt. Cold towels placed over R. Lung fields noted (with) crackles. O2 sat between 64% (and) 68%. Temp 104.2 Ax. (LPN #5) brought oxygen to room, placed on R. Still talking (with) R asking him to keep opening eyes, which he would do. Temp rechecked, 102.7 Ax. EMTs arrived. R transferred to gurney, ambulance left (with) R (at) 2250 (10:50 p.m.). This nurse notified (Resident #1's family member) (at) 2253 (10:53 p.m.) Administration aware (and) present. q. An Intervention Evaluation note written by LPN #1 at 8/12/17 at 6:29 p.m. documented, R returned to facility by (facility) transportation (at) 1615 (4:15 p.m.). r. On 8/17/17 at 4:50 p.m., CNA #2 was asked what event had occurred with Resident #1 on 8/11/17 and CNA #2 stated, I came in on 10-6 (10:00 p.m. to 6:00 a.m. shift). When (I) came on, he was in the whirlpool. The CNA was asked if she knew the resident was in the whirlpool and stated, . (CNA #1) told me he was in the whirlpool. The CNA was asked CNA #1 told her this and stated, A little before 10 (p.m.). The CNA was asked if she was on duty at that time and stated, Yes, just came on duty. I told her (CNA #2) she needed to get him out, because I'm the only one here at night. After I told her, me and (CNA #4) had to put (other resident's name) to bed. When we came out of the room, there was no one left. The CNA was asked what she meant by, no one left and stated, (CNA #3 name) and (CNA #1 name). They wasn't (sic) out here. The CNA was asked if she had seen those CNAs again after that and stated, No, the other CNA (CNA #5's name) came in the door and said that (another cottage's) washing machine was smoking or steaming, and that's when I looked over there and saw water coming out under the door. The CNA was asked which door and stated, The whirlpool room . I ran over there, opened the door and (Resident #1) was lying in there. I yelled for help. He was in the tub with water, his head lying on top of the tub. CNA #2 accompanied the surveyor to the whirlpool room and demonstrated how the resident was found in the whirlpool tub. The whirlpool was a walk-in type, with a wide door, and the CNA opened the door, sat on the whirlpool seat and placed her head on the top right edge of the tub. The door was positioned lower than the top edges of the tub. The CNA stated The door was closed, and he was lying here like this. The CNA was asked if the resident's head was out of the water and stated, Yes, the water was going over (side of tub). The CNA was asked if the water was going over the door and stated Yes, I straightened him up and held his head. (CNA #5 and CNA #6) came and (LPN #1), the nurse, and (LPN #5), nurse. They were right here immediately. He was breathing. He would open his eyes; he moaned. (We) opened the door (to the whirlpool), and (LPN #2 and LPN #1) held him. They got (LPN #2) from the other building. Me, (CNA #6, and LPN #5) got him and laid him on the floor and nurses started working on him, sternal rubs, had him on his side. The CNA was asked if residents can get in the spa room by themselves and stated Not anymore, we didn't have a policy, but we do now. The CNA was asked what the policy was and stated, You (residents) have 15 minutes with somebody (staff) in there with you. The CNA was asked if this was for every resident and stated, For everybody. They in-serviced us right after that. Before, they could go in there with a CNA, but if they ask for privacy, you leave, but in and out. They said we can stand outside the door with it cracked where we can hear. The CNA was asked if a resident can now be left in the whirlpool and the CNA stated, No, that's what the in-service told us. s. On 8/17/17 at 7:55 p.m., LPN #1 was asked what occurred with Resident #1 on 8/11/17 and stated, I had already given report to (LPN #2) and I heard the CNA who just came and the other CNA (CNA #6) I heard her say I need a nurse by whirlpool room. I ran. I heard her say they left (Resident #1) in the whirlpool. I think she meant the CNAs on my shift, (CNA #1) and another, new male CNA. The LPN was asked if she was aware that Resident #1 was in the whirlpool and stated, No, I was aware he was supposed to get a bath sometime on my shift. I just know there are some residents who get a bath. To my knowledge, I didn't know he had gone to the whirlpool. The LPN was asked if staff were to be with a resident when in the whirlpool and stated, My understanding, they were supposed to stay with him or near, to give him some privacy. The LPN was asked if she had seen the resident go into the whirlpool room and stated, No. LPN #1 was asked, When was the last time you had seen the resident that shift? She stated, About 7:15 p.m., when I gave him his medicine . When asked for further details about the incident, the LPN stated, When I walked in, (CNA #2 and CNA #6) were standing next to the whirlpool with (Resident #1). First thing I checked was to make sure he was breathing, he would open his eyes. When I touched him, he opened his eyes, so she (CNA #2) opened door after I held him in place. From there I called (LPN #5) and we started getting vitals. (LPN #5) was there, and (another LPN), (LPN #5) relief. So both got there and when they got there, I called (APN). (APN) said get a set of vitals and text, and if unresponsive, send to ER . ran and got (LPN #2). As soon as I got off the phone with (APN), I called the ambulance. Ambulance arrived approximately 10:50 or 11:00 p.m. I believe I called ambulance at 10:29 . We got vitals, (LPN #2) told me she checked pulse ox, they told me I'm pretty sure I wrote on it, it was 68. I was getting paperwork together. LPN #1 was asked where CNA #1 was during this incident and stated, She had clocked out and went home, or at least was off campus. I didn't see her after that. LPN #1 was asked if the CNA should have left the resident unattended in the whirlpool and stated, No, obviously not, I guess you could say. The LPN was then asked if CNA staff were supposed to leave the facility after assisting a resident into the whirlpool and stated, No I would say not. The LPN was asked how many CNA staff members were in the cottage on the night shift and stated, There's just one on nights. t. On 8/18/17 at 10:32 a.m., LPN #2 was asked what had occurred on 8/11/17 when Resident #1 had an incident. The LPN stated, I was in the (another cottage) at 10:30 (p.m.) and (LPN #1) came and got me and said we had an emergency . I ran in; as soon as I got in the whirlpool room, I said, 'is he breathing?' (LPN #5) said 'yes'. At that point, he (resident) was sitting in the whirlpool; we lifted him out of the whirlpool, and I listened to his lungs. I asked for cold towels, his skin was very warm, temp (temperature) was 104 axillary. His pulse ox was 64 to 68. I said '(LPN #5) go get oxygen'. She brought oxygen and put it on. He responded, not answered, but with his eyes, and he would grunt. I rechecked temp and blood pressure. We were unable to get the blood pressure. We tried a manual cuff. The EMTs got here. We sent him to the ER. They left at 10:50, and I notified the family at 10:53 p.m. Pulse I believe was 58. The LPN was asked if the blood pressure was audible when she attempted to check it with a manual cuff. The LPN stated, No. u. On 8/18/17 at 10:45 a.m., CNA #1 was asked what time the resident was taken to the whirlpool on the date of the incident and stated, I want to say maybe 8:30 or 9ish. I didn't look at my watch. The CNA was asked if she had remained with the resident in the whirlpool tub room and stated, He asked for me to step out and get underwear, and I gave him privacy. I came back and handed him the underwear on a chair. The CNA was asked what time she ended her shift and left the building. CNA #1 stated, About 10:05, or a little after. The CNA was asked if the resident was still in the whirlpool tub when she left the building and stated, Yes, and I told the CNA coming on that he was still in the whirlpool. CNA #1 was asked if the resident should have been left in the whirlpool tub when she left work for the day and stated, No, I shouldn't have. The CNA was asked how many CNAs worked the night shift in the cottage and stated, Evening there's (sic) 3, and nights there's (sic) 1. v. On 8/18/17 at 4:52 p.m., the Administrator was asked if the CNA should have gotten the resident out of the whirlpool prior to ending her shift and leaving the building. He stated, Oh yes. The Administrator was asked if CNA staff should ever leave a resident who requires extensive ADL assistance unattended in the whirlpool. The Administrator stated, No. w. On 8/18/17 at 5:00 p.m., the Director of Nursing (DON) was asked if CNA #1 should have gotten the resident out of the whirlpool tub prior to leaving the building. The DON stated, Absolutely. The DON was asked if the CNA staff should ever leave a resident who requires extensive ADL assistance unattended in the whirlpool. The DON stated, No. x. The facility removed the immediate jeopardy and corrected the failed practices on 8/11/17, as evidenced by the following: 1.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities dated 8/11/17, Section III - Findings and Actions Taken, documented, .(CNA #1) was asked to write a statement and was suspended until the investigation was completed. On 8/15/2017 (CNA #1) was terminated. (LPN #3 MDS Nurse / Guide) immediately went to each cottage and in-serviced all staff on duty on 3 things: (1) No one is to be left in the whirlpool unattended. (2) No one is to be in the whirlpool for more than 15 minutes and (3) The on-coming and off going staff are to do rounds on every resident in the cottage before the off going staff leave the premises. (LPN #2) did the same in-service with all oncoming staff at 6 am on 8/12/17, (LPN #2) did the in-service with all oncoming staff at 2:00 p.m. on 8/12/17 and (LPN #3 / Guide) did the in-service with all oncoming staff at 10:00 pm on 8/12/17. The in-service has been done at every shift change and will continue until all staff have received the in-service. All new hires will be in-serviced during the orientation prior to working in the cottages. DON/designee will monitor 3 times a week for 4 weeks and weekly thereafter to ensure compliance. Any negative findings will be reported to Administrator and corrective actions taken immediately . CNA #1's time sheet documented the CNA clocked out on 8/11/17 at 10:06 p.m. and did not return to duty after that date. 2.) An in-service form dated 8/11/17 documented, .Do not leave anyone in whirlpool unsupervised. No Elder should be left in W/P (whirlpool) more than 15 minutes. Everyone should be doing rounds (with) oncoming shift. The form was signed by all licensed and direct care nursing staff who worked on 8/11/17, then all oncoming staff on 8/12/17, 8/13/17, 8/15/17, and 8/20/17. An In-service Education Report dated 8/18/17 to the hospice agency staff documented, 1. No elder is to be left in the whirlpool longer than 15 minutes. There is a timer on the wall by the light switch. 2. No elder is to be left in the whirlpool unattended, for resident privacy staff / responsible person can stand outside the door with the door partially opened so they can be heard in case of an emergency. 3.) A revision to the resident's Plan of Care dated 8/12/17 documented, Provide supervision while in W/P (whirlpool) and do not exceed over 15 min (minutes). 4.) On 8/18/17 at 10:32 a.m., LPN #2 was asked if there had been any in-services since the incident and stated, We had a whirlpool in-service that entails that no one can leave a resident alone in the whirlpool . It (in-service) started that night (8/11/17), for everyone. The LPN was asked if any residents had been left unattended in the whirlpool since the staff in-servicing was completed and stated, No. 5.) On 8/18/17 at 2:50 p.m., Resident #6 was asked, Does staff assist with your bathing and stay with you? She stated, Yes. 6.) On 8/18/17, the Administrator provided documentation of monitoring of whirlpool baths in all cottages, initiated on 8/12/17. No further negative findings had been identified as of this date.