Every finding on record at The Hallmark

Based on observations, interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Residents #3, #20 and #36) and 2 of 2 (LVN A and LVN B) staff observed during medication administration. The facility failed to ensure staff Clarified any order that is incomplete, illegible, or presents any other concerns, prior to administering the medication for Resident #3, Resident #20 and Resident #36 on 03/18/2026. The failure could place residents at risk of receiving less than optimal results from their medication regimen. Findings included:Resident #3 Record review of Resident #3's undated admission record revealed a [AGE] year-old female with an admission on [DATE]. Resident #3 had diagnoses including multiple fractures (broken bones) of ribs and thoracic vertebrae (chest bones that protect the spinal cord) and cognitive communication deficit (difficulty with communication). Record review of Resident #3's Care Plan initiated on 02/18/2026 read, resident had pain in both legs. The interventions read, apply diclofenac (generic name for Voltaren) gel to both legs topically four times a day for pain. Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 12 with moderate cognitive impairment, meaning the resident had moderate memory, orientation, or decision-making challenges, often required increased assistance with daily activities. Record review of Resident #3's Physician Orders, dated 02/16/2026, revealed an active order of diclofenac gel 1%. Apply to affected area topically four times a day for pain. The order did not specify where to apply the gel over. Record review of Resident #3's Physician Orders, dated 02/18/2026, revealed an active order of polyethylene glycol 3350 oral (by mouth) powder 17 gm/scoop. Give 1 scoop by mouth daily for constipation. The order did not specify how much fluid to mix the powder with. During an observation on 03/18/2026 at 8:46 a.m., LVN A poured and mixed polyethylene glycol powder with an unmeasured amount of water and gave it to Resident #3. Further observation revealed LVN A prepared Voltaren gel and went to Resident #3 and asked the resident where she usually gets the gel. Resident #3 stated she did not know the answer to LVN A's question. Resident #3 added she did not have pain anywhere at that moment. LVN A held the medication. Resident #36Record review of Resident #36's undated admission record revealed a [AGE] year-old male with an admission on [DATE]. Resident #36 had diagnoses including contusion (tissue injury caused by a blunt impact) of lower back and pelvis. Record review of Resident #36's Care Plan initiated on 03/18/2026 read, resident had pain in both knees. The interventions read, apply diclofenac gel to both knees topically four times a day for pain. Record review of Resident #36's admission MDS dated [DATE] revealed a BIMS score of 15 meaning the resident was cognitively intact. Record review of Resident #36's Physician Orders, dated 03/12/2026, revealed the following:-An active order of diclofenac gel 1%. Apply to affected area topically four times a day for pain. The order did not specify where to apply the gel over.-An active order of polyethylene glycol 3350 oral powder 17 gm/scoop. Give 1 scoop by mouth daily for constipation. The order did not specify how much fluid to mix the powder with. During an observation on 03/18/2026 at 9:18 a.m., LVN A poured and mixed polyethylene glycol powder with an unmeasured amount of water and gave it to Resident #36. Further observation revealed LVN A prepared Voltaren gel and went to Resident #36 and asked the resident where he usually gets the gel. Resident #36 stated he was not aware where he should have received the gel over. LVN applied the Voltaren gel on the resident's leg near a lidocaine pain patch that staff applied earlier. In an interview on 03/18/2026 at 9:20 a.m., LVN A stated she should have held both residents' medication administration and contacted the provider for clarification on those orders. LVN A stated she checked orders for instructions on how to administer medications. She stated she did not follow the proper procedure this time. LVN A stated all orders were incomplete and that could cause Residents #3 and #36 to receive medications that were ineffective. Resident #20Record review of Resident #20's undated admission record revealed a [AGE] year-old male with an admission on [DATE]. Resident #20 had diagnoses including multiple fractures (broken bones) of left femur, dementia (decline in mental ability), constipation and cognitive communication deficit (difficulty with communication). Record review of Resident #20's Care Plan initiated on 11/01/2022 and last revised on 03/09/2026 read, resident had a diagnosis of constipation. The interventions read, monitor side effects of constipation and record bowel movement pattern each day. Record review of Resident #20's Quarterly MDS dated [DATE], revealed a BIMS score of 6 with severe cognitive impairment, meaning the resident had significant memory, orientation, or decision-making challenges, often required extensive assistance with daily activities. Record review of Resident #20's Physician Orders, dated 02/16/2026, revealed an active order of diclofenac gel 1%. Apply to affected area topically four times a day for pain. The order did not specify where to apply the gel over. Record review of Resident #20's Physician Orders, dated 05/13/2022, revealed an active order of polyethylene glycol 3350 oral powder 17 gm/scoop. Give 1 scoop by mouth daily for constipation. The order did not specify how much fluid to mix the powder with. During an observation on 03/18/2026 at 8:18 a.m., LVN B poured and mixed polyethylene glycol powder with an unmeasured amount of water and gave it to Resident #20. LVN B stated she should have held the medication administration and contacted the provider for order clarification. LVN B stated she checked orders for instructions on how to administer medications. She stated she did not follow the proper procedure this time. LVN B stated the medication order was incomplete and that could cause Resident #20 to receive a medication that was ineffective. In an interview on 03/18/2026 at 10:05 a.m., the MD stated polyethylene glycol orders should have included between 4 and 8 oz. of fluids to mix the powder with, and the Voltaren gel orders should have included the application area where the gel was indicated to treat. The MD stated she expected the prescribing provider, who was not available to interview, to include the amount of fluid in those orders and the application area or body parts. The MD stated she expected nurses to contact the provider for clarification about medication orders when those orders missed instructions on how to use them. She stated mixing the MiraLAX powder with fluids without specifying the amount could not cause significant harm. She stated those orders were incomplete and required medication verifications. The MD stated she reviewed residents' orders, including medications, every week. In an interview on 03/18/2026 at 10:28 a.m., the DON stated he expected Nurses to call the provider to request medication verifications on all incomplete orders when those orders missed instructions on how to administer them. She stated nurses should have sought clarification about the amount of water required to mix the powder with before each administration and verified where Voltaren gel should have been applied. The DON stated using the wrong amount of water to mix the powder could prevent the medication from working as prescribed and could cause fluid overload for residents with fluid restrictions. The DON stated not knowing where to apply the Voltaren gen could cause residents' pain to be left untreated. She stated she performed review on residents' medication orders every day during the morning clinical meetings. She stated all those incomplete orders must have been missed during the review. The DON added she performed random daily audits on medication passes. Record review of Miralax manufacturer's recommendations dated 2026, revealed, .Take 17 gram of powder once a day. Use the Miralax bottle top to measure 17gram by filling to the indicated line (white section in cap). Mix and dissolve into 4-8 ounces of any beverage (hot, cold or room temperature). Record review of the facility's Medication and Treatment orders Policy dated February 2014, revealed, .9. Orders for medications must include.e. clinical condition or symptoms for which the medication is prescribed. The policy did not mention medication orders for locally applied medications or instructed staff to follow manufacturers' recommendations to guide medication administration.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinent care. The facility failed to ensure Resident #1's catheter bag was not maintained below the bladder. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #1's face sheet dated 7/12/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses included: urinary tract infection, neuromuscular dysfunction of bladder (lacks bladder control due to brain, spinal cord or nerve problems), functional quadriplegic and hypertension (high blood pressure). Record review of Resident#1's admission quarterly assessment dated [DATE] revealed: Resident #1 had a BIMS score of 13 out of 15 indicating her cognition was intact. Further review revealed Resident #1 had an indwelling catheter. Record review of Resident #1's care plan dated 7/12/2024 revealed the following in part: Focus: [Resident #1 has a indwelling Catheter Neurogenic bladder (a condition that affects bladder function due to nervous system damage or disease) Date initiated 6/29/2021. Goal: Reduce the risk from catheter related trauma through review date. Date initiated 6/29/2021. Interventions: .Catheter: .Position catheter bag and tubing below the level of the bladder An observation on 7/12/2024 at 12:15 p.m. revealed Resident #1 was lying down in her bed. Resident #1's catheter bag and tubing was not visible on either side of her bed. During an interview on 7/12/2024 at 12:16 p.m., Resident #1 said she had a catheter. She said it should be hung on the side of her bed so it could drain. She called for assistance. During an observation 7/12/2024 at 12:17 p.m. revealed Manager A came into the room, lifted the blankets that covered Resident #1 and discovered the catheter bag and tubing was in the bed. The catheter bag was half full without urine draining from the tubing. During an interview on 7/12/2024 at 12:20 p.m., Manager A said Resident #1's catheter was not draining. She said the catheter bag and tubing should have been hanging below her bladder to aid in the drainage and prevent backing up in the tube that could cause infection. She said Resident #1 returned from a sister facility earlier that day and the assigned nurse should have ensured the catheter was in the correct position. During an interview on 7/12/2024 R 12:33 p.m., Agency LPN A said she had worked with Resident #1 once approximately a month ago. She said she started her shift this morning (7/12/2024) at the sister facility. She said she did not remember if Resident #1 had a catheter. Agency LPN A said, after arriving to the facility, she went into Resident #1's room approximately an hour ago and to adjust Resident #1's oxygen and provide her with a snack. She said she did not check for a catheter. She said the catheter should have been positioned below her bladder so it could drain. She said if the urine did not drain, then the Resident was at risk for developing an infection. Agency LPN A said she was trained to receive report from staff before providing care each shift. She said she did not recall if she received report on Resident #1's catheter status or care. During an interview on 7/12/2024 at 12:44 p.m., CNA A said she saw Resident #1 at the sister facility earlier today (7/12/2024) and the resident had the catheter on. She said after she arrived at the facility today (7/12/2024), she had not checked on Resident #1. She said Agency LPN A should have ensured the catheter was in place. CNA A said if the catheter was not draining, the urine could back up in the tubing and could cause an infection. During an interview on 7/12/2024 at 12:49 p.m., the DON said the nurse should have made sure the catheter was draining. She said Resident #1 was at risk for infection when the catheter was not draining properly or positioned below her bladder. She said the nurses should have given report to each other so the nurse coming on shift was aware of resident needs. She said catheter care was a basic nursing skill that was within a nurse's scope of practice. Record review of facility policy Catheter Care, Urinary (not dated) revealed the following in part: Purpose The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . Maintaining Unobstructed Urine Flow .3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on observation, interview and record review, the facility failed to ensure food was stored and prepared under sanitary conditions, in one of one kitchen that serviced residents, in that: - Food was found open or without labels, - The high-temp dishwasher was not reaching a temperature of 180F and chlorine levels were not being tested to ensure proper sanitation of dishes and utensils. This failure could affect residents and place them at risk of food borne illness. Findings included: Observations of the kitchen on 11/28/2023 beginning at 9:10AM revealed: - In the dry storage unit, a bag of macaroni was found open and unsealed. - In the fridge, a bin of mushrooms was found without a label of date. - In the freezer, an open bag onions ring was found unsealed. In observations and an interview with the Executive Chef, on 11/28/2023 beginning at 9:20AM, the dishwasher, in use at the time, was observed to be a high-temp dishwasher, but when the Executive Chef ran a test strip to test if the temperature reached 180F, the test strip failed to change colors, indicating the temperature of the water during the wash or rinse cycle failed to reach 180F. During the cycle, the gages read 140F for wash and 160? for rinse. The dishwasher was observed to have bleach dispensing into the dishwasher for sanitation. The Executive Chef reported the dishwasher was discovered at least a month ago during an inspection not boosting to the appropriate temperature of 180?. He stated he took the advice of the city inspector from the past to add bleach to ensure dishes were sanitized. No log for chlorine sanitation level for the dishwasher was observed in the kitchen. Record review of the sign posted on the dishwasher, titled Data Plate for High-temperature Machine, not dated, reflected Final rinse minimum temperature: 180F . Chemical sanitizer used as additional precaution cleanse. In an interview with the Maintenance Director, on 11/30/2023 at 9:31AM, he stated he was never informed of the dishwasher not working. He stated he been told in the past about a year ago and he managed to have the issue fixed, but no one brought the issue to him this time around. He stated he was unsure whether the use of bleach was appropriate the way that it was. He said the risk of not having the dishwasher temperature high enough or not ensuring the right level of chlorine used to sanitize the dishes was the residents who ate from the kitchen possibly experiencing illness. In an interview with the Executive Chef, on 11/30/2023 at 10:20AM, he stated he did not keep a log reflecting ppm levels were tested for the dishwasher that used bleach for sanitation. He stated after his discussion with the surveyor on 11/28/2023, he went ahead to order test strips. He stated bleach was typically used every time the dishwasher stopped working. He stated he never told the Maintenance man of the last time the dishwasher stopped working because he discussed it with the Administrator about the possibility of buying a new dishwasher for the kitchen. He also stated, regarding food storage, it was important to label foods and store them properly to ensure they are using first in and first out method to maintain the quality of the food and to prevent contamination. He stated unfortunately he cannot keep observing to see if all foods are labeled since they had a lot of food delivered on Tuesday. In an interview with the Administrator on 11/30/2023 at 2:00PM, he stated the dishwasher was converted into a chemical dishwasher [AGE] years ago by the manufacturers and therefore the use of bleach for chemical sanitation was appropriate. Record review of the facility's policy on food storage, dated 2013, stated All containers must be legible and accurately labeled and dated .food should be dated as it is placed on the shelves . A policy on maintenance of kitchen equipment was requested from the Administrator on 12/01/2023 and was not provided prior to exit.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 24 % based on 8 errors out of 33 opportunities, which involved 3 of 6 residents (Resident #9 and Resident #13) reviewed for medication errors. - LVN D failed to administer medications as ordered to Resident #17 by pouring dry powder medication into the resident's G-tube immediately after a bolus feed of enteral formula. - LVN D failed to administer medications to Resident #17 as ordered by administered 20 mg of Amlodipine instead of 10 mgs. - LVN D failed to administer medication to Resident #8 as ordered by applying Lidocaine 4 % patches to the resident's right knee and hip instead of Lidocaine 4% gel. - LVN D failed to administer medications as ordered to Resident #13 as ordered by failing to completely dissolve PEG 3350 (a stool softer commonly known as MiraLAX) and failing to administer the entire volume of suspended medication to the resident. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Included: Resident #17 Record review of Resident #17's Face Sheet dated 11/29/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: paralysis of the left non-dominant side, shortness of breath, dementia, hypertension, irregular heartbeat, and difficulty swallowing. Record review of Resident #17's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 08 out of 15, and use of a feeding tube while a resident. Record review of Resident #17's undated Care Plan revealed, focus- requires tube feeding related to difficulty swallowing; intervention: check for placement and gastric contents/residual per facility protocol, flush tube with 30 ml of water before and after all medications, when administering more than 1 medication flush tube with 5-10 ml of water between each medication. Record review of Resident #17's Order Summary Report dated 11/29/23 at 03:24 PM revealed the following active orders: - Digoxin 125 mcg- Give 1 tablet by mouth daily via G-tube for irregular heartbeat dated 05/02/23. - Cetirizine 10 mg- Give 1 tablet by mouth daily via G-tube for allergies dated 06/16/23. - Amlodipine 5 mg- give 2 tablets by via G-tube one time a day for hypertension dated 06/29/23. - Apixaban 5 mg- give 1 tablet via G-tube every 12 hours for irregular heartbeat dated 08/02/3. - Escitalopram 10 mg- Give 1 tablet by mouth daily via G-tube for depression dated 08/07/23. - Enteral Feed Order four times a day Give one carton of Isosource 1.5 cal. five times a day dated 10/05/23 - Enteral Feed Order four times a day Flush G-tube with 60cc of water before and after bolus feeding. Dated 10/11/23. Record review of Resident #17's Progress Note dated 11/29/23 revealed, Resident c/o abdominal discomfort/ fullness after medication/ bolus feeds and flushes were administered. Resident assessed by AL manager with no bloating noted. Resident expressed no c/o pain only discomfort. MD and Hospice notified with orders to continue monitoring. Hospice stated they are monitoring feedings and slowing weaning her r/t feeling of fullness. Recent change was from 5 bolus feeds to 4 bolus feeds/day. Hospice nurse to assess on next facility visit. An observation on 11/29/23 at 08:28 AM revealed, LVN D preparing for medication for administration to Resident #17. She retrieved 1 tablet of Escitalopram 10 mg, 1 tablet of Digoxin 125 mcg, 1 tablet of Apixaban 5 mg, 2 tablets of Amlodipine 10 mg instead of 1 tablet of 10 mg as ordered and 1 tablet of Cetirizine 10 mg and placed each medication in individual medication cups. At 08:32 AM LVN D crushed each medication, returned them into their individual medication cups and entered into the residents room. After repositioning the resident, LVN D retrieved room [ROOM NUMBER] cups temperature water (each cup containing about 60 ml) from Resident #17's bathroom and then checked the resident for placement and residual feeding at 08:38 AM. LVN D flushed Resident #17's G-tube with 30 ml of water, then 60 ml of Isosource and then poured undissolved powder medication down Resident # 17's G-tube followed by an unknown amount of water. LVN D repeated this pattern of Isosource, powdered medication, unknown water until she had administered 250 ml of Isosource and all 5 medications were administered and then flushed with 30 ml of water. During G-tube administration, LVN D did not allow all the fluid to pass into the tube before adding the next volume of liquid or the powered medications. LVN D asked Resident #17 how she felt after she completed G-tube medication and enteral feed administration and Resident #17 said I feel like I am going to explode. The surveyor did not observe any signs of pain on Resident #17's face but the resident did appear to be in discomfort. Resident # 8 Record review of Resident #8's Face Sheet dated 11/30/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: pain in left hip and right and left hip fracture. Record review of Resident #8's Admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, resident received scheduled and PRN pain medication and the resident experienced frequent pain up to 07 out of 10. Record review of Resident #8's Care Plan dated 11/09/23 revealed, focus- alteration in musculoskeletal status related to fracture of the right hip; interventions- give analgesics as ordered by the physician. Record review of Resident #8's Physician Order dated 11/15/23 at 02:26 PM entered by LVN D revealed, Lidocaine External Gel 4%- apply to R. Knee and R. Hip topically one time a day and remove per scheduled. Record review of Resident #8's Progress Note dated 11/29/23 at 04:35 PM and signed by the DON revealed, Medication error noted during med pass. Resident assessed for adverse reaction with No adverse reactions noted. No c/o pain/discomfort at present time. MD notified with order clarification received for Lidocaine 4% patch to right hip and knee daily. EMAR updated accordingly, Resident updated on medication change. An observation on 11/29/23 at 08:11 AM revealed, LVN D prepared for medication administration to Resident #8. After informing the resident she would be administering medication, she retrieved 2 Lidocaine 4% patches and 7 solid form medications and returned to Resident #8's beside with the medications. After administering the oral medications to Resident #8, LVN D applied a patch to Resident #8's right knee and right hip/lower buttock. An observation on 11/29/23 at 09:25 AM with LVN E revealed, a sealed an unused tube of Lidocaine 4% Cream for Resident #8 with a pharmacy fill date of 11/24/23. In an interview on 12/01/23 at 09:15 AM- Resident #8 said the facility had administered Lidocaine patches to her hip and knee since she November, she said a cream/gel had never been applied by the facility. In an interview on 12/01/23 at 10:58 AM, the Pharmacy said on 11/15/23 the pharmacy received a prescription for Lidocaine 4% topical gel but it was not filled due to Resident #8 being on Medicare until 11/24/23 when the facility requested a refill. The Pharmacy said there were no other orders filled or delivered for Lidocaine 4% until 11/24/23/ Resident #13 Record review of Resident #13's Face Sheet dated 11/29/23 revealed, an [AGE] year-old woman who admitted to the facility on [DATE] with diagnoses which included: Parkinson's Diseases, UTI, difficulty walking, hypertension and constipation. Record review of Resident #13's Admission MDS dated [DATE] revealed, Vision- adequate sees fine detail, such as regular print in the newspapers/books. No use corrective lenses (contacts, glasses of magnifying glass) and moderately impaired cognition as indicated by a BIMS score on 08 out of 15. Record review of Resident #13's undated care plan revealed, focus- constipation related to recent ileus (inability of the intestine to contract normally and move waste out of the body.) interventions- Administer stool softeners per MD Orders. Record review of Resident #13's Physician Order dated 09/09/23 revealed, MiraLAX Oral Packet 17 mg (PEG 3350)- give 1 packet by mouth one time a day for constipation. An observation on 11/29/23 at 09:09 AM revealed, LVN D preparing for medication administration to Resident #13. She retrieved 1 packet of powder PEG 3350 and 10 other solid form medications, she placed all 10 capsules/pills in a medication cup, poured the powdered PEG 3350 into a cup and dissolved it in approximately 30 mL of water. After stirring the mixture of water and PEG 3350, LVN D entered into the residents room, placing the PEG 3350 on the resident's bed side table and administered the 10 solid form medications. As the cup of PEG 3350 sat on the residents bed side table the surveyor observed undissolved powder cake up on the bottom and edges of the cup. LVN D then handed the cup of PEG 3350 solution to Resident #13, the resident consumed approximately 2/3rd of the liquid, and then LVN D discarded the remaining 1/3 of the PEG 3350 solution with caked up powder remaining on the bottom. Resident #13 did not receive her full dose of PEG 3350. In an interview on 11/29/23 at 11:24 AM, LVN D said prior to medication administration nurses are expected to introduce themselves to the resident, inform the resident that medication is to be administered and then check the resident's vitals. The medications should be verified against the MAR, and once vitals are confirmed to be within parameters the medications can be dispensed into a medication cup and then administered to the resident. She said when medication verification involved ensuring the dose and formulation to be administered matched the physician order and medications must be administered as ordered. LVN D said she did not notice that Resident #8's Lidocaine orders specified gel and she had always applied patches to the resident. She said patches and gel are not interchangeable and failure to apply topical medication as ordered could result in skin irritation. LVN D said she administered only 1/2 a packet of PEG 3350 to Resident #13, she could not see the undissolved powdered caked on the bottom of the cup after she stirred the solution but she believed the resident took the entire volume. She said failure to administer the correct volume of medication could place resident's at risk of not getting the full dose of their medication and in this case constipation, LVN D said she did not dissolve Resident #17's crushed medication in water prior to G-tube medication because there is some water in the tube prior to her pouring the powder and that is how she was trained in her state. She said she was not supposed to perform bolus feeds during medication administration but the resident had not had any food since 8 PM the previous day and she normally complained about being hungry. LVN D said she started in the facility as an agency nurse and she was trained in her home state. LVN D said she did not know if there were any potential reactions when medications are administered with feeds and Resident #17 received a total of 120 ml of water and 240 mL of Isosource for a total of 360 mL. She said Resident #17 had a cool sense of humor when she said she was going to explode, she did not believe the resident was experiencing any form of discomfort but administering too much volume during G-tube administration could place residents at risk of distension and aspiration. In an interview on 11/29/23 at 11:56 AM, the DON said prior to medication administration medications are verified against the MAR, acceptable administration parameters must be confirmed and medication administration must be observed in full. She said nurses must ensure the medication, dose, frequency and formulation are accurate and then medications can be dispensed. The DON said patches and gel/cream are not interchangeable, lidocaine patches must be removed after 12 hours while topicals were not so failure to administer the correct formulation of Lidocaine could place residents at risk for skin irritation. She said PEG 3350 should be dissolved in at least 8 ounces of water, the powder must be dissolved its entirety and the total volume must be consumed in order for the resident received the full dose as ordered. The DON said failure to administer the full dose/volume of PEG 3350 could place residents at risk of constipation. She said prior to administering medication via G-tube nurses must dissolve the medications in 5-10 mL and LVN D should not have poured powdered/crushed medications directly into the Resident #17's tube because it could clog the tube. The DON said LVN D should not have administered Bolus feed (Isosource) at the same time as medications because of possible food/medication interactions as well as volume overload which could result in the resident experiencing vomiting and discomfort. She said LVN D received a competency assessment with the nurse that oriented her and the pharmacy consultant should have completed a medication administration observation as well. Record review of LVN D's Medication Pass Observation Report dated 04/24/23 completed by the pharmacy consultant revealed, LVN D was observed with G-tube medication administration, oral medication administration, nasal sprays and inhaler administration. No errors were observed. Record review of the facility policy titled Medication Pass-Scheduled Oral Administration' revised 12/2010 revealed, 2- verify medications to be administered on the resident's MAR. 4- Check the label on each medication bottle or blister pack against the MA. Documentation on the MAR is initiated at the time of administration. Record review of the facility policy titled Policy for Administering Medications Through and Enteral Feeding Tube issued 06/2017 revealed, 2, a- tablets- crush each tablet into fine powder, using pill crushing device. Dissolve each tablet in separate cup of 10-30 ml of water or per physician's order. 5- if continuous enteral tube feeding is infusing, adjust infusion pump to hold tube feeding. 10,b- to administer more than one medication, give each separately and flush between medications with 10-30 cc of water as ordered by the physician. f Record review of the facility policy Physician Medication & Treatment Orders with no revision date revealed, procedures addressing administration of medications include: 4- assuring that Medications administered are to be: In the correct dose; In accordance with manufacturer's specifications and with standards of practice; To the correct person; The correct route; In the correct dosage form and; At the correct time.

Based on observation, interview and record review the facility failed to deliver appropriate treatment and services to prevent urinary tract infections for 1 (Resident #3) of 1 resident s reviewed for appropriate services and treatment to prevent urinary tract infections. The facility failed to ensure Resident #3 's urinary catheter bag was not left on the floor. The facility failed put a date on Resident #3's urinary catheter bag. The facility failed to change out Resident #3's urinary catheter according to physician orders 10/15/2023 and 11/15/2023. These failure could affect residents placing them at risk of not receiving appropriate treatment and services from facility staff. Findings: Record review of Resident #3's Face Sheet revealed a [AGE] year-old female with a diagnosis of Heart Failure (Heart does not pump enough blood), Functional Quadriplegia (Frailty with or without injury to spinal cord), Neuromuscular Dysfunction of Bladder (Lack of bladder control due to spinal cord or nerve problem). Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating the resident was cognitively intact. Section H revealed an indwelling catheter. The resident was dependent on toileting, dressing, bathing, rolling, sitting and chair to bed and bed to chair transfers. Record review of Resident #3's Care Plan dated 6/16/2021 to present read in part Resident #3 has an indwelling catheter .Neurogenic Bladder Catheter and the bag is to be changed each month . using an 18 French foley catheter. Record Review of Resident #3's Physician Orders dated 6/15/2023 read in part . Change indwelling Foley catheter size 16 every 30 days in the morning starting the 15th and ending on the 15th every month for incontinence care. Record review of facility notes written by RN C dated 10/15/2023 read in part . Foley catheter bag changed this shift. Record review of facility notes written by DON for Resident #3 in PCC (Charting System) dated 11/29/2023 read in part . Resident concerned about foley care and last time it was changed and no date on bag to clarify. Record review of facility MAR dated 10/2023 read in part . Change indwelling Foley catheter size 16 every 30 days in the morning starting on the 15th and ending on the 15th every month for incontinence care. Start date 6/15/2023. A check mark with the initials (RN C) in the box on 10/15/2023. Record review of facility MAR for Resident #3 dated 11/2023 read in part . Change indwelling Foley catheter size 16 every 30 days in the morning starting on the 15th every month for incontinence care. Start date 6/15/2023. A check mark with the initials KD2(LVN A) in the box on 11/15/2023. Observation and interview on 11/29/2023 at 8:35am, Surveyor observed Resident #3 with Foley Catheter bag on floor, no date on Foley Catheter bag. Resident #3 said she had been asking facility staff for her Foley Catheter to be changed out, she said facility staff came in and changed the bag out every two weeks, but they did not change the catheter out. She said she had asked the staff to change the catheter out and they never got back to her. She said the staff told her they were only supposed change the bag out not the internal part. She said the staff told her they were to change the bag out every 2 weeks. She said she did not have off of the facility staff names. In an interview on 11/29/2023 at 10:05am with LVN D she said she never documented she changed out resident Resident #3's foley catheter out on November 15th. She said she had never changed out the residents foley catheter. She said she assisted one time with holding Resident #3's leg but that was a while ago. She said her initials were in PCC, but she never put them there. She said someone else must have. She said she had changed out Resident #3's foley bag but not the entire catheter because the bag was leaking. She said other people have access to point click care and could have put her initials in showing the foley had been changed out. She said if a residents foley catheter is not changed out it would have put the resident at risk for infection. She said when the foley bag was on the floor it would have put the resident at risk for infection. In an interview on 11/29/2023 at 10:07am with the DON, she said no one could have put another person's initials into PCC. She said staff had to sign on to PCC with their own password and it had their initials in the system. She said staff could have only put their own initials into PCC. She said if a residents foley catheter bag was on the floor it could have been pulled and tugged on and could have also put the resident at risk for infection. In an interview on 11/30/2023 at 7:50am with the DON she said if a foley catheter was not changed out timely a resident could have contracted an infection leading to sepsis. In an interview on 11/30/2023 at 12:05pm with agency nurse RN C she said she had changed out the residents foley bag not the entire foley catheter when she cared for the Resident #3 on 10/15/2023. When asked if she was certain she said yes. She said she went to multiple facilities as an agency nurse but could not remember the physician orders but was certain she changed out the foley bag only. She said she was trained on foley catheters in nursing school and was not trained by the facility because she was an agency nurse and went to multiple facilities. In an interview on 12/1/2023 at 9:17am with LVN E she said she had worked at the facility for a year and a half and been a nurse since the year 2016. She said Foley catheters were not supposed to touch the floor. She said bacteria could have gotten in the bag and caused infection. She said if a foley catheter did not get changed out it could have become clogged, and the resident could have gotten an infection. In an interview on 12/1/2023 at 9:20am with CNA P she said she had been a CNA for [AGE] years and worked at the facility for six months. She said foley catheters were not supposed to be on the floor. She said they could have collected bacteria on the floor and could have been accidentally pulled on. She said if a foley catheter was on the floor, it could have caused an infection. She said the foley bag was supposed to be attached to the opposite side of the bed. She said they had in-services through the Relias module education system and in-serviced by the DON. In an interview on 12/1/2023 at 10:37am with CNA B she said she had worked at the facility for [AGE] years. She said she had worked at the facility part time and had worked for hospice part time. She said if a Foley catheter had touched the floor, it could have become contaminated, caused an infection and caused the catheter to leak. She said foley catheters were supposed to be dated and were supposed to be changed out once a month. She said if a foley were not changed out it could have caused an infection. She said they did a lot of in-services at this facility, and she had received in-services at the hospice on Foley care too. Record review of facilities policy titled; Infection Control dated 12/20/2017 read in part . The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 residents (Resident#8) reviewed for pharmaceutical services. - The facility failed to administer medication to Resident #8 as ordered by applying Lidocaine 4 % patches to the resident's right knee and hip instead of Lidocaine 4% gel on multiple occasions between 11/15/23 at 11/29/23. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and hospitalization . Findings included: Record review of Resident #8's Face Sheet dated 11/30/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnose which included: pain in left hip and right and left hip fracture. Record review of Resident #8's Admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, resident received scheduled and PRN pain medication and the resident experienced frequent pain up to 07 out of 10. Record review of Resident #8's Care Plan dated 11/09/23 revealed, focus- alteration in musculoskeletal status related to fracture of the right hip; interventions- give analgesics as ordered by the physician. Record review of Resident #8's Physician Order dated 11/15/23 at 02:26 PM entered by LVN D revealed, Lidocaine External Gel 4%- apply to R. Knee and R. Hip topically one time a day and remove per scheduled. Record review of Resident #8's Progress Note dated 11/29/23 at04:35 PM and signed by the DON revealed, Medication error noted during med pass . Resident assessed for adverse reaction with No adverse reactions noted No c/o pain/discomfort at present time . MD notified with order clarification received for Lidocaine 4% patch to right hip and knee daily. EMAR updated accordingly, Resident updated on medication change. Record review of Resident #8's November MAR revealed the resident was administered Lidocaine 4% patches to her right hip and knee on 13 different days between 11/16/23 and 11/29/23: 1. 11/29/23 scheduled for 8:00 and applied by LVN D. 2. 11/28/23 scheduled for 8:00 and applied by LVN D. 3. 11/27/23 scheduled for 8:00 and applied by LVN D. 4. 11/26/23 scheduled for 8:00 and applied by LVN E. 5. 11/25/23 scheduled for 8:00 and applied by LVN E. 6. 11/23/23 scheduled for 8:00 and applied by LVN D. 7. 11/22/23 scheduled for 8:00 and applied by LVN D. 8. 11/21/23 scheduled for 8:00 and applied by LVN D. 9. 11/20/23 scheduled for 8:00 and applied by LVN D. 10. 11/19/23 scheduled for 8:00 and applied by an unknown agency nurse. 11. 11/18/23 scheduled for 8:00 and applied by an unknown agency nurse. 12. 11/17/23 scheduled for 8:00 and applied by LVN D. 13. 11/16/23 scheduled for 8:00 and applied by LVN D. An observation on 11/29/23 at 08:11 AM revealed, LVN D prepared for medication administration to Resident #8. After informing the resident she would be administering medication, she retrieved 2 Lidocaine 4% patches and 7 solid form medications and returned to Resident #8's beside with the medications. After administering the oral medications to Resident #8, LVN D applied a patch to Resident #8's right knee and right hip/lower buttock. An observation on 11/29/23 at 09:25 AM with LVN F revealed, a sealed an unused tube of Lidocaine 4% Cream for Resident #8 with a pharmacy fill date of 11/24/23. In an interview on 12/01/23 at 09:15 AM- Resident #8 said the facility had administered Lidocaine patches to her hip and knee since she November, she said a cream/gel had never been applied by the facility. In an interview on 12/01/23 at 10:58 AM, the Pharmacy said on 11/15/23 the pharmacy received a prescription for Lidocaine 4% topical gel but it was not filled due to Resident #8 being on Medicare until 11/24/23 when the facility requested a refill. The Pharmacy said there were no other orders filled or delivered for Lidocaine 4% until 11/24/23. In an interview on 11/29/23 at 11:24 AM, LVN D said prior to medication administration nurses are expected to introduce themselves to the resident, inform the resident that medication is to be administered and then check the resident's vitals. The medications should be verified against the MAR, and once vitals are confirmed to be within parameters the medications can be dispensed into a medication cup and then administered to the resident. She said when medication verification involved ensuring the dose and formulation to be administered matched the physician order and medications must be administered as ordered. LVN D said she did not notice that Resident #8's Lidocaine orders specified gel and she had always applied patches to the resident. She said patches and gel are not interchangeable and failure to apply topical medication as ordered could result in skin irritation. In an interview on 11/29/23 at 11:56 AM, the DON said prior to medication administration medications are verified against the MAR, acceptable administration parameters must be confirmed and medication administration must be observed in full. She said nurses must ensure the medication, dose, frequency and formulation are accurate and then medications can be dispensed. The DON said patches and gel/cream are not interchangeable, lidocaine patches must be removed after 12 hours while topicals were not so failure to administer the correct formulation of Lidocaine could place residents at risk for skin irritation. Record review of LVN D's Medication Pass Observation Report dated 04/24/23 completed by the pharmacy consultant revealed, LVN D was observed with G-tube medication administration, oral medication administration, nasal sprays and inhaler administration. No errors were observed. Record review of the facility policy Physician Medication & Treatment Orders with no revision date revealed, procedures addressing administration of medications include: 4- assuring that Medications administered are to be: In the correct dose; In accordance with manufacturer's specifications and with standards of practice; To the correct person; The correct route; In the correct dosage form and; At the correct time.

Based on observation, interview and record review the facility failed to accurately assess each resident's status for 2 of 4 residents (Resident #13 and Resident #15) reviewed for assessment accuracy. - The facility failed to accurately assess and document Resident #13's visual impairment requiring the use of glasses. - The facility failed to accurately assess and document Resident #15's use of continuous oxygen and visual impairment requiring the use of glasses. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Resident #13 Record review of Resident #13's Face Sheet dated 11/29/23 revealed, an [AGE] year-old woman who admitted to the facility on [DATE] with diagnoses which included: Parkinson's Diseases, UTI, difficulty walking, hypertension and muscle weakness. Record review of Resident #13's Admission MDS dated [DATE] revealed, Vision- adequate sees fine detail, such as regular print in the newspapers/books. No use corrective lenses (contacts, glasses of magnifying glass) and moderately impaired cognition as indicated by a BIMS score on 08 out of 15. Record review of Resident #13's undated care plan revealed, focus- Resident #13 has impaired visual function related to macular degeneration; goal- resident will show no decline in visual function through the review date; intervention- identify/record factors affecting visual function including physiological ( .macular degeneration .) environmental and choices. An observation on 11/29/23 at 01:30 PM revealed, Resident #13 sitting in a wheelchair, well-groomed, well-dressed, wearing glasses and in no immediate distress. Resident #15 Record review of Resident #15's Face Sheet dated 11/29/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: chronic heart failure, Afib (irregular heartbeat), COPD (a group of diseases that cause airflow blockage and breathing related problems), SOB and a history of recurrent pneumonia. Record review of Resident #15's Quarterly's MDS dated [DATE] revealed, use of corrective lenses- no; ability to see in adequate light-adequate; moderately impaired cognition as indicated by a BIMS score of 09 out of 10, frequently incontinent of both bladder and bowel and no documented use of any oxygen therapy including continuous or intermittent. Record review of Resident #15's undated Care Plan revealed, no documentation of vision impairment or the use of visual appliances. Focus- Resident #16 has COPD exacerbation episodes of shortness of breath and the use of O2; Interventions- oxygen settings: O2 via nasal cannula at 2-3 L per minute. O2 tubing, cannula and humidifier bottle to be changed each Sunday 11-7 shift. Focus- oxygen therapy related to COPD; interventions- monitor s/sx of respiratory distress and report to MD PRN, oxygen setting: O2 via nasal canula at 2-3 L PRN. Record review of Resident #15's Order dated 09/20/22 revealed, Oxygen 2-3 L as needed to get oxygen level to 92 and above as needed for SOB. Record review of Resident #15's November 2023 MAR/TAR revealed, no documentation of oxygen administration for the month of November. An observation and interview on 11/28/23 at 09:45 AM revealed, Resident #15 with bright red glasses sitting in a recliner beside her bed crocheting receiving oxygen via nasal canula at 2.5 L/min. An observation and interview on 12/01/23 at 10:20 AM, Resident #15 sitting in her recliner on the side of her bed receiving oxygen via nasal Canula at 2.5 L/min, a magnifying glass was observed in a cup located on the bedside table in front of her. Resident #15 said she wore glasses when she reads or knits and she has been on continuous oxygen since she admitted . The resident said her oxygen was not PRN but continuous and she needed it all the time. In an interview on 12/01/23 at 09:39 AM, the MDS nurse said she has been responsible for the facility's MDS for the last 6 years. She said she completed Resident's MDS's using the RAI provided by CMS. The MDS coordinator said the MDS is completed using resident/family interviews, resident observations and clinical review of the resident's chart. She said the sections of the MDS that addressed the use of hearing aids or glasses were usually completed by the social worker who has been on leave since the first week of November, so was responsible for completing those sections. The MDS nurse said if a resident wore glasses then corrective lenses should be marked on their MDS, and their ability to see in adequate light should be documented based on the use of or absence of visual appliances. She said she was unaware that Resident #13 and Resident #15 used glasses. The MDS nurse said the respiratory treatments section (specifically oxygen therapy) of the MDS was completed by reviewing the resident's MAR/TAR and it was only documented for continuous use and not PRN. She said she did not know Resident #15 used oxygen since there was no documented administration of oxygen to Resident #15 during the 14 days before the resident's last MDS was completed. The MDS Nurse said since the MDS triggers focus areas in the care plan failure to complete the MDS accurately could place the resident at risk of not having their needs met and could impact In a way the accuracy of the resident's care plan. In an interview on 11/30/23 at 02:03 PM, the DON said she did not review the submitted MDS in its entirety. She said she only reviewed the sections of the MDS she was triggered to answer and she trusts the MDS nurse to do her job (complete the MDS correctly.) In an interview on 12/01/23 at 10:54 AM, MD A said Resident #15 has required continuous oxygen via nasal canula and had oxygen since admission. MD A said she was not aware that Resident #15's continuous use of oxygen was entered as PRN and failure to administer oxygen as ordered could result in insufficient oxygen supplementation, respiratory distress and hospitalization . Record review of the facility policy titled Resident Assessment Instrument revised September 2010 revealed, 3- the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4- information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her practicable level of functioning.

Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents (Resident #15) reviewed for care plans. -The facility failed to ensure Resident #15's comprehensive care plan addressed the residents use of glasses. This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings included: Record review of Resident #15's Face Sheet dated 11/29/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: chronic heart failure, Afib (irregular heartbeat), COPD (a group of diseases that cause airflow blockage and breathing related problems), SOB and a history of recurrent pneumonia. Record review of Resident #15's Quarterly's MDS dated [DATE] revealed, use of corrective lenses- no; ability to see in adequate light-adequate; moderately impaired cognition as indicated by a BIMS score of 09 out of 10, and frequently incontinent of both bladder and bowel. Record review of Resident #15's undated Care Plan revealed, no documentation of vision impairment or the use of visual appliances. An observation on 11/28/23 at 09:45 AM revealed, Resident #15 with bright red glasses sitting in a recliner besides her bed crocheting. An observation and interview on 12/01/23 at 10:20 AM, Resident #15 sitting in her recliner on the side of her bed, a magnifying glass was observed in a cup located on the bedside table in front of her. Resident #15 said she wore glasses when she read or knit. In an interview on 12/01/23 at 09:39 AM, the MDS nurse said she has been responsible for resident care plans for the last 6 years. She said each resident's care plan is completed by an IDT and each member (social worker, nursing, activities) completes their section and she reviews everything to ensure everything has been entered. The MDS nurse said the care plan should address everything about a resident including their diagnoses, vision and hearing impairments and anything needed to take care of the resident. She said the social worker, who was currently on leave since the beginning of November, was responsible for completing the hearing and vision sections of the resident's MDS and since the MDS triggers areas in the care plan an inaccurate MDS could impact the accuracy of the care plan. The MDS Nurse said inaccurate care plans could place residents at risk of not receiving necessary care. Record review of the facility policy titled Comprehensive Care Plan revised 05/2004 revealed, the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the assessment. The care plan will describe the following: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; the needs, strengths and preferences identified in the assessments. Record review of the facility policy titled Resident Assessment Instrument revised September 2010 revealed, 4- information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her practicable level of functioning. Record review of the facility policy titled Care Planning-Interdisciplinary Team revised September 2013 revealed, the care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team which includes, but is not necessarily limited to the following personnel: attending physician, RN, Dietician, Social Worker, Activity Director, Therapists, Consultants, DON and others as appropriate or necessary to meet the needs of the resident.

Based on observation, interview and record review the facility failed to consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a change in condition and a need to alter treatment significantly for 1 of 5 residents (Resident #121) reviewed for notification of changes. - The facility failed to notify the physician of Resident #121's red, swollen and tender right thumb identified on 11/30/23. This failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization , pain, and suffering. Findings Include: Record review of Resident #121's Face Sheet dated 11/30/23 revealed, a 77-yer-old male who admitted to the facility on [DATE] with diagnoses which included: high cholesterol, depression, hypertension and dementia. Record review of Resident #121's Admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence with most ADLs, total dependence with most functional abilities including rolling left to left, sit to lying, sit to stand, char/bed to char transfer, and walking was not attempted due to medical conditions or safety concerns and always incontinent of both bladder and bowel. Record review of Resident #121's undated Care Plan revealed, focus- little or no activity involvement related to immobility due to him unable to walk and needs assistance to and from areas, he is also assisted for and needs assistance with day to day needs; interventions- the resident needs assistance/escort to activity functions. Focus- ADL self-care performance deficit; interventions- extensive assistance to turn and reposition in bed, requires weekly skin inspection for redness, open areas, scratches and bruises and report changes to nurse, totally depended on staff to toilet use, requires mechanical life with 2 staff assistance for transfers. Record review of Resident #121's Skin assessment dated [DATE] at 08:33 PM signed by RN D revealed, notes- Bruise noted to left forearm. There was no documentation of pain and swelling to Resident #121's right thumb. Record review of Resident #121's Progress Notes dated 12/01/23 at 11:09 AM signed by the DON revealed, MD notified of resident's right thumb being swollen, red and tender. A new order for STAT xray of thumb and CBC received, POA notified of condition and new orders. An observation on 11/30/23 at 12:00 PM revealed, Resident #121 sitting in Geri Chair in the TV room. The resident was confused and would not answer questions, his right thumb was swollen, red and irritated. An observation on 12/01/23 at 09:23AM with PT A revealed, Resident #121 sitting in his Geri-Chair with a large purple bruise to the resident's upper left arm. The resident's right thumb was observed to the red/swollen and the resident said of pain to his finger. In an interview on 11/30/23 at 04:04 PM, CNA W said the last time she worked with Resident #121 was on 11/25/23 and the resident was already in bed so she didn't notice any bruising. She said today (11/30/23) she noticed a red and swollen thumb and the resident complained of pain so she notified her nurse. In an interview on 12/01/23 at 09:25 AM, LVN E said this morning she observed Resident #121's right thumb to be red/swollen and appeared to be infected. She said when she reviewed the resident's chart there was no documentation of irritation to Resident #121's right thumb and she was not notified by the nurse during change of shift. LVN E said the change in Resident #121's thumb should have been documented in the residents chart as a skin assessment, and the physician should have been notified of the injury to the resident's thumb in order to receive orders for treatment. She said failure to identify and take action on new changes in a resident's skin could place residents at risk for a delay in treatment and worsening of condition. In an interview on 12/01/23 at 09:30 AM, the DON said she just found out in the morning that Resident #121 had an injury to his right thumb. She said when she reviewed the resident's chart there was no documentation of issues with Resident #121's right thumb and to her knowledge the physician had not been notified but she was collaborating with the resident's nurse to contact the physician. The DON said nurses are expected to immediately notify the resident's physicians of any new injuries/concerned areas, notify the family and then notify her. She said failure to identify and take action on new areas of concern could place residents' at risk of a delay in treatment and worsening of condition. An attempt was made on 12/01/23 at 10:58 AM to contact Resident #121's physician, MD A. A message was left but MD A did not return the surveyors call prior to exit. In an interview on 12/01/23 at 11:48 AM, the DON said all staff are expected to report any new skin changes in residents. She said during care/showers CNAs are expected to observe for any new areas of skin breakdown, bruising, skin tears and any skin issues they have not noticed before. The DON said these skin changes can be documented in the POC/progress notes and the CNA should ensure the nurse is notified, the nurse is expected to ensure the resident is assessed through a skin assessment, the physician must be notified, and lastly notification should be sent to the family and the DON. The DON said she observed Resident #121's thumb and it looked infected. She said MD A was notified of Resident #121's swollen right thumb after the surveyor's alert and orders for x-rays and labs were received, and the facility contacted Resident #121's POA and emergency contact. The DON said failure to identify and treat new infections would lead to a more severe infection like sepsis. In an interview on 12/01/23 at 01:04 PM, RN D said when she worked with Resident #121 on 11/30/23 she observed a large bruise on his upper left arm and she documented it on the resident's skin assessment. She said she also observed Resident #121's thumb to be red and the resident reported pain. RN D said Resident #121's thumb was red/pink but there was no swelling so she treated the resident with Tylenol but she forgot to document the irritation to the resident's right thumb as well as administration of Tylenol RN D said she did not communicate Resident #121's red thumb to his physician, the DON or the oncoming nurse. RN D said nurses are expected to document accurately and timely any new changes in the resident's chart, notify the family and physician and failure to do so could place residents at risk of harm and further injury. Record review of the facility policy Policy for Notifying Physicians of Change of Conditions revised 02/10/16 revealed, it is the policy of the facility that the resident's physician and family members be notified of changes in a resident's condition that affect the resident's health. The following are examples of times when the physician must be immediately notified of a change of condition. After the physician is notified and the resident stabilized, the charge nurse is responsible to notify a family member or responsible

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the residents choices 1 of 4 residents (Resident #121) reviewed for quality of care. -The facility failed to identify and take action on bruising Resident #121's upper left arm and swelling and pain on his right thumb. This failure could place residents at risk of delayed identification/treatment of injuries, worsening of injuries, pain and infection. Findings Include: Record review of Resident #121's Face Sheet dated 11/30/23 revealed, a 77-yer-old male who admitted to the facility on [DATE] with diagnoses which included: high cholesterol, depression, hypertension and dementia. Record review of Resident #121's Admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence with most ADLs, total dependence with most functional abilities including rolling left to left, sit to lying, sit to stand, char/bed to char transfer, and walking was not attempted due to medical conditions or safety concerns and always incontinent of both bladder and bowel. Record review of Resident #121's undated Care Plan revealed, focus- little or no activity involvement related to immobility due to him unable to walk and needs assistance to and from areas, he is also assisted for and needs assistance with day to day needs; interventions- the resident needs assistance/escort to activity functions. Focus- ADL self-care performance deficit; interventions- extensive assistance to turn and reposition in bed, requires weekly skin inspection for redness, open areas, scratches and bruises and report changes to nurse, totally depended on staff to toilet use, requires mechanical life with 2 staff assistance for transfers. Record review of Resident #121's Skin Assessment completed dated 11/18/23 revealed, no documentation of a bruise on the residents left upper arm. Record review of Resident #121's Skilled Charting Notes from 11/27/23 to 11/29/23 revealed, no documentation of a bruise to the resident's left upper arm. Record review of Resident #121's Pain Level Summary dated 11/30/23 at 05:47 PM revealed: - pain of 1 out of 10 recorded by RN D. Record review of Resident #121's Skin Assessment completed dated 11/30/23 at 08:33 PM revealed, notes- Bruise noted to left forearm. There was no documentation of pain and swelling to Resident #121's right thumb. Record review of Resident #121's Progress Notes dated 11/30/23 revealed, no documentation of bruising to the residents left arm, no documentation of pain and swelling to Resident #121's right thumb. Record review of Resident #121's Progress Notes dated 12/01/23 at 11:09 AM signed by the DON revealed, MD notified of resident's right thumb being swollen, red and tender. A new order for STAT xray of thumb and CBC received, POA notified of condition and new orders. Record review of an email correspondence on 11/30/23 at 07:38 PM between the DON and the surveyor revealed, [CNA U] stated she reported the bruising to nurse [LVN D] on Monday (11/28/23) nurse stated she was going to see if anyone had documented / reported it yet. [CNA Q] stated she showed it to nurse [LVN D] and nurse was aware of bruise stating he leans and moves all over the place so he is going to have bruises all over. Record review of Resident #121's Order Summary revealed, - Clopidogrel 75 mg, a medication used to prevent blot clots- give 1 tablet by mouth one time a day - Aspirin 81 mg- give 1 tablet by mouth for stroke prevention. An observation and interview on 11/28/23 at 12:00 PM revealed, Resident #121 sitting in a Geri Chair ( a large, padded chair with a wheeled based designed to assist seniors with limited mobility) in his room. The resident had a red oval bruise approximately 5 inches long on his left upper arm, he was incoherent unresponsive to questions and just repeated help me. An observation and interview on 11/29/23 at 08:00 AM revealed, Resident #121 sitting in a Geri Chair in his room with a red oval bruise approximately 5 inches long on his left upper arm. An observation on 12/01/23 at 09:23AM with PT A revealed, Resident #121 sitting in his Geri-Chair with a large purple bruise to the resident's upper left arm. The resident's right thumb was observed to the red/swollen and the resident complained of pain to his finger. PT A said PT worked with Resident #121 almost every day and today was the first day she observed bruising to the resident's left arm. In an interview on 11/30/23 03:37 PM, the DON said Resident #121 had periods of confusion, and exhibited behaviors of digging in his brief, throwing feces, screaming out help and getting handsy with staff. She said Resident #121 was non-ambulatory and was frequently placed in a Geri Chair. The surveyor notified the DON of the bruise located on Resident #121's upper left arm and she said she was not aware of any bruises on Resident #121. The DON left the interview to assess Resident #121 and when she returned she said she observed a pretty big red bruise on Resident #121's upper left arm. She said the resident was on an anticoagulant, frequently leaned in his Geri Chair and he had no documented falls or injuries. The DON said when nursing staff observed the resident's bruise they should have done an incident report and notified the physician, family and then her. She said she did not know how the resident got the bruise and there was no documentation of the bruise prior to receiving notification from the surveyor. The DON said failure to take action on new skin conditions like bruising could result in failure to take action and have no intervention in place which could place residents' at risk for further bruising/injury. In an interview on 11/30/23 at 04:04 PM, CNA W said the last time she worked with Resident #121 was on 11/25/23 and the resident was already in bed so she didn't notice any bruising. She said today (11/30/23) she noticed a red and swollen and the resident complained of pain so she notified an unknown nurse. An attempt was made on 12/01/23 at 09:19 AM to contact CNA U, the facility provided number was disconnected. In an interview on 12/01/23 at 09:20 AM, CNA P said today, 12/01/23 was the first day she worked with Resident #121 and in the morning as she dressed Resident #121 she observed his right thumb to be swollen/infected so she reported the incident to the nurse. She said CNAs are expected to report any bruising/skin tears or injuries to the resident's nurse. In an interview on 12/01/23 at 09:25 AM, LVN E said this morning she observed Resident #121's right thumb to be red/swollen and appeared to be infected. She said when she reviewed the resident's chart there was no documentation of irritation to Resident #121's right thumb and she was not notified by outgoing nurse during change of shift. LVN E said the change in Resident #121's thumb should have been documented in the residents chart as a skin assessment, and the physician should have been notified of the injury to the resident's thumb in order to receive orders for treatment. She said failure to identify and take action on new changes in a resident's skin could place residents at risk for a delay in treatment and worsening of condition. In an interview on 12/01/23 at 09:30 AM, the DON said she just found out in the morning that Resident #121 had an injury to his right thumb. She said when she reviewed the resident's chart there was no documentation of issues with Resident #121's right thumb and to her knowledge the physician had not been notified. The DON said nurses are expected to immediately notify the resident's physicians of any new injuries/concerned areas, notify the family and then notify her. She said failure to identify and take action on new areas of concern could place residents' at risk of a delay in treatment and worsening of condition. In an interview on 12/01/23 at 10:50 AM, CNA M said she last worked with Resident #121 on Saturday 11/25/23 the resident had a purple bruise on his left upper arm so she reported it to her nurse as required. She said she did not remember the name of the nurse she reported the bruise to but CNAs are expected to notify their nurses of any new skin issues. An attempt was made on 12/01/23 at 10:58 to contact Resident #121's physician, MD A. A message was left but MD A did not return the surveyors call prior to exit. An attempt was made on 12/01/23 at 11:13 AM to contact CNA Q. A message was left but CNA Q did not return the surveyors call prior to exit. An attempt was made on 12/01/23 at 11:14 AM to contact LVN D. A message was left but LVN D did not return the surveyors call prior to exit. In an interview on 12/01/23 at 11:16 AM, CNA T said she last worked with Resident #121 on 11/30/23 and prior to that she worked with him more than a week. She said as a CNA she provides help with dressing and incontinence care. CNA T said on 11/30/23 she dressed Resident #121 in the morning but she did not observe any bruising, she said she did not pay attention. She said CNAs are expected to observe residents' skin while providing care and any new change should be reported to the nurse and failure to report resident skin changes could cause staff to get in trouble. In an interview on 12/01/23 at 11:48 AM, the DON said all staff are expected to report any new skin changes in residents. She said during care/showers CNAs are expected to observe for any new areas of skin breakdown, bruising, skin tears and any skin issues they have not noticed before. The DON said these skin changes can be documented in the POC and the CNA should ensure the nurse is notified, the nurse is expected to ensure the resident is assessed through a skin assessment, then the physician must be notified, lastly notification should then be sent to the family and the DON. The DON said she observed Resident #121's thumb after the surveyor's notification and it looked infected. She said MD A was notified of Resident #121's swollen right thumb and orders for x-rays and labs were received, and the facility contacted Resident #121's POA and emergency contact. The DON said failure to identify and treat new infections would lead to a more severe infection like sepsis. In an interview on 12/01/23 at 01:04 PM, RN D said when she worked with Resident #121 on 12/30/23 she observed a large bruise on his upper left arm and she documented it on the resident's skin assessment. She said she also observed Resident #121's thumb to be red and the resident also reported pain. RN A D said Resident #121's thumb was red/pink but there was no swelling so she treated the resident with Tylenol but she forgot to document the irritation to the resident's right thumb as well as administration of Tylenol RN D said she did not communicate Resident #121's red thumb to his physician, the DON or the oncoming nurse. RN D said she just treated the residents pain but didn't think it was anything that required further action. RN D said nurses are expected to document accurately and timely any new changes in a resident, notify the family and physician and failure to do so could place residents at risk of harm and further injury. Record review of the facility policy tilted Non-Pressure Skin Condition Report issued 03/18/08 revealed, 1- the non-pressure skin condition report will be used weekly to assess each resident's skin for any bruising, skin tears, and to document if the resident has no skin condition concerns. Completing the form- should any other skin condition be observed such as . skin tear, abrasion, bruise it will be documented on the non-pressure skin condition report. For each sire noted , the licensed nurse will document on the non-pressure skin condition report the date the site was first observed, the location of the site, the type of site, surgical, skin tear, etc. The licensed nurse will mark on the diagram the location of the site.

Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 residents (Resident #17) reviewed for gastrostomy tube management. - LVN D failed to administer medications as ordered to Resident #17 by pouring dry powder medication into the resident's G-tube immediately after a bolus feed of enteral formula resulting in the resident stating she felt like she was going to explode. This failure could place residents at risk for adverse reactions, pain and discomfort. Findings included: Record review of Resident #17's Face Sheet dated 11/29/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: paralysis of the left non-dominant side, shortness of breath, dementia, hypertension, irregular heartbeat, and difficulty swallowing. Record review of Resident #17's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 08 out of 15, and use of a feeding tube while a resident. Record review of Resident #17's undated Care Plan revealed, focus- requires tube feeding related to difficulty swallowing; intervention: check for placement and gastric contents/residual per facility protocol, flush tube with 30 ml of water before and after all medications, when administering more than 1 medication flush tube with 5-10 ml of water between each medication. Record review of Resident #17's Order Summary Report dated 11/29/23 at 03:24 PM revealed the following active orders: - Digoxin 125 mcg- Give 1 tablet by mouth daily via G-tube for irregular heartbeat dated 05/02/23. - Cetirizine 10 mg- Give 1 tablet by mouth daily via G-tube for allergies dated 06/16/23. - Amlodipine 5 mg- give 2 tablets by via G-tube one time a day for hypertension dated 06/29/23. - Apixaban 5 mg- give 1 tablet via G-tube every 12 hours for irregular heartbeat dated 08/02/3. - Escitalopram 10 mg- Give 1 tablet by mouth daily via G-tube for depression dated 08/07/23. - Enteral Feed Order four times a day Give one carton of Isosource 1.5 cal. five times a day dated 10/05/23 - Enteral Feed Order four times a day Flush G-tube with 60cc of water before and after bolus feeding. Dated 10/11/23. Record review of Resident #17's Progress Note dated 11/29/23 revealed, Resident c/o abdominal discomfort/ fullness after medication/ bolus feeds and flushes were administered. Resident assessed by AL manager with no bloating noted. Resident expressed no c/o pain only discomfort. MD and Hospice notified with orders to continue monitoring. Hospice stated they are monitoring feedings and slowing weaning her r/t feeling of fullness. Recent change was from 5 bolus feeds to 4 bolus feeds/day. Hospice nurse to assess on next facility visit. An observation on 11/29/23 at 08:28 AM revealed, LVN D preparing for medication for administration to Resident #17. She retrieved 1 tablet of Escitalopram 10 mg, 1 tablet of Digoxin 125 mcg, 1 tablet of Apixaban 5 mg, 2 tablets of Amlodipine 10 mg instead of 1 tablet of 10 mg as ordered and 1 tablet of Cetirizine 10 mg and placed each medication in individual medication cups. At 08:32 AM LVN D crushed each medication, returned them into their individual medication cups and entered into the residents room. After repositioning the resident, LVN D retrieved 2 cups of room temperature water (each cup containing about 60 ml) from Resident #17's bathroom and then checked the resident for placement and residual feeding at 08:38 AM. LVN D flushed Resident #17's G-tube with 30 ml of water, then 60 ml of Isosource and then poured un dissolved powder medication down Resident # 17's G-tube followed by an unknown amount of water. LVN D repeated this pattern of Isosource, powdered medication, unknown water until she had administered 250 ml of Isosource and all 5 medications were administered and then flushed with 30 ml of water. During G-tube administration, LVN D did not allow all the fluid to pass into the tube before adding the next volume of liquid or the powered medications. LVN D asked Resident #17 how she felt after she completed G-tube medication and enteral feed administration and Resident #17 said I feel like I am going to explode. The surveyor did not observe any signs of pain on Resident #17's face but the resident did appear to be in discomfort. In an interview on 11/29/23 at 11:24 AM, LVN D said prior to medication administration nurses are expected to introduce themselves to the resident, inform the resident that medication is to be administered and then check the resident's vitals. The medications should be verified against the MAR, and once vitals are confirmed to be within parameters the medications can be dispensed into a medication cup and then administered to the resident. She said when medication verification involved ensuring the dose and formulation to be administered matched the physician order and medications must be administered as ordered. LVN D said she did not dissolve Resident #17's crushed medication in water prior to G-tube medication because there was some water in the tube prior to her pouring the powder and that was how she was trained in her state. She said she was not supposed to perform bolus feeds during medication administration but the resident had not had any food since 8 PM the previous day and normally complained about being hungry. LVN D said she started in the facility as an agency nurse and said she did not know if there were any potential reactions when medications are administered with feeds and Resident #17 received a total of 120 ml of water and 240 mL of Isosource for a total of 360 mL. She said Resident #17 had a cool sense of humor when she said she was going to explode, she did not believe the resident was experiencing any form of discomfort but administering too much volume during G-tube administration could place residents at risk of distension and aspiration. In an interview on 11/29/23 at 11:56 AM, the DON said prior to medication administration medications are verified against the MAR, acceptable administration parameters must be confirmed and medication administration must be observed in full. She said nurses must ensure the medication, dose, frequency and formulation are accurate and then medications can be dispensed. The DON said prior to administering medication via G-tube nurses must dissolve the medications in 5-10 mL and LVN D should not have poured powdered/crushed medications directly into the Resident #17's tube because it could clog the tube. The DON said LVN D should not have administered Bolus feed (Isosource) at the same time as medications because of possible food/medication interactions as well as volume overload which could result in the resident experiencing vomiting and discomfort. She said LVN D received a competency assessment with the nurse that oriented her and the pharmacy consultant should have completed a medication administration observation as well. Record review of LVN D's Medication Pass Observation Report dated 04/24/23 completed by the pharmacy consultant revealed, LVN D was observed with G-tube medication administration. No errors were observed. Record review of the facility policy titled Policy for Administering Medications Through and Enteral Feeding Tube issued 06/2017 revealed, 2, a- tablets- crush each tablet into fine powder, using pill crushing device. Dissolve each tablet in separate cup of 10-30 ml of water or per physician's order. 5- if continuous enteral tube feeding is infusing, adjust infusion pump to hold tube feeding. 10,b- to administer more than one medication, give each separately and flush between medications with 10-30 cc of water as ordered by the physician.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 out of 1 medication carts ( Nursing Cart ) reviewed for medication storage. - The facility failed to ensure the Nursing Cart did not contain Insulin Lispro for Resident #121 with no open date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: Record review of Resident #121's Face Sheet dated [DATE] revealed, a 77-yer-old male who admitted to the facility on [DATE] with diagnoses which included: high cholesterol, depression, hypertension, dementia and diabetes. Record review of Resident #121's Admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence with most ADLs, total dependence with most functional abilities including rolling left to left, sit to lying, sit to stand, char/bed to char transfer, and walking was not attempted due to medical conditions or safety concerns and always incontinent of both bladder and bowel. Record review of Resident #121's undated Care Plan revealed, focus- diagnosis of type 2 diabetes; intervention- diabetes medications as ordered by doctor. Record review of Resident #121's Physician's Orders dated [DATE] revealed, Insulin Lispro- inject 6 units under the skin before meals for diabetes. An observation and interview with LVN D on [DATE] at 12:02 PM revealed, LVN D preparing for insulin administration to Resident #1211. She retrieved Resident #121's Insulin Lispro pen with no open date and Pharmacy fill date of [DATE]. LVN D said the insulin pen just arrived last night so it was not expired, She said all insulin pens should be dated with the day open in order to track the expiration date. She said most insulin are good for 28 days after which they can be less effective. She said Insulins without open dates should not be used because they might be expired and should be discarded in the drug disposal bin in the med room because use could result in ineffective blood sugar control. LVN D said since the pharmacy label said the insulin pen was recently filled it was still within 28 days and was safe to use. In an interview on [DATE] at 11:56 AM, the DON said nursing staff are expected to check their nursing carts daily as used for expired and inappropriately labeled medications. She said multi-dose insulin pens are labeled with the date opened in order to track the expiration date and must be discarded within 28 days. The DON said after insulin expires it is not as effective and should be discarded in the drug disposal cabinet and replaced. She said unlabeled insulin pens could be expired and if used in resident's it could result in uncontrolled blood sugars. Record review of the facility policy titled Storage of Medications revised ,d+[DATE] revealed, drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper for labeling before storing. Record review of the facility policy titled Labeling of Medication Containers revised ,d+[DATE] revealed, no specific instructions for labeling of multi-dose insulin pens.

Based on interview and record review, the facility failed to obtain diagnostic services as ordered by a physician for 1 of 2 residents (CR #20) reviewed for lab services, in that: - RN C failed to obtain stat labs for CR #20 as ordered by a physician. - This failure could place residents at risk of not receiving adequate medical care in a timely manner. Findings included: Record review of CR #20's face sheet, dated 11/30/2023, revealed a resident who was admitted into the facility on [DATE] and was diagnosed with type 2 diabetes, cerebral infarction and COPD. The resident was discharged on [DATE]. Record review of CR #20's MDS, dated [DATE], revealed the resident had a BIMS score of 10, indicating the resident's cognition was moderately impaired. Record review of CR#20's progress notes revealed, on 10/15/2023 10:30AM, [family member] came to visit him at this time, along with other family members . is requesting that resident be placed on Hospice care and that Morphine is provided Resident is also in agreeance in being placed under hospice care and for Morphine, stating he has been in pain all over at a 10/10 and that he has not been able to eat in 3 days. Resident did not complain of severe pain yesterday, however states he has been in pain for 6 days. Bowel sounds hyperactive , lung sounds, mildly dense, but clear bilaterally. No cough, or congestion noted. Denies [diarrhea], constipation, and nausea. Breathing non-labored with no signs of distress. Vital signs stable as documented in vitals tab with no changes. Phoned weekend on-call. Pending return call . Record review of CR #20's progress notes revealed, on 10/15/2023 11:20AM, [Doctor] phoned back and states to go ahead with the order for hospice consult, obtain a BMP and CBC stat and start 1000mg Tylenol by mouth, scheduled, 3 times daily x3days. Notified [family member] about all orders. Record review of CR #20's progress notes revealed, on 10/15/2023 10:05PM, Resident vomiting what appears to be coffee ground emesis. notified [family member] and she states she would like him sent to the emergency room . 911 called and pending pickup. Record review of CR #20's progress notes revealed, on 10/15/2023 10:15PM, Resident refused to go to ER when EMTs got to facility. In sound mind. States he has no pain and was upset because he wanted to stay and watch tv and sleep. Resident states he is fine. Notified [family member] and she spoke to EMTs as well and they told her they cannot force him to go. [NAME] states it is ok to wait to get labs in morning for the BMP and CBC. Record review of CR #20's orders, dated 12/01/2023, revealed no stat order was placed on 10/15/2023. There was only an order for CBC and BMP labs to be drawn on the morning of 10/16/2023. In an interview with the DON on 11/30/2023 at 1:26PM, she stated RN C, who was on duty on 10/15/2023 and working with CR #20, called the Staffing Coordinator, thinking she was the DON, and the Staffing Coordinator reported to the RN C if the doctor's orders were stat then they should be ordered right away, if not, the wait until Monday morning . The DON stated the stat order was not entered in and she did not actually find out about all of this until that Monday, 10/16/2023. She stated CR #20's labs were never drawn due to the delay. She stated the expectations were for stat orders to be to be ordered stat by the nurses when instructed by the physician. She stated stat lab services took about 4 hours for lab services to come out. She stated the risks of not doing so were that the patient's condition could further deteriorate. She stated RN C was the agency nurse that handled this patient on 10/15/2023 and she should have known there was a note at the nurses station for nurses to call her number and reach out to the DON. In an interview with the Staffing Coordinator on 11/30/2023 at 3:07PM, she stated RN C ran into her at the facility on 10/15/2023 and RN C introduced herself to her and reported that CR #20's family member requested for stat labs because the resident was not eating. The Staffing Coordinator said she told RN C to call doctor and provided RN C with the binder containing the DON and physician's contact number. She stated RN C called her again at night and reported to her that CR #20 had vomited. The Staffing Coordinator said she told RN C during the call that she can't help her with that, you need to call the physician or call or 911. She stated RN C would have likely done what she was supposed to do for CR #20 if she had notified the right people. A phone interview was attempted with RN C on 12/01/2023 at 10:17AM and 11:04AM but RN C never answered the call . Surveyor left a voicemail. Record review of the facility's policy on Reporting Lab and Diagnostic Results, dated, revealed .The nurse receiving results of all labs . will follow the protocol as set forward by the provider group . The policy did not address stat orders.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. -The facility failed to ensure the proper labeling and dating of all foods stored in the walk-in cooler, and freezer. -The facility failed to ensure proper discarding of expired food stored in the walk-in cooler and freezer. -The sanitizing solution water in the three-compartment sink was above the manufacture recommendation. These failures could place residents at risk for food-borne illnesses. Findings included: Observation on [DATE] at 9:30 a.m., of the kitchen walk in cooler revealed the following: - A container of prepped tuna was not dated, - A bag of citronella leaf was open and not dated. - Two 22 Liters of vegetable soup were not dated with Prep and discard date. - Two 22 litters of tomatoes soup were not dated with Prep and discard date - Opened micro greens and it was expired on [DATE]. - two head of lettuce was in a Ziploc bag, and it was open. the lettuce also brown in color, wilted and the expiration date was [DATE] - two heads of prepped cabbage in a Ziploc bag and another one in a bag by itself and the bags was open. there were brown streaks all over the three heads of cabbage and the expiration date was [DATE] Observation on [DATE] at 9:43 a.m., revealed the following in the freezer - long pan of carrot pastes expired [DATE] - a small pan of Roseto was not dated - a medium pan of sausage was not dated - 27 frozen cookies were left open in the freezer. - A loaf of bread had a prep date of [DATE] and discard date of [DATE] - A loaf of bread had a prep date of [DATE] and a dis card date of [DATE]. Observation [DATE] at 9:50 a.m. of the three-compartment sink revealed the sanitized water had excess sanitizing solution as indicated by the test strip which was dark green indicating the sanitizing solution was 500 ppm or more. The test strip range should be between 200 ppm and 400 ppm which were lighter colors. Interview on [DATE] at 10:20 a.m. The chef said the chemical for sanitizing the plates and cookware in the three-compartment sink should be between 200 and 400 psi, but it was green which was 500 psi and above. He said if the plates or cookware had a lot of residues, it could irritate the resident's stomach because there was more than the recommended quantity of the sanitizing solution in the water. Interview on [DATE] at 10:05 a.m., the chef said prepped food or soup should be dated with the prep date and discard date. He also stated any opened produce is stored in a Ziploc bag, and all air is removed from the bag before it is closed to keep the produce fresh. The chef said if food is left open in the freezer, it could have freezer burn, and it is not safe to serve the residents. He said food should be stored in a safe and sanitary condition to prevent residents from getting sick; the food must be labeled prep or open, discard date, and pulled out of the cooler and freezer as soon as it expired. The chef said he was responsible for checking the cooler and freezer to ensure the food was stored properly and there was no expired food, but he failed to make sure all expired food was pulled. He said he in-serviced the cooks on how to save food with dates and confirmed the bags were closed. He said he put the two loaves of bread in the freezer with those dates, but the facility did not have a policy for bread to be frozen. He did not respond on why the two loaves of bread were frozen. Interview on [DATE] at 10:47 a.m., The administrator said when the food is delivered, it is broken down and stored in the appropriate place and dated appropriately. He said soup that was prepared should be dated by whoever made it. He said expired items are discarded at the time of expiration. He said the facility policy is not to freeze bread to extend the self-live. He said if a resident is served expired food, there is a potential for the resident to get sick. He said he does not think a resident would have any negative outcome if the resident was served with a plate or utensil sanitized in water with more solution. Interview on [DATE] at 11:29 a.m. Cook A said he prepped the soups, and he forgot to label the soups with the prep date and discard date because he got busy. He said if food is placed in a Ziploc bag, he will make sure that all the air was left out of the bag before he closed the bag and then labeled it accordingly. He also said if any food was not in its original packet and it was also opened, it should be labeled too. Record review of the facility policy on food storage dated 2013 read in part . #14f . all foods should be covered, labeled and dated, fall foods will be checked to assure that foods will be consumed by their safe use by dates or discard . Record review of a ECOLAB manufacturer instruction guide dated 2013 eco lab USA Ink read in part . multi - quat sanitizer no -rise .testing solution should be between 200 - 400 ppm .

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for two (Resident#6 and Resident # 3) of six residents reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #6 required [CONDITION(S)] medication. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #3 required ADL (activity of daily living) care. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Resident #6 Record review of Resident #6's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's quarterly MDS dated ,d+[DATE] revealed BIMS of 13 indicating intact cognition. Further review revealed the resident required total assistance with ADL with two persons assist. It also triggered in CAA section that Resident #6 was on [CONDITION(S)] drug use and to care plan it. Record review of Resident #6's care plan did not reveal he was on any [CONDITION(S)] medication. Record review of Resident #6's order summary report dated August 2022 revealed an order of [MEDICATION(S)] HCI 20 mg, give on tablet by mouth one time a day for depression, and ordered on 05/13/22. In an interview on 08/11/22 at 8:42 a.m., the MDS coordinator said she was responsible for creating a comprehensive centered care plan, and it is due on the 21st day upon admission. She said resident #6's [CONDITION(S)] medication should be care planned, but she missed it. She stated it was necessary to care plan the medication because the nurses use it when providing care for the resident. she said it is vital to have it in the care plan because the nurses use it to care for the resident. She said it might affect the resident negatively because the nurses may not provide care adequately, which may affect the resident's health. Interview on 08/11/22 at 11:10 a.m., DON said the MDS coordinator was responsible for the patient's comprehensive cantered care plan within 14 days of admission, and she was not aware Resident #6's [CONDITION(S)] medication was not care planned. She said nurses use a care plan when providing care for the residents, and if it were not care planned, the nurses would not know the interventions that were put in place, and it would affect the care provided for the resident, and they may not receive appropriate care. Resident #3 Record review of Resident #3's face sheet reviewed a [AGE] year-old female was admitted to the facility on ,d+[DATE]/ 22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 3's quarterly MDS dated [DATE] revealed BIMS of 00 indicating severe impaired cognition. It further revealed resident required supervision with one person set up for toilet use and personal hygiene. She also needed extensive assistance with bathing with one person assist. She is also occasionally incontinent of bowel and bladder. Record review of Resident #3's undated care plan did not reveal ADLs were care planed. Record review and Interview on 09/11/22 at 8:45 a.m., MDS coordinator viewed Resident #3's MDS with the surveyor, and MDS coordinator stated Resident #3's comprehensive care plan was not completed because her ADL was not care planned. She said, it is what it is because she has other duties besides creating care plans and MDS. She said when a care plan is not patient care centered and complete, the resident may not get the care they need, which may affect the resident's wellbeing. Interview on 09/11/22 at 11: 15 a.m., DON said a comprehensive centered care plan should be completed within 14 days of admission. She also said ADL was an essential part of resident care and should be care planned because the nurses used it to provide care for the resident and were unaware of the omission. In addition, if ADL is not care planned, the resident may not get the required assistance, which may affect the quality of care. Record review of the facility undated care plan read in part . must develop a comprehensive care plan for each resident that includes measurable objective to meet a resident's medical, nursing, mental and psychosocial wellbeing .

Based upon observation and interview, drugs and biologicals used in the facility must be secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts ( Nurse Medication Cart) and 1 medication room ( South Medication Room) reviewed for drug labeling and storage. - The facility failed to ensure a previously opened Insulin pen stored on Nurse Medication Cart had an open date labeled on the pen to track expiration of insulin device. - The facility failed to ensure the South Medication Room did not contain expired IV Medications. These failures could place residents at risk of adverse medication reactions and drug diversions. Findings Included: Nurse Medication Cart In an observation and interview on 08/10/22 at 10:00 AM, inventory of the Nurse Medication Cart with LVN A revealed: - One (1) open and in-use [MEDICATION(S)] insulin pen at room temperature with no open date. LVN A said when insulin vials or pens are removed from the refrigerator or punctured, nursing staff must label the container with the date it was opened. She said the open date is used to track the expiration date and since the insulin pen did not have an open date the expiration dates could not be establish so it could no longer be used because after the beyond use date insulin loses its efficacy and can become contaminated. LVN A said nursing staff are expected to check their medication carts for expired and inappropriately labeled medications such as insulin and once identified they must be discarded in the locked drug disposal cabinet located in the medication storage room. She said the use of expired insulin could place residents at risk of ineffective therapy and infection. South Medication Room In an observation and interview on 08/10/22 at 10:05 AM, inventory of the South Medication Room with LVN A revealed: - Two (2) expired 100 mL IV Bags of [MEDICATION(S)] 360 mg, an antibiotic, with an expiration date of 07/13/22 in the refrigerator. LVN A said the medication belonged to a patient that discharged and the discharging nurse was responsible for removing all of the resident's medications from circulation located in the nursing carts or medications room. She said administration of expired medications could place residents at risk of adverse reactions. In an interview on 08/10/22 at 10:45 AM the Administrator said, once a resident is discharged their discharge nurse is responsible from removing all of the resident's medications in the medication carts/rooms. He said the night shift nursing staff are responsible for auditing the medication carts/rooms, removing any identified expired or inappropriately labeled medications and discarded them in the locked drug disposal cabinet. The Administrator said expired medications, if administered, could place residents at [NAME] for medication errors and ADRs. In an interview on 08/10/22 at 10:55 AM the Interim ADON said, nursing staff are expected to label insulin pens with the date once they are removed from the fridge or put in use in order to track the expiration date. She said if an insulin pen had no date it could not be used since its expiration could not be determined. The Interim ADON said once insulin expires it deteriorates and if used it could place residents at risk for ADRs due to inadequate therapy. She said that once a resident discharges their discharge nurse is responsible for removing all of the resident's medications from the med room and med cart. The Interim ADON said that the night shift nursing staff are responsible from auditing the medication rooms/carts and all expired medications are to be placed in the locked drug disposal cabinet. Record review of the facility policy titled Procedure for Medication Storage on Medication Cart revised 02/21/19 revealed, all injectables, eye drops, inhalers, nebulizer solutions, nasal sprays, ear drops, and blood glucose test strips will be dated once opened and discarded per manufacturer's storage guidelines specified on box. Must promptly pull medications from cart once medication is discontinued, resident is discharged to hospital, medication is expired. All discontinued and expired medications must be stored in the locked cabinet in the medication room designated for storage of discontinued and expired medications until turned into the nursing director for destruction.

Based on observation, interview and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #15) reviewed for respiratory care. The facility failed to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed residents who received oxygen therapy at risk of respiratory complications. Findings include: Record review of Resident #15's face sheet revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and readmitted on [DATE]. her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's quarterly MDS dated [DATE] revealed BIMS of 15 indicating intact cognition. Further review revealed the resident required minimal assistance with ADL with one person assist. Record review of Resident #15's care plan dated 06/03/22 revealed the resident has episodes shortness of breath related to congestion. It also read may have 02 at 3 liters per nasal cannula as needed. The date it was initiated was 01/21/2020. Intervention: Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Record review of Resident #15's order summary report for August 2022 read: May apply oxygen at 2L per NC as needed for oxygen saturation less than 90%, order date 03/17/21. Record review of Resident #15's progress notes dated from 08/02/22 through 08/09/22 revealed there was no documentation that Resident #15 oxygen saturations was 90 % or less. Record review of Resident #15 MAR for August 2022 revealed there was no section in the MAR for oxygen monitoring. Observation on 08/09/22 MA A said the oxygen was set at three liters on the concentrator. She said she does not know how many liters the resident should be on. MA A said she was a medication aide and does not change the setting on the concentrator. She said the nurse was the only person who could change the setting. Interview on 08/09/22 at 11:19 a.m., Resident #15 said she does not know how many liters of oxygen she should be on. Additionally, Resident # 15 said she does not know when or how to change the oxygen setting. Resident #15 said she could not tell the difference from 2 to 3 L. Observation and interview on 08/09/22 at 12:11 p.m. RN B said the oxygen setting on Resident #15's concentrator was on 3L. RN B said the aide checked Resident #15 oxygen saturation. She said she makes rounds every two hours and makes rounds when she comes in at 6:45 a.m., but she did not check the O2 concentrator setting today. RN B said she had no reason for not checking the setting on the concentrator. RN B said the resident was on oxygen at 2 to 3 liters, and it was continuous. She looked at her MAR and stated the resident's order was for 2 liters PRN (as needed). She said the resident could have adverse outcomes such as distress and do not feel like breathing, or it could affect her lungs. she said oxygen is considered medication and could not be changed without a doctor's order. She said she did not change the setting, which meant it was at that setting when she took over the shift. She said she was trained on how to monitor oxygen. She said the aide checked her oxygen saturation this morning when she checked her other vital signs, and it was at 96% and she had oxygen at the time. Interview on 08/09/22 at 12:23 p.m., CNA A said the aides checked Resident #15 and other residents 02 while checking vital. During training, they are told to take the O2 sat and not to touch the concentrator. She said she gives the vital signs to the medication aide and nurse as soon as she finished taking the vitals and her oxygen saturation was 96% and she had oxygen on. Interview on 08/10/22 at 2:43 p.m., Interim ADON said the CNAs does check O2 when they check all residents' vital signs and give it to the nurse. She stated the nurse checked the resident's oxygen saturation and setting on the concentrator Q shift (each shift). She said the nurse was not following the doctor by giving Resident #15 oxygen when it is above the perimeter and should not increase the setting on the concentrator. She said the nurse needs a doctor's order to change Resident #15's 02 setting on the concentrator. She stated the DON monitors nurses to ensure they follow the doctor's order for oxygen. She said if the resident oxygen was changed, either increased or decreased, it should reflect on the resident's care plan. She said it was not indicated on the MAR because her oxygen saturation had not been 90% or less. Interview and record review on 08/11/22 at 8:10 a.m. LVN B said he worked with Resident #15 on Sunday (08/07/22) and Monday (08/08/22) night. He did not change her oxygen setting from 2 liters to 3 liters, and Resident #15 could not have changed it because it was behind her bed and could not reach the concentrator. LVN B said the resident oxygen order was for 2 liters continuous, and the aides took the resident oxygen saturation, including Resident #15, and documented it on the vital section in PCC. LVN B reviewed Resident #15's physician and stated it should have been PRN (as needed) at 2 liters if her oxygen saturation was less than 90%. He said oxygen is considered a medication and could not be changed without a doctor's order. He further stated Resident #15 always wants the oxygen on all the time, but he had not notified the doctor or documented Resident #15 wants to wear her oxygen on all the time. He said he made rounds once to check the resident oxygen concentrator setting during his shift. He said administrating oxygen to Resident #15 incorrectly could affect the resident's lungs negatively. He said he had a skill check-off, which included oxygen administration, and the DON monitors the nurses to ensure they are administering oxygen as ordered. Interview on 08/11/22 at 11:00 a.m.; DON said the nurses checked 02 SATs for the resident on oxygen and documented it on the MAR (medication administration record). She said the nurses should follow the doctor's order while administering O2. She said oxygen is considered a medication. The nurses should get an order before changing the setting on the concentrator and transcribe the order to PCC (point click care), which should also reflect on the care plan. She said Resident #15 oxygen stated PRN; then it should be administered PRN after checking the O2 sat. If the resident always wants to keep it on, the nurses must notify the doctor and follow the doctor's instructions. If the oxygen was increased, the nurse should document why it was increased, and the doctor was notified. DON said administering O2 was more than needed; it could harm the resident lungs. She said she is responsible for checking on the nurses to make sure they provide O2 per physician order. She said the nurses had skills checked off, including oxygen administration. Record review of the facility medication administration dated 3/2004 read in part . to assure the safety and wellness of the resident's while they live in the healthcare center . Record review of the facility oxygen administration dated 11/01/17 read in part . policy interpretation and implementation #1 . verify physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13%, based on 4 errors out of 29 opportunities, which involved 2 (Resident #13 and #5) of 3 residents reviewed for medication errors. -LVN B administered the wrong dose of [MEDICATION(S)] nasal spray [Calcitonin to treat osteoporosis] , administered an expired [MEDICATION(S)] 10 mg tablet [allergy medication], and omitted (did not administer) [MEDICATION(S)] Adult 50+ vitamin for Resident #13. -LVN B omitted Resident #5's allergy medication, [MEDICATION(S)] 10 mg. These failures could affect residents receiving medication and place them at risk of inadequate therapeutic outcomes and a decline in health. Findings included: Resident #13 Record review of Resident #13's face sheet revealed a 92- year -old male admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating his cognition was intact. He required extensive assistance of 1 staff for bed mobility, transfers, dressing, and toilet use. Record review of Resident #13's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 10 mg give 1 tablet by mouth one time a day for allergies, order date 5/12/21. [MEDICATION(S)] (Calcitonin (salmon)) solution 200 unit/act 1 spray alternating nostrils one time a day for calcium reducer, order date 5/12/21. [MEDICATION(S)] Adult 50+ capsule (multiple vitamins-minerals) give 2 capsules by mouth one time a day for eye disease prevention, order date 5/13/21. Observation and interview on 6/2/21 at 8:20 a.m., LVN B prepared the following medications for Resident #13: [MEDICATION(S)] nasal solution, [MEDICATION(S)] 10 mg (expired 5/2021), [MEDICATION(S)] inhaler, [MEDICATION(S)] 40 mg, Vitamin C 1000 mg, [MEDICATION(S)] 25 mg, multivitamin with mineral 1 tablet, [MEDICATION(S)] 20 mEq, Senna-S 100 mg - 17.2 mg, Vitamin B-12 500 mcg, Vitamin D 2000 IU, [MEDICATION(S)] 50 mg, and Oyster shell Calcium 500 mg with vitamin D 200 IU. LVN B did not prepare Resident #13's [MEDICATION(S)] Adult 50+ vitamin for eye disease prevention and said it was ordered from the pharmacy on 5/13/21. LVN B entered the room and administered Resident #13's morning medication. She administered 1 spray of Calcitonin (salmon) solution in both nostrils instead of one spray in alternating nostrils according to Physician orders. Record review of Resident #13's MAR for June 2021 revealed a 9 was documented for [MEDICATION(S)] Adult 50+ capsule on 6/2/21 for the 9:00 a.m. administration. A 9 indicated Other/see progress notes. Record review of Resident #13's Progress Note dated 6/2/21 at 8:29 a.m. written by LVN B read in part, .[MEDICATION(S)] Adult 50+ capsule . medication on order Interview on 6/2/21 at 9:00 a.m., LVN B said she administered one spray of Calcitonin in both of Resident #13's nostrils because she thought alternating nostrils meant one spray in each nostril. She said she was trained to verify the resident's name, dosage, and expiration date prior to administration. She said she did not check the expiration date on the [MEDICATION(S)] because the facility's Consultant Pharmacist was recently in the building and checked the medication cart for expired medications. She said the [MEDICATION(S)] was expired and she was not supposed to administer expired medication to residents because the potency is decreased. LVN B said she did not follow up with the pharmacy on the status of Resident #13's [MEDICATION(S)] but would ask LVN A to clarify the medication. Observation on 6/2/21 at 9:08 a.m., LVN A told LVN B that alternating nostrils meant to administer one spray in one nostril on one day and administer one spray in the other nostril the next day. Interview on 6/2/21 at 11:58 a.m., Resident #13 said nursing staff usually administered one spray in one nostril on one day and one spray in the other nostril the next day. Interview on 6/3/21 at 9:40 a.m., LVN B said she did not return to administer [MEDICATION(S)] to Resident #13 yesterday (6/2/21). Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating her cognition was intact. She required limited assistance from one staff for dressing, toilet use, and personal hygiene. Record review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 6/2/21 at 9:41 a.m., LVN B prepared and administered the following morning medications to Resident #5: [MEDICATION(S)] 10 mg, Dok 100 mg, ASA 81 mg, [MEDICATION(S)] 50 mg, [MEDICATION(S)] 12.5 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] Adult, Acetaminophen 650 mg, Refresh tears, [MEDICATION(S)] 12.5 mg, Losartan 100 mg, and [MEDICATION(S)] 0.25 mg. LVN B did not prepare and administer Resident #5's [MEDICATION(S)] and said the house stock was expired. She said she would check the house supply for another bottle of [MEDICATION(S)]. Record review of Resident #5's Medication Administration Record for June 2021 revealed there was a 5 documented for [MEDICATION(S)] 10 mg on 6/2/21 for the 8:00 a.m. administration. An entry of 5 indicated Hold/see progress notes. Record review of Resident #5's Progress Note dated 6/2/21 at 9:51 a.m. read in part, .[MEDICATION(S)] 10 mg . pending delivery . Interview on 6/3/21 at 9:46 a.m., LVN B said she did not return to administer the [MEDICATION(S)] 10 mg to Resident #5 yesterday because the house stock was expired. She said she did not realize the resident had her own supply of [MEDICATION(S)] on the cart and got confused by the expired house stock. Interview on 6/3/21 at 10:15 a.m., the DON said she expected nurses to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said nurses should verify the medication is not expired. She said the day nurse was responsible for removing expired medications prior to the Consultant Pharmacist's visit. She said the Consultant Pharmacist also checked for expired medications and placed them in the designated locked cabinet in the medication room. She said she expected prescribed medications to be available and reordered when low (less than a 7-day supply remaining) to ensure it was on hand. She said nurses could also utilize the emergency medication kit. She said the nurse should follow up with pharmacy to check the status on an unavailable medication. She said if the facility had not received the medication in 3 days, the nurse should call the doctor, so the resident won't miss their medication. Record review of the facility's Policy for Administering Medications dated 1/19/16 read in part, .Policy Statement: medications shall be administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation: .6. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method of administration before giving the medication .7. Check the expiration date on the medication label.

Based on observation, interview, and record review, the facility failed to ensure nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 of 1 residents (Resident #6) provided care by 1 of 1 staff (CNA A) reviewed for proficiency of nurse aides. -The facility failed to ensure CNA A was proficient in providing incontinent care. CNA A failed to completely clean Resident #6 during incontinent care. This failure could affect residents who were incontinent of bowel and/or bladder, and place them at risk of cross contamination, infection, pain, and hospitalization . Findings include: Record review of the admission sheet for Resident #6 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's quarterly MDS assessment dated [DATE] revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. She was totally dependent on two persons physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #6's care plan initiated 12/17/2018 and revised on 2/5/21 revealed the following: Focus: Resident has bowel and bladder incontinence. She is physically unable to be toileted because of physical status. Goal: Reduce the risk of alteration in skin integrity r/t incontinent episodes. Interventions: Check her frequently and provide peri care and brief changes as needed. Provide pericare after each incontinent episode. Observation on 6/2/21 at 2:35 p.m., CNA A and LVN A provided Resident #6 with incontinence care. CNA A removed Resident #6's brief and tucked it under the resident's buttocks. CNA A did not spread Resident #6's labia to thoroughly clean the area and the resident's urinary meatus. CNA A assisted Resident #6 to turn onto her left side in order to clean her buttocks. CNA A completed perineal care and with the same soiled gloves on, touched the Resident's clean gown and brief. CNA A then removed her gloves, picked up trash and soiled linens and left the room without washing or sanitizing her hands. This Surveyor followed CNA A. CNA A went to the nurse's station across from Resident #6's room. CNA A opened the top drawer and grabbed a key and went to the room labeled soiled utility biohazard waste. In an interview on 6/2/21 at 2:49 p.m., with LVN A and CNA A, CNA A said she had been working at the facility for the past six months as a full-time employee. She said she had received training from other CNAs on the floor upon hire. CNA A confirmed she did not spread Resident #6's labia and clean the resident's meatus during incontinent care. She said she should have washed her hands or used hand sanitize before leaving the room. She said the failure placed the resident at risk for infections. She said she had been in-serviced on hand washing/ infection control recently. She could not recall the exact date. She said she did not recall having to do the CNA competency check for incontinent care with the DON. In an interview on 6/3/21 at 10:03 a.m., with the DON, she said she expected staff to make sure they were providing care properly to prevent UTI. She said they were in process of transitioning to new staffing coordinator. She is a CNA. They were planning to actually pull CNAs off the floor for a week and provide hands on training. She said CNAs were provided training upon hire. It was part of the orientation check list. CNAs also do Competency assessment booklet training upon hire that included topics such as infection control. She said nurses did spot checks and supervised CNAs. She said she had not started doing competency check offs for incontinent care with CNAs but would start soon. She said she would provide a blank competency check off for Surveyor to review. In an interview on 6/3/21 at 12:29 p.m., with the DON, she said she spoke to CNA A and CNA A told her that she washed her hands in the soiled utility room after throwing trash and soiled linens. This Surveyor explained to the DON that CNA A provided incontinent care, without washing and sanitizing hands went to the nurse's station, opened the top drawer, grabbed the key and went to soiled utility. The DON said she understood as this placed a risk for cross contamination and infection. Record review of facility's Competency Skills Sheet Provides Perineal Care (Peri-care) For Female (dated 2/2019) read in part: .8. Washes genital area, moving from front to back, while using a clean area of the washcloth for each stroke. 19. Removes and disposes of gloves (without contaminating self) into waste container and washes hands . Record review of facility's Resident Incontinent Care policy dated 03/01/2018 read in part: .Perineal care for a female resident: d. Wash labia majora. Use non-dominant hand to gently retract labia from thigh. Use dominate hand to wash carefully in skinfolds. Wipe in direction from perineum to rectum (front to back). Repeat on opposite side using separate section of washcloth. Rinse and dry area thoroughly. e. Gently separate labia with non-dominate hand to expose urethral meatus and vaginal orifice. With dominate hand wash downward from pubic area toward rectum in one smooth stoke. Use separate section of cloth for each stroke. Clean thoroughly over labia minora, clitoris, and vaginal orifice .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs for 1 (Resident #13) of 3 residents reviewed for pharmacy services. The facility failed to ensure Resident #13's [MEDICATION(S)] patch [for pain management] was removed per Physician's order. This failure could affect residents with pain and place them at risk of aderse clinical outcomes due to a medicated patch not being removed which could result in skin irritation and of receiving an overdose of medication and hospitalization . Findings include: Record review of Resident #13's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included pain, respiratory failure, pneumonia, unspecified protein-calorie malnutrition, [CONDITION(S)], and heart failure. Record review of Resident #13's admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating his cognition was intact. He required extensive assistance of 1 staff for bed mobility, transfers, dressing, and toilet use. Record review of Resident #13's Care Plan dated 5/28/21 read in part, .(Resident #13) has chronic pain r/t previous fracture of his back . Interventions: Administer [MEDICATION(S)] as per orders . Record review of Resident #13's Medication Review Report for June 2021 revealed an order for [MEDICATION(S)] Patch 5% apply to back topically in the morning for pain and remove per schedule . supply directions: apply 1 patch topically every morning (remove after 12 hours), order date 5/25/21. Record review of Resident #13's Medication Administration Record (MAR) for June 2021 revealed [MEDICATION(S)] Patch 5% was to be applied at 9:00 a.m. and removed at 9:00 p.m. There was a check mark documented for [MEDICATION(S)] on 6/1/21 at 9:00 p.m. with LVN C's initials. The check mark indicated it was administered/removed. Observation on 6/2/21 at 10:33 a.m., LVN B prepared Resident #13's [MEDICATION(S)] patch for administration. LVN B pulled Resident #13's shirt up and there was patch present on the middle of his back. LVN B removed the patch and showed it to the Surveyor. The patch read [MEDICATION(S)] patch 5% and was dated 6/1/21 with LVN A's initials. LVN B discarded the old [MEDICATION(S)] patch and applied the new [MEDICATION(S)] patch just below where the previous patch was. Interview on 6/2/21 at 10:38 a.m., LVN B said the [MEDICATION(S)] patch usually stayed on for 12 hours. She said the night shift nurse must not have removed the patch last night (6/1/21). Interview on 6/2/21 at 3:34 p.m., LVN C said she did not see the [MEDICATION(S)] patch on Resident #13's back or anywhere else last night (6/1/21). She said she documented that the patch was removed on the MAR but made a mistake because she was supposed to verify the patch was removed before checking it off as removed. Interview on 6/3/21 at 10:15 a.m., the DON said she expected nurses to follow Physician orders. She said the [MEDICATION(S)] patch was supposed to be on for 12 hours and off for 12 hours. She said LVN C falsely documented that the patch was removed because it was not removed. She said on 6/2/21 (at 10:33 a.m.) LVN B should have contacted the physician before applying the new patch to determine if it should have been held or applied since the previous patch was still in place. She said the NP was later notified and instructed the nurse to remove the one that was placed and restart it today (6/3/21). Record review of the facility's Policy for Administering Medications dated 1/19/16 read in part, .Policy Statement: medications shall be administered in a safe and timely manner, and as prescribed .

Based on observation, interview, and record review, the facility failed to ensure the services provided by the facility meet professional standards of quality for 1 of 5 residents (CR #1) reviewed for professional standards. -The facility failed to ensure CR #1 did not have a delay in receiving emergency treatment. CR #1 died . -The facility failed to ensure staff immediately consulted with CR #1's Physician when the resident had a change in condition. These failures could place all residents with dysphagia and respiratory care needs at risk of a delay in treatment during an emergency and could result in injury, hospitaliation and death. Findings include: Record review of CR #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 04 out of 15 indicating severe cognitive impairment. He required two-person assistance with bed mobility, transfer, dressing and toilet use. He required one-person assistance with locomotion on unit, eating and personal hygiene. He was coded as always incontinent for urinary and bowel. He was coded as having shortness of breath. Section K: Swallowing/Nutritional Status was coded as C. Coughing or choking during meals or when swallowing medications. Record review of CR #1's care plan initiated on [DATE] and revised on [DATE] revealed the following: -Focus: CR #1 admitted to hospice with dx of Alzheimer's with comorbidities of [MEDICAL CONDITION] and dysphagia. Goal: Will maintain CR #1's quality of life through integrated care provided by Hospice and nursing staff. Interventions: Family/ Hospice/ IDT to coordinate plan of care and reach common goals for CR #1; Monitor for any changes in condition and notify hospice; No labs, Diagnostic testing or hospitalization ; Provide comfort care; and Refer to chart for hospice plan of care. -Focus: Resident has an ADL self-care performance deficit r/t Activity Intolerance, Alzheimer's Date initiated: [DATE] Goal: Reduce the risk of a decline in current participation. Date initiated [DATE] Intervention: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Requires total assistance with 2 staff members for his showers Date Initiated: [DATE]. Bed mobility: Resident requires moderate assistance by 1 staff to turn and reposition in bed frequently and as necessary. Date Initiated: [DATE]. Dressing: Resident is totally dependent on 1 staff for dressing. Date Initiated: [DATE]. EATING: Resident is able to feed self with 1:1 supervision to monitor pace/rate. Diet is regular-mechanical soft consistency with thin liquids. Date Initiated: [DATE]. Personal Hygiene/Oral Care: Resident requires moderate assistance of 1 staff member for his hygiene. Date Initiated: [DATE]. Transfer: Resident requires 2-person assist with Hoyer lift transfers. Date initiated: [DATE]. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of CR #1's DNR, Do Not Resuscitate, Order revealed it was dated [DATE]. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician orders [REDACTED].@ 2lpm via nc as needed for spo2 < 92% as needed. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's progress notes written by RN on [DATE] read in part, 6 pm, sitter reported that the resident had been coughing during meals since this morning, resident has a communication deficit due to dementia, continues on aspiration precaution, HOB was kept on 90% (sic) during eating, VSS, no fever, temp 96.7 F, safety was maintained, call bell within reach, bed in low position, all needs attended. Record review of CR #1's progress notes written by LVN A on [DATE] read, Resident was [MEDICAL CONDITION] a 114 pulse, rechecked the pulse and it was 58. His O2 saturation was 90% on room air, prn duo-nebulizer treatment was given. His oxygen increased to 97% on room air. Continued monitoring. No pain, a-febrile, skin warm to touch, no sob, no signs/symptoms of COVID. Record review of CR #1's progress note written by LVN D on [DATE] read in part, .Suction patient PRN DX congestion as needed. PRN Administration was: Effective. No coughing at this time. Will continue to monitor . Record review of CR #1's progress note written by RN on [DATE] read in part, Resident remains alert and responsive to all stimuli, not in distress, not able to make needs known, noted coughing this shift during meds administration, aspiration precaution maintained, HOB was kept elevated, dependent to all ADL's., incontinent care provided, noted staring at the ceiling, smiling, VSS, no SOB noted, afebrile, temperature 96.5 f, incontinent care provided, will continue to monitor. Record review of CR #1's Orders-Administration note dated [DATE] written by LVN D revealed the following: Suction patient PRN DX congestion as needed. Resident coughing, unable to clear throat, suctioned at this time. Tolerated well. Oxygen saturation 95% to room air. HOB up 90-degrees. Record review of CR #1's progress note written by LVN D on [DATE] read in part, RN with Hospice here to evaluate resident. States 'resident may be transitioning.' Resident stable at this time, no productive cough at this time b/p ,[DATE], respirations 20, temperature 97.6, oxygen saturation 92% with oxygen at 2L/min via NC. New order obtained, [MEDICATION NAME] Tablet 0.125 mg give 1 tab SL for increased secretions. (Staff Name) will be back to evaluate in 2 days and if any further decline he will coordinate with the family for a visit. Record review of CR #1's Health Status note written by RN on [DATE] read in part, .625 pm, called by the sitter to check on the resident because he's unable to respond verbally and choking on the sandwich that he's eating. In the room resident was on his bed on upright 90-degree position, unresponsive, not breathing and cyanotic, he was placed immediately on side lying position and was suctioned and was able to take out some of the liquified food that was stuck on his throat, O2 on @ ,[DATE] LPM via NC. Resident was trying to cough out but unable to do so, BP ,[DATE] HR 126 respiratory 0, still cyanotic (blue due to lack of oxygen), suctioning continued until vital signs was unappreciated, unresponsive, no breathing, no heart sound, pupil- dilated and the time was noted 642 pm. Hospice Care was made aware, RP and MD. Record review of CR #1's progress notes for [DATE] revealed no documentation of RN or other staff making notification of change in condition to Hospice or Attending Physician during the change of condition for CR #1. In an interview on [DATE] at 4:15 pm with RN, he said he worked at the facility for almost 3 years. He said he was familiar with CR #1. He said the resident passed (died ). He said CR #1 had been at the facility since he had been working at the facility, so he knew him very well. He said on [DATE] he was charting for medications and the CNA for CR #1 was yelling and was calling his name to respond. He said he went over to CR #1's room and he saw the resident with both hands on his neck. He said he assumed he was choking. He said he asked the CNA if he was eating something. He said the CNA said the resident was eating a sandwich. He said he opened CR #1's mouth to assess and he saw a thick mucus. He said he did a finger sweep to clear his mouth and he retrieved some sticky mucous substance from his mouth and throat. He said it did not look like liquified bread. He said, It just looked thick like mucus. He said, I didn't see the sandwich. He said he lowered the bed to put the resident in a supine (lying flat face up) position. He said he gave the resident abdominal thrusts and nothing was coming out. He said he just used his judgement and told CNA to place the resident immediately on his side to drain the mucus. He said some secretions drained when he placed the resident on his side. He said he used the suction machine by the resident side table. He said he started to suction his mouth. He said there was some secretions post suctioning. He said the resident tried to gasp for air but, he was unable to continue to breathe on his own. He said he told the CNA to get CR #1's vitals while he was suctioning. He said at that point, the resident's blood pressure was low. He said he could not recall exactly how low. He said his heart was elevated. He said the resident was turning blue due to lack of oxygen. He said he continued suctioning because the resident was DNR, so he was unable to give him artificial ventilation. He said he kept suctioning because he knew they could not call 911 or use CPR because of the resident's DNR status. He said he wished he could have but, he knew that he needed to respect the resident's choice. He said it was past dinner time around 6:20 pm. He said the resident most likely got the sandwich from the kitchen but, he was not sure because he did not see it. He said the resident was on a restrictive diet. He said the resident's diet called for mechanical soft. He said the CNA knew the resident was on a mechanical diet. He said the CNA stayed to assist with post mortem care. He said he was the one that notified the family. He said he notified hospice, MD and the DON. He said he did not call the physician during the choking episode. In an interview on [DATE] at 4:38 pm with CNA, she said she worked for the department where sitters were assigned. She said she was a certified CNA. She said she went inside the restroom and when she came out, CR #1 was choking. She said the resident had mucus and foam coming out of his mouth. She said she hollered for the RN. She said he arrived and told her to turn the resident on his side, so he could use the suction machine. She said the RN tried to use the suction machine but, it was not plugged in. She said the RN was sitting on the side trying to get the suction machine to work, but it was not working because it was unplugged so she had to tell him that it was not plugged. She said she tried to plug it in. She said she did her best to help the RN get the suction machine going but she did not know how to use the facility's equipment. She said she spent time trying to plug the suction machine and the tubing. She said after she got the suction machine plugged in, the RN tried to suction CR #1's mouth but, it was too late, the resident had already passed. She said the RN pronounced him dead. She said she fed CR #1 a sandwich that she ordered from the facility's kitchen. She said she cut it up into bite size pieces for the resident. She said she fed him the sandwich about 5:10 pm on that day. She said the incident occurred about 5:45 pm because the resident passed around 6:45 pm. She said she worked with CR #1 for 2 ½ years. She said she worked almost every day. She said the facility was saying that he choked on the sandwich but, he choked on mucous. She said he would have episodes where the resident would have increased amount of mucus coming out of his mouth and the nursing staff would suction it out. She said it happened frequently. She said the resident used to spit it out on the floor and she always gave him tissue. She said she did not know why the facility was saying the resident choked on a sandwich because she had already fed him and gave him water behind the sandwich and he was doing fine. She said she was suspended because the facility told her they had to investigate the matter. In an interview on [DATE] at 5:13 pm with DON, she said the CNA's role was to know equipment. She said it was the nurse's responsibility to ensure the equipment, like the suctioning machines, were in good repair and plugged in, so they were ready to go. She said she was not aware the suctioning machine was not plugged in. In a follow up interview on [DATE] at 5:20 pm with RN, he said the suction machine was not plugged in because there were only two outlets; one had the nebulizer plugged in and the other had the oxygen concentrator plugged in. He said he forgot to tell this Surveyor he used oxygen on the resident because it was right there next to his bedside. He said he was the one that unplugged the oxygen, so he could plug the suction machine. He could not recall if the CNA helped him plug in the suctioning machine because it happened so quickly. In an interview on [DATE] at 12:19 pm with Executive Chef, he said he had worked for the facility for 1 year and 3 months. He said he was not at the facility at the time the sandwich was ordered. He said the next day he spoke with the Dietician. He said she told him what had happened with the sandwich. She said a resident choked the night before, (CR #1). He said the sandwich was not ordered as mechanical chop. He said that's why the sandwich was not mechanically chop. He said kitchen staff were in-serviced on the same day he found out. He said the facility changed the process on mechanical chop orders. He said the different diets were now color coded. He said staff had to keep their mask on at all times. He said staff also had to wear masks properly. He said properly was to cover nose, mouth and chin. He said staff always gave him excuses about the kitchen being hot but, he was trying to get them out of that mindset. In an interview on [DATE] at 12:51 pm with DON, she said the suctioning machine should have been plugged in and ready to go especially with CR #1 having a history of mucus in his throat. She said she did not feel the suction machine being unplugged and not ready to go contributed to CR #1's passing because the RN did all he could to preserve the resident's life. She said the RN did abdominal thrusts and gave him oxygen prior to suctioning. She said the resident was on hospice and he had been exhibiting a decline in respiratory functioning. She said he was having episodes where he had mucus buildup in his throat that had to be constantly suctioned. He said the RN was experienced with working with CR #1 so most of the time, the RN did not have to use the suction machine. In an interview on [DATE] at 1:10 pm with the Administrator, he said he questioned if the suction machine not being plugged in was the cause of death. He said he never got a clear answer. In a telephone interview on [DATE] at 1:42 pm with Hospice RN, he said CR #1 was one of his patients. He said he had not seen the death certificate because it was a duty of the funeral home. He said what happened in the hospice process was that there were two physician medical opinions and both certified a patient as hospice appropriate. He said they reviewed the case and selected the [DIAGNOSES REDACTED]. He said CR #1 was at end of life [MEDICAL CONDITION] with [MEDICAL CONDITION]. He said CR #1 was on PRN oxygen. He said he also had severe dysphagia (difficulty swallowing). He said prior to hospice and while on hospice CR #1 was exhibiting several episodes of severe dysphagia and choking but, it was usually handled appropriately with hospice interventions. He said his interventions were suctioning and PRN oxygen. He said CR #1 was also receiving scheduled [MEDICATION NAME]. He said what probably happened was that he had a choking episode and that was to be expected. He said the resident was declining already. He said, it was super sad. He said he did not believe that the delay in using the suction machine was the cause of death because the resident was already declining, and it was expected. In an interview on [DATE] at 9:38 am with LVN C, she said she worked 7 am to 3 pm. She said she had worked at the facility for 3 weeks. She said she was not familiar with CR #1. She said she was aware that he passed. She said the nurses were talking about it and that was how she became aware. She said the only thing she knew was that he had a sandwich and he choked on the sandwich. She said her understanding of DNR orders were to not resuscitate. She said DNR meant no life saving measures. She said she would probably use abdominal thrusts and back blows if she needed. She said she would not use CPR on a resident with DNR orders. She said her understanding of full code was CPR, oxygen and anything else that could preserve the resident's life. She said if a resident had a DNR on his medical record and he was choking, her approach would be to try to clear his airway to get the obstruction out. She said she would use oxygen. She said she would suction if oxygen did not work. She said if the resident had a history of [REDACTED]. She said she needed a physician's orders [REDACTED]. She said she would call 911 only if instructed by the physician. In a follow-up interview on [DATE] at 9:53 am with CNA, she said CR #1 finished eating the sandwich about 5:30 pm or 5:45 pm or close to 6:00 pm because he ate slow. She said CR #1 ate the whole sandwich. She said the sandwich did not have any ends on it. She said it was a turkey sandwich with cheese. In an interview on [DATE] at 9:57 am with ADON, she said her understanding of DNR was not to perform any CPR, cardiac pacing and AED. She said nursing staff was not prohibited from performing, [MEDICATION NAME], any type of suctioning or any other comfort measures. She said her understanding of full code was to use any kind of life sustaining measures, i.e. AED, CPR, airway management, call 911 and continue CPR until emergency paramedics arrived at the facility. She said her approach to CR #1's situation would be to observe if there was something physically lodged. Perform the [MEDICATION NAME], if unsuccessful, turn him on his side, and then try suctioning. She said since CR #1 was a DNR, her next step would be to call hospice. She said she was uncertain what to do when a resident was DNR and on hospice, so she would call hospice to get further instructions. She said if the resident had a history of [REDACTED]. She said physician orders [REDACTED]. She said, most times, the suctioning orders are PRN. She said she was told CR #1 had aspirated. She said she assumed it was related to the mucus episodes CR #1 kept experiencing. She said she went into the chart to read what the RN had documented. She said the RN's story and the CNA's were inconsistent and not adding up. She said she had not been involved in the facility's investigation. She said if the sandwich did not have the edges, the bread gets kind of liquified. She said if CR #1 finished the sandwich around 6 pm, she did not believe the sandwich could still be lodged in CR #1's throat. She said if CR #1 had [MEDICAL CONDITION] reflux there was a possibility that the sandwich could come back up. She said CR #1 had already had a lot of episodes where he would decline, become lethargic, loss of appetite, confusion, and mucus build up in his mouth and perk right up the next day. In an interview on [DATE] at 10:42 am with Prep Cook, he said he had been with the facility about one year. He said the staff from the healthcare side come to the kitchen to ask for sandwiches. He said they gave them specifics for how they wanted the sandwich made, i.e, bread with no crust or with no condiments or choking hazards. He said he made the sandwich for CR #1. He could not recall what type of meat. He said it could have been turkey. He said some staff were very specific when placing orders and some just placed the ticket on the service counter. He said on the day when CR #1 passed a staff person from healthcare approached him with an order for [REDACTED]. He said he did not remember if he cut the crust off. He said if the ticket said to cut the crust, then he cut it. He said he would only chop sandwiches upon request. He said the next day he found out that a resident passed from choking on a sandwich because the supervisor in charge of the servers along with the Executive Chef got cooks and servers in a huddle to let them know that whoever made the sandwiches last night caused the resident to choke on the sandwich. He said he defended himself because he said there were no instructions on the meal ticket that called for the sandwich to be mechanically chopped. He said an in-service training occurred next day. He said the facility's kitchen has a color-coded system now to identify mechanical chop, puree and ground. He said because before they would just go by whatever the healthcare staff told them to do. He said the pantry did not have any system like the hot food area had. He said they had a list of the residents with their diets. In an interview on [DATE] at 2:27 pm with Dietary Wait Staff, she said she had worked at the facility for two years. She said she put everyone's menu on serving line and for CR #1, staff ordered a turkey and cheese sandwich with the ends cut off. She said staff would order turkey and cheese sandwich a lot because that's what CR #1 liked. She said if they gave him his mechanical chop he would not eat it. She said he would just leave it there. She said the dishes got picked up about 6 pm. She said dinner usually started about 5:15 pm. She said around 5:45 pm they would bring CR #1's tray back to the kitchen and staff would say he didn't eat anything. She said on [DATE], the day the resident passed, the CNA forgot to tell the kitchen that the turkey and cheese sandwich order was for CR #1 (who was on mechanical chop). She said she delivered the sandwich to resident's room. She said she came back to work the next day and other staff that didn't work the evening before were saying CR #1 choked on a sandwich. She said her supervisor had a meeting with the kitchen staff to tell them if someone was on mechanical chop and they were going to order sandwiches, they had to be mechanically chopped. She said her supervisor developed a color-coded system to identify mechanical chop, puree and ground moving forward. Telephone interview on [DATE] at 12:31 pm with Physician, she said the facility notified her of CR #1's incident after he passed. She said they told her he choked on a sandwich. She said they told her they did everything they could for the resident while respecting his DNR status. She said she was told it happened so fast so there were no other interventions that they could have done while respecting his wishes. Observation on [DATE] at 1:00 pm revealed CR #1's past room had 1 outlet behind his end table located to the left as you entered the room. It had two plugs. There was another outlet behind the bed. It had two plugs. The bed was plugged into one plug. In an interview on [DATE] at 2:23 pm with DON, she said if a resident had signs of an obstructed airway or had a need for suctioning, the staff was expected to do the following: first, staff needed to make sure there was an order in place. She said if there was a suction machine in the room, there had to be an order. She said nurses would do a resident assessment and would suction as needed/accordingly. She said the facility did not have any residents with continuous suctioning orders. She said any resident with orders for suctioning should have the suctioning machine available for immediate use. She said when nurses conducted their rounds and assessed their resident's, O2 saturations were checked, they should be checking that all other emergency equipment was ready to go. She said if residents were on oxygen, they paid closer attention for the need to suction. She said O2 saturations gave nurses an idea of resident's condition. She said if O2 saturation dropped, the nurses would look into why. She said, the CNA's did vital signs at every shift. She said CNA's reported any change of condition to nurses. She said the nurses were responsible to ensure that machines or equipment used for respiratory care were properly working, maintained, and cleaned with a disinfectant. She said if the resident had a 24-hour CNA they too were responsible to ensure machines or equipment used for suctioning was plugged in, working and ready to go. She said CNA's sometimes used the electrical outlets for their personal use i.e. plug in cell phones. She said she had to constantly check on them to ensure they were not doing it. She said sometimes, they unplugged resident's equipment to charge their cell phones. She said the charge nurses were responsible to ensuring supervision of residents. She said the charge nurses gave direction to CNA's. She said, in my own opinion, I believed the resident had already passed at the time the CNA called for help. She said she could not explain the inconsistencies with the narratives provided by the RN and CNA because they were conflicting. She said the event occurred toward the end of the week and she did not find out what kind of sandwich until Monday. She said it was reported that the resident ate sandwiches every night. She said the resident could have had a sandwich just not turkey and cheese. She said the CNA gave the resident whatever he wanted. She said the CNA never told her she cut the sandwich up for the resident. Record review of the facility's policy titled Dysphagia Diets dated 2013 read in part . Procedure: 4. Nursing staff will notify the food service manager of needed consistency changes using the dietary order form. 7. Care will be taken to serve the foods and fluids as ordered on the consistency-altered diet or fluids. Note: Do not allow food consistency changes without a physician's orders [REDACTED]. Record review of facility's policy titled: Emergency Procedure for Choking revised ,[DATE] read in part . Policy Statement: Trained staff will assist the resident who is choking by attempting to expel the foreign body form the airway. Conscious Resident - Standing or Sitting. 1. Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. 2. Ask the resident to call or speak if at all possible to determine if his or her airway is obstructed. 3. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. 4. Call for help but stay with the resident. 5. Quickly assure the resident that you are going to stay and assist him or her. 6. If the resident cannot cough, only then should abdominal trust be performed as follows; a. Stand behind the resident. b. Wrap your arms around the resident's waist. c. Make a fist with one hand. d. Place the thumb side of your fist against the resident's upper mid-abdomen, below the rib cage and above the navel. e. Grass your clenched fist with your other hand. f. Press your fist into the resident's upper abdomen with a quick upward thrust. g. Do not squeeze the rib cage. Contain the force of the trust to your hands. h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Unconscious Resident - Lying Down 1. ease the resident as gently as possible to the floor. 2. Call for help if assistance is not already present but do not leave the resident unattended. 3. Position the resident on his or her back with the arms at his or her site. 4. Perform abdominal thrust as follows; a. Facing the resident, kneel down and straddle the resident's upper thighs with your body. b. Place the heel of one hand on the resident's upper mid-abdomen, below the rib cage and above the navel and with fingers pointed towards the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upper thrust. 5. Performed the finger sweep maneuver to check for a foreign body as follows; E. Keep the resident's face up . Record review of the Texas Board of Nursing, website at bon.texas.gov, Rules and Regulations relating to Nurse Education, Licensure, and Practice dated as published [DATE] read in part, . §217.11. Standards of Nursing Practice. The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse ' s license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board ' s rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse ' s current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client ' s status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client ' s status; .(L) Provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served; (M)Institute appropriate nursing interventions that might be required to stabilize a client ' s condition and/or prevent complications; .(Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care; .

Based on observation, interview, and record review, the facility failed to consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention and (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (CR #1) reviewed for notification of changes. - The facility failed to immediately notify and consult with CR #1's physician when the resident choked during an event that lasted approximately 17 minutes to one hour. CR #1 died . This failure placed all residents receiving respiratory care or difficulty swallowing at risk of delayed intervention and of Physician not being consulted to provide timely orders for interventions which could result in delayed treatment, inadequate treatment, hospitalization , or death. Findings Include: Record review of CR #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 04 out of 15 indicating severe cognitive impairment. He required two-person assistance with bed mobility, transfer, dressing and toile use. He required one-person assistance with locomotion on unit, eating and personal hygiene. He was coded as always incontinent for urinary and bowel. He was coded as having shortness of breath. Section K: Swallowing/Nutritional Status was coded as C. Coughing or choking during meals or when swallowing medications. Record review of CR #1's care plan initiated on [DATE] and revised on [DATE] revealed the following: -Focus: CR #1 admitted to hospice with dx of Alzheimer's with comorbidities of [MEDICAL CONDITION] and dysphagia. Goal: Will maintain CR #1's quality of life through integrated care provided by Hospice and nursing staff. Interventions: Family/ Hospice/ IDT to coordinate plan of care and reach common goals for CR #1; Monitor for any changes in condition and notify hospice; No labs, Diagnostic testing or hospitalization ; Provide comfort care; and Refer to chart for hospice plan of care. -Focus: Resident has an ADL self-care performance deficit r/t Activity Intolerance, Alzheimer's Date initiated: [DATE] Goal: Reduce the risk of a decline in current participation. Date initiated [DATE] Intervention: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Requires total assistance with 2 staff members for his showers Date Initiated: [DATE]. Bed mobility: Resident requires moderate assistance by 1 staff to turn and reposition in bed frequently and as necessary. Date Initiated: [DATE]. Dressing: Resident is totally dependent on 1 staff for dressing. Date Initiated: [DATE]. EATING: Resident is able to feed self with 1:1 supervision to monitor pace/rate. Diet is regular-mechanical soft consistency with thin liquids. Date Initiated: [DATE]. Personal Hygiene/Oral Care: Resident requires moderate assistance of 1 staff member for his hygiene. Date Initiated: [DATE]. Transfer: Resident requires 2-person assist with Hoyer lift transfers. Date initiated: [DATE]. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of CR #1's DNR, Do Not Resuscitate, Order revealed it was dated [DATE]. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician orders [REDACTED].@ 2lpm via nc as needed for spo2 < 92% as needed. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's progress notes written by RN on [DATE] read in part, 6 pm, sitter reported that the resident had been coughing during meals since this morning, resident has a communication deficit due to dementia, continues on aspiration precaution, HOB was kept on 90% (sic) during eating, VSS, no fever, temp 96.7 F, safety was maintained, call bell within reach, bed in low position, all needs attended. Record review of CR #1's progress notes written by LVN A on [DATE] read, Resident was [MEDICAL CONDITION] a 114 pulse, rechecked the pulse and it was 58. His O2 saturation was 90% on room air, prn duo-nebulizer treatment was given. His oxygen increased to 97% on room air. Continued monitoring. No pain, a-febrile, skin warm to touch, no sob, no signs/symptoms of COVID. Record review of CR #1's progress note written by LVN D on [DATE] read in part, .Suction patient PRN DX congestion as needed. PRN Administration was: Effective. No coughing at this time. Will continue to monitor . Record review of CR #1's progress note written by RN on [DATE] read in part, Resident remains alert and responsive to all stimuli, not in distress, not able to make needs known, noted coughing this shift during meds administration, aspiration precaution maintained, HOB was kept elevated, dependent to all ADL's., incontinent care provided, noted staring at the ceiling, smiling, VSS, no SOB noted, afebrile, temperature 96.5 f, incontinent care provided, will continue to monitor. Record review of CR #1's Orders-Administration note dated [DATE] written by LVN D revealed the following: Suction patient PRN DX congestion as needed. Resident coughing, unable to clear throat, suctioned at this time. Tolerated well. Oxygen saturation 95% to room air. HOB up 90-degrees. Record review of CR #1's progress note written by LVN D on [DATE] read in part, RN with Hospice here to evaluate resident. States 'resident may be transitioning.' Resident stable at this time, no productive cough at this time b/p ,[DATE], respirations 20, temperature 97.6, oxygen saturation 92% with oxygen at 2L/min via NC. New order obtained, [MEDICATION NAME] Tablet 0.125 mg give 1 tab SL for increased secretions. (Staff Name) will be back to evaluate in 2 days and if any further decline he will coordinate with the family for a visit. Record review of CR #1's Health Status note written by RN on [DATE] read in part, .625 pm, called by the sitter to check on the resident because he's unable to respond verbally and choking on the sandwich that he's eating. In the room resident was on his bed on upright 90-degree position, unresponsive, not breathing and cyanotic, he was placed immediately on side lying position and was suctioned and was able to take out some of the liquified food that was stuck on his throat, O2 on @ ,[DATE] LPM via NC. Resident was trying to cough out but unable to do so, BP ,[DATE] HR 126 respiratory 0, still cyanotic (blue due to lack of oxygen), suctioning continued until vital signs was unappreciated, unresponsive, no breathing, no heart sound, pupil- dilated and the time was noted 642 pm. Hospice Care was made aware, RP and MD. Record review of CR #1's progress notes for [DATE] revealed no documentation of RN or other staff making notification of change in condition to Hospice or Attending Physician during the change of condition for CR #1. In an interview on [DATE] at 4:15 pm with RN, he said he worked at the facility for almost 3 years. He said he was familiar with CR #1. He said the resident passed (died ). He said CR #1 had been at the facility since he had been working at the facility, so he knew him very well. He said on [DATE] he was charting for medications and the CNA for CR #1 was yelling and was calling his name to respond. He said he went over to CR #1's room and he saw the resident with both hands on his neck. He said he assumed he was choking. He said he asked the CNA if he was eating something. He said the CNA said the resident was eating a sandwich. He said he opened CR #1's mouth to assess and he saw a thick mucus. He said he did a finger sweep to clear his mouth and he retrieved some sticky mucous substance from his mouth and throat. He said it did not look like liquified bread. He said, It just looked thick like mucus. He said, I didn't see the sandwich. He said he lowered the bed to put the resident in a supine (lying flat face up) position. He said he gave the resident abdominal thrusts and nothing was coming out. He said he just used his judgement and told CNA to place the resident immediately on his side to drain the mucus. He said some secretions drained when he placed the resident on his side. He said he used the suction machine by the resident side table. He said he started to suction his mouth. He said there was some secretions post suctioning. He said the resident tried to gasp for air but, he was unable to continue to breathe on his own. He said he told the CNA to get CR #1's vitals while he was suctioning. He said at that point, the resident's blood pressure was low. He said he could not recall exactly how low. He said his heart was elevated. He said the resident was turning blue due to lack of oxygen. He said he continued suctioning because the resident was DNR, so he was unable to give him artificial ventilation. He said he kept suctioning because he knew they could not call 911 or use CPR because of the resident's DNR status. He said he wished he could have but, he knew that he needed to respect the resident's choice. He said it was past dinner time around 6:20 pm. He said the resident most likely got the sandwich from the kitchen but, he was not sure because he did not see it. He said the resident was on a restrictive diet. He said the resident's diet called for mechanical soft. He said the CNA knew the resident was on a mechanical diet. He said the CNA stayed to assist with post mortem care. He said he was the one that notified the family. He said he notified hospice, MD and the DON. He said he did not call the physician during the choking episode. In an interview on [DATE] at 4:38 pm with CNA, she said she worked for the department where sitters were assigned. She said she was a certified CNA. She said she went inside the restroom and when she came out, CR #1 was choking. She said the resident had mucus and foam coming out of his mouth. She said she hollered for the RN. She said he arrived and told her to turn the resident on his side, so he could use the suction machine. She said the RN tried to use the suction machine but, it was not plugged in. She said the RN was sitting on the side trying to get the suction machine to work, but it was not working because it was unplugged so she had to tell him that it was not plugged. She said she tried to plug it in. She said she did her best to help the RN get the suction machine going but she did not know how to use the facility's equipment. She said she spent time trying to plug the suction machine and the tubing. She said after she got the suction machine plugged in, the RN tried to suction CR #1's mouth but, it was too late, the resident had already passed. She said the RN pronounced him dead. She said she fed CR #1 a sandwich that she ordered from the facility's kitchen. She said she cut it up into bite size pieces for the resident. She said she fed him the sandwich about 5:10 pm on that day. She said the incident occurred about 5:45 pm because the resident passed around 6:45 pm. She said she worked with CR #1 for 2 ½ years. She said she worked almost every day. She said the facility was saying that he choked on the sandwich but, he choked on mucous. She said he would have episodes where the resident would have increased amount of mucus coming out of his mouth and the nursing staff would suction it out. She said it happened frequently. She said the resident used to spit it out on the floor and she always gave him tissue. She said she did not know why the facility was saying the resident choked on a sandwich because she had already fed him and gave him water behind the sandwich and he was doing fine. She said she was suspended because the facility told her they had to investigate the matter. In an interview on [DATE] at 5:13 pm with DON, she said the CNA's role was to know equipment. She said it was the nurse's responsibility to ensure the equipment, like the suctioning machines, were in good repair and plugged in, so they were ready to go. She said she was not aware the suctioning machine was not plugged in. In a follow up interview on [DATE] at 5:20 pm with RN, he said the suction machine was not plugged in because there were only two outlets; one had the nebulizer plugged in and the other had the oxygen concentrator plugged in. He said he forgot to tell this Surveyor he used oxygen on the resident because it was right there next to his bedside. He said he was the one that unplugged the oxygen, so he could plug the suction machine. He could not recall if the CNA helped him plug in the suctioning machine because it happened so quickly. In an interview on [DATE] at 12:19 pm with Executive Chef, he said he had worked for the facility for 1 year and 3 months. He said he was not at the facility at the time the sandwich was ordered. He said the next day he spoke with the Dietician. He said she told him what had happened with the sandwich. She said a resident choked the night before, (CR #1). He said the sandwich was not ordered as mechanical chop. He said that's why the sandwich was not mechanically chop. He said kitchen staff were in-serviced on the same day he found out. He said the facility changed the process on mechanical chop orders. He said the different diets were now color coded. He said staff had to keep their mask on at all times. He said staff also had to wear masks properly. He said properly was to cover nose, mouth and chin. He said staff always gave him excuses about the kitchen being hot but, he was trying to get them out of that mindset. In an interview on [DATE] at 12:51 pm with DON, she said the suctioning machine should have been plugged in and ready to go especially with CR #1 having a history of mucus in his throat. She said she did not feel the suction machine being unplugged and not ready to go contributed to CR #1's passing because the RN did all he could to preserve the resident's life. She said the RN did abdominal thrusts and gave him oxygen prior to suctioning. She said the resident was on hospice and he had been exhibiting a decline in respiratory functioning. She said he was having episodes where he had mucus buildup in his throat that had to be constantly suctioned. He said the RN was experienced with working with CR #1 so most of the time, the RN did not have to use the suction machine. In an interview on [DATE] at 1:10 pm with the Administrator, he said he questioned if the suction machine not being plugged in was the cause of death. He said he never got a clear answer. In a telephone interview on [DATE] at 1:42 pm with Hospice RN, he said CR #1 was one of his patients. He said he had not seen the death certificate because it was a duty of the funeral home. He said what happened in the hospice process was that there were two physician medical opinions and both certified a patient as hospice appropriate. He said they reviewed the case and selected the [DIAGNOSES REDACTED]. He said CR #1 was at end of life [MEDICAL CONDITION] with [MEDICAL CONDITION]. He said CR #1 was on PRN oxygen. He said he also had severe dysphagia (difficulty swallowing). He said prior to hospice and while on hospice CR #1 was exhibiting several episodes of severe dysphagia and choking but, it was usually handled appropriately with hospice interventions. He said his interventions were suctioning and PRN oxygen. He said CR #1 was also receiving scheduled [MEDICATION NAME]. He said what probably happened was that he had a choking episode and that was to be expected. He said the resident was declining already. He said, it was super sad. He said he did not believe that the delay in using the suction machine was the cause of death because the resident was already declining, and it was expected. In an interview on [DATE] at 9:38 am with LVN C, she said she worked 7 am to 3 pm. She said she had worked at the facility for 3 weeks. She said she was not familiar with CR #1. She said she was aware that he passed. She said the nurses were talking about it and that was how she became aware. She said the only thing she knew was that he had a sandwich and he choked on the sandwich. She said her understanding of DNR orders were to not resuscitate. She said DNR meant no life saving measures. She said she would probably use abdominal thrusts and back blows if she needed. She said she would not use CPR on a resident with DNR orders. She said her understanding of full code was CPR, oxygen and anything else that could preserve the resident's life. She said if a resident had a DNR on his medical record and he was choking, her approach would be to try to clear his airway to get the obstruction out. She said she would use oxygen. She said she would suction if oxygen did not work. She said if the resident had a history of [REDACTED]. She said she needed a physician's orders [REDACTED]. She said she would call 911 only if instructed by the physician. In a follow-up interview on [DATE] at 9:53 am with CNA, she said CR #1 finished eating the sandwich about 5:30 pm or 5:45 pm or close to 6:00 pm because he ate slow. She said CR #1 ate the whole sandwich. She said the sandwich did not have any ends on it. She said it was a turkey sandwich with cheese. In an interview on [DATE] at 9:57 am with ADON, she said her understanding of DNR was not to perform any CPR, cardiac pacing and AED. She said nursing staff was not prohibited from performing, [MEDICATION NAME], any type of suctioning or any other comfort measures. She said her understanding of full code was to use any kind of life sustaining measures, i.e. AED, CPR, airway management, call 911 and continue CPR until emergency paramedics arrived at the facility. She said her approach to CR #1's situation would be to observe if there was something physically lodged. Perform the [MEDICATION NAME], if unsuccessful, turn him on his side, and then try suctioning. She said since CR #1 was a DNR, her next step would be to call hospice. She said she was uncertain what to do when a resident was DNR and on hospice, so she would call hospice to get further instructions. She said if the resident had a history of [REDACTED]. She said physician orders [REDACTED]. She said, most times, the suctioning orders are PRN. She said she was told CR #1 had aspirated. She said she assumed it was related to the mucus episodes CR #1 kept experiencing. She said she went into the chart to read what the RN had documented. She said the RN's story and the CNA's were inconsistent and not adding up. She said she had not been involved in the facility's investigation. She said if the sandwich did not have the edges, the bread gets kind of liquified. She said if CR #1 finished the sandwich around 6 pm, she did not believe the sandwich could still be lodged in CR #1's throat. She said if CR #1 had [MEDICAL CONDITION] reflux there was a possibility that the sandwich could come back up. She said CR #1 had already had a lot of episodes where he would decline, become lethargic, loss of appetite, confusion, and mucus build up in his mouth and perk right up the next day. In an interview on [DATE] at 10:42 am with Prep Cook, he said he had been with the facility about one year. He said the staff from the healthcare side come to the kitchen to ask for sandwiches. He said they gave them specifics for how they wanted the sandwich made, i.e, bread with no crust or with no condiments or choking hazards. He said he made the sandwich for CR #1. He could not recall what type of meat. He said it could have been turkey. He said some staff were very specific when placing orders and some just placed the ticket on the service counter. He said on the day when CR #1 passed a staff person from healthcare approached him with an order for [REDACTED]. He said he did not remember if he cut the crust off. He said if the ticket said to cut the crust, then he cut it. He said he would only chop sandwiches upon request. He said the next day he found out that a resident passed from choking on a sandwich because the supervisor in charge of the servers along with the Executive Chef got cooks and servers in a huddle to let them know that whoever made the sandwiches last night caused the resident to choke on the sandwich. He said he defended himself because he said there were no instructions on the meal ticket that called for the sandwich to be mechanically chopped. He said an in-service training occurred next day. He said the facility's kitchen has a color-coded system now to identify mechanical chop, puree and ground. He said because before they would just go by whatever the healthcare staff told them to do. He said the pantry did not have any system like the hot food area had. He said they had a list of the residents with their diets. In an interview on [DATE] at 2:27 pm with Dietary Wait Staff, she said she had worked at the facility for two years. She said she put everyone's menu on serving line and for CR #1, staff ordered a turkey and cheese sandwich with the ends cut off. She said staff would order turkey and cheese sandwich a lot because that's what CR #1 liked. She said if they gave him his mechanical chop he would not eat it. She said he would just leave it there. She said the dishes got picked up about 6 pm. She said dinner usually started about 5:15 pm. She said around 5:45 pm they would bring CR #1's tray back to the kitchen and staff would say he didn't eat anything. She said on [DATE], the day the resident passed, the CNA forgot to tell the kitchen that the turkey and cheese sandwich order was for CR #1 (who was on mechanical chop). She said she delivered the sandwich to resident's room. She said she came back to work the next day and other staff that didn't work the evening before were saying CR #1 choked on a sandwich. She said her supervisor had a meeting with the kitchen staff to tell them if someone was on mechanical chop and they were going to order sandwiches, they had to be mechanically chopped. She said her supervisor developed a color-coded system to identify mechanical chop, puree and ground moving forward. Telephone interview on [DATE] at 12:31 pm with Physician, she said the facility notified her of CR #1's incident after he passed. She said they told her he choked on a sandwich. She said they told her they did everything they could for the resident while respecting his DNR status. She said she was told it happened so fast so there were no other interventions that they could have done while respecting his wishes. Observation on [DATE] at 1:00 pm revealed CR #1's past room had 1 outlet behind his end table located to the left as you entered the room. It had two plugs. There was another outlet behind the bed. It had two plugs. The bed was plugged into one plug. In an interview on [DATE] at 2:23 pm with DON, she said if a resident had signs of an obstructed airway or had a need for suctioning, the staff was expected to do the following: first, staff needed to make sure there was an order in place. She said if there was a suction machine in the room, there had to be an order. She said nurses would do a resident assessment and would suction as needed/accordingly. She said the facility did not have any residents with continuous suctioning orders. She said any resident with orders for suctioning should have the suctioning machine available for immediate use. She said when nurses conducted their rounds and assessed their resident's, O2 saturations were checked, they should be checking that all other emergency equipment was ready to go. She said if residents were on oxygen, they paid closer attention for the need to suction. She said O2 saturations gave nurses an idea of resident's condition. She said if O2 saturation dropped, the nurses would look into why. She said, the CNA's did vital signs at every shift. She said CNA's reported any change of condition to nurses. She said the nurses were responsible to ensure that machines or equipment used for respiratory care were properly working, maintained, and cleaned with a disinfectant. She said if the resident had a 24-hour CNA they too were responsible to ensure machines or equipment used for suctioning was plugged in, working and ready to go. She said CNA's sometimes used the electrical outlets for their personal use i.e. plug in cell phones. She said she had to constantly check on them to ensure they were not doing it. She said sometimes, they unplugged resident's equipment to charge their cell phones. She said the charge nurses were responsible to ensuring supervision of residents. She said the charge nurses gave direction to CNA's. She said, in my own opinion, I believed the resident had already passed at the time the CNA called for help. She said she could not explain the inconsistencies with the narratives provided by the RN and CNA because they were conflicting. She said the event occurred toward the end of the week and she did not find out what kind of sandwich until Monday. She said it was reported that the resident ate sandwiches every night. She said the resident could have had a sandwich just not turkey and cheese. She said the CNA gave the resident whatever he wanted. She said the CNA never told her she cut the sandwich up for the resident. Record review of the facility's policy titled: Physician Services revised ,[DATE] read in part . The medical care of each resident is under the supervision of a licensed physician. 1. The resident's attending physician participate in the resident's assessment and care planning, monitoring, changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. 2. The attending physician will determine the relevance of any recommended interventions from any discipline . Record review of the facility's policy titled: Policy for Notifying Physicians for Change of Condition, revised on [DATE] read in part . It is the policy of The Hallmark Anderson Healthcare Facility that the resident's physician and family members be notified of changes in a resident's condition that affect the resident's health. The following are examples of times when the physician must be immediately notified of a change in condition: Any episode of vomiting with change in vital signs or evidence of dehydration; shortness of breath that is sudden in onset, with chest pain, and/or with change in vital signs; and vital sign changes such as increase or decrease in systolic blood pressure, increase in pulse by 20 beats per minute, pulse below 50 beats per minute, increase or decrease in respirations by 6 breaths per minute, and oxygen saturation less than 90% .

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for 1 of 5 residents reviewed for suctioning care. (CR #1) reviewed for respiratory care. -The facility failed to ensure CR #1's suctioning machine was set up and plugged in causing a delay in successfully managing the airway for CR #1 during a choking emergency. This failure could affect all residents requiring respiratory services at risk of life-threatening [MEDICAL CONDITION] and could result in a delay in treatment, injury, hospitalization , and death. Findings include: Record review of CR #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 04 out of 15 indicating severe cognitive impairment. He required two-person assistance with bed mobility, transfer, dressing and toile use. He required one-person assistance with locomotion on unit, eating and personal hygiene. He was coded as always incontinent for urinary and bowel. He was coded as having shortness of breath. Section K: Swallowing/Nutritional Status was coded as C. Coughing or choking during meals or when swallowing medications. Record review of CR #1's care plan initiated on [DATE] and revised on [DATE] revealed the following: -Focus: CR #1 admitted to hospice with dx of Alzheimer's with comorbidities of [MEDICAL CONDITION] and dysphagia. Goal: Will maintain CR #1's quality of life through integrated care provided by Hospice and nursing staff. Interventions: Family/ Hospice/ IDT to coordinate plan of care and reach common goals for CR #1; Monitor for any changes in condition and notify hospice; No labs, Diagnostic testing or hospitalization ; Provide comfort care; and Refer to chart for hospice plan of care. -Focus: Resident has an ADL self-care performance deficit r/t Activity Intolerance, Alzheimer's Date initiated: [DATE] Goal: Reduce the risk of a decline in current participation. Date initiated [DATE] Intervention: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Requires total assistance with 2 staff members for his showers Date Initiated: [DATE]. Bed mobility: Resident requires moderate assistance by 1 staff to turn and reposition in bed frequently and as necessary. Date Initiated: [DATE]. Dressing: Resident is totally dependent on 1 staff for dressing. Date Initiated: [DATE]. EATING: Resident is able to feed self with 1:1 supervision to monitor pace/rate. Diet is regular-mechanical soft consistency with thin liquids. Date Initiated: [DATE]. Personal Hygiene/Oral Care: Resident requires moderate assistance of 1 staff member for his hygiene. Date Initiated: [DATE]. Transfer: Resident requires 2-person assist with Hoyer lift transfers. Date initiated: [DATE]. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of CR #1's DNR, Do Not Resuscitate, Order revealed it was dated [DATE]. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician orders [REDACTED].@ 2lpm via nc as needed for spo2 < 92% as needed. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's progress notes written by RN on [DATE] read in part, 6 pm, sitter reported that the resident had been coughing during meals since this morning, resident has a communication deficit due to dementia, continues on aspiration precaution, HOB was kept on 90% (sic) during eating, VSS, no fever, temp 96.7 F, safety was maintained, call bell within reach, bed in low position, all needs attended. Record review of CR #1's progress notes written by LVN A on [DATE] read, Resident was [MEDICAL CONDITION] a 114 pulse, rechecked the pulse and it was 58. His O2 saturation was 90% on room air, prn duo-nebulizer treatment was given. His oxygen increased to 97% on room air. Continued monitoring. No pain, a-febrile, skin warm to touch, no sob, no signs/symptoms of COVID. Record review of CR #1's progress note written by LVN D on [DATE] read in part, .Suction patient PRN DX congestion as needed. PRN Administration was: Effective. No coughing at this time. Will continue to monitor . Record review of CR #1's progress note written by RN on [DATE] read in part, Resident remains alert and responsive to all stimuli, not in distress, not able to make needs known, noted coughing this shift during meds administration, aspiration precaution maintained, HOB was kept elevated, dependent to all ADL's., incontinent care provided, noted staring at the ceiling, smiling, VSS, no SOB noted, afebrile, temperature 96.5 f, incontinent care provided, will continue to monitor. Record review of CR #1's Orders-Administration note dated [DATE] written by LVN D revealed the following: Suction patient PRN DX congestion as needed. Resident coughing, unable to clear throat, suctioned at this time. Tolerated well. Oxygen saturation 95% to room air. HOB up 90-degrees. Record review of CR #1's progress note written by LVN D on [DATE] read in part, RN with Hospice here to evaluate resident. States 'resident may be transitioning.' Resident stable at this time, no productive cough at this time b/p ,[DATE], respirations 20, temperature 97.6, oxygen saturation 92% with oxygen at 2L/min via NC. New order obtained, [MEDICATION NAME] Tablet 0.125 mg give 1 tab SL for increased secretions. (Staff Name) will be back to evaluate in 2 days and if any further decline he will coordinate with the family for a visit. Record review of CR #1's Health Status note written by RN on [DATE] read in part, .625 pm, called by the sitter to check on the resident because he's unable to respond verbally and choking on the sandwich that he's eating. In the room resident was on his bed on upright 90-degree position, unresponsive, not breathing and cyanotic, he was placed immediately on side lying position and was suctioned and was able to take out some of the liquified food that was stuck on his throat, O2 on @ ,[DATE] LPM via NC. Resident was trying to cough out but unable to do so, BP ,[DATE] HR 126 respiratory 0, still cyanotic (blue due to lack of oxygen), suctioning continued until vital signs was unappreciated, unresponsive, no breathing, no heart sound, pupil- dilated and the time was noted 642 pm. Hospice Care was made aware, RP and MD. Record review of CR #1's progress notes for [DATE] revealed no documentation of RN or other staff making notification of change in condition to Hospice or Attending Physician during the change of condition for CR #1. In an interview on [DATE] at 4:15 pm with RN, he said he worked at the facility for almost 3 years. He said he was familiar with CR #1. He said the resident passed (died ). He said CR #1 had been at the facility since he had been working at the facility, so he knew him very well. He said on [DATE] he was charting for medications and the CNA for CR #1 was yelling and was calling his name to respond. He said he went over to CR #1's room and he saw the resident with both hands on his neck. He said he assumed he was choking. He said he asked the CNA if he was eating something. He said the CNA said the resident was eating a sandwich. He said he opened CR #1's mouth to assess and he saw a thick mucus. He said he did a finger sweep to clear his mouth and he retrieved some sticky mucous substance from his mouth and throat. He said it did not look like liquified bread. He said, It just looked thick like mucus. He said, I didn't see the sandwich. He said he lowered the bed to put the resident in a supine (lying flat face up) position. He said he gave the resident abdominal thrusts and nothing was coming out. He said he just used his judgement and told CNA to place the resident immediately on his side to drain the mucus. He said some secretions drained when he placed the resident on his side. He said he used the suction machine by the resident side table. He said he started to suction his mouth. He said there was some secretions post suctioning. He said the resident tried to gasp for air but, he was unable to continue to breathe on his own. He said he told the CNA to get CR #1's vitals while he was suctioning. He said at that point, the resident's blood pressure was low. He said he could not recall exactly how low. He said his heart was elevated. He said the resident was turning blue due to lack of oxygen. He said he continued suctioning because the resident was DNR, so he was unable to give him artificial ventilation. He said he kept suctioning because he knew they could not call 911 or use CPR because of the resident's DNR status. He said he wished he could have but, he knew that he needed to respect the resident's choice. He said it was past dinner time around 6:20 pm. He said the resident most likely got the sandwich from the kitchen but, he was not sure because he did not see it. He said the resident was on a restrictive diet. He said the resident's diet called for mechanical soft. He said the CNA knew the resident was on a mechanical diet. He said the CNA stayed to assist with post mortem care. He said he was the one that notified the family. He said he notified hospice, MD and the DON. He said he did not call the physician during the choking episode. In an interview on [DATE] at 4:38 pm with CNA, she said she worked for the department where sitters were assigned. She said she was a certified CNA. She said she went inside the restroom and when she came out, CR #1 was choking. She said the resident had mucus and foam coming out of his mouth. She said she hollered for the RN. She said he arrived and told her to turn the resident on his side, so he could use the suction machine. She said the RN tried to use the suction machine but, it was not plugged in. She said the RN was sitting on the side trying to get the suction machine to work, but it was not working because it was unplugged so she had to tell him that it was not plugged. She said she tried to plug it in. She said she did her best to help the RN get the suction machine going but she did not know how to use the facility's equipment. She said she spent time trying to plug the suction machine and the tubing. She said after she got the suction machine plugged in, the RN tried to suction CR #1's mouth but, it was too late, the resident had already passed. She said the RN pronounced him dead. She said she fed CR #1 a sandwich that she ordered from the facility's kitchen. She said she cut it up into bite size pieces for the resident. She said she fed him the sandwich about 5:10 pm on that day. She said the incident occurred about 5:45 pm because the resident passed around 6:45 pm. She said she worked with CR #1 for 2 ½ years. She said she worked almost every day. She said the facility was saying that he choked on the sandwich but, he choked on mucous. She said he would have episodes where the resident would have increased amount of mucus coming out of his mouth and the nursing staff would suction it out. She said it happened frequently. She said the resident used to spit it out on the floor and she always gave him tissue. She said she did not know why the facility was saying the resident choked on a sandwich because she had already fed him and gave him water behind the sandwich and he was doing fine. She said she was suspended because the facility told her they had to investigate the matter. In an interview on [DATE] at 5:13 pm with DON, she said the CNA's role was to know equipment. She said it was the nurse's responsibility to ensure the equipment, like the suctioning machines, were in good repair and plugged in, so they were ready to go. She said she was not aware the suctioning machine was not plugged in. In a follow up interview on [DATE] at 5:20 pm with RN, he said the suction machine was not plugged in because there were only two outlets; one had the nebulizer plugged in and the other had the oxygen concentrator plugged in. He said he forgot to tell this Surveyor he used oxygen on the resident because it was right there next to his bedside. He said he was the one that unplugged the oxygen, so he could plug the suction machine. He could not recall if the CNA helped him plug in the suctioning machine because it happened so quickly. In an interview on [DATE] at 12:19 pm with Executive Chef, he said he had worked for the facility for 1 year and 3 months. He said he was not at the facility at the time the sandwich was ordered. He said the next day he spoke with the Dietician. He said she told him what had happened with the sandwich. She said a resident choked the night before, (CR #1). He said the sandwich was not ordered as mechanical chop. He said that's why the sandwich was not mechanically chop. He said kitchen staff were in-serviced on the same day he found out. He said the facility changed the process on mechanical chop orders. He said the different diets were now color coded. He said staff had to keep their mask on at all times. He said staff also had to wear masks properly. He said properly was to cover nose, mouth and chin. He said staff always gave him excuses about the kitchen being hot but, he was trying to get them out of that mindset. In an interview on [DATE] at 12:51 pm with DON, she said the suctioning machine should have been plugged in and ready to go especially with CR #1 having a history of mucus in his throat. She said she did not feel the suction machine being unplugged and not ready to go contributed to CR #1's passing because the RN did all he could to preserve the resident's life. She said the RN did abdominal thrusts and gave him oxygen prior to suctioning. She said the resident was on hospice and he had been exhibiting a decline in respiratory functioning. She said he was having episodes where he had mucus buildup in his throat that had to be constantly suctioned. He said the RN was experienced with working with CR #1 so most of the time, the RN did not have to use the suction machine. In an interview on [DATE] at 1:10 pm with the Administrator, he said he questioned if the suction machine not being plugged in was the cause of death. He said he never got a clear answer. In a telephone interview on [DATE] at 1:42 pm with Hospice RN, he said CR #1 was one of his patients. He said he had not seen the death certificate because it was a duty of the funeral home. He said what happened in the hospice process was that there were two physician medical opinions and both certified a patient as hospice appropriate. He said they reviewed the case and selected the [DIAGNOSES REDACTED]. He said CR #1 was at end of life [MEDICAL CONDITION] with [MEDICAL CONDITION]. He said CR #1 was on PRN oxygen. He said he also had severe dysphagia (difficulty swallowing). He said prior to hospice and while on hospice CR #1 was exhibiting several episodes of severe dysphagia and choking but, it was usually handled appropriately with hospice interventions. He said his interventions were suctioning and PRN oxygen. He said CR #1 was also receiving scheduled [MEDICATION NAME]. He said what probably happened was that he had a choking episode and that was to be expected. He said the resident was declining already. He said, it was super sad. He said he did not believe that the delay in using the suction machine was the cause of death because the resident was already declining, and it was expected. In an interview on [DATE] at 9:38 am with LVN C, she said she worked 7 am to 3 pm. She said she had worked at the facility for 3 weeks. She said she was not familiar with CR #1. She said she was aware that he passed. She said the nurses were talking about it and that was how she became aware. She said the only thing she knew was that he had a sandwich and he choked on the sandwich. She said her understanding of DNR orders were to not resuscitate. She said DNR meant no life saving measures. She said she would probably use abdominal thrusts and back blows if she needed. She said she would not use CPR on a resident with DNR orders. She said her understanding of full code was CPR, oxygen and anything else that could preserve the resident's life. She said if a resident had a DNR on his medical record and he was choking, her approach would be to try to clear his airway to get the obstruction out. She said she would use oxygen. She said she would suction if oxygen did not work. She said if the resident had a history of [REDACTED]. She said she needed a physician's orders [REDACTED]. She said she would call 911 only if instructed by the physician. In a follow-up interview on [DATE] at 9:53 am with CNA, she said CR #1 finished eating the sandwich about 5:30 pm or 5:45 pm or close to 6:00 pm because he ate slow. She said CR #1 ate the whole sandwich. She said the sandwich did not have any ends on it. She said it was a turkey sandwich with cheese. In an interview on [DATE] at 9:57 am with ADON, she said her understanding of DNR was not to perform any CPR, cardiac pacing and AED. She said nursing staff was not prohibited from performing, [MEDICATION NAME], any type of suctioning or any other comfort measures. She said her understanding of full code was to use any kind of life sustaining measures, i.e. AED, CPR, airway management, call 911 and continue CPR until emergency paramedics arrived at the facility. She said her approach to CR #1's situation would be to observe if there was something physically lodged. Perform the [MEDICATION NAME], if unsuccessful, turn him on his side, and then try suctioning. She said since CR #1 was a DNR, her next step would be to call hospice. She said she was uncertain what to do when a resident was DNR and on hospice, so she would call hospice to get further instructions. She said if the resident had a history of [REDACTED]. She said physician orders [REDACTED]. She said, most times, the suctioning orders are PRN. She said she was told CR #1 had aspirated. She said she assumed it was related to the mucus episodes CR #1 kept experiencing. She said she went into the chart to read what the RN had documented. She said the RN's story and the CNA's were inconsistent and not adding up. She said she had not been involved in the facility's investigation. She said if the sandwich did not have the edges, the bread gets kind of liquified. She said if CR #1 finished the sandwich around 6 pm, she did not believe the sandwich could still be lodged in CR #1's throat. She said if CR #1 had [MEDICAL CONDITION] reflux there was a possibility that the sandwich could come back up. She said CR #1 had already had a lot of episodes where he would decline, become lethargic, loss of appetite, confusion, and mucus build up in his mouth and perk right up the next day. In an interview on [DATE] at 10:42 am with Prep Cook, he said he had been with the facility about one year. He said the staff from the healthcare side come to the kitchen to ask for sandwiches. He said they gave them specifics for how they wanted the sandwich made, i.e, bread with no crust or with no condiments or choking hazards. He said he made the sandwich for CR #1. He could not recall what type of meat. He said it could have been turkey. He said some staff were very specific when placing orders and some just placed the ticket on the service counter. He said on the day when CR #1 passed a staff person from healthcare approached him with an order for [REDACTED]. He said he did not remember if he cut the crust off. He said if the ticket said to cut the crust, then he cut it. He said he would only chop sandwiches upon request. He said the next day he found out that a resident passed from choking on a sandwich because the supervisor in charge of the servers along with the Executive Chef got cooks and servers in a huddle to let them know that whoever made the sandwiches last night caused the resident to choke on the sandwich. He said he defended himself because he said there were no instructions on the meal ticket that called for the sandwich to be mechanically chopped. He said an in-service training occurred next day. He said the facility's kitchen has a color-coded system now to identify mechanical chop, puree and ground. He said because before they would just go by whatever the healthcare staff told them to do. He said the pantry did not have any system like the hot food area had. He said they had a list of the residents with their diets. In an interview on [DATE] at 2:27 pm with Dietary Wait Staff, she said she had worked at the facility for two years. She said she put everyone's menu on serving line and for CR #1, staff ordered a turkey and cheese sandwich with the ends cut off. She said staff would order turkey and cheese sandwich a lot because that's what CR #1 liked. She said if they gave him his mechanical chop he would not eat it. She said he would just leave it there. She said the dishes got picked up about 6 pm. She said dinner usually started about 5:15 pm. She said around 5:45 pm they would bring CR #1's tray back to the kitchen and staff would say he didn't eat anything. She said on [DATE], the day the resident passed, the CNA forgot to tell the kitchen that the turkey and cheese sandwich order was for CR #1 (who was on mechanical chop). She said she delivered the sandwich to resident's room. She said she came back to work the next day and other staff that didn't work the evening before were saying CR #1 choked on a sandwich. She said her supervisor had a meeting with the kitchen staff to tell them if someone was on mechanical chop and they were going to order sandwiches, they had to be mechanically chopped. She said her supervisor developed a color-coded system to identify mechanical chop, puree and ground moving forward. Telephone interview on [DATE] at 12:31 pm with Physician, she said the facility notified her of CR #1's incident after he passed. She said they told her he choked on a sandwich. She said they told her they did everything they could for the resident while respecting his DNR status. She said she was told it happened so fast so there were no other interventions that they could have done while respecting his wishes. Observation on [DATE] at 1:00 pm revealed CR #1's past room had 1 outlet behind his end table located to the left as you entered the room. It had two plugs. There was another outlet behind the bed. It had two plugs. The bed was plugged into one plug. In an interview on [DATE] at 2:23 pm with DON, she said if a resident had signs of an obstructed airway or had a need for suctioning, the staff was expected to do the following: first, staff needed to make sure there was an order in place. She said if there was a suction machine in the room, there had to be an order. She said nurses would do a resident assessment and would suction as needed/accordingly. She said the facility did not have any residents with continuous suctioning orders. She said any resident with orders for suctioning should have the suctioning machine available for immediate use. She said when nurses conducted their rounds and assessed their resident's, O2 saturations were checked, they should be checking that all other emergency equipment was ready to go. She said if residents were on oxygen, they paid closer attention for the need to suction. She said O2 saturations gave nurses an idea of resident's condition. She said if O2 saturation dropped, the nurses would look into why. She said, the CNA's did vital signs at every shift. She said CNA's reported any change of condition to nurses. She said the nurses were responsible to ensure that machines or equipment used for respiratory care were properly working, maintained, and cleaned with a disinfectant. She said if the resident had a 24-hour CNA they too were responsible to ensure machines or equipment used for suctioning was plugged in, working and ready to go. She said CNA's sometimes used the electrical outlets for their personal use i.e. plug in cell phones. She said she had to constantly check on them to ensure they were not doing it. She said sometimes, they unplugged resident's equipment to charge their cell phones. She said the charge nurses were responsible to ensuring supervision of residents. She said the charge nurses gave direction to CNA's. She said, in my own opinion, I believed the resident had already passed at the time the CNA called for help. She said she could not explain the inconsistencies with the narratives provided by the RN and CNA because they were conflicting. She said the event occurred toward the end of the week and she did not find out what kind of sandwich until Monday. She said it was reported that the resident ate sandwiches every night. She said the resident could have had a sandwich just not turkey and cheese. She said the CNA gave the resident whatever he wanted. She said the CNA never told her she cut the sandwich up for the resident. Record review of the facility's policy titled: PAS Policy Manual revised on [DATE] read in part . Personal Assistance Services: Routine ongoing care or services required by an individual in a residence or independent living environment that enable the individual to engage in the activities of daily living or to perform the physical functions required for independent living, including respite services. The term includes: Personal care - The provisions of one or more of the following services required by an individual in a residence or independent living environment: Bathing, Dressing, Grooming, Feeding, Exercising, Toileting, Positioning, Assisting with self-administered medications, Routine hair and skin care; and Transfer of ambulation. Health-related services performed under circumstances that are defined as not constituting the practice of professional nursing by the Board of Nurse Examiners through a memorandum of understanding with the department in accordance with the delegation's rules adopted by the Board of Nurse Examiners . Record review of the facility's statement of acknowledgement between IHA Staff and IHA Management not dated read in part . I understand that the ADL's tasks include the following (but not limited to): transfer/repositioning, assist with feeding, bathing, dressing/grooming, oral care, toileting and record/reporting percentages of input and output or meals and taking vital signs. In understand that my assistance may be needed, and I am NOT eliminated from participating in the assistance for the resident. Tasks outside of ADL's may be required and should be supported as appropriately . Record review of the facility's job description for charge nurse dated [DATE] read in part . Job specific responsibilities: A. Delivery of Resident Care. 8. Assembles and utilizes resident care equipment and ancillary supplies . Record review of publication, titled: Emergency suction equipment: barriers to use and effective interventions located at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 00/, published on [DATE] read in part . Emergency suction is a fundamental item of equipment which should be readily available for use to all healthcare professionals in the hospital setting. Use of emergency suction can be vital in an emergency, for example when dealing with vomit or secretions. It is natural to assume that emergency suction would be maintained in a state of readiness and that the equipment would be, by its nature, intuitive to use. In studies, individuals however had personal experiences where they were let down by the inability of ward staff to effectively use emergency suction, either due to deficiencies in equipment readiness or operator inability . Record review of publication, titled: Journal of Medical Services located at https://www.jems.com/[DATE]/overview-of-prehospital-airway-suctioning/, dated [DATE] read in part . SUCTION EQUIPMENT: Prehospital suction units fall into two categories: portable and vehicle mounted. Both types depend on essentially the same components: catheters and tubing, collection canister and ability to create a vacuum, typically with a positive displacement pump and power source. Each of these components are integral in creating suction and thus must be checked each shift and after every use, to be considered response-ready. Each component, if not properly cared for, can become the weak link that renders your suction unit useless during the exact moment your patient needs it most. Required suction unit checks should be clearly spelled out in department policies and procedures. Documentation they've been checked is your best defense if a unit fails to operate. At a minimum, a quick 10-second system check can be conducted by following these simple steps: unplug the suction unit from the onboard charging system, pinch the distal end of the large bore suction tubing, turn the unit on while listening for the distinct sound of the motor being put under a load. This quick check provides the following: 1. The tubing is connected properly, and the integrity of the tubing hasn't been compromised by a significant crack or break; 2. The canister and lid are maintaining an airtight seal; 3. The motor is functioning properly (see your manufacturer specifications for the vacuum pressure your device should be able to achieve); and 4. The batteries are charged and connected correctly. It's important to note that this quick shift check doesn't replace the manufacturer's suggested bench tests and maintenance schedule. In addition, providers should check to ensure responding apparatus have manufacturer-sealed spare tubing and suction catheters in the event replacements are needed on scene. Lastly, agencies should be prepared with appropriate equipment and training to rapidly suction a variety of very different airways .

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable weight range for one resident (Resident #10) of 12 residents reviewed for weight in that -Resident #10 experienced a significant weight loss in six months. - Dietitian recommendation and physician order for [REDACTED]. -The resident exhibited additional weight loss after the date of the order. These failures affected one resident and placed her at risk for additional weight loss, skin breakdown and decline in overall health. Findings included: Record review of the Admission Record for Resident #10 revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the most recent MDS assessment, dated 12/04/18, revealed Resident #10 exhibited severely impaired cognition. The MDS revealed she required total assist with eating. Record review of the Care Plan 1/29/19 for Resident #10 revealed no reference to weight loss, other than the resident required total assist with eating. The Care Plan reflected the resident had a stage 3 pressure sore r/t (related to) immobility and poor nutritional status, but it did not have interventions mentiones for actual weight loss. Record review of Resident #10's weights revealed a weight of 117.4# on 08/02/18, and weight of 103.5 on 01/05/19, and 102.3# on 02/15/19 indicating a weight loss of 15.1# or 12.8% , a significant weight loss in six months. Record review of the Nutrition/Dietary Note dated 01/11/19 revealed in part: .95 y/o. Height: 67 1/5 weight: 103.5 lbs. BMI: 16.2 (underweight). IBW: 135 lbs, 76% IBW. The resident weighed 103.5# (pounds) on 01/05/19. The Note revealed the resident was underweight and had exhibited a 5.4% (percent) weight loss in the previous 30 days. The Note revealed the resident had exhibited a 8.3% weight loss over the previous 90 days. The Note revealed Increased risk for nutritional problems due to low body weight .Diet: Regular, puree. Supplements: medpass 90 cc TID and health shakes po BID. Res. eats in dining room, is fully dependent on staff for meals .Goal: gradual weight gain to above IBW x 3 months. Recommendation: Increase Health Shakes to TID, provide snack b/t meals, appetite stimulant . Record review of a Communication between the Dietitian and Attending Physician, dated 01/11/19, revealed the Dietitian had identified a weight loss concern regarding Resident #10. The form revealed a recommendation for an increase of the Health Shake from twice daily to three times daily. The form revealed the physician checked the box agree on 01/14/19. Record review of the TAR and MAR indicated [REDACTED]. Record review of the (MONTH) 2019 MAR indicated [REDACTED]. Record review the (MONTH) 2019 MAR indicated [REDACTED] Observation on 02/14/19 at 8:15 am. revealed Resident #10 was in the dining room. CNA U was assisting the resident to eat breakfast. There was no Health Shake on the table. The resident ate approximately 50%. Observation on 02/14/19 at 12:26 p.m. revealed Resident #10 was in her room. CNA U was providing assistance with lunch. There was no Health Shake with the meal. Observation on 02/14/19 at 1:05 p.m. revealed Resident #10 and CNA U were still in the room. The resident had only eaten the salad. There was no Health Shake in the room. Interview on 02/14/19 at 1:40 p.m. with CNA U she said the resident ate 15% of her lunch. She said she had not seen any Health Shakes provided to the resident with meals. She said LVN G gave the Health Shakes. Interview on 02/14/19 at 1:45 p.m. LVN G said she provided Resident #10 with Med Pass 2.0 supplement with meals, and occasionally if the resident did not eat well. Record review of the Physician's Orders for (MONTH) 2019 revealed the Med Pass 2.0 was a different order than the Health Shakes recommended by the dietitian and ordered by the doctor. Observation on 02/15/19 at 11:15 a.m. revealed CNA J and CNA P weighted Resident #10, using a Hoyer lift. CNA J said that was the method always used for weighing this resident. The scale revealed a weight of 102.3#. CNA J verbally verified the weight. Interview on 02/14/19 at 2:37 p.m. with LVN G she said when a Nutritional consult was received, the staff was to place it in a folder for the physician to sign, then it was taken to the kitchen. When asked about the Nutrition consult/physician order for [REDACTED]. She then said, We must have missed it. Record review of the facility policy Dietitian Recommendation to Medical Director Group and other Credentialed Providers (no date) revealed 2. After the physician signs, off the recommendation the nurse on the unit will follow up on the recommendations. The nurse the order in to the EMR and carry out the orders. Record review of facility Policy titled Weight Management (revised 11/01/17) reveale din part: .Purpose: Standing order protocol for severe weight loss in Health Care Residents Policy: Verbal communication of orders and test results should be used in situations where any delay in writing the order or test result could cause harm or have a possible negative outcome .