Every finding on record at Weakley Rehabilitation and Nursing Center

Based on medical record review, hospital records review, and interview, the facility failed to implement a physician's order for a Bilevel Positive Airway Pressure (BIPAP) (a compact, non-invasive ventilator that assists with breathing by delivering pressurized air through a mask) for 1 of 3 (Resident #1) residents reviewed for respiratory care. The findings include: Review of the [named hospital] AFTER VISIT SUMMARY dated 2/10/2026, revealed Discharge Orders to SNF .BIPAP with settings of F102 [Fraction of inspired oxygen (FiO2) is the percentage or concentration of oxygen in the air mixture that a person inhales] .IPAP [Inspiratory Positive Airway Pressure is the higher pressure applied during inhalation] 25, EPAP [Expiratory Positive Airway Pressure is the lower pressure applied during expiration] 8 . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease, Emphysema, Obstructive Sleep Apnea, Sepsis, and Dementia. Review of the Baseline Care Plan dated 2/12/2026, revealed Special Treatments, Procedures, and Programs BiPAP/ CPAP [Continuous Positive Airway Pressure] while a resident was not selected. Review of the facility's Order Summary Report dated 2/12/2026, revealed there was no order for the use of a BIPAP for Resident #1. Review of the Medication Administration Record dated February 2026, revealed Resident #1 was not scheduled for the use of a BiPAP. The facility failed to initiate a physician's order for the use of a BIPAP or obtain an order for the use of a CPAP machine. During an interview on 5/18/2026 at 2:14 PM, the Director of Nursing (DON) stated, .the order for the CPAP machine was not put in as an order and therefore it would not have shown up on the Physician Orders or the Medication Administration Record.the orders should have been changed to CPAP by the discharge nurse at the hospital .the wife stated she was told by the hospital discharge nurse during discharge the resident could use his personal CPAP machine .she brought the CPAP machine to the facility the day prior to his arrival to the facility .the discharge orders were not changed to reflect the CPAP machine use nor was it clarified by our nurses when the wife brought the CPAP machine to the facility the day before . During a telephone interview on 5/19/2026 at 1:50 PM, the Physician's Assistant stated .I was not notified by the staff to clarify orders for a CPAP machine.I thought he had a BIPAP machine.I should have been notified if there was an order change, if clarification was needed or notified there was not an order for the CPAP . During a telephone interview on 6/5/2026 at 1:00 PM, DON stated .We failed to put the order in for the CPAP.there is no order for it.and there should have been clarification when we reconciled the discharge orders .we should have called the doctor to clarify the BIPAP order and got the orders clarified . PAST NON-COMPLIANCE VERIFICATION A facility document non titled self-imposed action plan signed 2/20/26, was implemented on 2/16/26 and completed on 2/17/26 with ongoing monitoring to ensure compliance. This concludes the action plan and any potential citation associated with this action plan should be considered past noncompliance as of 02/18/26. 1) What corrective actions will be accomplished for those residents found to have been affected by the deficient practice. [Resident #1] transferred to emergency room 2/14/2026 at 8:30 AM. 2/16/26- Provider notified of transcription error for Bilevel Positive Airway Pressure (BiPAP) order by Director of Nursing (DON). 2) How will the facility identify other residents having the potential to be affected by the same deficient practice: All new admission/readmissions are at risk for the deficient practice; no other residents were identified or affected. On 2/16/26, all admissions/readmissions for previous 60 days were reviewed by DON/designee to ensure all hospital discharge orders were transcribed from the depart to the current EMR [Electronic Medical Record] to include BIPAP. 2/17/26 - Whole house audit of all resident rooms was completed by DON/designee to ensure no resident has BIPAP in room without a physician's order. No other issues were found. 3) What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not occur: 2/16/26 - Regional Clinical Director educated DON, Assistant Director of Nursing (ADON), and all other members of nursing administration on the requirement to ensure that one nurse is utilized to verify orders with the orders are placed in Point Click Care (PCC) queue. The second nurse will validate that the orders match the orders in the discharge summary and have been correctly transcribed into the EMR (Electronic Medical Record). The nursing administration team will review the admission orders in morning clinical meeting Monday through Friday to provide a final check for accuracy in transcription. 2/16/26 - all nurses were educated by the DON/designee on the requirement to have a second nurse verify that orders from the hospital discharge summary are all transcribed to the EMR for all new admissions and readmissions. All newly hired nurses will be educated by the DON/Designee on the verification process. 4) How will the facility monitor its corrective actions to ensure the deficient practice will not recur: DON/designee will review all new admissions/readmission orders 5x weekly x 4 weeks to ensure that all orders from the hospital discharge summary are transcribed to the facility EMR. Result of audits will be reported to and reviewed by Quality Assurance Process Improvement (QAPI) committee and will continue at the discretion of the committee. The surveyor verified the above corrective actions had been implemented by the facility; through record review, interview, in-service, audits and QAPI review. The facility will audit 5 admissions/readmissions per month for 6 months or until compliance is met and sustained. The process of a second nurse reviewing admission/readmission orders then the orders being reviewed in the morning clinical meeting, to validate that the orders were transcribed correctly, will be ongoing. The facility was cited at past noncompliance.

Based on policy review, medical record review, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status and implement nutritional interventions for 1 of 4 (Resident #38) sampled residents reviewed for weight loss. This resulted in an actual Harm when the facility failed to implement interventions following a significant weight loss for Resident #38 resulting in another significant weight loss 29 days later. The findings include: 1. Review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised September 2012, revealed .The threshold for significant unplanned and undesired weight loss will be based on the following criteria.1month - 5% [percent] weight loss is significant; greater than 5% is severe.3 months - 7.5% weight loss is significant; greater that 7.5% is severe.6 months- 10% weight loss is significant; greater than 10% is severe.staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include .Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals.Monitoring is also required for residents whose current nutritional status is stable.Observing for and documenting any sustained decline in appetite and/or food intake;.Observing for and reporting significant weight gain or loss . 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia, Anxiety, Anemia, Depression, and Gastro-Esophageal Reflux Disease. Review of the Care Plan for Resident #38 dated 6/28/2025, revealed .has nutritional problems or potential nutritional problem.Monitor/record/report to MD [Medical Doctor] PRN [as needed] s/sx [signs/symptoms] of malnutrition.significant weight loss: 3lbs [pounds] in 1 week, > [greater than] 5% in 1 month, >7.5% in 3 months, >10% in 6 months.Monitor: intake, weight, skin, labs, medication, diet tolerance and hydration status.Nursing will inform MD/family/POA [Power of Attorney] of significant weight changes. Provide and serve supplements as ordered.Provide, serve diet as ordered. Monitor intake and record q [every] meal.RD [Registered Dietician] to evaluate and make diet change recommendations PRN. On 7/4/2025, Resident #38 weighed 120.8 lbs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #38 was severely cognitively impaired and required substantial/maximum assistance of staff with meals. On 8/6/2025 Resident #38 weighed 112.8 lbs., a severe weight loss of 6.6% in one month. Review of the Nutrition/Hydration Status (Dietitian) assessment dated [DATE], revealed .current weight (lbs.) 112.8.CBW [Current Body Weight].BMI [Body Mass Index] is below WNL [Within Normal Limits].IBW [Ideal Body Weight] 149-180 . Interventions: Recommend house supplement BID d/t [due to] weight loss .Obtain weight weekly and monitor trends. Review of the [Named Facility] order review history report dated 8/9/2025-9/9/2025 revealed there was no order for house supplements or weekly weights. The facility failed to follow RD recommendations for weekly weights and failed to implement nutritional interventions in August 2025 for the severe weight loss. On 9/4/2025, Resident #38 weighed 102 lbs, a severe weight loss of 9.5%. Review of the Weight Change Note dated 9/9/2025 at 5:10 PM, revealed Significant weight loss change: -5.0% change [ Comparison Weight 8/6/2025, 112.8 Lbs, -9.6%, -10.8 Lbs ] -7.5% change [ Comparison Weight 7/4/2025, 120.8 Lbs, -15.6% , -18.8 Lbs ] -10.0% change [ Comparison Weight 4/4/2025, 122.0 Lbs, -16.4% , -20.0 Lbs ] Recommend 200ml house supplement TID,[Three times daily] and weekly weight monitoring. During an interview on 9/9/2025 at 3:35 PM, Registered Dietitian (RD) #1 acknowledged the Director of Nursing (DON) notified her of Resident #38's August weight. RD #1 stated RD #2 was completing assessments for the facility the day of the notification and RD #2 was notified of the weight loss. RD #1 acknowledged that recommendations for house shakes and weekly weights were made on 8/8/2025. RD #1 was asked were the recommendations followed. RD #1 stated, I'm not seeing the actual order for the supplement in the chart.she does not have weekly weights. I'm really surprised they did not accept this supplement order. RD #1 stated Resident #38's next weight was on 9/4/2025, the weight was 102.0 lbs, which was a significant weight loss. RD #1 was asked were you notified of the 9/4/2025 weight. RD #1 stated No. RD #1 acknowledged that she should have been notified of Resident #38's severe weight loss on 9/4/2025. During a telephone interview on 9/10/2025 at 11:58 AM, RD #2 stated she was notified of Resident #38's 8/6/2025 significant weight loss and recommended house shakes and weekly weights. RD #2 acknowledged there was no documentation in the record that the supplement was given or that weekly weights were obtained. RD #2 confirmed Resident #38 had another severe weight loss on 9/4/2025. During a telephone interview on 9/10/2025 at 2:08 PM, the Medical Director acknowledged she was notified of the 8/6/2025 weight loss but was not notified of the 9/4/2025 weight loss. During a telephone interview on 9/10/2025 at 2:15 PM, the Nurse Practitioner (NP) revealed that she could not recall if she was notified or not of Resident #38's weight loss. The NP stated that the facility does not call them on a week to week basis related to weight loss and she sees resident weights when she makes rounds monthly. The NP confirmed that she had not seen Resident #38 since July. During a telephone interview on 9/10/2025 at 2:32 PM, the Assistant Director of Nursing (ADON) confirmed that the DON should notify the physician of weight loss. The ADON stated staff meets weekly to discuss weight loss and any interventions that should be put in place. The ADON stated the facility can write an order for a house supplement and weekly weight without contacting the physician. The ADON stated that Resident #38 would have an order if she was receiving house supplement and weekly weights. During an interview on 9/10/2025 at 3:42 PM, the Administrator stated that the DON is in charge of the weight loss program, and the Physician should be notified of significant weight loss.

Based on policy review, facility documentation review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when the dishwasher did not meet the sanitary temperature requirement of 180 degrees Fahrenheit (F), and when staff failed to accurately complete the dishwasher temperature logs for 48 of 51 residents receiving meal trays. The findings include: 1. Review of the facility policy titled, Sanitization, revised 10/2008, revealed .The food service area shall be maintained in a clean and sanitary manner.Dishwashing machines must be operated using the followings specifications.High- Temperatures Dishwasher (Heat Sanitization).Wash temperature (150-165 F) for at least forty-five (45) seconds.Rinse temperature (165-180 F) for at least twelve (12) seconds. 2. Review of the Dishwasher Temperature Chart dated 6/2025, revealed the facility failed to monitor and document dishwasher temperatures at a sanitary degree for wash and final rinse for the following dates: a. 6/27/2025 noon temperature b. 6/28/2025 evening temperature c. 6/29/2025 evening temperature d. 6/30/2025 evening temperature e. 6/31/2025 evening temperature 3. Review of the Dishwasher Temperature Chart dated 7/2025, revealed the facility failed to monitor and document dishwasher temperatures at a sanitary degree for wash and final rinse. The following dates were not documented. a. 7/24/2025 noon and evening temperature b. 7/25/2025 noon and evening temperature c. 7/26/2025 noon temperature d. 7/27/2025 noon evening temperature e. 7/28/2025 noon and evening temperature f. 7/29/2025 noon and evening temperature g. 7/30/2025 noon temperature h. 7/31/2025 noon temperature 4. Review of the Dishwasher Temperature Chart dated 8/2025, revealed the facility failed to monitor and document dishwasher temperatures at a sanitary degree for wash and final rinse. The following dates were not documented. a. 8/15/2025 morning temperature b. 8/16/2025 morning temperature c. 8/19/2025 morning and noon temperature d. 8/20/2025 morning, noon and evening temperature e. 8/21/2025 morning and evening temperature f. 8/22/2025 noon temperature g. 8/24/2025 morning and noon temperature h. 8/25/2025 evening temperature i. 8/26/2025 noon and evening temperature j. 8/27/2025 noon temperature k. 8/31/2025 noon temperature During an observation and interview on 9/8/2025 starting at 2:35 PM, Dietary [NAME] I pushed the meal cart containing trays from droplet precautions rooms, from the hallway to the kitchen. Dietary Aide J removed all items from the meal cart, and placed the soiled trays, cups, and serving utensils on the dish room counter. Dietary Aide K placed the soiled trays, cups, and serving utensils on separate dishwasher racks and placed them in the dishwasher. Dietary [NAME] I confirmed the final rinse temperature was 176 degrees F. The Dietary Manager stated that the dishwasher was a high temp dishwasher with sanitizing solution as a back up. Dietary [NAME] I was asked to perform a sanitation test of the dishwasher. The Dietary Manager acknowledged that the facility was out of sanitation testing strips for the dishwasher. During an interview on 9/8/2025 at 3:17 PM, the Director of Nursing (DON) confirmed the dishwasher was not temping correctly and the facility should have sanitation testing supplies to ensure the proper sanitation of dinnerware and utensils.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 5 of 10 staff (Certified Nursing Assistant (CNA) D, E, F, Housekeeping Aide G and H) failed to donn (put on) and doff (remove) proper Personal Protective Equipment (PPE) and perform hand hygiene for 4 of 21 (Residents #11, #12, #19 and #28) residents in droplet precautions and when 1 of 4 staff (Licensed Practical Nurse (LPN) C) failed to sanitize reusable equipment during medication administration. The findings include: 1. Review of the facility policy titled, Coronavirus Disease (COVID-19) Infection Prevention and Control Measures, dated 4/29/2024, revealed .The facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility.These measures include: ensuring everyone is aware of recommended IPC practices in the facility.implementing source control measures.implementing universal use of PPE for staff. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 10/2024, revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .All personnel are expected to adhere to hand hygiene policies and practices .Hand hygiene is indicated .after touching a resident .after touching the resident's environment .immediately after glove removal .Single-use disposable gloves should be used .when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . Review of the Droplet Precautions signage revealed .Prior to entering the room.Clean Hands, Mask, Eye Protection or mask with eye protection.Clean hands prior to donning personal protective equipment (PPE), Wear mask over mouth and nose and eye protection.PPE Removal.should be removed before exiting patient room or care area, clean hands prior to removing mask and eye protection.clean hands again after removal of PPE. Review of the facility policy titled, Infection Control Guidelines., dated 12/29/2020, revealed .Transmission Based Precautions will be used whenever measure are more stringent than Standard Precautions are needed to prevent the spread of infection.Wear personal protective equipment as necessary to prevent exposure to.body fluids or other potentially infectious materials. Review of the undated facility policy titled, Cleaning and Disinfection of Resident-Care Items., revealed .Resident-care equipment, including reusable items.will be cleaned and disinfected.Reusable items are cleaned and disinfected or sterilized between residents. 2. Random observation and interview on 9/8/2025 at 8:55 AM, Housekeeping Aide G exited Resident #16's room wearing an isolation gown and gloves. Housekeeping Aide G entered the clean linen storage room with soiled gloves and obtained linens. Housekeeping Aide G stated staff should not enter the clean linen storage room with soiled gloves. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Diabetes, Anxiety, Parkinson's Disease, and Covid. Observation during dining on 9/8/2025 at 12:38 PM, revealed CNA D exited Resident #11's room while wearing an isolation gown and soiled gloves, and returned the resident's meal tray to the meal cart in the hallway. 4. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, COVID-19, and Diabetes. During an observation and interview on 9/8/2025 at 11:05 AM, Housekeeping Aide H entered Resident #12's droplet precaution room without an N-95 mask, goggles and/or face shield. Housekeeping Aide H acknowledged that she was not wearing an N-95 mask. Observation during dining on 9/8/2025 at 12:12 PM, CNA F entered Resident #12's room to collect resident's tray without donning a gown, gloves, and N-95 mask. CNA F did not perform hand hygiene after exiting the resident's room. During an interview on 9/8/2025 at 12:18 PM, CNA F stated that staff should wear PPE including a gown, gloves, and a N-95 mask prior to entering a resident's room in droplet precautions. 4. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Dementia, Congestive Heart Failure, Hypertension, and Covid-19. Observation during dining on 9/8/2025 at 12:34 PM, revealed CNA D exited Resident #19's room while wearing an isolation gown and soiled gloves and returned the resident's meal tray to the meal cart in the hallway. CNA D then returned to the resident's room to remove the gown and gloves. 5. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Dementia, COVID-19, and Malnutrition. Observation during dining on 9/8/2025 at 11:30 AM, CNA F entered Resident #28's droplet precaution room without donning a gown, gloves, and N-95 mask. During a telephone interview on 9/8/2025 at 3:17 PM, the Director of Nursing (DON) stated that all staff should wear appropriate PPE of gown, gloves, and a N-95 mask prior to entering a COVID-19 positive resident's room and staff should remove and perform hand hygiene prior to exiting the resident's room. During an interview on 9/10/2025 at 3:35 PM, the Director of Clinical Services stated that staff should wear the proper PPE and perform hand hygiene prior to entering and exiting COVID-19 positive resident's rooms.

Based on policy review, medical record review, and interview, the facility failed to ensure medication monitoring related to the use of an antipsychotic (a type of medication used to treat psychiatric conditions) medication for 1 of 5 (Resident #8) sampled residents reviewed for unnecessary medications. The findings include: 1.Review of the facility policy titled, Psychotropic Medication Use, dated 7/2022, revealed .Psychotropic medication management includes.adequate monitoring for efficacy and adverse consequences.preventing, identifying and responding to adverse consequences.Residents receiving psychotropic medication are monitored/assessed for adverse consequences. Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, dated 3/2019, revealed .will monitor for side effects and complications related to psychoactive medications. 2.Review of the medical record revealed Resident #8 was admitted on [DATE], with diagnoses including Traumatic Brain Injury, Dementia, Anxiety, and Psychosis. Review of the Physicians Order dated 7/25/2025, revealed OLANZapine [used to treat mood disorders] Oral Tablet 5 MG [milligrams] (Olanzapine) Give 5 mg by mouth at bedtime. Review of the Medication Administration Record (MAR) dated 7/25/2025 through 9/10/2025, revealed Resident #8 had no monitoring for antipsychotic medication. Reviews of the MAR dated 7/25/2025 through 9/10/2025, revealed Olanzapine was administered as ordered. Review of the admission Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #8 was cognitively intact, and received an antipsychotic medication. During an interview on 9/10/2025 at 10:57 AM, the Administrator in Training (AIT)/ Registered Nurse (RN) confirmed Resident #8 had an order for Olanzapine and monitoring should have been completed

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when medications were found unsecured and unattended in 2 of 51 (Resident #4 and Resident #34) resident rooms and when 2 of 5 (Licensed Practical Nurse (LPN) B and C) staff left medications unsecure and unattended on 2 of 6 (North Hall Cart and South Hall Cart) medication storage carts. The findings include: 1.Review of the facility policy titled, Storage of Medication, revised 4/2019, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, sanitary manner.Compartments (including, but not limited to, drawers, cabinets .carts) containing drugs and biologicals are locked while in use .Unlocked medication carts are not left unattended . 2.Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Intracranial Injury, Dementia, Anxiety, Dry Eye, and Allergic Rhinitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not conducted due to Resident #4 was severely cognitively impaired. Observations in Resident #4's room on 9/8/2025 at 8:53 AM, 9:48 AM, 10:01 AM, and 11:02 AM, revealed a nasal spray and a bottle of eye drops on Resident #4's bedside table. During an observation and interview in Resident #4's room on 9/8/2025 at 11:03 AM, Registered Nurse (RN) A was shown the nasal spray and eye drops on Resident #4's bedside table. RN A stated that medication should not be left at bedside unsecured and unattended. Observation during medication administration on 9/10/2025 at 9:55 AM, LPN C prepared Resident #4's medications and placed a medication cup of Valproic Acid (used to treat seizures) 250 milligram (mg)/5 milliliters (ml) 10 ml on top of the North Hall cart and walked away leaving the medication unsecure and unattended on the North Hall med cart. During an interview on 9/10/2025 at 10:04 AM, LPN C confirmed meds should not be left out unattended and unsecure on the med cart. During an interview on 9/10/2024 at 10:57 AM, the Administrator in Training (AIT)/ RN confirmed that medications should not be left in the resident's room at bedside unsecured and unattended. 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, and Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #34 was moderately cognitively impaired and required moderate assistance with activities of daily living. Review of the Physician's Order dated 9/9/2025, revealed Flonase Allergy Relief [used to treat congestion] Nasal Suspension .1 spray in each nostril every 12 hours as needed . Random observation on 9/9/2025 at 7:30 AM, Resident #34 was ambulating down the hall with a walker, and a bottle of Flonase nasal spray was on her walker. During an observation and interview in Resident #34's room [ROOM NUMBER]/9/2025 at 7:40 AM, the resident was sitting on the bedside with her walker in front of her. The Flonase nasal spray was on the front of her walker. The resident confirmed that the nasal spray was hers and she keeps it at bedside. During an interview on 9/9/2025 at 10:00 AM, the Administrator acknowledged that the Resident #34 did not have a self-administration assessment and confirmed medications should not be at bedside. 4. Random observation and interview on 9/9/2025 at 8:08 AM, a medication cup with 5 pills was unattended and unsecure on the top of the South Hall medication cart. LPN B stated that medications should not be left unsecure and unattended on the med cart. During an interview on 9/10/2025 at 4:34 PM, the Director of Clinical Services stated medications should not be left unsecure or unattended.

Based on review of the State licensure regulations, job description review, policy review, medical record review, review of facility investigations, observation, and interview, the facility failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures were measured for 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93) rooms, and when the facility failed to provide a safe environment and adequate supervision to prevent falls and injury for 7 of 7 (Resident #2, #11, #21, #28, #46, #52, and #54) sampled residents reviewed for accidents. On 6/24/2024 and 6/28/2024, dangerous elevated hot water temperatures ranging from 123 degrees Fahrenheit (F) to 130 degrees Fahrenheit (F) were observed in 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93). Two Residents who were physically and/or cognitively impaired (Residents #43 and #52) resided in a room with elevated dangerous hot water temperatures and two residents were able to access the hot water in their rooms. Two cognitively intact (Residents #40 and #55) stated the water would get too hot. The facility's failure to prevent the dangerously elevated hot water temperatures placed all residents with the ability to access the hot water in Immediate Jeopardy. The facility's failure to implement effective fall interventions resulted in actual harm when Resident #11 fell and sustained a closed fracture (broken bone) of the left distal femur (large upper bone of the leg). The failure of the facility to maintain safe hot water temperatures placed all residents with access to these rooms in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance has caused, or has potential to cause serious injury, harm, impairment, or death to a resident). The facility's census was 63. The Administrator, Director of Nursing (DON) and the Maintenance Supervisor were notified of the Immediate Jeopardy (IJ) for F689 on 6/24/2024 at 3:23 PM, in the facility Conference Room. An acceptable allegation of removal was received on 6/25/2024 at 12:38 PM. On 6/28/2024 beginning at 8:38 AM, while attempting to validate the allegation of removal, dangerously elevated hot water temperatures ranging from 122.5 degrees F to 123.6 degrees F were observed in resident rooms #13, #17 and #18. The Administrator was notified of the Immediate Jeopardy (IJ) for the amended F689 on 6/28/2024 at 10:47 AM, in the facility Conference Room. An extended survey was conducted 6/26/2024 through 6/28/2024. The Immediate Jeopardy for F-689 began on 6/24/2024. The Immediate Jeopardy is ongoing. The findings include: 1. Review of the State Licensure Regulations, CHAPTER 0720-18 STANDARDS FOR NURSING HOMES revised July 2022, revealed at 720-18-.08 17 (c), Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105 F and 115 F. 2. Review of the undated ADMINISTRATOR JOB DESCRIPTION revealed .Position Purpose .Leads, guides, and directs the operations of the healthcare facility in accordance with local state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents .Plans, develops, implements, evaluates, and directs the overall operation of the facility as well as its programs and activities in accordance with current state and federal laws and regulations .Leads and coordinates .management team meetings to discuss priorities and develop solutions .Knows and understands general nursing practices and procedures .Code of Federal Regulations, Appendix PP State Operations Manual .collaborates with members of the interdisciplinary team .to resolve issues . Promotes .effective communication .Ensures the facility's plan of correction response to any regulatory, inspection survey is completed, adequate, implemented, and timely .Communicates directly with .medical staff, nursing staff .department heads, and members of the interdisciplinary team to coordinate care .Responds and resolves complaints and concerns . Protects residents from abuse .Follows established infection control policies . Review of the undated DIRECTOR OF NURSING JOB DESCRIPTION revealed .Position Purpose .Planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulation, established facility policies .to provide appropriate care and services to the residents .Communicates policies and procedures to nursing staff and monitors staff practices and implementations .Participates in daily or weekly management team meetings to discuss .resident change in status, complaints, or concerns .Ensures delivery of .quality care .Oversees resident incidents .daily .reports them promptly to the Administrator .for appropriate action .Monitors for allegations of potential abuse or neglect .and participates in the investigative process .Acts in an administrative capacity in the absence of the administrator . Review of the undated MAINTENANCE DIRECTOR JOB DESCRIPTION revealed, .Position Purpose .Directs .Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing the facility and to assure the facility is maintained in a safe and comfortable manner .Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility which includes .plumbing .Develops and implements preventative maintenance tasks .instructions, and procedures for the preventative maintenance of the facility .Ensures the facilities compliance with the law and other regulatory terms such as safety .Performs and monitors required inspections of facility equipment .Maintains a safe and secure working environment free of .situations that could cause harm .to residents, families, visitors . 3. Review of the facility policy titled, .FALL PROGRAM GUIDELINES, dated 11/8/2019, revealed FALL RISK ASSESSMENT PURPOSE: IDENTIFY RESIDENTS AT RISK FOR FALLS AND APPLY MEASURES TO REDUCE THE OCCURRENCE OF ALL RELATED INCIDENTS .Complete a Fall Risk Assessment form on admission, quarterly and prn [as needed]. A resident who scores 7 or higher on the Fall Risk Assessment will be considered high risk for falls. If it is determined that a resident is high risk for falls perform the following: Review and assess on a quarterly basis or with significant changes- resident's fall history, environmental factors and mediation use which could contribute to the risk of falling .Perform personal assessment on resident to address factors which would increase fall risk with annual MDS [Minimum Data Set] assessments or any significant changes of status .Assess resident for need to use adaptive equipment that could decrease fall risk, such as, walker, quad cane, body alarm, low bed or other adaptive equipment as determined on an individual basis .Care plan risk factors and any interventions in place for each individual based on their specific needs .Fall Risk Assessment will include assessment of anticoagulant use with severely impaired cognitive residents . Review of the facility policy titled, .POST FALL GUIDELINE, dated 11/8/2019, revealed PURPOSE: TO EVALUATE EACH INDIVIDUAL FALL AND DETERMINE NEW INTERVENTIONS FOR THE EVENT OF FUTURE FALLS .Complete Post Fall Investigation Form immediately after a fall for each resident when a fall occurs .The immediate intervention of Q 15 [every 15] minute checks will act as a care planned intervention until the Fall Committee meets and reviews the fall; At that time of the Fall meeting the immediate intervention will become void .The Fall Committee will collaborate and form a fall intervention based on the resident's individual needs and medical condition .The Fall Committee Leader will complete a Fall Investigation and develop a summary of the events surrounding each individual fall. 4. The surveyor's thermometer was calibrated (a procedure using ice water to ensure the thermometer is measuring correctly) before water temperature checks were obtained. The surveyor's hot water temperature checks in resident rooms on 6/24/2024 beginning at 10:11 AM, revealed the following: room [ROOM NUMBER] was 130 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 130 degrees F. The Maintenance Director and the surveyors' hot water temperature checks using a calibrated thermometer in resident rooms on 6/24/2024 beginning at 12:11 PM, revealed the following: room [ROOM NUMBER] was 126 degrees F. room [ROOM NUMBER] was 125 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 123 degrees F. The Maintenance Director and the surveyor's hot water temperature checks using a calibrated thermometer in resident rooms on 6/28/2024 beginning at 8:38 AM, revealed the following: room [ROOM NUMBER] was 123.6 degrees F. room [ROOM NUMBER] was 123.6 degrees F. room [ROOM NUMBER] was 122.5 degrees F. 5. Review of the current MDS assessments revealed Residents #43 and #52 were cognitively and/or physically impaired, and the residents had access to the hot water with the dangerously elevated hot water temperatures. The facility provided a list of residents who wander. The list revealed Residents #43 and #52 were cognitively impaired and had been identified by the facility as Residents with wandering behaviors (random, repetitive, or aimless locomotion/movement throughout an area) and had the potential to be affected by dangerously hot water temperatures. 6. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Fracture of the Right Femur, Fracture of Shaft of Right Radius, and Dementia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #17 scored a 6 on the Brief Interview for Mental Status (BIMS) which indicated the Resident was severely cognitively impaired. Observation and interview in Resident #17's bathroom with the Maintenance Director present on 6/28/2024 at 8:45 AM, revealed a hot water temperature of 122.5 degrees F in the hand sink. The Maintenance Director stated, It's out of range, too high. 7. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dysphagia, Anxiety, Hypertension and Osteoarthritis. Review of the admission MDS dated [DATE], revealed Resident #40 scored a 14 on the BIMS, which indicated the resident was cognitively intact. Resident required moderate assistance with Activities of Daily Living (ADLs). Observation and interview in the Resident #40's room on 6/24/2024 at 9:38 AM, revealed the Resident was sitting up in a chair his room. The Resident reported that water was hot when washing hands in the bathroom. Resident #40 resided in a room which measured a dangerously hot water temperature of 123 degrees F. 8. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes. Review of the admission MDS dated [DATE], revealed Resident #41 scored a 15 on the BIMS, which indicated the Resident was cognitively intact. Observation and interview in Resident #41's bathroom with the Maintenance Director present on 6/28/2024 at 9:40 AM, revealed a hot water temperature of 123.6 degrees F in the hand sink. The Maintenance Director stated, It's too high . 9. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Major Depression, Asthma, and Urinary Tract Infection. Review of the Physician's Order dated 8/10/2023, revealed WANDER GUARD TO LEG AS ORDERED . Review of the quarterly MDS dated [DATE], revealed Resident #43 scored a 4 on the BIMS, which indicated the Resident was severely cognitively impaired. The Resident required moderate assistance from staff to perform ADLs. Observation and interview in the Resident #43's room on 6/24/2024 at 9:33 AM, revealed the Resident was resting in bed and was asked about the water temp in her bathroom. The Resident stated the water gets too hot and will scald you if you don't add cold water with the hot water. Resident #43 resided in a room which measured a dangerously hot water temperature of 123 degrees F. Observation and interview in the Resident #43's bathroom with the Maintenance Director present on 6/24/2024 at 12:09 PM, revealed a hot water temperature of 123 degrees F in the hand sink. The Maintenance Director stated, It's hot. It's over the limit today girls. We had trouble with that boiler [water heater], so I had to turn it up. 10. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Chronic Obstructive Pulmonary Disease, Depression, and Heart Failure. Review of the quarterly MDS dated [DATE], revealed Resident #44 scored a 15 on the BIMS, which indicated the Resident was cognitively intact. The Resident required supervision assistance of staff to perform ADLs. Observation and interview in Resident #44's bathroom on 6/24/2024 beginning at 12:15 PM with the Maintenance Director present revealed a hot water temperature of 125.8 degrees F. The Maintenance Director stated, This is my fault. I did not turn the boiler [water heater] back down. The Maintenance Director was asked when the boiler was turned up. The Maintenance Director stated, Last week sometime maybe Monday [6/17/2024] .We had a bird get in the pipe. The Maintenance Director was asked what the boiler was usually set on. The Maintenance Director stated, 120. The Maintenance Director was asked what the boiler temperature was turned up to. The Maintenance Director stated, 134. Observation of the North Hall utility room on 6/24/2024 at 12:19 PM with the Maintenance Director present revealed a water heater that was set at 135 degrees F. 11. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Coronary Artery Disease, Heart Failure, Cerebrovascular Vascular Accident, and Dementia. Review of the significant change MDS dated [DATE], revealed Resident #52 scored a 6 on the BIMS, which indicated he was severely cognitively impaired. Resident #52 resided in a room which measured a dangerously elevated hot water temperatures of 123 degrees F and had the ability to access the hot water. 12. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Hypertension, Chronic Kidney Disease, Chronic Diastolic Heart Failure, Asthma, Depression, and Coronary Artery Disease. . Review of the quarterly MDS dated [DATE], revealed Resident #55 scored a 14 on the BIMS, which indicated the Resident was cognitively intact. Resident #55 required maximum assistance of staff to perform ADLs and the use of wheelchair required for mobility. Resident #55 resided in a room with a dangerous hot water temperature of 126 degrees F and the ability to reach the water. 13. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Congestive Heart Failure and Coronary Artery heart Disease. Review of the admission MDS dated [DATE], revealed Resident #59 scored a 5 on the BIMS, which indicated the Resident was severely cognitively impaired. Observation and interview in Resident #59's bathroom with the Maintenance Director present on 6/28/2024 at 8:45 AM, revealed a hot water temperature of 122.5 degrees F in the hand sink. The Maintenance Director stated, It's out of range, too high. During an interview on 6/24/224 at 12:20 PM, the Maintenance Director was asked how often water temperatures were checked. The Maintenance Director stated, Once a week . During an interview and observation of the North Hall Utility Room on 6/24/2024 at 12:49 PM, the Maintenance Director was asked, what was the difference in a water heater and a boiler. The Maintenance Director stated, They both do the same thing . The Maintenance Director confirmed the facility had a water heater, but he referred to it as a boiler. The Maintenance Director was asked what alerted him that there was a problem with the water temperature last week. The Maintenance Director stated, The water temps [on the North Hall] were off. They were 103-110 [degrees F.]. The Maintenance Director was asked if he had documented the water temps from the North Hall. The Maintenance Director stated, No, because I got them [water temps] back where they were supposed to be. The Maintenance Director was asked if the water temperatures were rechecked after the water heater had been turned up. The Maintenance Director stated, Yes. Thursday [6/20/2024] or Friday [6/21/2024]. The Maintenance Director was asked if these water temperature checks were documented. The Maintenance Director stated, No ma'am. The Maintenance Director was asked how the bird got in the water heater pipe. The Maintenance Director stated, It's a gas water heater. The Maintenance Director pointed to a pipe coming from the water heater and going to the wall, and stated, That is an exhaust pipe that lets fumes out. Observation outside the building revealed a white pipe sticking out from the side of the building with a mesh covering the end. The Maintenance Director confirmed the end of the pipe had been uncovered since the water heater was installed on 9/8/2021, and that he had placed the mesh on the end after 2 birds got in the pipe. The Maintenance Director stated, That is a vent to let the exhaust fumes out, the birds getting in stopped the fumes from getting out and the hot water heater shut off. The Maintenance Director confirmed he was the only one who checked water temperatures in the resident rooms. The Maintenance Director was asked should he have documented when the water temperatures were low. The Maintenance Director stated, No I had one that was right. I only have to have one from each hall. I don't have to document them all unless you all have changed your guidelines. The Maintenance Director was asked should he have documented that he had rechecked the water temps later in the week once he had increased the temperature of the water heater. The Maintenance Director stated, Last Friday [6/21/2024] I was good, and I needed to turn it back down .I didn't turn it back down. During an interview on 6/24/2024 at 1:22 PM, the Administrator was asked if she was aware there were some problems with the water temperatures last week. The Administrator stated, No ma'am. The Administrator was asked were you notified that there was a problem and the Maintenance Director had to turn up the temperature on the water heater. The Administrator stated, No, not that I recall. The Administrator was asked, have you been notified today that you have water temperatures greater than 120 degrees. The Administrator stated, No ma'am. During an interview on 6/24/2024 at 3:02 PM, the Administrator was asked who monitored water temperatures. The Administrator stated, That would be [named the Maintenance Director]. The Administrator was asked do you expect him to notify you if the water temperatures are out of range. The Administrator stated, Yes. The Administrator was asked what staff should do if they think the water is too hot. The Administrator stated, They should call [named the Maintenance Director] .he is always on call . The Administrator was asked were you aware of any problems with the water temperatures. The Administrator stated, No ma'am. The Administrator was asked has [the Maintenance Director] reported any problems with the water temperatures today. The Administrator stated, No ma'am. During an interview on 6/24/2024 at 3:10 PM, the Maintenance Director confirmed he checked water temperatures weekly. The Maintenance Director was asked, when did he notice the water temperature was low last week. The Maintenance Director stated, They [facility staff] called me and told me they didn't have no hot water. The Maintenance Director was asked who called him. The Maintenance Director stated, I'm not for sure, a CNA [Certified Nursing Assistant] or the hairdresser .I found the bird in there, so I boosted the temps up [on the hot water heater] to get it where it needed to be, because I needed to get my water temps. I told the guy who works with me, we aren't going to record these temps yet . The Maintenance Director was asked, when staff called you, did you put in a work order. The Maintenance Director stated No, I just started addressing the problem. The Maintenance Director was asked when you have a problem like the one last week [with the water temperatures] do you let the Administrator know. The Maintenance Director stated, I try to, but I don't tell her every little thing. During an interview on 6/28/2024 at 9:20 AM, the Administrator confirmed the Maintenance Director had notified her that there was a problem with the water being too hot but did not tell her the temperature of the water. During an interview on 6/28/2024 at 4:11 PM, the Administrator confirmed she had not notified the Medical Director of the Immediate Jeopardy and that the facility had not conducted an ad hoc [when necessary] QAPI [Quality Assurance Performance Improvement] meeting related to the water temperatures. 14. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], and a reentry date of 5/11/2024, with diagnoses including Left Femur Fracture, Alzheimer's Disease, Malnutrition, Glaucoma, Osteoporosis, Congestive Heart Failure, and Insomnia. Review of the Care Plan dated 7/5/2023, revealed .Fall r/t [related to] poor safety awareness . Offer toileting at bedtime and upon rising. Review of the quarterly MDS dated [DATE], revealed Resident #11 scored an 8 on the BIMS, which indicated severe cognitive impairment, and required moderate assistance with bed mobility and sit to stand, maximum assistance with toileting and toilet transfer, and was always continent of bowel and bladder, was not on a toileting program, and experienced two (2) or more falls with no injury since admission or prior assessment. Review of Resident #11's Un-witnessed [Fall Report], for Fall #1, dated 12/13/2023 at 5:31 AM, revealed .This nurse heard a sound come from resident's room, as this nurse entered the room nurse observed resident sitting in the floor .Resident states she had an accident and was trying to get cleaned up and fell .assisted to W/C [wheelchair] .Bed linen changed. Resident assisted back to bed .Oriented to Person .Incontinent .Ambulating without Assist .Improper Footwear . Review of Resident #11's Post Fall Evaluation dated 12/13/1033 at 5:47 AM, revealed .Wheelchair was involved in fall. Wheelchair was not locked at time of fall .Footwear at time of fall: Bare feet .Resident was not using cane/walker as instructed .Resident was using incontinent supplies at time of fall. Incontinent at time of fall: Yes. Bedside call light on when Resident was found: No . Review of the FALL COMMITTEE MEETING dated 12/13/2023, for Resident #11 revealed .INTERVENTION: Offer toileting @ [at] HS [hours of sleep] and upon rising . Review of the revision to Resident #11's care plan dated 12/14/2023 revealed the intervention for falls was, .12/14/2023 Anti-rollbacks to w/c [wheelchair] . Review of the facility's Un-witnessed [Fall Report], for Resident #11's Fall #2, dated 12/18/2023 at 2:16 PM, revealed .observed her [Resident #11] laying on the floor .Resident states she was trying to put away her clothes that were in the basket. She said had one hand on the basket and the other on the walker and fell over the walker .Confused .Gait Imbalance .Improper Footwear .Using [NAME] . Review of the FALL COMMITTEE MEETING dated 12/18/2023, for Resident #11 revealed INTERVENTION: Encourage family to put away laundry once returned . Review of the revision to Resident #11's care plan dated 12/18/2023 revealed, . Encourage family to put away laundry when brought . Review of Resident #11's Un-witnessed [Fall Report], for Fall #3, dated 12/26/2023 at 4:59 AM, revealed .Resident observed sitting in floor between bed and wheel chair [wheelchair] .Non-skid socks placed on Resident .Resident states she was attempting to get into wheel chair because it was storming outside and slid between the bed and the chair .Confused .Impaired Memory .Ambulating without Assistance .Improper Footwear . Review of the FALL COMMITTEE MEETING dated 12/27/2023, for Resident #11 revealed INTERVENTION: Ensure w/c [wheelchair] is beside Bed for Convivence [convenience] . Review of the revision to Resident #11's care plan dated 12/27/2023 revealed, . Ensure w/c is beside bed for convenience. Review of Resident #11's Un-witnessed [Fall Report], for Fall #4, dated 2/9/2024 at 5:15 AM, revealed .Resident observed sitting on the floor in her room .Resident was wearing regular socks and no shoes at the time .resident stated she was going to the bathroom .Current UTI (Urinary Tract Infection) .Ambulating without Assistance .Improper Footwear . Review of the FALL COMMITTEE MEETING dated 2/9/2024, for Resident #11 revealed INTERVENTIONS: Bowel and Bladder while awake . Review of the revisions to Resident #11's care plan dated 2/9/2024 revealed, . B&B [bowel and bladder] program q [every] 2 hrs [hours] while awake . Review of the quarterly MDS dated [DATE], revealed Resident #11 scored a 3 on the BIMS, which indicated the Resident was severely cognitively impaired. Resident #11 used a walker and wheelchair for mobility, received moderate assistance for sitting to standing and walking 10 feet, and maximum assistance with bed mobility, transfer, and toileting. Resident #11 was frequently incontinent of bladder, always continent of bowel, was not currently on a toileting program (such as scheduled toileting, prompted voiding or bladder training). The MDS documented the Resident had one fall since the previous assessment. Review of Resident #11's Un-witnessed [Fall Report], for Fall #5, dated 3/5/2024 at 4:39 AM, revealed .Resident sitting on buttocks with feet towards bathroom. Resident states she was trying to go to the bathroom to see what her husband was doing in there .Impaired Memory .Ambulating without Assist . Review of the FALL COMMITTEE MEETING dated 3/5/2024, for Resident #11 revealed INTERVENTIONS: Pressure Alarm [to bed] during sleep hours . Review of the revisions to Resident #11's care plan dated 3/5/2024 Pressure alarm to bed during sleep hours .MD [Medical doctor] to do medication review d/t [due to] increased confusion. Review of Resident #11's Un-witnessed [Fall Report], for Fall #6, dated 4/13/2024 at 4:05 PM, revealed .CNA [Certified Nursing Assistant] tried to transfer resident from toilet to w/c [wheelchair] but resident would not sit in chair. CNA lowered resident to the floor . Review of the FALL COMMITTEE MEETING dated 4/15/2024, for Resident #11 revealed INTERVENTION: Therapy to screen . The facility was unable to provide evidence of a therapy screen. Review of Resident #11's Un-witnessed [Fall Report], for Fall #7, dated 4/17/2024 at 9:50 AM, revealed .went into resident room notice [noticed] her laying on the floor against the door . Review of Resident #11's care plan interventions dated 4/18/2024 revealed, . Nursing staff to re-educate resident on safety awareness during transfers. There was no documentation for Therapy to screen Resident #11 per the Fall Committee interventions. Review of the FALL COMMITTEE MEETING dated 4/18/2024, for Resident #11 revealed INTERVENTION: Refer to MD or NP [Nurse Practitioner] to Assess . The medical record revealed the NP assessed Resident #11 on 4/19/2024. There were no new recommendations or interventions implemented to prevent Resident #11 from further falls. Review of Resident #11's Witnessed Fall [Fall Report], for Fall #8, dated 5/2/2024 3:30 PM, revealed .CNA entered the room and resident [Resident #11] was standing in the middle of the room. Resident would not sit in w/c . CNA lowered resident to the floor and went for help .Oriented to Person .Confused .Ambulating without Assist . Review of the FALL COMMITTEE MEETING dated 5/3/2024, revealed INTERVENTION: Provide door Alarm to Bathroom door . Review of Resident #11's Un-witnessed [Fall Report], for Fall #9, dated 5/5/2024, revealed .observed resident on the floor .Resident stated she was trying to get some panties .Confused .Gait Imbalance .Recent change in Cognition .Ambulating without Assist . Review of the FALL COMMITTEE MEETING dated 5/6/2024, for Resident #11 revealed INTERVENTION: MD [medical doctor] to perform Med [Medication] Review secondary to increased confusion . The facility was unable to provide evidence of an immediate med review performed for the resident's 5/5/2024 fall. Review of the revisions to Resident #11's care plan dated 5/6/2024, revealed . NP [Nurse Practitioner] to assess resident. There was no documentation to include the intervention of adding a door alarm to the bathroom door until 5 days after the 5/2/2024 fall (on 5/7/2024). There was no evidence of how adding a door alarm to the Resident bathroom door would prevent further falls. Review of Resident #11's Un-witnessed [Fall Report], for Fall#10 dated 5/8/2024, revealed .Called to the room per housekeeping that resident [Resident #11] was on the floor. Observed her [Resident #11] laying on left side. Tried to move resident but she started yelling out. Left resident comfortably on the floor to get more assistance and called for [abbreviation for local emergency medical services (EMS)]] .resident stated she was getting her coat out [of] the closet so they could get out of facility .Resident was sent to [named hospital] .Injuries Observed at Time of Incident .left trochanter (hip) .Left ankle (outer) Level of Pain .7 .Mobility: Ambulatory with assistance . Record review revealed Resident #11 was admitted to the hospital on 5/8/2024 - 5/13/2024 with a Left Fractured Femur. The Resident's family declined surgical intervention and the Resident was discharged back to the nursing facility with a 2-week Orthopedic consult and activities as tolerated. Review of the annual MDS dated [DATE], revealed Resident #11 had a BIMS score of 2, which indicated severe cognitive impairment. Resident #11 had physical behaviors toward others, rejection of care, and behaviors were worse than previous assessment. Two or more fall and one with major injury since the previous assessment. Review of the FALL COMMITTEE MEETING dated 5/9/2024, revealed Intervention: Send to ER for Eval [Evaluation]/[and] Adjust closet rod for easier access of clothes . Review of the revisions to Resident #11's care plan dated 5/9/2024, revealed .The resident is .risk for falls r/t [related to] Confusion, Gait/balance problems, Hypotension, Incontinence, Unaware of safety needs, Vision/hearing problems, Wandering .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed . Review of Progress Notes for Resident #11 dated 5/13/2024 (misdated 5/30/2024), revealed Received report from [city of hospital] hospital @ [ [TRUNCATED]

Based on policy review, facility investigation review, police report review, documentation review, medical record review, and interview, the facility failed to protect the resident's right to be free from abuse from another resident for 1 of 4 (Resident #42) sampled residents reviewed for abuse. The facility's failure to protect the resident's right to be free from abuse resulted in actual HARM, when on 1/17/2024, Resident #42 sustained two lacerations to the forehead when Resident #166 hit Resident #42 in the head with a hard plastic drinking cup. The findings include: 1. Review of the facility undated policy titled ABUSE PREVENTION POLICY revealed, .Every precaution will be taken to prevent mistreatment, neglect and abuse of residents .Residents must not be subjected to abuse by anyone, including .other residents . Review of the facility undated policy titled RESIDENT ABUSE POLICY revealed, .Purpose: To investigate any suspected or alleged abuse to residents by anyone. Definition: Abuse is the willful infliction of injury .with resulting physical harm or pain .PROCEDURE: ALLEGATION OF ABUSE BY ANOTHER RESIDENT .Allegations of abuse will be thoroughly investigated and documented .Residents will be protected from possible further abuse during the investigation . 2. Review of a Psychiatric Hospital Admission Record revealed Resident #166 was admitted to a behavioral health facility on 12/6/2023, with the Reason for Admission being .Patient lives at home with his spouse .hx [history] of Vascular Dementia .Wife reports on 11/28 [2023] .busted the front door, sheriff was called . has been throwing bricks at the wife and the windshield . Review of the medical record revealed Resident #166 was admitted to the nursing home facility on 1/4/2024, with a diagnosis including Dementia with Agitation and Behaviors. Resident #166 was documented to have behaviors from admission on 1/4/2024 until discharge on [DATE]. The behaviors included wandering the halls, going into other resident's rooms, rummaging through other's belongings and the Personal Protective Equipment (PPE) carts on the hall, yelling, cursing, disrobing, and grabbing staff and experienced sexually inappropriate behaviors toward staff. Resident #166's prescriptions of antipsychotic, antidepressants, and anxiety medications and redirection were ineffective in controlling the Resident's behaviors. Physician Orders revealed, .UA with C&S [urinalysis culture and sensitivity test] 1/4/2024 .Document adverse behaviors [Target behaviors .] .Haloperidol 1 mg [milligram] two times a day for agitation/anxiety .Haloperidol 2 mg at bedtime for agitation/anxiety .Lorazepam 1 mg every 4 hours as needed for anxiety . Review of a Nursing Progress Note dated 1/4/2024 at 12:47 PM revealed at 8:03 PM, Resident #166 struck Licensed Practical Nurse (LPN) B as she was walking out the door of his room. Review of a Nursing Progress Note dated 1/6/2024 at 1:26 PM, revealed Resident #166 was observed walking in the hallway while naked, and at 6:38 PM, Resident #166 was found in another resident's room. When Certified Nursing Assistant (CNA) E attempted to redirect Resident #166 back to bed, Resident #166 grabbed CNA E's arm and told her he was going to break it. The Resident then grabbed CNA E by the throat and told her he was going to kill her. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #166 scored a 2 on the Brief Interview for Mental Status (BIMS), which indicated the Resident had severe cognitive impairment. Resident #166 was dependent on staff for all care except for feeding self. Review of a Nursing Progress Note dated 1/14/2024 at 5:13 PM, revealed Resident #166 wandered into the Activity Room and had both hands on a resident's head before being redirected by LPN B. Review of a Nursing Progress Note for Resident #166 dated 1/17/2024, revealed .called to the room of [named Resident #42] . This resident [Resident #166] went into his [Resident #42] room and picked up phone . [Resident #42] put phone back. Then resident [Resident #166] went over to . [Resident #42] picked up water glass and stuck [struck] him [Resident #42] in the head. Resident [#42] has 2 [two] cut about 1/4 inch at left eye brow. Resident [#166] was redirected to his room . Resident #166 was discharged from the nursing facility to a Psychiatric Hospital on 1/17/2024 after the incident with Resident #42. Review of Resident #166's Care Plan dated 1/18/2024, (after Resident #166 was discharged from the facility) revealed .The resident has a behavior problems: entering other residents room, rummaging, spitting, agitation, anxious/restlessness, wandering, grabbing others, hitting others, kicking others, pushing others, physically aggressive towards others, exit seeking, expressing anger at others, screaming at others, threatening others, disrobing in public, public sexual acts, throwing/smearing food, delusions, hallucinations, panic, withdrawn .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes .wander guard to leg as ordered to alert staff of any attempts to elope .Administer Depakote, Haloperidol, Seroquel, Zoloft as ordered. Monitor for side effects/effectiveness. Notify MD as needed .The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia, BIMS, inattention, disorganized thinking, wandering, and behaviors . The resident has delirium or an acute confusional episode r/t BIMS, inattention, disorganized thinking .Provide medications to alleviate agitation as ordered by MD. Monitor/document side effects and effectiveness . There was no documentation of a Care Plan for Resident #166's behaviors prior to the Resident's discharge from the facility. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Polyneuropathy, Diabetes, Peripheral Vascular, Chronic Kidney Disease, Heart Disease, Non-Pressure Chronic Ulcer of Right Foot, and Hypertension. Review of the Annual MDS dated [DATE], revealed Resident #42 scored a 15 on the BIMS, which indicated the Resident had no cognitive impairment. Resident #42 was independent and required minimal assist. Review of the weekly skin assessment for Resident #42 dated 1/17/2024, revealed Resident #42 with two lacerations on the left side of the forehead, both measuring 0.4 centimeters (cm) long. Review of facility records and the facility investigation revealed on 1/17/2024, Resident #166 wandered into Resident #42's room. Resident #166 picked up a hard plastic drinking cup and hit Resident #42 in the forehead causing a laceration to the Resident's forehead. Review of the Witness Statement by LPN B on 1/17/2024 at 3:45 PM, revealed Resident #42 had been involved in an altercation with Resident #166, .called to Room [number of the room] . [Resident #166] . wandered into [Resident #42's room] . and struck Resident [Resident #42] . in the head with a water glass. Resident has 2 [two] 1/4 [one quarter] inch cuts at left eyebrow . Review of the Witness Statement by Social Services on 1/17/2024 at 4:25 PM, revealed, .resident [Resident #42] .stated resident .[Resident #166] walked into his room and picked up the phone. Resident [Resident #166] . then knocked everything off the bedside table and spilled the water all over the floor. Resident [Resident #166] . then hit [Resident #42] .with the glass in his hand on his left temple and cheek area. A nurse assisted [Resident #42] . with his cut [laceration] . Review of the quarterly MDS dated [DATE], revealed Resident #42 scored a 15 on the BIMS, which indicated the Resident had no cognitive impairment. Resident #42 was independent and required minimal assist. 4. During an interview on 6/28/2024 at 8:30 AM, CNA E was asked to describe the incident of Resident #166 grabbing her arm and throat and threatening her. CNA E stated she tried to redirect Resident #166 and pulled up his briefs, but the Resident was very agitated and kept pulling away from her. CNA E stated she was walking Resident #166 down the hallway and the Resident was very agitated, and .grabbed my arm as hard as he could and said he was going to break if off . CNA E stated Resident #166 then grabbed her (CNA E) by the throat and said he, .was going to [F word expletive] kill me . CNA E stated at this point she [CNA E] was very upset and stated, . I just dropped everything and walked out . CNA E stated she told the charge nurse what had happened and that she (CNA E) was told to write a statement and chart the behaviors. CNA E stated, .I wrote the statement .I think I may have just left it on the nurse station, but I don't believe I charted the behaviors .I can't remember .it was all such a blur after that . CNA E stated no one interviewed her or talked about the incident. During an interview on 6/28/2024 at 10:56 AM, the Director of Nursing (DON) stated, .he [Resident #166] was a handful .wandered . very agitated .hard to redirect . The DON was asked what interventions were put into place. The DON stated, . we referred him [Resident #166] to psych services .tried redirection .notified the doctor .PRN [as needed] Ativan [a medication for anxiety) for his agitation . During an interview on 6/28/24 at 10:56 AM, the DON was asked if she felt like adequate interventions were put into place to keep staff and resident's safe. The DON stated, .In hindsight, probably not . trying to think of him [Resident #166] particularly with him having issues coming in .we didn't do one on one . outside of putting stop signs on everyone's doors to keep him [Resident #166] from going in there .I don't know what else we could have done .other than he's [Resident #166] leaving and not coming back kind of thing again that's hindsight. That's what we know now .

Based on review of the job description review, review of the State Licensure Regulations, policy review, medical record review, observation, and interview, the facility Administration failed to provide oversight to monitor and prevent hot water temperatures in resident care areas, failed to ensure a safe environment and adequate supervision to prevent falls, failed to prevent resident to resident abuse, and failed to ensure a resident with behaviors received appropriate care and services for 10 of 63 residents (Resident #17, 36, 40, 41, 43, 44, 52, 55, 166, and 370) residents. The findings include: 1. Review of the undated ADMINSITRATOR JOB DESCRIPTION revealed .Position Purpose .Leads, guides, and directs the operations of the healthcare facility in accordance with local state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents .Plans, develops, implements, evaluates, and directs the overall operation of the facility as well as its programs and activities in accordance with current state and federal laws and regulations .Leads and coordinates .management team meetings to discuss priorities and develop solutions .Knows and understands general nursing practices and procedures .Code of Federal Regulations, Appendix PP State Operations Manual .collaborates with members of the interdisciplinary team .to resolve issues .Promotes .effective communication .Ensures the facility's plan of correction response to any regulatory, inspection survey is completed, adequate, implemented, and timely .Communicates directly with .medical staff, nursing staff .department heads, and members of the interdisciplinary team to coordinate care .Responds and resolves complaints and concerns .Protects residents from abuse .Follows established infection control policies . Review of the undated DIRECTOR OF NURSING JOB DESCRIPTION revealed .Position Purpose .Planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulation, established facility policies .to provide appropriate care and services to the residents .Communicates policies and procedures to nursing staff and monitors staff practices and implementations .Participates in daily or weekly management team meetings to discuss .resident change in status, complaints, or concerns .Ensures delivery of .quality care .Oversees resident incidents .daily .reports them promptly to the Administrator .for appropriate action .Monitors for allegations of potential abuse or neglect .and participates in the investigative process .Acts in an administrative capacity in the absence of the administrator . Review of the undated MAINTENANCE DIRECTOR JOB DESCRIPTION revealed .Position Purpose .Directs .Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing the facility and to assure the facility is maintained in a safe and comfortable manner .Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility which includes .plumbing .Develops and implements preventative maintenance tasks .instructions, and procedures for the preventative maintenance of the facility .Ensures the facilities compliance with the law and other regulatory terms such as safety .Performs and monitors required inspections of facility equipment .Maintains a safe and secure working environment free of .situations that could cause harm .to residents, families, visitors . 2. The facility Administration failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures and failed to provide a safe environment and adequate supervision to prevent falls and injury. a. The facility Administration failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures were measured for 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93) rooms. On 6/24/2024 and 6/28/2024, dangerous elevated hot water temperatures ranging from 123 degrees Fahrenheit (F) to 130 degrees Fahrenheit (F) were found in 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93). Two Residents who were physically and/or cognitively impaired (Residents #43 and #52) resided in a room with elevated dangerous hot water temperatures and two residents were able to access the hot water in their rooms. Two cognitively intact (Residents #40 and #55) stated the water would get too hot. During an interview on 6/24/2024 at 1:22 PM, the Administrator was asked if she was aware there were some problems with the water temperatures last week. The Administrator stated, No ma'am. The Administrator was asked were you notified that there was a problem and the Maintenance Director had to turn up the temperature on the water heater. The Administrator stated, No, not that I recall. The Administrator was asked if they had been notified today that you have water temperatures greater than 120 degrees. The Administrator stated, No ma'am. During an interview on 6/24/2024 at 3:02 PM, The Administrator was asked who monitors water temperatures. The Administrator stated, That would be [named the Maintenance Director]. The Administrator was asked do you expect him to notify you if the water temperatures are out of range. The Administrator stated, Yes. The Administrator was asked are you aware of any problems with the water temperatures. The Administrator stated, No ma'am. The Administrator was asked has [the Maintenance Director] reported any problems with the water temperatures today. The Administrator stated, No ma'am. During an interview on 6/24/2024 at 3:10 PM, the Maintenance Director confirmed there was a problem with the water temperatures the previous week and he had adjusted the water heater. The Maintenance Director was asked when you have a problem like the one last week [with the water temperatures] do you let the Administrator know. The Maintenance Director stated, I try to, but I don't tell her every little thing. During an interview on 6/28/2024 at 9:20 AM, the Administrator confirmed the Maintenance Director had notified her that there was a problem with the water being too hot but did not tell her the temperature of the water. During an interview on 6/28/2024 at 4:11 PM, the Administrator confirmed she had not notified the Medical Director of the Immediate Jeopardy and that the facility had not conducted an ad hoc [when necessary] QAPI [Quality Assurance Performance Improvement] meeting related to the water temperatures. b. The facility Administration failed to provide a safe environment and adequate supervision to prevent falls and injury for 7 of 7 (Resident #2, #11, #21, #28, #46, #52, and #54) sampled residents reviewed for accidents. Resident #11 sustained a fracture of the left distal femur (large upper bone of the leg). Record review revealed the facility failed to conduct fall risk assessments quarterly and after each fall in accordance with the facility policy for Residents #2, #11, #21, #28, #46, #52, and #54) sampled residents reviewed for accidents. During an interview on 6/27/2024 at 3:45 PM, the DON was asked about the fall with Resident #11 when she broke her hip. The DON stated, We have tried nonskid socks, med review, anti-roll backs to wheelchair, family agreed to put clothes in closet and not leave it in basket in floor. We tried to get the family to leave the wheelchair by the bed. We offered toileting at bedtime and upon getting up in mornings .dementia was getting worse. On 3/5 [3/5/2024] the bed alarm was put in place. She has moved rooms now and cannot get up by herself in the room she is in. Are the reminders to call for assistance and educate the resident with a BIMS of 2 appropriate interventions. That should be taken out I don't think she could comprehend to use a call light. Refer to F-689 3. The facility Administration failed to ensure Resident #42's right to be free from abuse when on 1/17/2024, Resident #42 sustained two lacerations to the forehead when Resident #166 hit Resident #42 in the head with a hard plastic drinking cup, resulting in actual HARM. During an interview on 6/28/2024 at 10:56 AM, the Director of Nursing (DON) stated, .he [Resident #166] was a handful .wandered . very agitated .hard to redirect . The DON was asked what interventions were put into place. The DON stated, . we referred him [Resident #166] to psych services .tried redirection .notified the doctor .PRN [as needed] Ativan [a medication for anxiety) for his agitation . During an interview on 6/28/24 at 10:56 AM, the DON was asked if she felt like adequate interventions were put into place to keep staff and resident's safe. The DON stated, .In hindsight, probably not . trying to think of him [Resident #166] particularly with him having issues coming in .we didn't do one on one . outside of putting stop signs on everyone's doors to keep him [Resident #166] from going in there .I don't know what else we could have done .other than he's [Resident #166] leaving and not coming back kind of thing again that's hindsight. That's what we know now . Refer to F-600 4. The facility Administration failed to ensure services to meet the behavioral needs and implement effective behavior monitoring for 1 of 4 sampled (Resident #166) residents reviewed for behavioral health needs. Resident #166 was documented to have behaviors from admission on 1/4/2024 until discharge on [DATE]. The behaviors included wandering the halls, going into other resident's rooms, rummaging through other's belongings and Personal Protective Equipment (PPE) carts on the hall, yelling, cursing, disrobing, and grabbing staff. Resident #166 was prescribed antipsychotic, antidepressants, and anxiety medications which were ineffective in controlling behaviors. In addition to grabbing staff and hitting resident #52 in the head as follows: a. A Progress Note dated 1/6/2024 at 1:26 PM, revealed Resident #166 was observed walking in the hallway while naked, and at 6:38 PM, Resident #166 was found in Resident #52's occupied room, had briefs pulled down to his knees, and was displaying sexually inappropriate behaviors to Resident #52's walker. When the Certified Nursing Assistant (CNA) E attempted to redirect Resident #166 back to bed, Resident #166 grabbed CNA E's arm and told her he was going to break it. He then grabbed her (CNA E) by the throat and told her he was going to kill her. b. A Nursing Progress Note on 1/17/2024 at 3:27 PM, revealed Resident #166 entered the room of Resident #42. Resident #166 got Resident #42's cellular phone, and when Resident #42 told resident #166 to put the phone back on the overbed table, Resident #166 struck Resident #42 in the head with a water glass, causing a laceration to the Resident's forehead. On 1/17/2024, after the incident with Resident #42, Resident #166 was discharged back to the Named Psychiatric Hospital. During an interview on 6/28/2024 at 10:56 AM, the Director of Nursing (DON) stated she had not heard about Resident #166 displaying sexually inappropriate behaviors with a walker in an occupied resident room. The DON confirmed she had heard about Resident #166 becoming physically aggressive with a CNA who was attempting to redirect during behaviors. The DON stated she had heard about the incident when Resident #166 was found in another resident's bed but stated her understanding was that Resident #166 was stopped before he could actually get into the bed. The DON stated, .he [Resident #166] was a handful .wandered . very agitated .hard to redirect . The DON was then asked what interventions were put into place. The DON stated, . we referred him [Resident #166] to psych services .tried redirection .notified the doctor .PRN Ativan for his agitation . The DON was asked if she felt like adequate interventions were put into place to keep staff and resident's safe. The DON stated, .In hindsight, probably not . Refer to F-741

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 6 medication carts (Northeast Cart and [NAME] Cart) was left unlocked and unattended during medication administration. The findings include: 1. Review of the facility's policy titled Medication Storage undated, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the pharmacy and/or medication rooms .All drugs and biologicals will be stored in locked compartments .During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . Review of the facility's policy titled Medication Administration Policy dated 6/2024 revealed .Medication carts must be kept locked when not in use during medication pass . 2. Observation during medication administration on 6/24/2024 at 4:28 PM, LPN B unlocked the Northeast Medication Cart at the North Hall nurse's station, LPN B walked away leaving the cart unlocked and unattended while she walked down the hall to retrieve a computer mouse off another cart. After LPN B returned to the medication cart, she walked away from the medication cart to answer the telephone at the nurse's station leaving the cart unlocked. LPN prepared medications for Resident #42 and entered the resident's room leaving the medication cart outside the resident's room unlocked and unattended. 3. Random observation on 6/28/2024 at 9:02 AM, the west medication cart was noted unlocked and unattended in the hallway, outside Resident #28's room. LPN A exited Resident #27's room and walked to the medication cart and locked the cart outside Resident #28's room. 4. During an interview on 6/28/2024 at 7:52 AM, the DON confirmed that the medication carts should not be left unlocked and unattended by nursing staff during medication administration.

Based on policy review, medical record review, observation, and interview, the facility failed to follow Enhanced Barrier Precautions to prevent the spread of infection when 1 of 1 Licensed Practical Nurse (LPN) D failed to wear the correct Personal Protective Equipment (PPE) and when LPN D contaminated the wound during wound care for 1 of 3 (Resident #28) sampled residents for wound care. The findings include: 1. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 5/30/2024, revealed .Enhanced barrier precautions, (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities .an order for enhanced barrier precautions will be obtained for residents with any of the following .chronic wounds such as pressure ulcers .Implementation of Enhanced Barrier Precautions .make gloves and gowns available immediately near or outside of the resident's room .High-contact resident care activities include .wound care .any skin opening requiring a dressing . 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Carcinoma of Skin, Scalp, and Neck, Dementia, Squamous Cell Carcinoma of Skin, Malnutrition, Depression, and Anxiety. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #28 had a Brief Interview for Mental Status score of 6, which indicated she was severely cognitively impaired. Review of the Physician's Orders dated June 2024, revealed no order for Enhanced Barriers. Review of the Physician's Orders dated 6/20/2024, revealed .Cleanse unstageable pressure injury to coccyx with wound cleanser, pat dry, apply calcium alginate (used to absorb excess moisture and promote healing in wound dressings), and cover with foam dressing daily every day shift . Review of the Progress Notes dated 6/19/2024 at 1:35 PM, revealed .Skin/Wound Note .Nurse observed unstageable pressure injury to coccyx .Cleanse unstageable pressure injury to coccyx with wound cleanser, pat dry, apply calcium alginate, and cover with foam dressing daily . During wound care observation on 6/26/2024 at 10:10 AM, revealed LPN D cut a strip of calcium alginate and dropped it onto a contaminated surface. She then proceeded to complete the wound care for Resident #28 using the contaminated calcium alginate. LPN D also did not wear a gown during the wound care. During an interview on 6/28/2024 at 1:40 PM, the Infection Preventionist confirmed staff should wear gown and gloves while performing wound care. During an interview on 6/28/2024 at 1:46 PM, LPN D confirmed she should have worn PPE and disposed of dressing that was contaminated.

Based on policy review, observation, and interview, the facility failed to update and revise the Three-Day Disaster Menu to accurately reflect the 3 Day Emergency Food Supply. The findings include: 1. Review of the facility policy titled Emergency Food Supply dated 4/2022, revealed .The Dietary Manager shall maintain a 3-to-7-day supply of nonperishable foods .The emergency food is rotated/replenished every six months . Review of the undated facility policy titled Disaster Planning revealed .Disaster Menu prepared from nonperishable foods. This should include 3 to 7 days depending on state or local requirements .Disaster supplies should be checked routinely . Review of the undated facility policy titled, Three-Day Disaster Menu revealed .Breakfast Day 1 Peanut Butter .Protein Bar .Day 3 Peanut Butter .Protein Bar . 2. Review of the undated facility 3-Day Supply list revealed no supply of peanut butter or protein bars. Observation and Interview in the kitchen on 6/25/2024 at 8:23 AM, revealed the Emergency Food Supply Menu listed peanut butter and protein bars. Observation of Emergency Food Supply revealed that peanut butter and protein bars were not in the Emergency Stock. The Dietary Supervisor confirmed that if food items are on the menu, they should also be in the emergency food supply. During an Interview on 6/26/2024 at 3:34 PM, the Registered Dietician confirmed that if a food item is on the 3-day Emergency Food Supply Menu, it should be included in the 3-day Emergency Food Supply.

Based on policy review, review of the medical record, Controlled Substance Inventory Record review, and interview, the facility failed to ensure the proper reconciliation of controlled medications when 1 of 4 nurses (Licensed Practical Nurse (LPN C) failed to sign out controlled medications on the Controlled Substance Inventory Record and keep a running count of medications on hand. The findings include: 1. Review of the facility's policy titled, Narcotic Control dated 8/2023, revealed .Each time a controlled medication is administered, the nurse must complete the Controlled Substance Inventory Record and keep a running count of medications used and medications on-hand .Verification of the quantities of controlled substances must be recorded on the Controlled Dosage System -Controlled Substance -Shift Change Count Check Sheet . 2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses Dementia, Carotid Artery Stenosis, Hypertension, Depression and Generalized Anxiety Disorder. Review of the Physician's Order dated 6/4/2024 revealed .Lorazepam (an anti-anxiety medication) 0.5mg 1 tab three times a day . 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses Parkinson's Disease, Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of the Physician's Orders dated 5/26/2024 revealed Lorazepam 0.5mg 1 tab two times a day . 4. Observation and interview during medication storage review of the [NAME] Hall Med Cart on 6/26/2024 at 2:45 PM, revealed Resident #32's Lorazepam 0.5mg medication card had 29 tabs in the card and the resident's Controlled Substance Inventory Record reflected a count of 30 tabs. When LPN C realized the count was incorrect, she started to sign the medication out on the controlled sheet. LPN C was informed that a copy was needed prior to alteration of documentation. LPN C reported that she administered the medication at 2:00 PM to the resident. Review of Resident #22's Lorazepam 0.5mg medication card had 4 tabs in the card, but the resident's Controlled Substance Inventory Record for Lorazepam had a count of 5 tabs. LPN C confirmed that she should have signed the medications out in the controlled book when administering the medications. During an interview on 6/26/2024 at 3:08 PM, the Director of Nursing (DON) confirmed that nursing staff should sign the medications out on the resident's Controlled Substance Inventory Record as the medications are pulled and administered. The DON confirmed that the narcotic controlled counts should match the number of actual pill count in the medication card.

Based on policy review, medical record review, and interview, the facility failed to provide services to meet the behavioral needs and implement effective behavior monitoring for 1 of 4 sampled (Resident #166) residents reviewed for behavioral health needs. The findings include: 1. Review of the facility policy titled Behavioral Health Services, dated 6/2023, revealed .It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .The facility will ensure that necessary behavioral health care services are person-centered .while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports based upon residents' individual needs, include, but are not limited to: Depression . Anxiety and Anxiety Disorders .The assessment and care plan will include goals that are person-centered and individualized .Monitor the resident closely for expressions or indications of distress .Share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes .Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident .includes non-pharmacological interventions. 2. Review of medical records and facility documentation revealed that Resident #166 was admitted to Named Psychiatric Hospital from 12/6/2023 to 1/4/2024 with diagnoses including Cognitive Social or Emotional Deficit following Cerebral Infarction, Vascular Dementia, and Falls. The psychiatric hospital record revealed, .Patient lives at home with his spouse .hx [history] of Vascular Dementia .Wife reports on 11/28 [2023] .busted the front door, sheriff was called . has been throwing bricks at the wife and the windshield . Medical record review revealed Resident #166 was admitted from the psychiatric hospital to the nursing home facility on 1/4/2024, with diagnoses including Dementia with Behavioral Disturbance, Agitation, Anxiety, and Palliative Care. Review of a Nursing Progress Note on 1/4/2024 at 6:30 PM, revealed Resident #166 was in another resident's room. Resident #166 was also observed going through dressers on the hall containing isolation equipment, prompting staff to remove dressers to an empty room with a closed door. Review of a Nursing Progress Note on 1/4/2024 at 8:03 PM, revealed LPN (Licensed Practical Nurse) B documented that after completing Resident #166's skin assessment, she was walking out of the room when Resident #166 struck her in the back. Resident #166 then began wander the halls. Resident #166 was resistant to redirection and was given PRN Ativan (medication for anxiety) for agitation. Physician's Orders revealed .UA [Urine Analysis] with C&S [Culture and Sensitivity] 1/4/2024 .Document adverse behaviors (Target behaviors .) in relation to psych meds prn (as needed) .wander guard to leg as ordered to alert staff of any attempts to elope .weekly skin assessment .document adverse behaviors .Haloperidol 1 mg (milligram) two times a day for agitation/anxiety .Haloperidol 2 mg at bedtime for agitation/anxiety .Lorazepam (medication for anxiety) 1 mg every 4 hours as needed for anxiety . Review of a Nursing Progress Note on 1/5/2024 at 1:37 PM, revealed Resident #166 was wandering the halls and going into other resident's rooms. Review of a Nursing Progress Note on 1/5/2024 at 9:49 PM, revealed Resident #166 threw his supper tray on the floor. Resident #166 wandered into other residents' rooms and was discovered going through other residents' belongings. Redirection was unsuccessful. Review of a Nursing Progress Note on 1/6/2024 at 1:26 PM, revealed Resident #166 was observed walking in the hallway while naked, and at 6:38 PM, Resident #166 was found in Resident #52's occupied room, had briefs pulled down to his knees, and was displaying sexually inappropriate behaviors to Resident #52's walker. When the Certified Nursing Assistant (CNA) E attempted to redirect Resident #166 back to bed, Resident #166 grabbed CNA E's arm and told her he was going to break it. He then grabbed her (CNA E) by the throat and told her he was going to kill her. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #166 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated he had severe cognitive impairment and was dependent on staff for all care. Review of a Nursing Progress Note on 1/10/2024 at 10:59 PM, revealed a Hospice CNA attempted to give Resident #166 a shower and he was trying to touch her (Hospice CNA) breasts and buttocks and tried to kiss her. Review of a Nursing Progress Note on 1/11/2024 at 6:09 PM, revealed Resident #166 overturned the chair and bedside table in his room, urinated on the floor, and dumped the water pitcher on the floor. While staff was cleaning up the room, Resident #166 sat in the lobby to watch TV, and tipped over the table in the lobby. Review of a Nursing Progress Note on 1/13/2024 at approximately 7:00 PM, revealed Resident #166 was found in Resident #23's room lying in the bed asleep next to Resident #23. Review of a Nursing Progress Note on 1/14/2024 at 5:13 PM, revealed Resident #166 wandered into the Activity Room and had to be redirected by LPN B after being observed with both hands on another resident's head. Resident #166 was documented to have behaviors from admission on 1/4/2024 until discharge on [DATE]. The behaviors included wandering the halls, going into other resident's rooms, rummaging through other's belongings and Personal Protective Equipment (PPE) carts on the hall, yelling, cursing, disrobing, and grabbing staff. Resident #166 was prescribed antipsychotic, antidepressants, and anxiety medications which were ineffective in controlling behaviors. Review of Care Plan dated 1/18/2024, after Resident #166 was discharged , revealed .The resident has behavior problems: entering other residents room, rummaging, spitting, agitation, anxious/restlessness, wandering, grabbing others, hitting others, kicking others, pushing others, physically aggressive towards others, exit seeking, expressing anger at others, screaming at others, threatening others, disrobing in public, public sexual acts, throwing/smearing food, delusions, hallucinations, panic, withdrawn .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes .wander guard to leg as ordered to alert staff of any attempts to elope .Administer Depakote (medication for seizures), Haloperidol (medication for agitation), Seroquel (medication for depression), Zoloft (medication for social anxiety) as ordered. Monitor for side effects/effectiveness. Notify MD (physician) as needed .The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia, BIMS, inattention, disorganized thinking, wandering, and behaviors . The resident has delirium or an acute confusional episode r/t BIMS, inattention, disorganized thinking .Provide medications to alleviate agitation as ordered by MD [Medical Doctor]. Monitor/document side effects and effectiveness . During an interview on 6/27/2024 at 2:53 PM, LPN B stated, .I can't remember much about him [Resident #166]. LPN B stated that Resident #166 wasn't in the facility very long and that she couldn't remember any behaviors. LPN B confirmed she did find him in Resident #23's bed but that Resident #23 was under the covers and Resident #166 was laying down asleep, on top of the covers next to Resident #23. LPN B was asked if she knew who the resident was that Resident #166 was documented to have .both hands on another resident's head . LPN B stated she could not remember. During an interview on 6/28/2024 at 8:30 AM, CNA E was asked to describe the incident of Resident #166 grabbing her (CNA E) arm and throat and threatening her. CNA E stated, .he [Resident #166] was going in and out of resident rooms and I found him in another resident's [Resident #52] room with his brief down to his knees and had grabbed the other resident's [Resident #52] walker and started to [display sexually inappropriate behavior] .The resident [Resident #52] was upset and used a pillow and tried to cover him [Resident #166] up. CNA E stated she tried to redirect him and pulled up his brief, but he was very agitated and kept pulling away from her. CNA E stated she was walking Resident #166 down the hallway and the resident was very agitated, .grabbed my arm as hard as he could and said he was going to break if off . CNA E stated Resident #166 then grabbed her (CNA E) by the throat and .said he was going to [F word expletive] kill me . CNA E stated at this point she (CNA E) was very upset, . I just dropped everything and walked out . CNA E stated she told the charge nurse what had happened and that she (CNA E) was told to write a statement and chart the behaviors. CNA E stated, .I wrote the statement .I think I may have just left it at the nurse station, but I don't believe I charted the behaviors .I can't remember .it was all such a blur after that . CNA E stated no one came to interview her or talk about the incident. During an interview on 6/28/2024 at 10:56 AM, the Director of Nursing (DON) stated she had not heard about Resident #166 displaying sexually inappropriate behaviors with a walker in an occupied resident room. The DON confirmed she had heard about Resident #166 becoming physically aggressive with a CNA who was attempting to redirect during behaviors. The DON stated she had heard about the incident when Resident #166 was found in another resident's bed but stated her understanding was that Resident #166 was stopped before he could actually get into the bed. The DON stated, .he [Resident #166] was a handful .wandered . very agitated .hard to redirect . The DON was then asked what interventions were put into place. The DON stated, . we referred him [Resident #166] to psych services .tried redirection .notified the doctor .PRN Ativan for his agitation . The DON was asked if she felt like adequate interventions were put into place to keep staff and resident's safe. The DON stated, .In hindsight, probably not .

Based on policy review, medical record review and interview, the facility failed to complete a baseline care plan within 48 hours for 2 of 10 (Resident #21 and 369) sampled residents reviewed for baseline care plans. The findings include: 1. The facility policy titled, Baseline Care Plan revised 12/5/2022, revealed, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .The baseline care plan will .be developed within 48 hours of a resident's admission .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .Initial goals based on admission orders .Physician orders .Dietary orders .Therapy services .A supervising nurse shall verify within 48 hours that a baseline care plan has been developed . 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Chronic Atrial Fibrillation, Diabetes, Dialysis, and End Stage Renal Disease. Review of the Baseline care plan dated 11/11/2023, revealed the baseline care plan was initiated but not completed when it was left unsigned by the resident or family. During an interview with the Minimum Data Set (MDS) Coordinator on 6/26/2024 at 2:30 PM, revealed the MDS Coordinator confirmed Resident #21's base line care plan was not signed by the resident or family within 48 hours of initial admission or hospital return. 3. Review of the medical record revealed Resident #369 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Pneumonia, Congestive Heart Failure, Diabetes, Hypertension, and Benign Prostatic Hypertrophy. Review of the Baseline care plan dated 5/20/2024, revealed that the baseline care plan was initiated but not completed it was left unsigned by the resident or family. During an interview on 6/28/2024 at 12:00 PM, the MDS Coordinator confirmed that the baseline care plans should be signed by the resident or the family. The MDS Coordinator confirmed that Resident #369's baseline care plan was not signed by the resident or the family.

Based on policy review, medical record review, facility investigation, named Sheriff's Department Incident Report, and interview, the facility failed to thoroughly investigate an alleged incident of Employee to Resident abuse for 1 of 4 sampled residents (Resident #216) reviewed for abuse. The findings include: 1. Review of the undated facility policy titled Nursing Home's Resident Abuse Policy, revealed .Procedure: Allegation of abuse by an employee .will be thoroughly investigated and documented .Any staff member who witness a suspicious situation .is to immediately notify the supervisor on duty .The Charge nurse will examine the alleged victim immediately and complete an incident report with a summary of her interview and notify the Director of Nursing and the Administrator . Review of the facility policy titled Investigation Reporting/Response dated 5/2024, revealed .The facility will have written procedures that include .Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) .Taking all necessary actions as a result of the investigation, which may include, but not limited to, the following .Analyzing the occurrence(s) to determine why abuse .occurred and what changes are needed to prevent further occurrences .Defining how care provisions will be changed and/or improved to protect residents . 2. Review of the medical record revealed Resident #216 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Depression and Dementia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #216 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated she was moderately cognitively impaired without behaviors. Review of the Employee to Resident Allegation of Abuse investigation provided by the facility revealed there was no Incident Report or summary provided. Review of the witness statements all dated 10/23/2023, and untimed revealed the incident had happened on 10/22/2023. The incident was not reported to the Abuse Coordinator (Administrator) until the following day. Review of the named Sheriff's Department Incident Report dated 10/26/2023, revealed .At this point I have decided there is not sufficient evidence to warrant further investigation or prosecution. The alleged victim is not in danger as she is no longer exposed to her accused abuser .I cannot determine if the incident did or did not occur but I am declining to further continue an investigation unless new compelling evidence arises . Investigation summary and documentation that a report had been made to Adult Protective Services was unable to be provided by the Administrator. During an interview on 6/26/2024 at 3:36 PM, the Administrator was asked if she had done a thorough investigation. The Administrator stated that she had given me everything that she had for the investigation. The Administrator was asked if there was an incident report done by the nurse. The Administrator confirmed an incident report had not been completed. When asked where her investigation was, she stated it was in the IRS (Incident Reporting System). During an interview on 6/27/2024 at 3:45 PM, the Director of Nursing was asked if she felt this was a complete investigation. She stated, .I feel like a narrative would be helpful and a good idea going forward. The facility failed to conduct a thorough investigation for an allegation of Employee to Resident Abuse. The facility failed to immediately report the allegation of abuse to the Abuse coordinator. The incident was not investigated until the day after the allegation. An incident was not completed in accordance with the facility policy. And Adult Protective Services was not notified.

Based on facility policy, medical record review, observation, and interview, the facility failed to ensure residents were free of physical restraints for 1 of 1 (Resident #9) sampled residents reviewed for restraints. The findings include: 1. Review of the facility policy titled, Restraint Free Environment dated 3/28/2019, revealed .A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .physical restraints may be used on emergency care situations for brief periods .Falls do not constitute self-injuries, behavior or a medical symptom that warrants the use of a physical restraint .A physician's order alone is not sufficient to warrant the use of a physical restraint .the length of time the restraints anticipated to be used .time and frequency that the restraint will be released .The type of direct monitoring and supervision that will be provided during the use of the restraint . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, and Non-Traumatic Brain Dysfunction. Review of the care plan dated 4/10/2023, revealed .Resident had actual fall. Date Initiated: 05/05/2023 Revision on: 02/26/2024 .Intervention .Implement self-release seat belt. Date Initiated: 06/12/2023 .Follow facility fall protocol . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #9 had a Basic Interview for Mental Status (BIMS) score of 3, which indicated Resident #9 was severely cognitively impaired. The resident required maximum assistance for all mobility, had no falls since the prior assessment, used a floor mat alarm, Wander alarm and other alarm daily. Review of the Order Summary Report dated 6/25/2024, revealed there was no physician's order for the self-release seat belt. Observation and interview in the front lobby on 6/24/2024 at 9:30 AM, revealed Resident #9 was sitting in the wheelchair with a self-release seat belt around her waist. Resident was asked if she could unlatch the seat belt. She looked at it and pulled on it and was not able to release the belt. Observation and interview in the resident's room on 6/24/2024 at 12:25 PM, revealed Resident #9 was unable to release the seat belt when asked by the surveyor. Observation and interview in the front lobby on 6/25/2024 at 8:38 AM, revealed Resident #9 was asked if she could release her seat belt. The resident looked at the seat belt and stated she didn't know how to do that and looked at it. Observation in the front lobby on 6/25/2024 at 3:37 PM, revealed Resident #9 had the seat belt in place. During an interview on 6/25/2024 at 4:10 PM, the Director of Nursing (DON) was asked if the resident had a restraint. The DON stated, She can release the belt herself . The DON and the surveyor went to the resident in the hall and the DON asked Resident #9 if she could release the seat belt. The DON asked several times and in different ways for the resident to release the seat belt. Resident #9 was not able to release the seat belt without being told to press the button while the DON tapped the red button. The DON was asked if that was a restraint. The DON stated, Well, now it is since she can't undo it . The DON was asked if there should be an order for a restraint. The DON states, Yes, but this is a no restraint facility so we will have to figure something else out. The DON confirmed something should have been on the Treatment Administration Record to ensure the resident was able to release the seat belt.

Based on policy review, medical record review, and interview, the facility failed to accurately assess residents for Respiratory Services and Weight Loss for 2 of 17 (Resident #7, and #55) sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments. The findings include: Review of the facility's policy titled, MDS 3.0 Completion, dated 12/5/2023, revealed .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .According to federal regulations, the facility conducts intially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity . Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Diabetes, Hemiplegia, Non-Alzheimer's Dementia, and Congestive Heart Failure. Review of the quarterly MDS dated [DATE] revealed Resident #7 was severely cognitively impaired and was not coded for oxygen therapy. Review of the Physician's Order dated 1/30/2023, revealed, .O2 [OXYGEN] AT 2-4 L/MIN [2 to 4 liters per minute] .NASAL CANNULA every shift .CHANGE NEB [nebulizer] O2 [oxygen] SETUP .CHECK AND CLEAN EQUIPMENT Q [EVERY] TUESDAY & [AND] PRN [as needed] . Review of the medical record revealed Resident #7's was not coded for oxygen therapy during this assessment period. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Muscle Wasting, Burn of 3rd Degree of Buttock, Dementia and Sepsis. Review of the quarterly MDS dated [DATE] revealed Resident #55 had a Brief Interview Mental Status (BIMS) score of 5, meaning Resident #55 was severely cognitively impaired. Resident #55 was coded Weight Loss .Loss of 5% or more in the last month .No . The MDS was coded incorrectly. Review of the Weight and Vital Summary Sheet revealed Resident #55 had a loss of 5% or more in a month. During an interview 4/12/2023 at 2:34 PM, the Director of Nursing (DON) was asked should Resident #55's MDS have weight loss documented. The DON stated, Yes, Ma'am it should have . During an interview on 4/13/2023 at 5:34 PM, the DON confirmed Resident #7 required oxygen therapy and the quarterly MDS did not reflect oxygen therapy.

Based on policy review, medical record review, and interview, the facility failed to ensure a discharge summary was written within 14 days for 2 of 3 (Resident #59 and #110) discharged sample residents. The findings include: Review of the facility's policy titled Discharge Summary and Plan of Care, dated 2018 revealed .It is the policy of this facility to ensure that a discharge planning process is in place which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies .Discharge planning is a process that generally begins on admission and involves identifying each resident's goal and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure successful discharge .Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary will be provided to the receiving care provider. The Discharge Summary should include: An overview of the resident's stay that includes .diagnoses course of illness/treatment .lab, radiology .A final summary of the resident's status at the time of discharge .Reconciliation of all pre-discharge medications with the resident's post discharge medication . Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses of Orthostatic Hypertension, Coronary Artery Disease, Chronic Ischemic Heart Disease, Hyperlipidemia, Acute Kidney Failure, Major Depressive Disorder, and Palliative Care. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #59 had severe cognitive impairment. Review of a Physician Order dated [DATE] revealed DNR [Do Not Resuscitate]. Review of the Hospice Skilled Nursing Visit Note, dated [DATE] revealed Resident #59 .this morning .sent to the ER [emergency room ] .due to change in condition and nonresponsive .admitted to Hospice .met with the .family .actively dying expected within next ,d+[DATE] hours . Resident #59 had been sent out to the ER this morning for change in condition and unresponsiveness and sent back to the facility to be admitted to Hospice. Resident #59 expired on [DATE] at the facility. No discharge summary was documented for Resident #59. Review of the facility Discharge Summary dated [DATE] at 11:33 AM revealed Resident #59 expired in the facility on [DATE]. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Heart Failure, Hydronephrosis, Cerebral Ischemia, and Psychotic Disorder. Review of the quarterly MDS dated [DATE] revealed Resident #110 had a BIMS of 11 which indicated moderate cognitive impairment. No behaviors documented. Resident #110 required extensive assistance for ADLs. Review of the progress note dated [DATE] revealed [DATE] .Promethazine 12.5 mg [milligram] IM [Intramuscular] given per standing order due to profuse vomiting . Review of the progress note dated [DATE] revealed Began vomiting within 10 minutes of supper trays being passed. She vomited 3 times. Per standing orders of [Medical Director], resident received 12.5 mg IM injection of promethazine in her upper right arm. Two hours later resident said that the shot only partially relieved her nausea . Review of the progress note dated [DATE] revealed LATE ENTRY .Resident is sick and refused Restorative Program . Review of the progress note dated [DATE] revealed Resident is feeling unwell today. She has been vomiting with im phenergan [medication for nausea and vomiting] given. She has diarrhea noted. She is on a clear liquid diet. She noted with fever later in shift of 102 F [Fahrenheit] with [NAME] [Tylenol] supp.[suppository] given. MD [Medical Doctor] called with new orders. 1) Obtain swab for Flu A & B send to [named hospital]. 2) Obtain UA [urinalysis] with micro [microscopic] C&S [culture and sensitivity] 3) CBC [complete blood count] with diff [differential] and BMP [basic metabolic panel] send to [named hospital]. EMAR [Electronic medical record] revised. Attempt to reach RP [responsible party] with no answer or voicemail available . Review of the progress note dated [DATE] LATE ENTRY .Resident sent to [named hospital] @ [at] 0715 [7:15 AM] per EMS [Emergency Medical Services] . Review of the progress note dated [DATE] revealed Resident discharged to the hospital on [DATE], from the hospital she transferred to [named facility] . Review of the Physician Order dated [DATE] revealed .RISPERIDONE 0.25 MG TABLET Give 1 tablet by mouth at bedtime related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION . Review of the Physician Order dated [DATE] revealed TRAZODONE 50 MG TABLET Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER . Resident #110 was discharged to hospital on [DATE] and did not return to the facility. Facility was unable to provided a discharge summary until [DATE]. Review of the discharge summary dated [DATE] revealed Resident admitted to facility [facility] from home to where she was receiving home health services. Decline in functional status and ability to stay by herself. Daughter was providing assistance while in home. Resident received therapy services of PT [physical therapy] and OT [occupational therapy] during stay to which resident had refused some services at times. Resident with history of falls, to which resident suffered injury to ankle, requiring therapy services to address gait training, balance training, transfer training, safety education [education] and training. ADLs education and modalities also provided. Residnet [Resident] noted with decline in GI [Gastrointestinal] status with nausea and vomiting in march. MD [Medical Director] made aware with orders received and implemented. Improvement noted following interventions, but resident continued to not feel well MD was notified with orders to transfer to acute care setting on ,d+[DATE] and was DCd [discharged ] to [named facility] . During an interview on [DATE] at 2:03 PM, the Director of Nursing (DON) was asked when the discharge summary was completed. The DON stated, Today. The DON was asked when should the discharge summary have been done. The DON stated, within 2 weeks. The DON was asked if today [DATE] was acceptable to write the discharge summary? The DON stated, No. During an interview on [DATE] at 2:49 PM, LPN #2 was asked about Resident #110. LPN #2 stated, She had a stomach bug started one day before I sent her out. I gave her a Zofran [medication for nausea/vomiting] at 11:31 AM, for vomiting. I also gave her at 2:10 PM a Tylenol suppository. The next morning on [DATE] at 6:30 AM, I came in her fever was 103.5 and Blood Pressure was ,d+[DATE] called the doctor and her daughter at 7:05 AM, 7:08 AM called EMS, and at 7:09 AM called report to [named Hospital]. She had order to sent [send] to ER due to lethargy, hypotensive, and high fever. On [DATE], I had 7 residents on that hall (South) that day with that stomach bug .

Based on policy review, medical record review and interview, the facility failed to develop a baseline care plan within 48 hours for 1 of 3 (Resident #58) closed record reviews. The findings included: The facility's policy titled Baseline Care Plan revised 12/5/2022, revealed, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .The baseline care plan will .be developed within 48 hours of a resident's admission .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .Initial goals based on admission orders .Physician orders .Dietary orders .Therapy services .A supervising nurse shall verify within 48 hours that a baseline care plan has been developed . Review of the medical record review revealed Resident #58 was admitted to the facility on [DATE], with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes, Acute Kidney Injury, Hypokalemia, and COVID-19. During an interview on 4/12/2023 at 3:45 PM, the Director of Nursing (DON) confirmed the baseline care plan was not dated, signed, or completed. The DON confirmed this baseline care plan should have been filled completely out. The facility was unable to provide documentation a baseline care plan had been developed or provided to the resident or her family within 48 hours of admission.

Based on review of the Center for Disease Control and Prevention (CDC) guidelines, review of the BinaxNOW COVID-19 Ag ([MEDICATION NAME]-a foreign substance that induces an immune response) Card instructions, policy review, medical record review, observation, and interview, the facility failed to follow CDC infection control guidelines when the facility labeled and stored worn, potentially contaminated surgical masks in open, zippered, plastic bags labeled with the staff member's name outside of 5 of 5 resident rooms (Resident #14, #15, #16, #17, and #18) on the COVID Monitoring Unit (designated unit for new admissions, hospital admissions, and residents that had been out of the facility for appointments). The facility had 5 wandering residents who had access to the potentially contaminated masks. The facility failed to have appropriate signage for 5 of 5 resident rooms (Resident #14, #15, #16, #17, and #18) on the COVID Monitoring unit that were in isolation; 2 of 7 staff members (Certified Nursing Assistant (CNA) #4 and Housekeeper #1) failed to don the proper personal protective equipment (PPE) when delivering trays at meals and cleaning rooms; and 1 of 6 sampled residents (Resident #8) who tested positive for COVID-19 after a Rapid COVID-19 test, was placed on the Observation Unit (a unit for exposed/symptomatic residents but who are not positive at that time) for 2 days, instead of the COVID Unit (where positive residents are placed), the Polymerase Chain Reaction (PCR) test returned positive, 1 day after the resident was placed on the Observation Unit. There were 8 residents on the Observation Unit that had the potential to be exposed to COVID-19 when Resident #8 was placed on this unit. These facility failures resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 2/13/2021 at 2:28 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880. The Immediate Jeopardy was effective from 2/1/2021 through 2/16/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/15/2021 at 4:19 PM, and was validated on site by the surveyors on 2/15/2021-2/17/2021 through interviews, review of the Ad Hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign in sheet, review of in-service training records, and audits. The findings include: Review of CDC guidelines titled, Strategies for Optimizing the Supply of Facemasks: COVID-19, dated 11/23/2020, showed, .Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the out surface during storage .the folded mask can be stored between uses in a clean sealable paper bag . Review of the facility's policy titled, Wandering Risk, revised on 8/29/2019, showed, .This facility ensures that residents who exhibit wandering behavior .receive adequate supervision to prevent accidents .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for .unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks . Review of CDC guidelines titled, COVID-19, Prevention, Monitoring, and Management for Long-Term Care Facilities .Version 2, dated 12/10/2020, showed, .Create a plan for managing new admission and readmission whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 for 14 days. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection ( .goggles or a disposable face shield that covers the front and sides of the face), gloves and gown .Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE . Review of BINAXNOW COVID-19 AG CARD instructions for use, revised 12/12/2020, showed, .RESULTS INTERPRETATION .A negative specimen will give a single pink/purple colored Control Line in the top half of the window, indicating a negative result .A positive specimen will give two pink/purple colored lines (one single pink/purple line in the top half of the window and one pink/purple line in the bottom half of the window). This means that COVID-19 [MEDICATION NAME] was detected. Specimens with low levels of [MEDICATION NAME] may give a faint Sample Line (in the bottom half of the window). Any visible pink/purple colored line is positive . Review of the medical record, showed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed, Resident #10 had wandering behaviors. Observation in the South Hall on 2/12/2021 at 11:02 AM, showed Resident #10 ambulating. She stopped at another resident's room and looked in the room for several seconds, then continued wandering down the hall. The COVID Monitoring Unit was a part of the South Hall, there were double doors separating the COVID Monitoring Unit, but the doors were open. Observation on 2/12/2021 at 12:31 PM, showed Resident #10 wandering in the East Hall (at the end of the South Hall). Resident #10 resided on the South Hall. Observation on 2/13/2021 at 1:24 PM, showed Resident #10 wandering in the South Hall. Review of the medical record, showed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], showed Resident #13 had wandering behaviors daily. Observation in the South Hall on 2/10/2021 at 12:44 PM, showed Resident #13 wandering down the hall and then stood in front of the Nurses' Station. Observation in the South Hall on 2/12/2021 at 11:07 AM, showed Resident #13 wandering down the hall, stopped outside the Activity Room and leaned against the wall. Then Resident #13 wandered up to the entrance hall by the Nurse's Station and turned around. Observation in the South Hall on 2/14/2021 at 1:54 PM, showed Resident #13 wandering down the hall. Observation in the South Hall on 2/15/2021 at 9:44 AM, showed Resident #13 wandering down the hall. Random observation on the COVID Monitoring Unit on 2/3/2021 at 1:00 PM, showed masks inside zippered plastic bags on the wall outside residents' rooms, with staff names written on them. Some bags had a surgical mask, some had an N95 device (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), and some bags were empty. Masks were located in the bags on the walls throughout the hallway. There was no signage posted on the doors of Resident #14, #15, #16, #17 and #18's room to designate the residents were in isolation. Random observations on the COVID Monitoring Unit on 2/9/2021 at 10:30 AM, 2/10/2021 at 5:00 PM, and 2/12/2021 at 11:30 AM, showed surgical masks with staff names written on them, in a small plastic bag, taped to the wall outside the residents' rooms. There was no signage posted on the doors of Resident #14, #15, #16, #17 and #18's room to designate the residents were in isolation. Observation in the COVID Monitoring Unit on 2/12/2021 at 11:30 AM, showed CNA #4 entered Resident #16's room. CNA #4 did not don a gown before she entered the resident's isolation room. Observation in the COVID Monitoring Unit on 2/12/2021 at 11:35 AM, showed Housekeeper #1 entered Resident #15's isolation room. Housekeeper #1 wore a surgical mask and gloves but failed to don a gown when she entered the resident's room. Observation in the COVID Monitoring Unit on 2/12/2021 at 11:35 AM, showed CNA #4 entered Resident #18's isolation room. CNA #1 wore a surgical mask and gown but failed to don gloves when she entered the resident's room. Observation in the COVID Monitoring Unit on 2/12/2021 at 11:37 AM, showed CNA #4 entered Resident #17's isolation room. CNA #4 wore a surgical mask but failed to don a gown when she entered the resident's room. Observation in the COVID Monitoring Unit on 2/12/2021 at 11:43 AM, showed CNA #5 entered Resident #17's isolation room. CNA #5 wore a surgical mask, but failed to don a gown or gloves before entering the resident's room. CNA #5 sat down in a chair next to the resident's bed and assisted her with her meal. During an interview on 2/12/2021 at 12:55 PM, Housekeeper #1 was asked the process for cleaning the COVID Monitoring Unit. Housekeeper #1 stated, If they are isolation we are to wear gown, gloves, mask and goggles .but I didn't know that till (until) a while ago .this is the first time I have done south (South Hall) .it's just when they are isolation .wearing .gown, gloves, masks. Housekeeper #1 was asked if she changed her mask when she went into each room. Housekeeper #1 stated, We are supposed to but I don't have any extra ones .probably need to see (ADON) or somebody about giving me some (masks) . Housekeeper #1 confirmed she did not have a mask hanging on the wall for herself. Housekeeper #1 confirmed there was no signage posted for isolation on Resident #15's door and stated, .didn't see anything was isolation .usually will have isolation cart .I didn't see any signs on her door .so I assumed she wasn't .sometimes you don't know if someone doesn't tell you .that's what I go by .I see a cart by the door .that would get anyone confused .they have told me now .everyone passed the double doors are isolation . Housekeeper #1 was asked if she saw residents wandering. Housekeeper #1 stated, (Resident #10 and #13) .walks up and down the halls . During an interview on 2/12/2021 at 1:32 PM, CNA #4 confirmed that new admissions and residents in quarantine were on the COVID Monitoring Unit. CNA #4 was asked what staff were to do when they entered the rooms where residents were in isolation. CNA #4 stated, .supposed to change out our mask, put on gown and then gloves .change mask when we come out .we have mask in the bags on the wall . CNA #4 confirmed she didn't don a gown before entering Resident #16's room. CNA #4 confirmed she did not don gloves before entering Resident #18's room and she did not don a gown before entering Resident #17's room. CNA #4 confirmed there was no signage posted on the door of residents in isolation for staff or visitors to see the nurse before entering. CNA #4 stated, .put up (signage) after lunch today . During an interview on 2/12/2021 at 1:45 PM, CNA #5 confirmed this was her first day to work on the COVID Monitoring Unit. CNA #5 was asked how many residents were on the COVID Monitoring Unit. CNA #5 stated, .I think there is one that is not on isolation and they are getting ready to move her. CNA #5 confirmed there was no signage on the residents' doors for residents that were in isolation, and stated, .put up (signage) after lunch today . CNA #5 was asked what PPE should be donned before entering the isolation rooms. CNA #5 stated, Put on gown, gloves change our mask .we already have eye wear on .there is masks hanging outside the door .put on the one that is hanging outside the door .take off the mask and put it in the bag and put the other back on .today is my first day down there. CNA #5 was asked if there were any residents that wandered in the South Hall. CNA #5 stated, .I've seen maybe two . During an interview on 2/12/2021 at 2:30 PM, the ADON was asked about isolation signage not being posted on the doors in the COVID Monitoring Unit. The ADON stated, I noticed that too .if you go back and look you will find them .they were in storage room .the reason they were taken down I have no idea . The ADON was asked if staff on the COVID Monitoring Unit should wear PPE. The ADON stated, Yes .if you have 5 residents down there you have 5 masks down there .carts supposed to have gowns .supposed to change that mask and wear the one you had wore in that room then take off .what I understand treat it like it's infected. The ADON confirmed residents on the COVID Monitoring Unit were considered to be in isolation. During an interview on 2/13/2021 at 9:51 AM, the Infection Preventionist was asked how long the process of placing masks in plastic bags on the wall had been in place. The Infection Preventionist stated, .At least a month for sure, probably a little bit longer, it's been so hectic I can't tell you specifically .it's been a very difficult time for us .usually do a lot better than what you all have seen. The Infection Preventionist was asked what residents resided on the COVID Monitoring Unit. The Infection Preventionist stated, Any new admits, any hospital returns, if they go out to Doctor appointment . The Infection Preventionist was asked what guidelines the staff followed for the use of the PPE. The Infection Preventionist stated, .wear a gown, gloves and a mask specifically for that room .a dirty and a clean bag beside that room (in the hall) for the staff member .change mask, put mask on (that was) in a clean mask bag, put on the mask specifically for that room, gown and gloves, out (when leaving the room) take off PPE, wash hands, take off mask for that specific room and put it back in the bag (a potentially contaminated mask is placed in a bag in the hall beside resident's room), take your clean mask and put it back on. The Infection Preventionist was asked if there should have been signage on the doors for residents in isolation. The Infection Preventionist stated, Yes ma'am .I don't know who took it (signage) off .I actually found them in the storage room in a pile stuck together, don't know who thought it was there job to take them off .they've all been trained, all been in-serviced. Review of the medical record, showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's COVID-19 Testing form from a Rapid COVID-19 test dated 2/2/2021, showed, Resident #8's result was .Indeterminate (this was handwritten on the form) . Review of the Departmental Notes showed Resident #8 was placed on the Observation Unit on 2/2/2021 after her Rapid COVID-19 test result. Review of the laboratory results collected 2/2/2021, reported 2/3/2021, and reprinted 2/4/2021, showed Resident #8 had a positive COVID-19 test. Review of the Departmental Note dated 2/4/2021 showed Resident #8 was placed on the COVID-19 Unit on 2/4/2021. During an interview on 2/3/2021 at 11:40 AM, the Quality Assurance(QA) Nurse stated, .last week the rapid (COVID-19 test) (for Resident #8) appeared positive, but was sitting on the cart a little longer than should have been, then it went negative .sent PCR (polymerase chain reaction COVID-19 test) and it was negative .yesterday appeared positive again (rapid POC test for Resident #8) .we moved her in Observation (Unit) and waiting on PCR to come back today so we will know if she's 100% (percent) positive . The QA Nurse was asked why Resident #8 was still on the Observation Unit and not on the COVID-19 Unit if her rapid test appeared positive. The QA Nurse stated, Because of what happened last week with the test . During an interview on 2/13/2021 at 9:51 AM, the Infection Preventionist was asked when Resident #8 was moved to the Observation Unit. The Infection Preventionist stated, The day (1/28/2021) she tested positive with POC (point of care or rapid COVID-19 testing) .PCR came back and was negative .approximately a week later (2/2/2021) she tested positive again (the rapid COVID-19 test) .moved her to Observation (Unit) again .did a PCR that day .came back and she was positive .we moved her (on 2/4/2021) to the COVID end (COVID-19 Unit) . The Infection Preventionist stated, .We tend to like to wait until we get a confirmatory PCR to make sure she is positive because the POC are not the most accurate at times . The Infection Preventionist confirmed Resident #8 was not moved to the COVID Unit when she appeared to test positive with the POC test on 2/2/2021. The Infection Preventionist stated that if there is a faint line on the POC test and the resident is asymptomatic, the resident is moved to the Observation Unit, but if there is a faint line on the POC test and the resident is symptomatic, the resident is moved to the COVID Unit. The surveyor verified the Removal Plan by: 1. On 2/13/2021, all the surgical masks and plastic bags were removed from the walls on the South Hall isolation area (COVID Monitoring Unit). Staff are to apply a separate surgical mask prior to entering rooms in the COVID Monitoring Unit but the same mask can be used in all rooms per CDC guidance-Crisis capacity in use with manufacturer guidelines followed on re-use and extended use per CDC guidance. (Storage of personal surgical masks will be stored in a brown paper bag with name and date behind a locked keypad door). The surveyors observed the removal of the surgical mask on the wall and the surgical mask in a brown paper bag behind a locked keypad door. The surveyors interviewed the Infection Preventionist. 2. On 2/13/2021-2/15/2021, all staff members were in-serviced on wearing surgical masks and wearing a separate mask for providing resident care on the COVID Monitoring Unit. The surveyors reviewed the in-services and interviewed staff on all shifts. 3. On 2/14/2021-2/15/2021, the facility policies and procedures were reviewed and revised according to CDC recommendations. The surveyors reviewed the updated polices and interviewed the Quality Assurance Nurse. 4. On 2/14/2021-2/15/2021, in-services were provided to all staff on the updated policies, identification of situations warranting change in surgical masks and appropriate donning/doffing procedures. The surveyors reviewed the in-services on updated policies and procedures and interviewed staff on all shifts. 5. Beginning 2/14/2021, the Clinical Educator or designee will monitor the infection prevention and control education for all new hires. The surveyors interviewed the Clinical Educator. 6. Beginning 2/14/2021, the Infection Preventionist or designee will review the 24-hour report for the residents requiring Transmission Based Precautions to ensure appropriate signage is placed on the isolation area and that staff are familiar with the policy and procedures. The surveyors interviewed the Infection Preventionist. 7. Beginning 2/14/2021, the Infection Preventionist or designee will randomly monitor isolation precaution practices every day for two weeks, three times a week for one month, then weekly for the next three months. The surveyors interviewed the Infection Preventionist and reviewed the audit forms. 8. On 2/14/2021, the QA Nurse implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Plan (PIP) as a source to gather and process information from the audits/monitoring processes. The findings will be reported monthly in the Quality Assurance and Assessment (QAA) meetings for at least three months. The surveyors interviewed the Quality Assurance Nurse and reviewed audit forms. Noncompliance of F-880 continues at a scope and severity of E for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility video footage review, medical record review, observation, and interview, the facility failed to ensure a resident was free from neglect when Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 neglected to respond immediately to a resident's change in condition for 1 of 7 sampled residents (Resident #4) reviewed for neglect and change in condition, which resulted in Immediate Jeopardy for Resident #4. RN #1 and LPN #1 neglected to respond immediately to concerns of Physical Therapist (PT) #1 that the resident did not look good and her breathing was not normal. LPN #1 sent a Nurse Aide (a non-certified nursing assistant) (NA) #1 to check on the resident. NA #1 checked Resident #4's vital signs and Resident #4 had an oxygen saturation (O2 sat) (amount of oxygen measured in the blood) of 48 percent (%) (Normal range is 95-100%) at that time. The licensed nursing staff neglected to respond to Resident #4's change of condition until 38 minutes after the nursing staff were notified of the resident's status from PT #1. Resident #4 was transferred by Emergency Medical Services (EMS) to a local emergency room where it was determined she had experienced a non-ST segment elevated [MEDICAL CONDITION] infarction (NSTEMI) (a type of [MEDICAL CONDITION]) and [MEDICAL CONDITION]. Resident #4 was transferred to another facility for a higher level of acute care. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were notified of the IJ on 2/13/2021 at 2:28 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 2/1/2021 through 2/16/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/15/2021 at 4:19 PM, and was validated onsite by the surveyors 2/15/2021-2/17/2021, through policy review, Ad Hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign-in sheet, medical record review, observation, in-service training review, audits, and staff interviews. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident Property and Exploitation, revised 4/2017, showed, .Each resident has the right to be free from abuse, neglect .'Neglect' means failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the facility's policy titled, Resident Rights, revised 2018, showed, .The right to reside and receive services in the facility with reasonable accommodation of resident needs . Review of the medical record, showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Physician order [REDACTED]. The form described limited additional interventions as medical treatment, antibiotics, intravenous (IV) fluids, and cardiac monitoring. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #4 had moderate cognitive impairment and required limited assistance to total dependence on staff for all activities of daily living except eating. Review of a Departmental Note dated 2/1/2021, showed Resident #4 was alert and verbally responsive, had increased cough, congestion in both lungs, and yellow sputum. The resident's physician was in the facility that morning and ordered labarotory (labs) work to be drawn, intramuscular (IM) and oral (PO) antibiotics, and a chest x-ray. The labs were drawn, the first dose of IM antibiotic was administered, and the chest x-ray was ordered. Review of a Departmental Note dated 2/1/2021 at 4:56 PM, written by LPN #1, showed, .Called to resident's (Resident #4) room by staff. O2 stat (sat) of 48% on room air. Supplemental O2 put in place @ (at) 3 L (liters)/ (per) min (minute) with an increase in O2 (saturation) to 73%. MD (Medical Doctor) called and notified .New Order given to send resident to (local hospital) .EMS arrived and resident departed facility . During an interview on 2/8/2021 at 4:02 PM, PT #1 confirmed that she told the RN #1 and LPN #1 she was concerned about Resident #4. PT #1 stated, It was right after change of shift (2:15 PM) .she (Resident #4) was in the bed .was not looking good .I asked if she felt good and she just looked at me .I asked her again and she just looked at me .she was just a little pale to me .her eyes were just a little big .breathing maybe a little bit more than normal .I went to get the nurse .it was (named LPN #1) I talked to right after change of shift .the first nurse I approached was (named RN #1) and she said she wasn't familiar with her . Review of the facility's video footage with timestamps revealed the following: a. On 2/1/2021 at 2:23 PM, PT #1 entered Resident #4's room, exited the room at 2:24 PM, and walked to the Nurses' Station. PT #1 stopped at the medication cart, spoke to RN #1, and then walked out of sight around the corner of the Nurses' Station. LPN #1 was not visible on the video footage at this time. b. At 2:28 PM and 5 seconds, PT #1 returned to the resident's room and exited at 2:28 PM and 52 seconds. c. At 2:30 PM and 7 seconds, LPN #1 walked up the hallway from the Nurses' Station and passed Resident #4's room. LPN #1 did not enter the resident's room to check on the resident. LPN #1 returned to the Nurses' Station. d. At 2:30 PM and 28 seconds, LPN #1 appeared to talk briefly to someone, turned and walked back up the hall at 2:30 PM and 36 seconds. LPN #1 glanced in Resident #4's room as she passed. LPN #1 walked by Resident #4's room [ROOM NUMBER] times and did not enter the room to check on the resident. e. At 2:30 PM and 59 seconds, NA #1 walked up the hallway from the Nurses' Station and passed Resident #4's room. NA #1 did not enter the room to check on the resident. f. At 2:32 PM and 28 seconds, NA #1 walked down the hallway toward the Nurses' Station and passed Resident #4's room. NA #1 did not enter the room to check on the resident. g. At 2:32 PM, NA #1 walked up the hallway from the Nurses' Station and entered the room across from Resident #4's room. NA #1 did not enter the room to check on Resident #4. h. At 2:33 PM, LPN #1 entered the video frame from the East Hall and stopped at a room across from Resident #4's room and appeared to talk to someone in that room. LPN #1 had a drink and bag of chips in her hand. i. At 2:34 PM, LPN #1 walked by the resident's room for the 4th time and did not enter the room to check on the resident. j. At 2:35 PM, NA #1 exited the room across from Resident #4's room and entered the next room to the left. k. At 2:37 PM, LPN #1 walked up the hallway from the Nurses' Station and walked by Resident #4's room for the 5th time and did not enter the room to check on the resident. l. At 2:38 PM, LPN #1 walked up the hallway from the Nurses' Station and walked by Resident #4's room for the 6th time and did not enter the room to check on the resident. m. At 2:39 PM, NA #1 entered Resident #4's room. n. At 2:45 PM, NA #1 exited the room and entered the room to the right of Resident #4's room. n. At 2:53 PM, Certified Nursing Assistant (CNA) #1 entered Resident #4's room with an ice pitcher. CNA #1 exited the room at 2:54 PM and continued passing ice pitchers. o. At 3:00 PM and 3 seconds, CNA #1 and NA #1 entered Resident #4's room. At 3:00 PM and 58 seconds, NA #1 exited the resident's room, walked up the hall to the Nurses' Station, appeared to look for someone, and returned to the resident's room. p. At 3:01 PM, CNA #1 and NA #1 exited Resident #4's room, walked up the hall toward the Nurses' Station, and located LPN #1 at 3:02 PM on the South Hall. q. At 3:02 PM, LPN #1 entered Resident #4's room, 38 minutes after PT #1 spoke to RN #1. CNA #1 and NA #1 entered the room shortly after LPN #1. r. At 3:03 PM, LPN #1, CNA #1, and NA #1 exited Resident #4's room. s. At 3:04 PM, LPN #1 entered Resident #4's room. At 3:06 PM and 14 seconds, LPN #1 exited the resident's room. t. At 3:06 PM and 26 seconds, LPN #1, CNA #1, and NA #1 entered Resident #4's room with an oxygen tank. CNA #1 exited the resident's room at 3:06 PM and 41 seconds. Oxygen was not administered until 42 minutes after PT #1 spoke to RN #1. u. At 3:11 PM, RN #1 entered Resident #4's room. At 3:12 PM, RN #1 exited the resident's room. LPN #1 and NA #1 remained in the room. v. At 3:13 PM, LPN #1 and NA #1 exited Resident #4's room. w. At 3:17 PM and 6 seconds, CNA #1 entered Resident #4's room. At 3:17 PM and 55 seconds, CNA #1 exited the resident's room. x. At 3:18 PM and 18 seconds, CNA #2 and CNA #3 entered Resident #4's room with linens in their arms. At 3:18 PM and 53 seconds, CNA #1 entered the room. CNA #1 exited the room at 3:19 PM. At 3:22 PM, CNA #2 and CNA #3 exited the room. y. At 3:34 PM, NA #1 entered Resident #4's room. At 3:35 PM, NA #1 exited the room. z. At 3:37 PM, LPN #1 entered Resident #4's room. At 3:40 PM, NA #1 and CNA #1 entered the resident's room. NA #1 and CNA #1 exited the resident's room at 3:41 PM. At 3:42 PM, LPN #1 exited the resident's room. Review of the (named county) Ambulance Service Prehospital Care Report dated 2/1/2021, showed, .Response Urgency: Lights and Sirens .Time Received: 15:34 (3:34 PM) .Type of Response: 911 Response (life or property are in danger) .Complaint Reported: Breathing Problem .EMS received direct call from (Named Long Term Care Facility) for a female in respiratory distress, decreased O2 saturation .responded immediately, emergency traffic. Upon arrival, there was a delay in patient contact due to staff looking for a thermometer and gowns before allowing us to enter building .She (Resident #4) has very audible rales (abnormal rattling sound in the lungs). Patient is pale and clammy. She is tachypneic (fast breathing) with labored breathing. Staff states they have been unable to get her O2 saturation above 79% .She is on nasal cannula at 2 LPM (liters per minute). Closer auscultation (listening) of lung sounds reveals bilateral [MEDICAL CONDITIONS] (excessive fluid in the lungs) .has decreased O2 saturation .Cardiac monitor applied. IV access established. 40 mg (milligrams) [MEDICATION NAME] (a diuretic which pulls excess fluid from the body) administered IVP (intravenous push). [MEDICAL CONDITION] (continuous positive airway pressure) is applied .begins to show improvement shortly after Tx (treatment) .Respiration Rate: 24; Labored .SPO2 (oxygen saturation) 83% . Review of the local hospital Emergency Department record dated 2/1/2021, showed Resident #4 was diagnosed with [REDACTED]. Review of the higher level of acute care hospital Emergency Department record dated 2/1/2021, showed Resident #4 tested positive for COVID-19 in the emergency room , was diagnosed with [REDACTED]. During an interview on 2/8/2021 at 3:37 PM, NA #1 confirmed she worked the second shift on 2/1/2021 and took care of Resident #4. NA #1 confirmed that LPN #1 sent her to check on Resident #4 right after she began work on 2/1/2021 (second shift starts at 2:15 PM). NA #1 stated, .She was having a hard time breathing, I went and found the nurse and let her know what was going on . NA #1 was asked if Resident #4 verbalized anything to her when she went in the room. NA #1 stated, No, she was having a hard time verbalizing anything .because she was struggling to breathe . NA #1 confirmed that Resident #4's O2 sat was in the 40's. During an interview on 2/9/2021 at 2:08 PM, PT #1 confirmed that she immediately went to the Nurses' Station to voice her concern after she entered Resident #4's room the first time. The PT stated, I forgot to tell you that I went back and told her (Resident #4) they were going to do a chest X-ray (that had been previously been ordered prior to Resident #4's current change in condition) after I talked to (LPN #1) .she looked at me with her eyes kind of scared .just knew something was wrong . The PT was asked if Resident #4 normally had a scared look. The PT stated, No, she has a very flat affect (normally) . The PT confirmed that Resident #4 normally would answer her when she asked her how she was doing, but was unable to that day. During an interview on 2/9/2021 at 3:30 PM, LPN #1 stated, .When I came in (2/1/2021) I was getting report .the nurse that was actually here was already gone .she (Resident #4) had seen the doctor that day .the MD had been in the facility .labs (that were previously ordered) came in while we were giving report .He (LPN #2) had already give (given) her first round of [MEDICATION NAME] (antibiotic) (for possible Pneumonia) .in the middle of talking (in report) .(PT #1) said have you heard the way (Resident #4) breathing is .my CNAs get the COVID screening vitals .the girls (NA #1 and CNA #1) came and said the O2 sat is low .once I got in there it (breathing) was not hard but fast paced .I said give me the pulse ox (oximeter) (a device used to check the oxygen level or saturation in the blood) .so I just ran and found a cylinder (oxygen tank) and ran to her .told (named RN #1) that (Resident #4) sat (O2 sat) was really low .when I checked it myself it was 48 (%) .had her up to 73 (%), then 75 (%) .bumped up to 4 (liters of oxygen) and it went up to 80 (%) .I told the girls to stay with her .called (Resident #4's doctor) and he gave order to send her out .went back down there (to Resident #4's room) to do the Head to Toe (assessment) .in the middle of the Head to Toe EMS pulled up .sent one of the aides and said see if (RN #1) can check them in .from what I gathered she was busy and would get in a second .I was like I have to finish this Head to Toe .came out and met (RN #1) in front of Nurses' Station .took gowns from her and the clipboard .went to the middle (East Hall) .entrance .I thought maybe she (Resident #4) had some pneumonia going on because he (doctor) was treating her with antibiotics . LPN #1 was asked why she sent a NA or CNA instead of going herself. LPN #1 stated, I tried to think .if it is pneumonia .maybe just because she's sick having a hard time breathing .soon as the girls (NA #1 and CNA #1) came back, I was still on the count (narcotic count) . LPN #1 was asked how Resident #4 was when she entered the room. LPN #1 stated, Color was still good .asked are you (Resident #4) alright .she just looked at me .chest moving fast .definitely not her normal . LPN #1 was asked if she noticed anything unusual about her face or eyes. LPN #1 stated, Her eyes were bigger, and she was just like staring at me . During an interview on 2/9/2021 at 4:09 PM, RN #1 confirmed she was the Nursing Supervisor on second shift on 2/1/2021. RN #1 was asked to describe what happened with Resident #4 on 2/1/2021. RN #1 stated, The Physical Therapist (PT #1) asked who (Resident #4's) nurse was .said she (Resident #4) just didn't look right so I told her it was (LPN #1) .was not familiar with her (Resident #4) . RN #1 confirmed she did not go check on Resident #4. RN #1 confirmed that one of the CNAs notified her when the ambulance arrived at the facility. RN #1 stated, She said (LPN #1) needs you to go check them (EMS) in and I said give me just a minute because I'm still doing the paperwork .but by the time I got the paperwork finished .I went to the closet to get the gowns .she (LPN #1) was back up here and I said here's the gowns you can go ahead and check them (EMS) in . During an interview on 2/10/2021 at 9:38 AM, LPN #3 confirmed she worked on 2/1/2021 and was leaving for the day when PT #1 came to the Nurses' Station and told LPN #1 that Resident #4 did not look good (LPN #3 was not Resident #4's nurse on the day shift but heard the conversation between PT #1 and LPN #1). LPN #3 stated, .said she (Resident #4) seemed like short of breath . LPN #3 was asked what she would expect a licensed nurse to do when told that a resident seemed short of breath. LPN #3 stated, .hightail it (run fast) down there . LPN #3 was asked if she expected a licensed nurse to send a NA or CNA to check on a resident in that situation. LPN #3 stated, No, I would send myself .that's beyond their scope (of practice) . Observation on 2/13/2021 at 3:11 PM, 2/14/2021 at 2:20 PM, and 2/15/2021 at 12:05 PM, in the resident's room showed, Resident #4 resting in bed on the COVID-19 Unit with the door closed. During an interview on 2/13/2021 at 10:51 AM, the Administrator was asked what the role of the licensed nursing staff was. The Administrator stated the role of the licensed nursing was, To make sure the residents receive the care they need, to also monitor the resident .they should make sure the resident is being assessed properly, maybe send the CNA back down there to be with the patient .make sure the information is relayed to the direct supervisor .if she goes or the supervisor goes .make sure it's handled quickly .everybody must work together as a team . The Administrator confirmed that every minute is vital during an emergency. The surveyor verified the Removal Plan by: 1. On 2/14/2021, RN #1 and LPN #1 who failed to respond in a timely manner to the resident's significant change in condition were provided a 1 on 1 in-service with review of policies and procedures. The surveyors reviewed the in-services and interviewed the RN #1 and LPN #1. 2. On 2/15/2021, all residents' physical assessments were reviewed to determine if any signs of neglect were identified when changes in condition occurred and assessments were completed if identified. If concerns were identified, details were reported to the Quality Assurance (QA) Nurse. The surveyors reviewed residents' assessment and interviewed the QA Nurse. 3. On 2/14/2021-2/15/2021, the facility's Abuse/Neglect policies and procedures were reviewed and updated to include all potential sources of neglect, including resident change in condition. The surveyors reviewed the updated polices and interviewed the QA Nurse. 4. On 2/14/2021, all staff members were in-serviced on Abuse and Neglect policies. The surveyors reviewed the in-services and interviewed staff on all shifts. 5. On 2/14/2021, in-services were provided to all licensed nurses on oxygen administration, residents' change of condition, providing a timely response with new interventions, and the Abuse and Neglect policy. The surveyors reviewed the in-services and interviewed licensed staff on all shifts. 6. On 2/14/2021-2/15/2021, all nursing assistants were in-serviced to use the emergency light, call light, and not to leave a resident in distress alone. The surveyors reviewed the in-services and interviewed the Nurse Aides on all shifts. 7. Staff were not allowed to work if the in-services were not done by 2/15/2021 at 11:59 PM. The surveyors interviewed the QA Nurse. 8. New licensed nurses will be provided in-services on the Abuse /Neglect policies and responsiveness to a change in a residents' condition. The surveyors interviewed the Clinical Educator. 9. On 2/14/2021, the QA Nurse executed a Quality Assurance Performance Improvement (QAPI) Performance Improvement Plan (PIP) as a source to collect information on the nurses' response to a resident with significant changes. The findings will be reported monthly in the QA meetings for at least three months. The surveyors interviewed the QA Nurse. 10. Beginning 2/14/2021, the DON or designee will audit the 24-hour report to monitor for changes in residents' condition and nurse responsiveness. The surveyors interviewed the DON. 11. Beginning 2/14/2021, the DON or designee will perform chart audits and health document assessments for four residents daily for two weeks, three residents weekly for four weeks, two residents weekly for two weeks, and then two residents a month for two months. The results will be reported to the QA Nurse weekly and reviewed in monthly QA meetings. The surveyors reviewed the audit forms and interviewed the QA Nurse. The facility's noncompliance of F-600 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective action plan. The facility is required to submit a Plan of Correction.

Based on the Centers for Medicare and Medicaid Services (CMS) QSO (Quality, Safety, Oversight)-,[DATE]-NH (Nursing Home) Memorandum Summary (MEMO), policy review, Ambulance Report, facility video footage, hospital record review, medical record review, observation, and interview, the facility failed to provide the needed care and services timely when Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 did not respond immediately to a resident's change in condition and Emergency Medical Services (EMS) were not allowed immediate entrance into the facility for 1 of 7 sampled residents (Resident #4) reviewed for change in condition, which resulted in Immediate Jeopardy for Resident #4. RN #1 and LPN #1 failed to respond timely to a Physical Therapist's (PT #1) request to check Resident #4 because the resident did not look good and her breathing was not normal. LPN #1 sent a Nurse Aide (a non-certified nursing assistant) (NA) #1 to check on the resident instead of going to check on the resident. Resident #4's oxygen (O2) saturation (sat) (amount of oxygen measured in the blood) level was 48 percent (%) (normal range is ,[DATE]%) on room air when NA #1 obtained the vital signs. A licensed nurse did not enter the room to assess the resident until 38 minutes after notification by PT #1. Resident #4's O2 sat was 48% when the nurse checked the resident. The facility failed to respond timely when Emergency Medical Services (EMS) arrived to transport Resident #4 to the hospital. EMS waited outside the facility for approximately 3 minutes for staff to retrieve personal protective equipment (PPE) and a thermometer to screen them prior to entry to the facility. Resident #4 was transported to the hospital by EMS with a non-ST segment elevated [MEDICAL CONDITION] Infarction (non-STEMI-[MEDICAL CONDITION]). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on [DATE] at 2:28 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-684. The facility was cited F-684 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 4:19 PM, and validated onsite by the surveyors on [DATE]-[DATE] through policy review, Ad Hoc (as needed) Quality Assurance Performance Improvement (QAPI) meeting sign-in sheet, medical record review, observation, review of in-service training, audits, and staff interviews. The findings include: Review of the facility policy's titled, Provision of Quality Care, revised ,[DATE], showed, .the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice .Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being . Review of the facility's policy titled, Oxygen Administration, revised 2020, showed, .Oxygen is administered to residents who need it, consistent with professional standards of practice .Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control . Review of the facility's policy titled, Resident Rights, revised 2018, showed, .The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents . Review of the CMS QSO ,[DATE]-NH MEMO dated [DATE], showed, .We note that EMS personnel do not need to be screened so they can attend to an emergency without delay . Review of the medical record showed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Orders for Scope of Treatment POST form dated [DATE], showed, .Do Not Attempt Resuscitation .no CPR (cardiopulmonary resuscitation) .Limited Additional Interventions .use medical treatment, antibiotics, IV (intravenous) fluids and cardiac monitoring as indicated . Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #4 had moderate cognitive impairment and required limited to total staff assistance for all activities of daily living with the exception of eating. Review of a Departmental Note dated [DATE] showed Resident #4 was alert and verbally responsive, had increased cough, congestion in both lungs, and yellow sputum. The resident's physician was in the facility that morning and ordered laboratory (labs) work to be drawn, intramuscular (IM) and oral (PO) antibiotics, and a chest x-ray. The labs were drawn, the first dose of IM antibiotic was administered, and the chest x-ray was ordered. Review of the facility laboratory results dated [DATE] showed a white blood cell (WBC) count of 22.8 per microliter (mcl) of blood. The normal range for a WBC is 4XXX,[DATE].0. The resident's facility rapid COVID-19 test, dated [DATE], was negative. Review of a Departmental Note dated [DATE] at 4:56 PM, written by LPN #1, showed, .Called to resident's (Resident #4) room by staff. O2 stat (sat) of 48% on room air. Supplemental O2 put in place @ (at) 3 L (liters)/ (per) min (minute) with an increase in O2 to 73%. MD (Medical Doctor) called and notified .New Order given to send resident to (named local hospital) .EMS arrived and resident departed facility . During an interview on [DATE] at 4:02 PM, PT #1 confirmed that she told the RN #1 and LPN #1 she was concerned about Resident #4. PT #1 stated, It was right after change of shift (2:15 PM) .she (Resident #4) was in the bed .was not looking good .I asked if she felt good and she just looked at me .I asked her again and she just looked at me .she was just a little pale to me .her eyes were just a little big .breathing maybe a little bit more than normal .I went to get the nurse .it was (named LPN #1) I talked to right after change of shift .the first nurse I approached was (named RN #1) and she said she wasn't familiar with her . Review of the facility's video footage with timestamps showed the following on [DATE]: a. PT #1 spoke to RN #1 at 2:24 PM. LPN #1 was not visible on the video footage at this time. b. LPN #1 walked past Resident #4's room at 2:30 PM, 2:33 PM, 2:34 PM, 2:37 PM, and 2:38 PM, and did not enter the room to check on the resident. c. NA #1 entered the room across the hall from Resident #4 at 2:32 PM, exited that room at 2:35 PM, and entered the next room to the left. d. NA #1 entered Resident #4's room at 2:39 PM, exited the room at 2:45 PM, and entered the next room to the right. e. At 2:46 PM, NA #1 exited that room and walked away from the Nurses' Station. f. Certified Nursing Assistant (CNA) #1 entered Resident #4's room with an ice pitcher at 2:53 PM, exited the room at 2:54 PM, and continued passing ice pitchers. g. At 3:00 PM and 3 seconds PM, CNA #1 and NA #1 entered Resident #4's room. h. NA #1 exited the resident's room at 3:00 PM and 58 seconds, walked up the hall to the Nurses' Station, appeared to be looking for someone, and returned to the resident's room. i. At 3:01 PM, CNA #1 and NA #1 exited the resident's room, walked toward the Nurses' Station, and located LPN #1 at 3:02 PM. j. At 3:02 PM, LPN #1 entered Resident #4's room, 38 minutes after PT #1 spoke to RN #1. k. At 3:02 PM, CNA #1 and NA #1 entered Resident #4's room and exited the room at 3:03 PM with LPN #1. l. At 3:04 PM, LPN #1 entered Resident #4's room and exited the room at 3:06 PM and 14 seconds. m. At 3:06 PM and 26 seconds, LPN #1, CNA #1, and NA #1 entered Resident #4's room with an oxygen tank. n. At 3:11 PM, RN #1 entered Resident #4's room and exited the room at 3:12 PM. o. At 3:13 PM, LPN #1 and NA #1 exited Resident #4's room. p. At 3:17 PM and 6 seconds, CNA #1 entered Resident #4's room. At 3:17 PM and 55 seconds, CNA #1 exited the resident's room. q. At 3:18 PM and 18 seconds, CNA #2 and CNA #3 entered Resident #4's room with linens in their arms. At 3:18 PM and 53 seconds, CNA #1 entered the room. CNA #1 exited the room at 3:19 PM. At 3:22 PM, CNA #2 and CNA #3 exited the room. r. At 3:34 PM, NA #1 entered Resident #4's room. At 3:35 PM, NA #1 exited the room. s. At 3:37 PM, LPN #1 entered the room. t. At 3:42 PM, LPN #1 went to the Nurses' Station and retrieved gowns, thermometer, and clipboards. u. EMS personnel arrived at the facility at 3:40 PM and 0 seconds, were at the facility door at 3:40 PM and 39 seconds, and they both were wearing a mask and gloves. v. At 3:43 PM and 25 seconds, LPN #1 opened the East Hall entrance door and dispensed gowns to EMS personnel. EMS personnel donned gowns and entered the facility at 3:44 PM and 1 second, after temperature checks by LPN #1. EMS personnel were allowed entrance into the facility 3 minutes and 22 seconds after their arrival at the facility door. w. At 3:44 PM, RN #1 pushed the Medication Cart to a resident's room across the hall and began the medication administration process, as EMS personnel were en route to Resident #4's room. Review of the (named county) Ambulance Service Prehospital Care Report dated [DATE], showed, .Response Urgency: Lights and Sirens .Time Received: 15:34 (3:34 PM) .Type of Response: 911 Response (life or property are in danger) .Complaint Reported: Breathing Problem .EMS received direct call from (Named Long Term Care Facility) for a female in respiratory distress, decreased O2 saturation .responded immediately, emergency traffic. Upon arrival, there was a delay in patient contact due to staff looking for a thermometer and gowns before allowing us to enter building .She (Resident #4) has very audible rales (abnormal rattling sound in the lungs). Patient is pale and clammy. She is tachypneic (fast breathing) with labored breathing. Staff states they have been unable to get her O2 saturation above 79% .She is on nasal cannula at 2 LPM (liters per minute). Closer auscultation (listening) of lung sounds reveals bilateral [MEDICAL CONDITIONS] (excessive fluid in the lungs) .has decreased O2 saturation .Cardiac monitor applied. IV access established. 40 mg (milligrams) [MEDICATION NAME] (a diuretic which pulls excess fluid from the body) administered IVP (intravenous push). [MEDICAL CONDITION] (continuous positive airway pressure) is applied .begins to show improvement shortly after Tx (treatment) .Respiration Rate: 24; Labored .SPO2 (oxygen saturation) 83% . Review of the local hospital Emergency Department record, dated [DATE], showed Resident #4's respirations were 30 breaths per minute and her O2 sat was 96% on bilevel positive airway pressure ([MEDICAL CONDITION]) (a device to assist with breathing). The resident had an elevated Troponin I (a protein the heart releases into the blood following a [MEDICAL CONDITION]) of 5.213 nanograms (ng)/ (per) ml (milliliter) with a normal range between 0.000 and 0.056 ng/ml. Her natriuretic peptide (NT-proBNP) (a prohormone that increases when heart failure develops or worsens) was 1955 picograms/milliliter (pg/ml) with a normal range between 0 and 125 pg/ml. The resident was diagnosed with [REDACTED]. Review of the higher level of acute care hospital's Emergency Department record dated [DATE], showed Resident #4 was positive for COVID-19, her WBC had increased to 28.8 per mcl of blood, her 2nd Troponin I was 6.340 ng/ml, her NT-pro BNP was 3480 pg/ml and she was admitted to an inpatient telemetry (heart monitoring) unit with [DIAGNOSES REDACTED]. The resident's Power of Attorney confirmed she was DNR but wanted medical therapy for her. During a telephone interview on [DATE] at 4:48 PM, the Paramedic confirmed that his unit was the one that responded to the facility's emergent call for Resident #4. The Paramedic stated, .(Resident #4's) O2 sats were not above 80 (%) and she had [MEDICAL CONDITIONS] back-up (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) .water breathing .when we got to the room The Paramedic stated, .Several times we've been delayed at the door with them (facility staff) trying to find gowns and sometimes the thermometer .we counted, my partner and I, 5 or 6 staff walk past the door and tell us they were trying to find gowns .I, myself, have called the DON (Director of Nursing) once, if not twice .and nothing has been done . During a telephone interview on [DATE] at 12:43 PM, LPN #2 confirmed that EMS personnel must be screened at the door, and wear a gown, gloves, and mask in the facility. LPN #2 stated, When we know we're sending someone out .only nurses are allowed to let someone in .take PPE (personal protective equipment) with them as soon as they call the ambulance .have the PPE out and ready . LPN #2 confirmed he took care of Resident #4 on [DATE]. LPN #2 stated, .went in about 7:30 (AM) that day to help out and worked until 2:00 (PM) . LPN #2 stated, That morning she was alert and oriented .(named doctor) came and saw her that morning .ordered a chest x-ray and CBC (complete blood count), ordered antibiotics for chest congestion .I drew her labs .her WBC was elevated .came back right before I left .(Staff Development Nurse) called doctor .he wanted to see chest x-ray results .had already called (radiology company) that morning and was waiting on them to come .she had some coughing and congestion and was spitting up yellow phlegm .but did not appear to be struggling to breathe . During a telephone interview on [DATE] at 3:02 PM, LPN #1 confirmed she took care of Resident #4 on [DATE]. LPN #1 confirmed she was called to the resident's room by NA #1 and CNA #1. LPN #1 stated, The CNAs had went in the room .I told them to go ahead and be checking her vitals because I literally had just clocked in and got report .they came back and said it (O2 sat) was 48 (%) .I think it was therapy (PT #1) who asked if I had seen her .I went ahead and ran down there when they said it was 48 (%) .she (Resident #4) had really rapid breaths, was trying to get in her breaths .ran back down there and got the oxygen .sat there with her 4 to 5 minutes to see how much I needed to administer .(O2 sat) went up to 73 (%) with 3 liters .up to 80 (%) with 4 (liters) .that's the highest I was able to get her . LPN #1 was asked how she knew EMS was at the door. LPN #1 stated, .My CNAs had already seen them pull up and notified me they were here . LPN #1 confirmed that EMS personnel had to stand at the door ,[DATE] minutes before she let them in the facility. During an interview on [DATE] at 3:28 PM, RN #1 confirmed she worked as the second shift Nursing Supervisor on [DATE], the day Resident #4 was transferred to the hospital. RN #1 stated, Yes .I was on a different hall .(LPN #1) said her oxygen level was low and went and got a concentrator .put her on some oxygen, notified the doctor .sent her to the hospital . During a telephone interview [DATE] at 3:37 PM, NA #1 confirmed that LPN #1 asked her to check on Resident #4 right after her shift began. NA #1 confirmed she took Resident #4's vital signs when she entered the room and her oxygen saturation was low. NA #1 stated, She (Resident #4) was having a hard time breathing, I went and found the nurse and let her know what was going on .the nurse went to assess her . NA #1 confirmed that Resident #4's O2 sat was in the 40's. During a telephone interview on [DATE] at 3:52 PM, CNA #1 confirmed she was in the room when Resident #4 was having difficulty breathing. CNA #1 stated, .my hall partner was like, her O2 (sats) was low .I was like, did you try warming her fingers .she said yes .she's (NA #1) kind of new so I went in there .we tried every single finger .one time it was 52, then it was 46 and it kept declining .I immediately told her to get the nurse (LPN #1) .she (LPN #1) came in there, checked it again .said go get an oxygen concentrator .we couldn't find one (concentrator) so we got an oxygen tank . CNA #1 stated, .she (Resident #4) was really pale .her respirations were going fast .breathing was heavy .CNA #1 confirmed she saw EMS personnel arrive at the facility. CNA #1 stated, .EMS arrived .we've had a rise in COVID so they made them get their temp (temperature) and ask a bunch of questions .we kept trying to find a nurse, running back and forth .(LPN #1) was busy doing the head to toe (assessment) .we went to the supervisor (RN #1) and she said she was doing something .and couldn't right now, so EMS had to wait outside until a nurse came .the CNAs can't let them in . During a telephone interview on [DATE] at 11:02 AM, Advanced Emergency Medical Technician (AEMT) confirmed his unit responded to the emergency call for Resident #4. The AMT stated, .called for a patient in respiratory distress .of course their doors are locked, somebody has to let you in .standing here and people go by XXX,[DATE] people .hold up a finger saying just a minute .once we finally got access (into the facility) started around the corner to the room and you could hear the lady breathing so bad .was in congestive (heart) failure .was drowning .in respiratory distress big time .our gripe was if you've got a critical patient don't hold us out here waiting for a thermometer .ongoing thing (with this facility) .if you know you have an ambulance coming you should have somebody at the door .unless somebody is walking by, you have to call the number .and then have to stand there in the lobby and wait for somebody to get you a gown . During an interview on [DATE] at 12:27 PM, the Infection Preventionist confirmed she had tested Resident #4 for COVID-19 that morning with the rapid test and she was negative. The Infection Preventionist stated, I would never have believed she had COVID .around 11ish (time tested 11:00 AM) .some sputum changing in color .but not even a doubt (the test was negative) . During an interview on [DATE] at 2:08 PM, PT #1 stated, .I forgot to tell you that I went back and told her (Resident #4) they were going to do a chest x-ray .she looked at me with eyes kind of scared .I just knew something was not right . During an interview on [DATE] at 4:19 PM, NA #1 confirmed LPN #1 told her to check on Resident #4 when her shift began. NA #1 stated, When I walked into my shift, we got report, I went to her (Resident #4's) room first, her breathing was not right .I was trying to talk to her and she wasn't talking .was hard for her to talk due to heavy breathing . NA #1 was asked what she did next. NA #1 stated, I tried to find (CNA #1) .we both went in there and (CNA #1) checked sats (O2 sat) .my reading and her reading were right . NA #1 confirmed that she and CNA #1 left the resident alone and went to find LPN #1 .told her (Resident #4) oxygen level was very low .(LPN #1) went right in to assess .still in the 40's .we went to get oxygen .very scary for me .I stayed until she (LPN #1) got it up as high as she could .when I left it was 73 (%) .when I went back to check, it got up to 80 (%) .she was still having trouble breathing with the oxygen as well, you could tell the rattling in her throat . NA #1 confirmed that she told LPN #1 that EMS was there. NA #1 stated, She told us to get (RN #1) .RN #1 told us she was too busy to let them in . NA #1 confirmed that she went back to LPN #1 and told her that RN #1 would not let EMS in the facility. During an interview on [DATE] at 10:26 AM, the DON stated the role of the NAs was, To take care of the basic needs of the resident and report findings to the nurse. The DON was asked what nursing staff should do when told by a staff member that a resident has had a change in their condition. The DON stated, Assess the resident, get oxygen if needed .report their findings . The DON was asked should a licensed nurse send a NA to assess a resident in respiratory distress. The DON stated, They don't assess .they might just go down there and take a quick look .the only reason I would think is because she was trying to get there and the aide might get there just a little bit faster . The DON confirmed that every minute is important in an emergent situation. The DON was asked if EMS should be delayed from entering the building during an emergency. The DON stated, No more than what would be necessary .taking them half a moment to get dressed out .and screened .you can walk and screen at the same time . The DON confirmed that the facility staff should work together in an emergent situation. The DON stated the facility followed CDC infection control guidelines to the best of their ability. The DON was asked if she was she aware that EMS did not have to be screened during an emergency. The DON stated, No .under the impression they had to be screened . Observation in the resident's room on [DATE] at 12:05 PM, showed Resident #4 was awake with the head of the bed elevated and holding a drink. The surveyor asked her how she felt and the resident stated she wasn't feeling well. Observation in the resident's room on [DATE] at 2:15 PM, showed, Resident #4 was in bed with the head of bed elevated, she held a small glass with a dark brown liquid in her hand and stated, I'm not feeling well. During an interview on [DATE] at 10:51 AM, the Administrator stated the role of the Nursing Supervisor was, .mainly over the other staff members .she's pulled from all directions .sometimes have to make quick decisions and look ahead .also to take the information given them .as a Supervisor .looking at not only the whole building but a lot to think about .have to process it in a quick way . The Administrator confirmed a staff member should not leave a resident with an O2 sat of 48% alone and stated, Only if they have to leave the room and get someone else. The Administrator confirmed the call light could be utilized in such a situation and stated, .can be used for that purpose .it's hard to know how to make that rash decision to know what to do .make a quick decision .information needs to be relayed ASAP (as soon as possible) to a Supervisor . The Administrator confirmed EMS should not be delayed from entering the building during an emergency and stated, Not during an emergency .I don't think they should be delayed regardless of the situation at hand . The Administrator was asked if the Nursing Supervisor should intervene when asked to allow EMS entrance in the building while the licensed nurse was doing her assessment. The Administrator stated, I feel like if she's in a position she can that she should or make sure someone else takes care of it . The surveyor verified the Removal Plan by: 1. On [DATE], RN #1 and LPN #1 who failed to respond in a timely manner were provided a 1 on 1 review of policies and procedures related to a change in resident condition and nurse responsibility to respond timely. The surveyors reviewed the 1 on 1 in-service and interviewed RN #1 and LPN #1. 2. On [DATE], in-services were provided to all licensed nurses on policies and procedures, oxygen administration, resident change of condition, and providing a timely response to a resident with a serious change of condition. The surveyors reviewed the in-services and interviewed licensed staff on all shifts. 3. On [DATE], all residents were assessed to identify any change in condition. and rapid response. If there was a change in the resident's condition, the resident was assessed to determine any physical or emotional signs of neglect. Any concerns identified were reported to the Quality Assurance (QA) Nurse. The surveyors reviewed resident assessments and interviewed the QA Nurse. 4. On [DATE]-[DATE], all nursing assistants were in-serviced on their duties related to resident assessment and reporting residents change of condition to a charge nurse immediately. The surveyors reviewed the in-services and interviewed the nurse aides on all shifts. 5. On [DATE]-[DATE], all nursing assistants were in-serviced on not leaving a resident showing signs of distress alone. The surveyors reviewed the in-services and interviewed the nurse aides. 6. Staff were not allowed to work if the in-services were not completed by [DATE] at 11:59 PM. The surveyors interviewed the QA Nurse. 7. New hires (licensed nurses and nursing assistants) will be provided in-services on policies, procedures, oxygen administration, change of a residents' condition, and responsiveness. The surveyors interviewed the Clinical Educator. 8. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented related to nursing staff notification and the nurse response to significant changes. The surveyors interviewed the QA Nurse. 9. The DON or designee will perform daily audits of the 24-hour report for changes in residents condition. The surveyors reviewed the audit forms and interviewed the DON. 10. The Emergency Medical Service (EMS) that comes to the facility to provide emergency services will no longer be required to be screened and don personal protective equipment. On [DATE]-[DATE], the licensed nurses were in-serviced on ensuring that during an emergency, a staff member will be waiting at the ambulance entrance waiting on EMS to arrive at the facility, and will immediately let EMS in the facility to provide emergency services and transport. The surveyors reviewed the in-services and interviewed staff on all shifts. 11. Beginning on [DATE], the DON or designee will perform chart audits and health assessments for four residents daily for two weeks, then three residents weekly for four weeks, then two residents weekly for two weeks, and then two residents a month for two months. The results will be reported to the QA Nurse weekly and reviewed in monthly QA meetings. The surveyors reviewed the audit forms and interviewed the DON. The facility's noncompliance of F-684 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.