Every finding on record at Wedgewood Nursing Home

Based on observation, interview and record review the facility failed to ensure each resident bedside was adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 5 residents (Resident#43, Resident#79, Resident#92) reviewed for resident call system. The facility failed on 04/21/2026 to ensure the call light system was adequately equipped, the call light string was hanging down from the wall, away from the residents. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for activities of daily living.Findings included:1. Record review of Resident #43's MDs assessment dated [DATE] reflected he was a [AGE] year old male with an admission date of 12/06/2014, diagnoses included Hemiplegia and hemiparesis following cerebral infraction affecting left dominant side (severe paralysis of one side of the body due to brain damage), Cognitive communication deficit (A communication impairment resulting from underlying cognitive issues such as memory, attention, or executive function deficits), and Vascular Dementia (Decline in thinking skills). Resident #43 had a BIMS score of 03 indicating severe cognitive impairment, he needed moderate assistance with shower and toileting hygiene. Review of Resident #43's care plan, revised on 04/28/2025 reflected he had cognitive impairment. Interventions: . Resident #43 needed supervision/assistance with all decision making, Resident #43 had ADLs self-care Performance deficit related to: Hemiplegia, Debility, Impaired Cognition. Interventions: . Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. In an observation and interview on 04/21/2026 10:16 AM with Resident #43 in his room revealed he was lying in his bed, his call light was hanging down from the wall, away from him. Resident #43 stated he could not reach the call light at that time. 2. Record review of Resident # 79's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 11/01/2024. Diagnoses included Depression, and Cognitive communication deficit (A communication impairment resulting from underlying cognitive issues such as memory, attention, or executive function deficits). Resident #79 had a BIMS score of 00 indicating severe cognitive impairment, he was dependent on staff for toileting hygiene and shower. Record review of Resident #79's care plan, revised on 04/22/2025 reflected he had an ADLs self-care Performance deficit and is at risk for not having his needs met in a timely manner. Functional limitations in range of motion. Hemiplegia/Hemiparesis secondary to a stroke. Interventions: ADL assistance required. Provide shower shave, oral care, hair care and nail care per schedule and when needed. In an observation and interview on 04/21/2026 at 10:24 AM with Resident #79 in his room it was revealed he was lying in his bed, his call light was hanging down from the wall, away from the resident. Resident #79 stated he could not reach the call light at that time. 3. Record review of Resident #92's MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date of 02/25/2022, diagnoses included Unspecified Dementia (memory loss), Legal blindness,. Resident #92 had a BIMS score of 03 indicating severe cognitive impairment, she was dependent on facility staff for toileting hygiene and shower. Record review of Resident #92's care plan, revised on 04/11/2022 reflected she was legally blind, Intervention; . Anticipate needs and meet them as able, Care Plan review dated 01/19/2026 reflected Resident #92 had an ADLs self-care Performance deficit and is at risk for not having her needs met in a timely manner. Interventions: Resident #92 was a high fall risk. In an observation and interview on 04/21/2026 11:16 AM with Resident #92 in her room revealed she was lying in her bed, and the call light was hanging down from the wall, away from the resident. Resident #92 stated she could not reach her call light. An interview with RN K 04/22/26 at 11:18 AM revealed she was the charge nurse for Hall north A. RN K stated all employees going into a resident's room were responsible to ensure the call light was always within reach of the resident. RN K stated residents who did not have their call light within reach were not able to let the staff know of their needs and were at risk for falls, injury skin tear, chocking and even death. RN K stated she could not remember the last time she or her staff received in- service on call light devices. An interview on 04/22/2026 at 12:02 PM with CNA L revealed she was working in hall north A that day, she stated all staff were responsible to ensure the call light was always within the reach of the resident. CNA L stated it was very important to have the call lights for the residents to let the staff know of their immediate needs and not having a call light within reach out residents at risk of falls, injury and skin tears. CNA L stated she had received in-service on call lights within a month. Interview on 04/23/2026 at 10:30 AM with the DON revealed all staff were responsible for ensuring the call light was within the reach of the resident before they left the resident's room. DON stated not having the call light within reach of the resident was detrimental to their safety, it could lead to falls, injury, chocking and even cause death because the resident was not able to let the staff know of their needs. She stated the most recent in-service on call light device was offered to the employees within a week. Record review of facility policy subject Call light-use of Applies to all staff, revised on 1/1/2024 reflected:Policy:It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use.PROCEDURE12.Be sure call lights are placed near the resident, never on the floor or bedside stand .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 7 residents (Resident #1, Resident #9, Resident #22, Resident #48, Resident #57, Resident #79, Resident #87) of 18 residents reviewed for ADLs. The facility failed to ensure Resident #1, Resident #9, Resident #22, Resident #87 had their fingernails trimmed and cleaned on 04/28/2026. Resident #48, Resident #57, Resident #79 had their fingernails trimmed on 04/28/2026. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, skin breakdown, and a decreased quality of life.1. Record Review of Resident #1's Annual MDS assessment dated [DATE] as a [AGE] year-old male with admission date of 2/10/2025 to the facility. His pertinent diagnoses included: Stroke (occurs when blood flow to the brain is blocked causing brain cells to die), Arthritis, paraplegia (loss of function in the lower body), and Contracture of right hand (stiff joints and reduced mobility). His BIMS score was 15, which indicated Resident #1 had intact cognition. Resident #1 needed setup for personal hygiene. Review of Resident #1's Comprehensive Care Plan, revised 4/24/2025 reflected, Category: [Resident #1] has an ADL self-care performance deficit related to Late effect Stroke, right hemiplegia, Debility, incontinent episodes, and cognitive deficits .Interventions: Check nail length and trim and clean on bath day Report any changes to the nurse. In an interview and observation on 04/21/2026 at 11:19 AM with Resident #1 revealed he had long and dirty fingers nails on both hands measuring approximately 0.2 - 0.4 inches in length extending from the tip of his fingers. He stated he would like his nail to be cleaned and trimmed and stated that staff had not offered nailcare to him for last few weeks. He stated he was unable to trim nails himself related to his contracture. In an interview and observation on 04/22/2026 at 10:49 AM, CNA A stated Resident #1 had long, dirty fingernails. CNA A stated CNAs were responsible for providing nail care, including trimming and cleaning fingernails, unless the resident had diabetes. She stated nail care should be provided on shower days and as needed. CNA A stated the risks of long, dirty fingernails included potential skin tears, and infection. 2. Record review of Resident #9's quarterly MDS Assessment, dated 03/11/2026, reflected the Resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Cerebrovascular Accident (CVA) (a medical emergency where blood flow to part of the brain is interrupted or reduced, depriving tissue of oxygen and causing brain cells to die), and muscles weakness. Resident#9 had a BIMS score of 00/15 indicating severe cognitive impairment. His Functional Abilities assessment indicated he was dependent on staff for his personal hygiene. Record review of Resident #9's care plan, dated 01/29/2026, reflected Focus: [Resident#9] is at risk for not having his needs met in a timely manner. Performance deficit is related to: CVA, contracture right hand. Goal: [Resident#9] will improve current level of function in Bed Mobility. and Personal Hygiene, through the review date. Interventions: Personal Hygiene: dependent. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Observation and interview on 04/21/2026 at 10:59 AM revealed Resident#9 was lying in bed quietly, he had long nails on both hands, they were approximately 0.4cm in length extending from the tip of his fingers. The nails were discolored tan and the underside, and the nail beds had dark brown colored residue. Resident #9 stated he wanted his fingernails trimmed and cleaned. In an observation and interview on 04/21/2026 at 2:32 PM, RN D looked at Resident#9 fingernails and stated, they needed to be trimmed and cleaned. He stated that Nurses and CNAs were responsible for cleaning and trimming residents' fingernails. He stated that for residents with diabetes, Nurses were responsible for trimming fingernails as needed. RN D stated the risks of long, dirty fingernails included increased risk of infection and decreased quality of life. 3. Record review of Resident #22's MDS assessment dated [DATE] reflected he was an [AGE] year-old male with an admission date of 08/29/2025, diagnoses included Unspecified Dementia (memory loss), and cognitive communication deficit,. He had a BIMS score of 10 indicating moderate cognitive impairment. Resident #22 needed moderate assistance with personal hygiene. Record Review of Resident #22's care plan, revised on 02/18/2026 reflected Resident #22 had an ADLs self-care Performance deficit and was at risk for not having his needs met in a timely manner. Interventions: . provide shower, shave, oral care, hair care and nail care per schedule and when needed. In an interview and observation on 01/21/2026 at 01:50 PM Resident #22 revealed he was sitting in his room, he had and approximately .2 - .4 inches long and dirty fingernails extending from the tip of his fingers on both hands. He had dark residue under several of his fingernails. Resident #22 stated he liked his fingernails trimmed short and cleaned. 4. Record review of Resident #48's MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date of 09/24/2025, diagnoses included paraplegia (loss of function in the lower body), Hypertension (elevated blood pressure), Depression. Resident #48 had a BIMS score of 15 indicating intact cognitive function. Resident #48 was dependent on facility staff for toileting hygiene and showers. Record Review of Resident #48's care plan, revised on 10/01/2025 reflected Resident #48 had an ADLs self-care Performance deficit and was at risk for not having her needs met in a timely manner.In an observation and interview with Resident #48 on 04/21/2026 11:29 AM revealed she was lying in her bed. Resident #48 had approximately .2 - .4 inches long fingernails extending from the tip of her fingers on both hands. Resident #48 stated she likes her fingernails trimmed and the staff had not offered to trim it recently. 5. Record review of Resident #57's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 06/09/2023, diagnosis of Vascular Dementia (Decline in thinking skills). Resident #57 had a BIMS score of 02 indicating severe cognitive impairment, he needed supervision with personal hygiene. Record Review of Resident #57's care plan, revised on 04/24/2025 reflected he had an ADLs self-care Performance deficit and is at risk for not having his needs being met in a timely manner. In an observation and interview on 04/21/2026 at 11:49 AM with Resident #57 revealed he was sitting in the TV room, Resident #57 had approximately .2 - .4 inches long fingernails extending from the tip of his fingers on both hands, he stated he would like his fingernails trimmed. 6. Record review of Resident # 79's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 11/01/2024. Diagnosis of Cognitive communication deficit (A communication impairment resulting from underlying cognitive issues such as memory, attention, or executive function deficits),. Resident #79 had a BIMS score of 00 indicating severe cognitive impairment, he was dependent on staff for toileting hygiene and shower. Record review of Resident #79's care plan, revised on 04/22/2025 reflected he had an ADLs self-care Performance deficit and is at risk for not having his needs met in a timely manner. Functional limitations in range of motion. Hemiplegia/Hemiparesis secondary to a stroke. Interventions: ADL assistance required. Provide shower shave, oral care, hair care and nail care per schedule and when needed. In an observation and interview on 04/21/2026 at 10:24 AM with Resident #79 in his room revealed he had approximately .25-.50 inches long fingernails extending from the tip of his fingers on both hands, he stated he would like his fingernails trimmed. 7. Record review of Resident #87's MDS assessment dated [DATE] reflected she was an [AGE] year-old female with an admission date of 09/26/2024, diagnoses included Intracerebral Hemorrhage (Bleeding into the brain), Hypertension ((Elevated blood pressure), Cognitive communication deficit (A communication impairment resulting from underlying cognitive issues such as memory, attention, or executive function deficits). Resident #87 had a BIMS score of 15 indicating intact cognitive function, he needed supervision with shower. Record review of Resident #87's care plan, reviewed on 04/29/2025 reflected he had an ADLs self-care Performance deficit and is at risk for not having her needs met in a timely manner., review on 07/30/2025 reflected she had impaired visual function. Interventions: . Anticipate needs and meet them as able. In an observation and interview on 04/21/2026 at 10:30 AM with Resident #87 in her room revealed she had approximately .2 - .4 inches long and dirty fingernails extending from the tip of his fingers on both hands, some of her fingernails had dark residue under it. Resident #87 stated she would like her fingernails cleaned and trimmed. In an interview on 04/22/2026 at 11:00 AM LVN B stated that Nurses and CNAs were responsible for clipping residents' fingernails. He stated that for residents with diabetes, Nurses were responsible for trimming fingernails She stated that the expectation was CNAs provide ADL care to residents on shower days and as needed. LVN B stated the risks of long, dirty fingernails included skin tears and increased risk of infection. She stated they would document refusal of care on the progress note, if needed. An interview with RN K 04/22/2026 at 11:18 AM revealed she was the charge nurse for Hall north A. RN K stated all the nursing staff were responsible to ensure the resident's fingernails were cleaned and trimmed, nurses were responsible to trim the fingernails if the resident was diagnosed with diabetes. RN K stated she was responsible for ensuring the CNAs were doing their job, she stated she could not remember when the last time she received in- service on fingernail care. RN K stated not trimming and cleaning the fingernails put residents at risk for infections and skin tears. She stated she expected her staff to reattempt the fingernail care if a resident refused care, and to let the charge nurse know. An interview on 04/22/2026 at 12:02 PM with CNA L revealed she was working on hall north A that day, she stated CNAs were responsible to do the fingernail care for all residents except the residents who were diagnosed with diabetes. She stated the residents who had not had their fingernails cleaned and trimmed were at risk of infections, hurting themselves or others and skin tears. She stated she would reattempt the fingernail care if a resident refused care and let the charge nurse know. She stated she received in-service on fingernail care a week ago. In an interview on 04/23/2026 10:38 AM with the DON stated that the CNAs and the nurses were responsible for keeping the resident's fingernails clean and trimmed. The DON stated nurses were responsible for trimming fingernails for diabetic residents. She stated that her expectation was fingernails care to be provided as needed. She added that if a resident refused care, CNAs should report any refusals to charge nurses. The DON stated that not cleaning and trimming resident's fingernails could lead to the risk for skin tears and infection risk. She stated that as a DON of the facility, she ensured quality of life was maintained in residents by daily rounding and checking 24-hour nursing reports. Record review of the facility's Nail Care policy, dated 01/01/25, reflected nail care was necessary To provide for personal hygiene and prevent infection.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for the facility's only kitchen observed for food service safety . The facility failed to ensure food items in the kitchen were appropriately covered on 04/21/2026. This failure could affect residents by placing them at risk for food-borne illness and food contamination. Findings included: Observation of the facility's dry storage on 04/21/2026 at 10:18 AM revealed about 3/4th Packet of tortillas left open exposed to air in a cardboard box. Observation of facility's walk-in refrigerator on 04/21/2026 at 10:22 AM revealed a cardboard box with about 5-6 heads of lettuce open to cold air. In an interview on 04/22/2026 at 1:30 PM with the Dietary Manager revealed stated that her expectation was that all food items in the kitchen be covered at all times. She stated that everyone working in the kitchen, including cooks, dietary aides, and herself, was responsible for ensuring food items were properly covered. She stated that the risk of not appropriately covering food items included cross contamination of food and decreased food quality. She further stated that, as the Dietary Manager, she provided frequent in services to all kitchen staff on appropriate food storage practices. In an interview on 04/22/2026 at 1:47 PM, [NAME] C stated that everyone working in the kitchen was responsible for ensuring that food items were properly covered at all times and not exposed to air. She stated that failure to cover food items could result in cross contamination and could cause residents to become sick. He stated that if the food items were left uncovered, the should be promptly discarded. Record review of facility policy titled, Food Storage: Cold revised October 2019 reflected, It is the center policy to ensure all .frozen and refrigerated food will be appropriately stored in accordance with guidelines of FDA (Food and Drug Administration) Food Code.The Dining Services Director/Cook (s) insures that all food items are store properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . Record review of facility policy titled, Food Storage: Dry goods revised October 2019 reflected, It is the center policy to ensure all dry goods will be appropriately stored in accordance with guidelines of FDA Food Code. Record Review of FDA Food Code 2022 reflected, . Annex 7: Model Forms, Guides, and Other Aids. Protection from Contamination . 15. Food separated and protected .This item should be marked OUT of compliance when .food is not packaged or covered during storage (unless in the process of cooling); .

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 6 residents (Resident #9) observed for infection control. The facility failed to ensure CNA E performed hand hygiene, and proper use of gloves, while providing incontinent care to Resident #9 on 04/22/2026. These failures could place residents at risk for development of infection.Record review of Resident #9's quarterly MDS Assessment, dated 03/11/26, reflected the Resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of muscles weakness. Resident#9 had a BIMS score of 00/15 indicating severe cognitive impairment. Further review revealed bladder continence indwelling catheter, and bowel continence frequently incontinent. Record review of Resident #9's care plan, dated 01/29/26, reflected Focus: [Resident#9] has a urinary catheter and is at risk for urinary tract infections and injury. Urinary catheter related to chronic bladder outlet obstruction. Goal: [Resident#9] will be/remain free from catheter-related trauma and complications through next review date. Interventions: Catheter care:. Monitor for and report to the physician any signs or symptoms of a urinary tract infection such as pelvic pain, burning with urination, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. Observation on 04/22/26 at 1:30 PM, reflected CNA E and CNA H entered Resident #9's room and washed their hands, put on gown, and gloves. Both CNAs uncovered Resident#9. There was a bedside table dropped with towel and had on the top: box of gloves, a bottle of hands sanitizer, plastic bag with loose clean wipes. CNA E positioned at the right side of the bed unfastened Resident#9 brief, then proceeded to clean the Resident. CNA E cleaned Resident#9's front area starting across his pubic area, and both groin area using one wipe per stroke. CNA E sanitized her gloved hands (Sanitized her hands with gloves on). CNA E cleaned Resident#9 indwelling catheter tubing starting from the insertion site out using one wipe at a time. CNA E with the help of CNA H turned Resident#9 to his right side. CNA E sanitized her gloved hands, cleaned Resident#9 buttocks area, folded the brief and push it under Resident#9. The brief was dirty from resident body sweat. CNA E sanitized her gloved hands, got a clean brief put it under Resident#9. Both CNAs turned Resident#9 on to his back. CNA H removed the dirty brief put it in the trash can. CNA H changed gloves with hands hygiene. CNA E finished putting the brief on Resident#9. Both CNAs pulled the Resident up in the bed and covered him. Both CNAs removed their gowns and gloves, completed hands hygiene and exited the room. In an interview on 04/22/26 at 1:47 PM, CNA E stated she was supposed to change her gloves with hand hygiene after she cleaned the resident before applying the clean brief. CNA E stated she was not supposed to sanitize her gloved hands but change gloves with hands hygiene. CNA A stated not following proper hand hygiene and infection control policy could lead to cross contamination and development of infection for residents. In an interview on 04/23/26 at 11:31 AM, The DON stated during care the staff was to use hand sanitizer or wash hands if they were physically soiled. The DON stated the staff was expected to change gloves with hands hygiene, and not to sanitize gloved hands. She stated during incontinent care the staff was supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean one. The DON stated proper hands hygiene and following proper infection control policy was to be followed to prevent the development of infections for residents and staff. Review of the facility policy dated 11/12/2017 and titled Hand Hygiene reflected, Staff involved in direct resident contact will perform proper hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene indicated and will be performed under condition listed.before applying and after removing personal protective equipment (PPE), including gloves. When, during resident care, moving from a contaminated body site to a clean body site. When in doubt. The use of gloves does not replace hand washing. Wash hands after removing gloves.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident # 9) reviewed for resident rights. The facility failed to ensure Resident # 9 was assisted with eating in a dignified manner on 04/22/26, CNA I stood while feeding the resident. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Record review of Resident #9's quarterly MDS Assessment, dated 03/11/26, reflected the Resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Cerebrovascular Accident (CVA) (a medical emergency where blood flow to part of the brain is interrupted or reduced, depriving tissue of oxygen and causing brain cells to die), and muscles weakness. Resident#9 had a BIMS score of 00/15 indicating severe cognitive impairment. His Functional Abilities eating: Setup or clean-up assistance. Record review of Resident #9's care plan, dated 01/29/26, reflected Focus: [Resident#9] is at risk for not having his needs met in a timely manner. Performance deficit is related to: CVA, contracture right hand. Goal: [Resident#9] will improve current level of function in Bed Mobility. and Personal Hygiene, through the review date. Interventions: Eating: set up. During an observation on 04/22/26 at 08:54 AM, Resident #9 was in bed with the head of the bed elevated, and CNA I was standing while assisting Resident #9 with his meal. Resident #9 was unable to state how he felt about staff standing during his meal. During an interview on 04/22/26 at 08:59 AM, CNA I stated she was supposed to sit next to Resident #9 while assisting with his meal today. She said she should have gotten a chair and sat while assisting because standing could make a resident uncomfortable, and lead to loss of dignity. During an interview on 04/23/26 at 11:31 AM, the DON said that all staff were responsible for ensuring resident's dignity was maintained and all staff was trained on resident rights. She said when a resident required assistance with meals, the staff should be seated to prevent the residents from being uncomfortable. Record review of a facility policy titled Resident Rights date 02/23/2016 indicated, .11. 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. Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (100/200 hall nurses' cart) of 5 medication nurse cart reviewed for pharmacy services in that: The facility failed to ensure LVN F removed medications in unsecure containers from the 100/200 Hall nurses' cart This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications, and place residents at risk of not having the medication available due to possible drug diversion.Observation on 04/22/26 at 1:19 PM, of Nurses' Cart Hall 100/200, with LVN F revealed the blister pack for Resident #29's Temazepam 15 mg cap (controlled medication used for pain) had 2 blisters seal broken with pills still inside the broken blisters. One of the blisters had a tape over. Interview on 04/22/26 at 1:19 PM, LVN F stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blisters pack seals were broken, and she was not aware of who might have damaged the blisters. She stated it was not acceptable to tap over the broken seal. She stated the risk would be potential for drug diversion. She stated the nurses and med aides were responsible for checking the medication blister packs for broken seals during the count of narcotics, and during the change of shift. She stated when a broken seal was observed, she would waist the pill with another nurse. Interview on 04/23/26 at 8:56 AM, the DON stated she expected if a blister pack medication seal was broken the pill would be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. She stated taping over the broken blister with medication inside was unacceptable. The DON stated the risk would be potential for drug diversion and infection control issues. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADONs were supposed to check the carts daily. The DON stated the pharmacy consultant checked the carts monthly and she stated ADONs were supposed to do random checks of the medication carts for monitoring. Record review of the facility's policy titled Storage of Medications, dated 01/20/2021, revealed in part . 8. Medication Carts are routinely inspected for discontinued, Outdated, defected or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy .

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (06/18/25 lunch meal) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed rice pilaf as a pudding consistency for residents who required pureed diets during the lunch meal on 06/18/25. This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs. Findings included: Record review of the facility's menu for 06/18/25 reflected the following: Beef Hamburger Steak (80/20), [NAME] Beans, [NAME] Pilaf- TX, Dinner Roll Buttered, Sherbet Orange. Observation and interview of the sample tray on 06/18/25 beginning at 1:07 PM with the DM revealed the test tray included pureed beef hamburger steak, pureed vegetables, pureed rice, and pureed bread. The pureed rice had chunks of rice grains in it and was not fully pureed. The DM said [NAME] A had prepared the pureed food items for the lunch meal today (06/18/25). The DM said the pureed rice should have been more smooth so that it was easy to swallow. The DM said she did not check the texture of the pureed food items because she just started here a week ago and she thought [NAME] A knew what to do for the pureed food items. The DM said the purpose of making sure the pureed food items were smooth and pudding-like consistency was that a resident could choke on the food. Interview on 06/18/25 at 1:13 PM, with [NAME] A revealed she normally made the pureed foods for the lunch service and did so today (06/18/25). [NAME] A said she thought the pureed rice became chunky because she added thickener to it. [NAME] A said she did not think the pureed rice served today was pudding-like or smooth, but she still served it. Record review of the facility's Diets, Nutrition and Hydration policy, revised August 2023 reflected: The facility will provide each resident with three meals a day and a nourishing snack at bedtime. Each meal will be provided according to physician orders, Facility Diet Manual, and menu spread sheet.

Based on interview and record review, the facility failed to maintain clinical records that were complete and accurate for one (Resident #1) of five residents reviewed for clinical records. The facility failed to ensure Resident #1's clinical record was complete and accurate when the resident experienced a change in condition on 02/02/25. LVN A did not accurately and completely document Resident #1's blood sugar monitoring, medication administration, and contact with the NP or EMS. These failures could place residents whose records are maintained by the facility at risk for delays and errors in their care and treatment. Findings include: Record review of Resident #1's undated Admission Record reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Type 1 Diabetes, (body does not use insulin effectively or does not produce enough insulin), Major Depressive Disorder, End Stage Renal Disease, (kidneys can no longer function adequately to meet the body's needs), Dependence on Renal Dialysis, Chronic Respiratory Failure with Hypoxia (a condition where there is not enough oxygen in the tissues of your body), Congestive Heart Failure (heart can no longer pump blood well enough to meet the body's needs), dysphagia (difficulty swallowing) Record review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 01/30/25, reflected a Brief Interview of Mental Status (BIMS) score of 8, indicating he had moderate cognitive impairment. Record review of Resident #1's progress note, dated 02/13/25, reflected on 02/02/25 he had been transferred via EMS to the hospital after having hypoglycemia (low blood sugar). Record review of Resident #1's progress note, dated 02/13/25, reflected on 02/02/25 the resident had five blood glucose monitoring tests that indicated hypoglycemia (low blood sugar). The time was not documented for five of five of the blood glucose monitoring test. Record review of Resident #1's progress note, dated 02/13/25, reflected on 02/02/25 the resident had been administered three medications. The time was not documented for medication administration for three of three medications (Baqsimi Nasal Powder 3 MG/Dose-2 doses; Ipratropium-Albuterol Inhalation Solution 3 MG/3 ML). Record review of Resident #1's progress note, dated 02/13/25, reflected on 02/02/25 LVN A had contacted the Nurse Practitioner (NP) three times. The time was not documented for three of three NP contacts. Record review of Resident #1's nurses note, dated 02/13/25, reflected on 02/02/25 LVN A had called Emergency Medical Services (EMS) to transport the resident to the hospital. The time was not documented for when EMS was called or when EMS arrived. Interview on 04/22/25 at 2:00 PM with Medication Aide (MA), she stated when she gave a medication, she was required to document the date, time, drug, and dose. She stated if she did not document the medications she gave, the next shift would not know what medications the resident had received and could possibly double dose the resident. Interview on 04/22/25 at 2:35 PM with LVN B, she stated that timing events in the medical record was important to show what occurred with the resident and not documenting medications given could result in a resident receiving the wrong dose of medication. She stated when giving a medication she should document the patient, drug, date, time, and route. Interview on 04/22/25 at 3:15 PM with Licensed Vocational Nurse (LVN) A, she stated complete documentation of a medication should contain the drug, the dose, the route, and the time. She stated, If we don't document the care we give, it can cause a lot of problems and the next shift won't know what happened with the resident. She stated she usually documented all care at the end of the shift, and she did not know why she did not document care and medications on 02/02/25. Interview on 04/23/25 at 12:00 PM with the Administrator, he stated it was his expectation significant events would be documented appropriately and relayed to leadership. He stated every nurse should document and timeline the events that occurred to provide clear understanding of what took place with the resident's care. Interview on 04/23/25 at 3:20 PM with the Assistant Director of Nurses (ADON). The ADON reviewed Resident #1 progress note for 02/02/25 dated 02/13/25. She stated a nurse should document any change of condition, medications given with time administered, to chronologically tell story of what took place. She stated it was her expectation documentation of care provided, should be documented no later than the end of shift by the nurse who provided the care. She stated failure to properly document could cause delay in care and interfere with overall care. Record review of the facility's policy titled Clinical Document Guideline dated 01/01/2025, reflected the following: The patient's clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing healthcare services provided to the patient. The clinical record is used by healthcare team to record, preserve and communicate the patient's progress and current treatment. 1. Clinical document entries should be objective, factual information and communication that pertain to the care of the patient i.e. patient centered 2. Clinical document entries should not be used to voice complaints, free of subjective assumptions and interdepartmental grievances 3. Clinical document entries should contain the month, day, year and time the narrative is written 4. Entries are signed by the person writing the narrative and include the first initial, last name and title or credentials of the author. 5. Each healthcare team member must document his or her own clinical record entries 6. Initialed entries on clinical documents should have corresponding full signature identification of the initials on the same form or signature legend. 7. Initials are used to authenticate entries on flow sheets, medication record or treatment records. Documentation on flow sheets, medication and treatment records are completed daily or based on the physician orders. 8. Documentation entries on a clinical document should be in in chronological order. 9. Duplicate and repetitive routine entries supported by other clinical documents such as flow sheets and route standards of care should be avoided. i.e. as a routine practice charting meal intake on food acceptance records and in nurse progress notes 10. Documentation by exception is acceptable (clinical entry is made upon occurrence) in some clinical areas i.e. side effect monitoring, behaviors are a few examples. 11. Documentation may be performed via a daily predetermined pathway, flow sheet and documentation system. Types of Clinical Record Entries Late Entry When it is necessary to complete a late or out of sequence entry due to a missed narrative, omitted information from a previous entry or additional pertinent information that occurred during the shift of work use the following process: Identify the entry as late entry Enter the current date and time Identify or refer to the date and incident for which the late entry is written. Clarification Entry A clarification entry is written to avoid incorrect interpretation of previously documented information in the clinical record. Complete the entry as soon as possible after the original entry using the following format: Document the current date Write clarification and refer to the previous entry which is being clarified Identify or refer to the date and incident for which the clarification is written. Omissions on Flow Records It is appropriate to complete a late entry on a flow record when the staff member recalls the provision of service or care. In such case use the following format: Initial and circle of the omission Enter the current date and time Document the care or service provided Error Corrections Correction of charting errors should be made as soon as possible. The following format should be followed: You would strike out error and add correct entry using verbiage Clarification. Initial and date the entry State the reason for the error in the margin or below the note Record the correct information Addendum Entry An addendum is a type of late entry that is used to provide additional information in conjunction with a previous entry. Addendums provide additional information to address a specific situation or incident. Addendums are not used to correct a previous entry. Complete the addendum as soon as possible using the following format: Document the current date and time Write addendum and state the reason for the addendum Refer back to the original entry

Based on observations, interviews, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 residents (Resident #67) reviewed for enteral feeding. 1. RN G failed to contact the physician and obtain orders before using a de-clogger (a device designed to clear obstructed feeding tubes) to unclog Resident #67's g-tube (Gastrostomy tube, tube inserted through the belly that brings nutrition directly to the stomach) on [DATE]. The facility had de-clogger tools onsite, even though they did not train nurses on their use, and it was not an approved method for de-clogging a g-tube. 2. The facility failed to follow physician orders for Resident 67's enteral feeding tube to be flushed with 100 ml of water every 2 hours. An Immediate Jeopardy was identified on [DATE] at 8:42 AM. The IJ template was provided to the facility on [DATE] at 9:00 AM. While the Immediate Jeopardy was removed on [DATE] at 3:30 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a severity level of immediate threat, due to the facility's continuation of in-servicing and monitoring the plan of removal. This failure placed residents at risk for serious injury and serious harm such as injury to the gastrointestinal tract such as ulceration, bleeding, and perforation. Findings included: 1. Record review of Resident #67's Admission Record dated [DATE] reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment dated [DATE] reflected his diagnoses included cerebral artery (supplies blood to the brain), aphasia (language disorder) following cerebral infarction (stroke), tracheostomy status (procedure to help air and oxygen reach the lungs), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphasia (swallowing difficulties) following cerebral infarction, respiratory failure, and renal failure. Resident #67's BIMS score was not complete. The MDS further revealed Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube. Record review of Resident #67's care plan revised date [DATE] reflected: Feeding Tube: Resident requires the use of a feeding tube and is at risk for aspirations, weight loss, and dehydration. Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable, no signs or symptoms of malnutrition, or dehydration through review date. Interventions: Administer tube feeding and water flushes as ordered. Record review of Resident #67's physician orders dated [DATE] reflected an order for Enteral Feed Order every shift Intermittent Pump Enteral Feeding: Formula Glucerna 1.5 Amount: Rate: 65 cc Frequency: Total mls/22 hours. Record review of Resident #67's physician orders dated [DATE] reflected an order for Enteral Feed Order every 4 hours flush 200 mls of water to run concurrently with enteral feeding. D/C Date - [DATE]. Record review of Resident #67's physician orders dated [DATE] reflected an order for Enteral Feed Order every 2 hours flush 100 mls of water to run concurrently with enteral feeding. Observation on [DATE] at 11:02 AM revealed Resident #67 lying in bed. He could not answer questions. Resident #67 was connected to his feeding pump, and the feeding rate was set at 65 mL/hr. and the water flush rate was set at 200 mL every 4 hours. The formula bag was dated [DATE] at a rate 65 mL/hr. The water bag was dated [DATE]. Observation on [DATE] at 9:30 AM revealed Resident #67 lying in bed with his feeding pump connected. The feeding rate was set at 65 mL per hour, and the water flush rate was set at 200 mL every 4 hours. Interview on [DATE] at 1:32 PM with RN F revealed she was the nurse assigned to Resident #67. RN F stated Resident #67 had a g-tube, she stated the night shift placed a new formula and water bag. RN F reviewed Resident #67's physician orders and stated the resident had an order to flush 100 mls of water every 2 hours. Observed RN F entered Resident #67's room and observed the resident's feeding pump. She stated the feeding pump rate was incorrect, it was set at 200 mls of water every 4 hours. Observed RN F adjust the feeding pump to 100 ml of water flush every 2 hours. She stated when she came in for her shift (6 AM -2 PM) she completed her rounds and checked on residents feeding pumps. RN F stated she might have missed it. She stated the potential risk of not providing Resident #67 with the correct timed flushes could lead to the g-tube clogging. Interview on [DATE] at 2:29 PM ADON B stated Resident #67's water flushes were changed from 200 ml every 4 hours to 100 mls every 2 hours in the month of [DATE]. She stated she was made aware Resident #67's feeding pump was not accurate; however, there were times that Resident #67's FM had concerns regarding the amount of water the resident received. She stated water flushes were changed upon Resident #67's family member request. She stated Resident #67's family member had been educated on why that amount of water was given to the resident. She stated it was believed Resident #67's FM might have changed the water flushes amount. However, it was expected for the nurses to follow physician orders and if the family did not agree, the nurses should notify the doctor and obtain orders. She stated the potential risk would be the g-tube clogging. Interview on [DATE] at 11:37 AM with NP revealed Resident #67 had issues with g-tube clogging. She stated she was aware of Resident #67's water flushing orders. She stated the orders were changed back in [DATE] to increase the frequency of the water flushes to prevent the g-tube to clog. She stated she was unaware that the resident was receiving water flushes every 4 hours. She stated the water flushes were changed to every 2 hours specifically to prevent the g-tube to clog. She stated her expectations were for the nurses to follow physician orders. She stated the potential risk would be the g-tube to clog. Interview on [DATE] at 2:25 PM with RNC revealed her expectations were for the nurses to follow physician orders regarding water flushes. She stated she was unaware Resident #67 had any issues with his g-tube clogging. She stated water flushes were needed to prevent the g-tube from clogging. 2. Record review of Resident #67's progress notes dated [DATE] at 06:31 AM by RN G reflected Unable to administer AM medications due g-tube being clogged. Multiple attempts made by x 3 nurses to unclog g-tube. De-clogger tool and coke used. Attempts were unsuccessful. Physician contacted awaiting response. [FM] is aware and present at the bedside. Record review of Resident #67's progress notes dated [DATE] at 09:50 by RN F reflected The night nurse reported that the patient's g-tube is clogged, initial attempt to unclog the tube was unsuccessful, NP was notified. Order received from NP to try to unclog it first with [Don], if unsuccessful then send pt to ER. The [Don] was notified and assisted in successfully unclogging the tube. Bowel sounds were present, and the patient had a bowel moment this morning. NP was notified, got an order to resume his feeding. Observation and interview on [DATE] at 9:30 AM revealed Resident #67 lying in bed with his feeding pump connected and he had a trach. Resident #67's family member was in the room visiting, she stated she had no concerns regarding the care the resident was receiving at the facility. Resident #67's family member stated in [DATE] unknown of the exact dates, the resident was having issues with his g-tube clogging. She stated she could not recall much of the events; however, the facility staff made several attempts to unclog the g-tube and when unsuccessful the resident was transported to the hospital. She stated she recalled the nurses using a de-clogger but did not recall much of what happened or how it was used. Interview on [DATE] at 2:22 PM with RN F stated in the month of [DATE], Resident #67 had issues with g-tube clogging. She stated she could not recall the exact dates; however, one morning she arrived for her 6 AM-2 PM shift and the night nurse informed her that Resident #67's g-tube was clogged, and she could not provide him with his medications. She stated she was unsure if a de-clogger was used. She stated if a nurse used a de-clogger, the nurse must obtain a physician order. She stated she was unsure if a physician order was obtained. Interview on [DATE] at 2:29 PM with ADON A stated Resident #67 had his g-tube replaced once since being admitted to the facility. She stated since Resident #67's g-tube had been changed there had not been any issues. She stated when a g-tube clogs the nurses use methods like pulling back residual, use warm water, cranberry juice, or use coke to break it down. She stated it was up to the nurse's discretion on what method to use and if nothing was successful the resident should go to the hospital. She stated de-cloggers should not be used because it was not part of their training and was unaware if any de-clogger had been used. She stated she was unsure if they had any de-clogger tool in the facility. However, if a nurse knows how to use a de-clogger and felt comfortable using that method it would be up to the nurse's judgment. She stated nurses should obtain physician orders before using a de-clogger. Observation on [DATE] at 4:07 PM with Central Supply Tech of supply room located in the North Station revealed one 16 Fr. 39.5 cm de-clogger tool and on the South Station supply room revealed four 16 Fr. 39.5cm de-clogger tool. Central Supply Tech stated she was unsure why the facility had de-cloggers. She stated she just orders them, she stated she was not a nurse and was unsure why the de-cloggers were used for. Interview on [DATE] at 4:21 PM with RN J stated he had worked with Resident #67 before; he stated he had not had any issues with Resident #67's g-tube clogging. He stated a couple of weeks ago, unknown of the exact date, Resident #67's g-tube clogged. He stated he went to Resident #67's room to assist and help unclog the g-tube. He stated they tried different methods and a de-clogger was used. Then stated he was unsure if a de-clogger was used and was unsure if the nurse was able to unclog the g-tube. RN J stated he could not recall the nurses who were assigned to Resident #67 and was unsure if the physician was notified. RN J stated he had not used a de-clogger before and had not been in-serviced on how to use one. Interview by phone on [DATE] at 8:08 AM with the Medical Director revealed he was aware of Resident #67's g-tube having multiple issues with clogging. The Medical Director stated each facility used different methods to unclog a g-tube. He stated he did not recall any staff notifying him or him giving any orders for the use of a de-clogger. He stated he was not sure what a de-clogger was. The Medical Director stated if the facility nurses had proper training on how to use a de-clogger and if the tool/device was FDA approved he did not have any issues with the nurses using it. He stated he was not familiar with the device to know of any possible risk, he stated there could be risk, but he did not know what the probability of it would be. The Medical Director stated the use of coke had been used at hospitals in the ERs because the carbonation helped with unclogging g-tubes. He stated he had no issues with nurses using that method. The Medical Director stated he did not necessarily need to be called all the time when situations happened. Interview on [DATE] at 8:52 AM with ADON B revealed when a resident's g-tube clogs it was the expectation for the nurse to notify the doctor, attempt to unclog it by using methods like flushing with warm water, milk it down (hold the tube on the top and push down), and if nothing was working send the resident out to the emergency room . She stated they have used a de-clogger in the past usually after talking to the doctor if they cannot clear the line. She stated on her station they have not used any de-cloggers and was unaware if de-cloggers had been used in the South station. She stated it was up to the doctor's discretion if de-cloggers were to be used. She stated if a de-clogger was used it should be documented and had obtained a physician order. She stated a de-clogger was not part of their training and not part of the nurses check off. Interview on [DATE] at 11:37 AM with NP revealed Resident #67 had issues with his g-tube clogging. She stated it was not normal for his g-tube to clog. She stated in [DATE], unknown of exact date, the resident was sent out to the ER twice. The first time was because the g-tube was partially dislodged. She stated the hospital should have changed the g-tube bud did not. She stated the resident returned to the facility and the g-tube clogged. She stated she was notified, and she recommended to try to unclog it first in house and if unsuccessful send the resident to the hospital; however, the nurse was able to successfully unclog the g-tube. She stated she was unaware a de-clogger and coke was used. She stated her expectations were for the nurses to use methods like using a 10 ml syringe to push back pressure, or to use water. She stated she would not recommend using a de-clogger and had never been a point in time where they would use a de-clogger. She stated maybe there was a misunderstanding when she said de-clog in house that maybe the nurses thought to use any method to unclog it. The NP stated the risk of using a de-clogger could cause injury or if the de-clogger was long enough to perforate something. She stated nurses should be trained to use a de-clogger and should obtain orders if a de-clogger was being used. The NP stated, unknown of the exact date, Resident #67 went to the hospital again because his g-tube clogged again, his g-tube was changed, and it had been working fine since then. Interview on [DATE] at 1:26 PM with RN G stated in [DATE], unknown of the exact date, she was going to give Resident #67's morning medications; however, the g-tube was clogged. She stated she tried to flush it with warm water to try to de-clog it but did not work, she then used a de-clogger and it was effective. She stated RN F was in the room present and tried to assist with unclogging the g-tube. She stated she was the one who used the de-clogger to unclog the g-tube. She stated she did not contact the physician and did not obtain orders prior to using the de-clogger. She stated she was unsure if the other nurses present contacted the doctor or NP. She stated she had used a de-clogger in the hospital setting, was comfortable using a de-clogger and she knew how to use it. She stated it was the first time using a de-clogger at the facility. She stated she should have contacted the doctor first and obtained orders before using a de-clogger. She stated the risk of using a de-clogger would be puncturing the tube if not careful or harming the tube more itself. Interview on [DATE] at 2:25 PM with RNC revealed her expectation for when a g-tube clogs was the nurses were expected to follow policy and procedure for g-tube care. If there were any issues, the nurses should contact the doctor and obtain orders. She stated the nurses should not be using a de-clogger because the facility did not have any policy for a de-clogger, and they could not ensure the nurses had been trained on how to use one. She stated she was unsure why the facility had any de-cloggers in the facility. She stated the only policy the facility had if any complications occur the nurses, were to notify the physician or any abnormalities. Record review of the facility's Following Physician Orders policy, dated [DATE] reflected the following: The policy provide guidance on receiving and following physician orders. . For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement physician orders. Record review of the facility's Clinical Practice Guideline: Care of Tube Feed Resident policy, review date [DATE] reflected the following: Resident will remain free of complications related to use of a feeding tube. Tube feeding care should be consistent with the current standards of practice and overall therapeutic goals of the resident and delivered in an ethical manner. Prevention of gastrointestinal complications: Provide formula at prescribed rate using appropriate delivery method . Notify physician of any abnormalities. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 8:30 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 9:00 AM. The facility's Plan of Removal was accepted on [DATE] at 2:15 PM XXX[DATE] @ 8:42 Immediate Jeopardy Called F-693 The facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feedings. IJ F693 Plan of Removal Immediate Actions taken I. Resident specific On [DATE] resident was immediately assessed BY ADON head to toe without any noted signs or symptoms of injury. On [DATE] the 2 other g-tube residents with g-tubes were immediately assessed By ADON LVN head to toe without any noted signs or symptoms of injury. II. System changes On [DATE] all g-tube de-clogger devices were immediate removed from the facility at the time they were identified during the annual survey as this is not part of our policy. On [DATE] all g-tube de-cloggers were brought to the DON office by Central supply for immediate destruction. On [DATE] Central supply and ADON's were immediately instructed to not order any g-tube de-cloggers moving forward no matter who requested them. And to notify the Administrator if asked. On [DATE] Director of Nurses was terminated for failure to participate in this investigation. On [DATE] Facility policy was updated by VP of clinical services to include problem solving to prevent g-tube clogging. III. Education On [DATE] all licensed nurses were immediately in-serviced by ADON on the facility policy is not to use g-tube de-cloggers and on the facility policy on care of the tube fed resident (prevention of gastrointestinal complications, prevention of mechanical complications, prevention of dignity issues, observations and reporting) On [DATE] all licensed nurses were immediately in-serviced by ADON on following physicians orders for administering flushes. This in-service included validating the pump was programmed to match the physician's order at the beginning of their shift. On [DATE] all nurses were in-serviced by ADON on the updated facility policy for care of the tube fed resident (which includes the notification of the physician anytime a g-tube is clogged). All staff that did not attend the in-service's will be in-serviced on all education completed by ADON prior to their next scheduled shift. IV. Monitoring Nursing supply orders will be pulled weekly x 1 month to ensure de-cloggers are not being ordered. DON/Designee will do random checks weekly x 4 weeks to ensure auto flush pumps are programmed to match the flush ordered by the physician. DON and Administrator will review nursing orders monthly at the facility QAPI meeting to ensure continued compliance. Monitoring of the Immediate Jeopardy continued: Record review on [DATE] at 9:20 AM of Resident #67's MAR indicated he had no medications via g-tube scheduled until bedtime. Interview on [DATE] at 9:25 AM a family member of Resident #67 was bedside, the family member stated they were bedside the majority of the day. The family member described how the nurse administers the resident's medications via the g-tube. They described the medications being in separate cups, the nurse administers one cup at a time followed by some water. The medications were allowed to go in on their own, they never used the syringe to force the medications in. Observation on [DATE] at 9:25 AM of Resident #67's feeding pump indicated he was receiving Glucerna at 65 ml/hr and a 100 ml water flush was scheduled every two hours. Record review on [DATE] at 9:30 AM of Resident #67's nursing notes indicated no issues with his g-tube clogging since [DATE]. Record review on [DATE] at 9:50 AM of Resident #70's MAR reflected she was not scheduled to receive any medications via g-tube until the next morning. Record review on [DATE] at 9:53 AM of Resident #70's nursing notes reflected there had been no issues with her g-tube clogging since [DATE]. Observation on [DATE] at 9:55 AM of Resident #70's feeding pump reflected her Glucerna was infusing at 50 ml/hr and a 125 ml water flush was scheduled every 4 hours. Record review on [DATE] at 10:00 AM of Resident #58's MAR revealed she was not scheduled to receive any medications via her g-tube until bedtime. Record review on [DATE] at 10:03 AM of Resident #58's nursing notes reflected there were no issues with her g-tube clogging since [DATE]. Observation on [DATE] at 10:05 AM of Resident #58's feeding pump reflected she was receiving Glucerna at 55 ml/hr with a 75 ml water flush every four hours. Attempts to interview RN G were made via phone on [DATE] at 11:10 AM and 1:40 PM in an attempt to what size and length of de-clogger to use on Resident #67's g-tube. Interview on [DATE] at 11:20 AM with the ADON revealed she did not know how long de-cloggers had been in the facility, they were just always here. Interview on [DATE] at 11:33 AM with the Central Supply Tech revealed she had been in the position since around [DATE] and the de-cloggers were in stock at that time. Several were expired so she ordered more to replace them. The last time she ordered a de-clogger was on [DATE]. She stated on [DATE] all the de-cloggers were turned over to the Administrator. She was advised not to re-order them and to notify the DON if she was asked by anyone to order one. Interview on [DATE] at 11:40 AM with the RNC revealed the previous DON had refused to assist the investigation into de-clogger use, so she was termed. The RNC stated as far as she could determine the previous DON had ordered them to be kept on hand. The DON had stated she trained staff on the use of de-cloggers, but the RNC was unable to locate any training material, no in-services, or anything to indicate de-clogging training had been done with staff. The RNC stated on [DATE] all nursing staff were in-serviced by herself and the ADONs that de-cloggers were not to be used on clogged g-tubes. The nurse was to contact the physician for orders to send the resident to the hospital to have the g-tube replaced or de-clogged. Interview on [DATE] at 12:22 PM with LVN K revealed she had been in-serviced by the ADON on g-tubes. She stated she was not allowed to use the de-clogger, but she had never used one before. She stated she was to call the physician for orders to send the resident to the hospital. If the physician ordered it, they could try to milk or massage the tube to unclog it. Interview on [DATE] at 12:25 PM with LVN H revealed she had been recently in-serviced on g-tubes. She was to call the physician for orders to send them to the hospital. The physician could order them to attempt to unclog the tube by massaging or milking the tube. If the interventions were unsuccessful the resident was to go to the hospital. Interview on [DATE] at 12:30 PM with RN F revealed she had recently been in-serviced on g-tubes. If the resident's g-tube was clogged they were not to use the de-clogger, they were to call the physician for orders to send the resident to the hospital. The physician could order them to attempt to unclog the tube using water on the pump like a bolus or massaging it. Interview on [DATE] at 12:39 PM with LVN L revealed she had been in-serviced on g-tubes recently. She stated it was made clear that de-cloggers were not to be used, and they had been removed from the facility. They were to call the physician for orders to send the resident to the hospital for replacement of the g-tube. Interview on [DATE] at 1:55 PM with RN-J revealed he had been in-serviced on g-tubes. He stated if the tube was clogged, he was to call the physician for orders to send them to the hospital, or to try massaging the tube to unclog it. Phone interview on [DATE] at 2:00 PM with LVN M revealed she had been in-serviced on g-tubes. She stated it was made clear that de-cloggers were not allowed to be used, and they had been removed from the facility. She stated she had never used a de-clogger and had never been trained on them. She stated she was to call the physician for orders. Interview on [DATE] at 2:24 PM with RN N revealed she had been in-serviced on g-tubes recently. She stated de-cloggers had been removed from the facility. She stated she had used the de-clogger in the past, but she had not been trained at this facility. She stated she knew how to use them from past experience. She stated she was now supposed to call the physician for orders to send the resident to the hospital. Interview on [DATE] at 2:28 PM with LVN O revealed he had been in-serviced on g-tubes recently. He stated if the tube is clogged, he can try to massage it first, and if that didn't work he would call the physician for orders to send the resident out. Telephone interview on [DATE] at 3:10 PM with RN Q revealed she had been in-serviced on g-tubes. She stated if the tube was clogged, she was to call the physician for orders. The physician could order the resident sent out, or to try milking the tube before sending the resident out. She stated de-cloggers were not to be used. Record review of the facility's monitoring tool Weekly Monitoring of G-tube Flush reflected it had been completed weekly since [DATE]. Record review of the facility's Ad Hoc QAA meeting, held on [DATE], reflected physician orders, g-tubes orders had been reviewed. Discussion of g-tube de-clogging process was held. All de-clogging tools were removed, and all nurses were to be educated on the new process. An Immediate Jeopardy was identified on [DATE] at 8:42 AM. While the Immediate Jeopardy was removed on [DATE] at 3:30 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal.

Based on interview and record review, the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis for one of one Social Worker reviewed for qualifications. The facility, licensed for more than 120 beds, had not employed a full-time, qualified Social Worker since 09/26/24. This deficient practice could result in residents' social service needs not being met. Findings included: Record review of the facility's license revealed the facility had a licensed capacity of 128 residents. Record review of the facility's Department Heads list revealed no Social Worker. Record review of the Social Worker's electronic file revealed she was hired on 03/01/24 and was terminated 09/25/24. During the confidential resident group interview 10 of the 10 residents in attendance revealed the facility had not had a social worker in months. Residents stated they were being told that the facility was actively looking for a social worker. Record review of Resident Council Meeting for the months of October 2024 revealed Social Services: Resident mentioned that we need a staff member. Interview on 01/16/25 at 12:29 PM with HR revealed the facility had not had a Social Worker since the end of September. She stated the facility was actively looking for a new Social Worker. She stated as of today (01/16/25) they hired someone but they had not started yet, she stated she was going to provide the hiring paperwork. She stated the previous Administrator, who was no longer employed, had SW license and the MDS Coordinators would assist with any social service's needs. Interview on 01/16/25 at 2:36 PM with the Administrator revealed he had been employed since 01/13/25. He stated interviews were completed yesterday (01/15/25) and he made an offer, and the offer was accepted. He stated the facility had been without a Social Worker for about 60 days. The Administrator stated the DON, Medical Records, MDS, and ADONs were following up with resident social service's needs. He stated a social worker was needed to advocate resident's rights, be part of the care plan team and make sure psychosocial needs were being met. The Administrator stated the facility did not have a policy for social services.

Based on observation, interview, and record review, the facility failed to assure full visual privacy for four (Residents #3, #46, #47, and #61) of twelve residents reviewed for privacy curtains. The facility failed to provide privacy curtains that assured each resident had full visual privacy. This failure could cause anxiety to residents during personal care. Findings included: Observation and interview on 01/14/25 at 10:10 AM revealed Resident #3 had a privacy curtain between the beds that was hanging by 4 hangers, the rest of the curtain hung down to the floor. Resident #3 stated she did not like not having privacy during incontinent care and the staff never bothered pulling that curtain. She stated anyone could walk in and see her when she was exposed. Record review of Resident #3's undated Admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included emphysema, dementia, and muscle weakness. Record review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 9, indicating she had moderate cognitive impairment, Her Functional Status indicated she required assistance with all her ADLs. Record review of Resident #3's care plan, dated 12/04/24, reflected she had cognitive impairment, impaired visual function, and a communication deficit. Observation and interview on 01/14/25 at 10:14 AM revealed Resident #47 had no privacy curtain at the foot of his bed. Resident #47 stated it bothered him to not have the curtain. He stated it had not been in place since he was moved to the room, and he had asked staff for a curtain or to move him to a room that had more privacy. Record review of Resident #47's EHR reflected he had been moved to his current room on 09/06/24. Record review of Resident #47's undated Admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke, diabetes, and weakness. Record review of Resident #47's quarterly MDS, dated [DATE], reflected a BIMS score of 12 indicating he was moderately cognitively impaired. His Functional Status indicated he needed set-up assistance with his ADLs. Record review of Resident #47's care plan, dated 12/19/24, reflected he had a communication impairment, he was incontinent of bowel and bladder, and had a self-care deficit. Observation and interview on 01/14/25 at 10:21 AM revealed Resident #61 had no privacy curtain between the beds. Resident #61 stated it did not bother him now that he did not have a roommate, but when he had one, it was uncomfortable. Record review of Rfesident #61's undated Admission Reocrd reflected he was a [AGE] year-old male admitted to the facility on [DATE] wu=ith disgises which included stroke, anxiety, aand cataracts. Record review of resident #61's quarterly MDS, dated [DATE] reflecctrd A BIMS score of 14 indicating he was cognitively intact. His Functional Status indicated he requierd partial assistance with his ADLs. Record review of Resident #61's care plan, dated 11/05/24 reflected he had a cognitive impairment, impaired communication, and an ADL self-care deficit. Observation and interview on 01/14/25 at 10:55 AM revealed Resident #46 did not have a privacy curtain at the foot of the bed and no track for hanging a curtain was present. Resident #46 stated it had been that way since being moved into the room. Record review of Resident #46's undated Admission Record reflected he was admitted to the facility on [DATE] with diagnoses of chronic kidney disease diabetes, and muscle weakness. Record review of Resident #46's quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he was independent with his ADLs. Record review of Resident #46's care plan, dated 1/12/25 reflected he had an ADL self-care deficit, depression and was a smoker. Observations on 01/15/25 and 01/16/25 of the resident rooms revealed privacy curtains had not been addressed. Interview on 01/16/25 at 10:45 AM with ADON A revealed housekeeping was responsible for changing and cleaning the privacy curtains. Maintenance would hang damaged curtains if needed. Interview on 01/16/25 at 12:35 PM with CNA E revealed each resident should have a privacy curtain. She was unaware Resident #46 did not have a curtain in place. She stated privacy curtains were needed for privacy. Interview on 01/16/25 at 12:38 PM RN F revealed she was the nurse assigned for Resident #46 and was not aware he did not have a privacy curtain. She stated Resident #46 did not have the tracks for a privacy curtain . She stated it was the responsibility of housekeeping staff and maintenance staff to change and put up privacy curtains. Interview on 01/16/25 at 1:19 PM with the Housekeeping Supervisor revealed her staff were responsible for changing out privacy curtains when they were soiled. If the curtains needed to be re-hung because the hangers were damaged, maintenance was responsible for making the repairs. The Housekeeping Supervisor stated all curtains were checked monthly by her; the last check was on 01/13/25. She was unaware Resident #3's curtain was only hanging by four hooks, but she would address it with maintenance. Interview on 01/16/25 at 3:20 PM with the Maintenance Supervisor revealed he had been working at the facility for four years and he was not aware of all the curtains that needed to be replaced. He stated housekeeping took them down to be washed when needed but they did not have a surplus of curtains to allow them to be replaced with a clean one while the other was being washed. He stated it was important to have a privacy curtain for each resident to ensure they had privacy. Interview on 01/16/25 at 3:06 PM with the Administrator revealed the facility had no policy addressing resident privacy or privacy curtains. There was only the Resident Rights policy stating the residents had the right to a clean, comfortable, home like environment. 44140

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed mash potatoes as a pudding consistency for residents who required pureed diets during the lunch meal on 01/15/25. This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs Findings included: Record review of Week-At-A-Glance Texas 4 Week 4 menu revealed the menu for the lunch service was . Boiled Potato . Observation on 01/15/25 at 11:16 AM of the Dietary Manager pureed mashed potatoes with a hand whisk, was observed removing the potato skins and then proceeded to place it on the steam table. The Dietary Manager did not check the consistency or ensure it was all blended to have a pudding consistency. Observation of the test tray on 01/15/25 beginning at 12:55 PM with the Dietary Manager, the test tray included the regular textured menu items and the pureed menu items. Pureed mashed potatoes did not have a smooth/pudding consistency. The mashed potatoes had chunks of potato not fully mashed. The Dietary Manager stated when she prepared the mashed potatoes, it appeared it was smooth. She stated she used a whisk instead of the blender. She stated she thought it had the correct consistency. She stated the risk if everything was not completely pureed, was the resident could choke. Follow-up interview on 01/15/25 at 3:43 PM with the Dietary Manager revealed her expectation was for pureed food to have a smooth/ pudding consistency. She stated when she was preparing the mashed potatoes, she thought it was smooth until she tried the test tray, and it was not. She stated the mashed potatoes had lumps in it. She stated she normally oversees her staff complete the puree meals; however, she was the one who prepared the mashed potatoes. She stated the potential harm to residents was the possibility chocking. Record review of the facility's current, undated Pureed Recipe Book General Guidelines policy reflected: When processing foods to obtain a pureed consistency, it is important to know that we want a moist mashed potato consistency. If the product is too dry it may cause difficulty in swallowing too moist may cause aspiration or at the very least be too runny on the plate and give a poor appearance.

Based on observations and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two resident (Residents #5 and #60) of five residents reviewed for infection control. MA D failed to sanitize a re-useable blood pressure cuff between uses on Resident #5 and Resident #60. This failure could place the residents at risk of exposure to infections. Findings included: Record review of Resident #5's undated Admission Record reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney disease, diabetes, high blood pressure, and heart failure. Record review of Resident #5's quarterly MDS assessment, dated 11/20/24, reflected a BIMS score of 12 indicating he was cognitively intact. His Functional Assessment indicated he required assistance with all of his ADLs. Record review of Resident #5's care plan, dated 11/04/24, reflected he had an ADL self-care deficit, high blood pressure with interventions of administering medications and monitoring his vital signs. Record review of Resident #60's undated Admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included complete paralysis, mild cognitive impairment, and personal care assistance. Record review of Resident #60's quarterly MDS, dated [DATE], reflected a BIMS score of 14 indicating he was cognitively intact. His Functional Assessment indicated he required assistance with all of his ADLs. Record review of Resident #60's care plan, dated 12/02/24, reflected he had an ADL self-care deficit requiring total assistance with his ADLs. Observation on 01/15/25 at 7:32 AM revealed MA D checked Resident #60's blood pressure with a re-useable blood pressure cuff and returned it to her cart without sanitizing it. Observation on 01/15/25 at 7:45 AM revealed MA D checked Resident #5's blood pressure with the same re-useable blood pressure cuff used on Resident #60. MA D failed to sanitize the cuff prior to or after using it on Resident #5. Interview on 01/15/25 at 12:32 PM with MA D revealed she was unaware she had not sanitized the blood pressure cuff between uses on the residents. She stated she had sanitizing cloths in her cart but she forgot to use them. She stated the risk of not sanitizing between resident uses could be spreading an infection from one resident to another. Interview on 01/16/25 at 2:27 PM with the RNC revealed re-useable medical equipment only had to be sanitized between residents if it was visibly soiled. When asked the risks of not sanitizing equipment between use the RNC shrugged her shoulders and did not provide an answer. She stated staff follow the facility policies. Record review of the facility's Blood Pressure-Obtaining policy, dated 01/01/24, reflected: .5. Closing steps: a. Clean and store re-useable items and discard disposables

Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Residents #10) reviewed for ADL care. The facility failed to ensure Resident #10's fingernails were kept trimmed. These failures could place the residents at risk of infections or injuries. Findings included: Record review of Resident #10's undated Admission Record reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included myopathy (muscle weakness and involuntary muscle movement), reflux, unsteadiness on feet, and failure to thrive. Record review of Resident #10's annual MDS Assessment, dated 12/16/24, reflected a BIMS score of 6 indicating severe cognitive impairment. Her Functional Abilities assessment indicated she required assistance for her personal hygiene. Record review of Resident #10's care plan, dated 11/14/24, reflected she had an ADL Self-care deficit with an intervention of extensive assistance for personal hygiene. Observation and interview on 1/14/25 at 10:14 AM revealed Resident #10 was lying in bed quietly, her fingernails were all uneven lengths, several were jagged or broken, and there was a black substance under them. Resident #10 stated she wanted her fingernails trimmed but the girl that usually did it had not been there in a while. She stated she had broken some of the nails because they get caught in her bedding. She stated she did not like her nails looking like that. Observation on 1/15/25 at 1:36 PM revealed Resident #10's fingernails had not been trimmed. Interview on 1/15/25 at 1:48 PM CNA-C stated nail care could be done by the CNAs if the resident did not have diabetes, in which case the nurse would have to do it. If the CNAs notice a resident needed nail care during bathing, they notified the nurse. Record review of the facility's Nail Care policy, dated 02/10/20, reflected: Precaution should be used when trimming nails of residents with diabetes and should be done by a licensed nurse of physician. 1. Assemble equipment 2. Knock on door and request entrance 3. Introduce self, explain procedure and provide privacy 4. Wash hands 5. Fill basin with warm water and alternate soaking hands 6. Carefully brush nails with nailbrush to remove dirt or clean with orange stick 7. Dry hands 8. Gently push cuticles back with orange stick Discard orange sticks after use 9. Trim nails and file for smoothness, as needed 10. Apply moisturizing lotion to hands 11. Reposition for comfort with call light in reach 12. Wash hands 13. Return equipment to designated area and clean/dispose as indicated.

Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 3 residents (Resident #25) reviewed for contracture management The facility failed to provide equipment/services for Resident #25's right hand contracture (a permanent tightening of the muscles). This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures, and a decline in physical capabilities. Findings included: Record review of Resident #25's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included aphasia (language disorder that affects a person's ability to communicate), hemiplegia (muscle weakness or partial paralysis on one side of the body). The MDS further reflected Resident #25 has memory problems. Record review of Resident #25's care plan revised on 08/15/24 reflected the resident had ADL self-care performance deficit related to functional limitations in range of motion, decreased mobility, and hemiplegia secondary to a stroke. Interventions included therapy to screen, evaluate, and treat as needed. Observation on 01/14/25 at 2:53 PM of Resident #25 revealed he was in his room sitting in his wheelchair. The resident was noted with a contracture to his right hand and there was no device in place. Resident #25 was not able to speak but appeared to shake his head when asked yes/no questions. Observation on 01/15/25 at 12:46 PM of Resident #25 revealed he was in his room eating lunch. The resident's right hand was contracted, and there was no contracture management device in place his right hand. Interview on 01/16/25 at 9:25 AM with CNA I revealed Resident #25 did have a splint for his hand contracture and either therapy or the nurse were responsible for applying it. CNA I said the resident did not have it the past two days because it was probably in the laundry as it would frequently get soiled. CNA I further stated if the splint was being laundered, the resident should have a rolled washcloth placed in the contracted hand until the splint was returned. Interview on 01/16/25 at 9:01 AM with LVN H revealed Resident #25 did have a splint for his contracted right hand and either therapy or the nurses were responsible for applying the splint . LVN H said she was not aware the resident did not have the splint in his hand the past two days and did not recall the last time she saw him with it. LVN H further stated she did not recall Resident #25 having an order for a splint for his contracture. LVN H said if the resident did not wear the splint for his contracture it could cause the contracture to tighten. Interview on 01/15/25 at 3:12 PM with the Occupational Therapist revealed she began working at the facility September 2024 and Resident #25 had a palm guard that was being used for his contracted right hand. She stated she was not aware who had initiated the palm guard for the resident's contracture. The Occupational Therapist said it had been about two weeks since she had been able to locate the palm guard and did not know if it had been taken to the laundry to get washed . The Occupational Therapist said there should be an order in place for the palm guard to remind staff to be consistent in applying the palm guard. The Occupational Therapist further stated the palm guard was used to maintain gross motor movement and prevent further limitation in range of motion. Interview on 01/16/25 at 2:02 PM with ADON B revealed Resident #25 normally had a palm guard in place for his contracture and it was usually placed in his right hand by therapy or the nurse. ADON B said she was not sure why the resident was not wearing it the past two days. She said if the palm guard had been taken to the laundry, staff should replace it with a rolled washcloth until the palm guard was brought back from laundry. ADON B further stated not having anything in place in Resident #25's contracture could cause skin breakdown in his hand, advancement of the contracture, and pain from stiffness. ADON B also said there should have been an order for the palm guard, and she would need to clarify why there was not one already in place . Record review of the facility's policy titled Splinting revised January 2020 reflected the following: Policy Splinting is used to protect joints and surrounding soft tissue. This can be accomplished by maintaining joints at position of rest, preventing positions that contribute to contracture and/or deformity, protecting the system of arches within the hand and increasing and maintaining ROM in the joint. Requirements: Physician's order and Occupational Therapist Evaluation

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 6 residents (Resident #67) reviewed for respiratory care. The facility failed to ensure there was a physician order for Resident #67's tracheostomy care, suction tubing, and emergency trach kit. This failure could place residents with a tracheostomy requiring tracheostomy care at risk for respiratory distress, hospitalization s, and a decline in their quality of life. Findings included: Record review of Resident #67's Admission Record dated 01/16/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment dated [DATE] reflected his diagnoses included cerebral artery (supplies blood to the bran), aphasia (language disorder) following cerebral infarction (stroke), tracheostomy status (procedure to help air and oxygen reach the lungs), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties) following cerebral infarction, respiratory failure, and renal failure. Resident #67's BIMS score was not complete. The MDS further revealed Section O - Special Treatments, Procedures, and Programs indicated resident received oxygen therapy and tracheostomy care. Record review of Resident #67's care plan revised date 10/11/24 reflected: Tracheostomy: Resident has a tracheostomy and is at risk for potential complications such as weight loss, increased secretions, congestion, infection, and respiratory distress. Goal: Resident will have clear airways with adequate ventilation through the next review date. Interventions: Provide oxygen, humidity, tracheostomy care, and tubing changes as indicated by physician's orders. Record review of Resident #67's January MAR revealed O2 @ 3 LPM via Trach. Notify MD if SpO2 falls below 90% while using O2. Perform resp . assess if O2 applied. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA (lungs cannot effectively transfer oxygen from the air to the bloodstream, resulting in low blood oxygen levels). Start date 01/14/25. There were no physician orders for Trach care or Suction or Emergency supplies. Observation on 01/14/25 at 11:02 AM revealed Resident #67 lying in bed. The resident had a tracheostomy and feeding tube. The resident was not able to answer questions. An emergency kit was at the resident's bedside. Resident #67's family member was in the room visiting. The Family Member stated Resident #67 had a stroke and admitted to the facility with a trach. Interview on 01/15/25 at 1:32 PM RN F stated she was the nurse assigned to Resident #67. She stated Resident #67 admitted to the facility with a trach. She stated she provided trach care every morning and as needed to Resident #67. She stated she completed suctioning and changes the cannula every day. RN F reviewed Resident #67's physician orders and stated the resident did not have any trach care orders. She stated a couple of weeks ago, unknown of the exact date, Resident #67 had gone to the hospital. She stated the orders might have been deleted. RN F stated the admitting nurse should have put in orders and if the orders were missing the admitting nurse should have contacted the doctor. She stated she was unaware Resident #67 did not have any trach care orders. She stated the potential risk of not having any physician orders would make it appear that they were not providing any care to Resident #67. Record review of Resident #67's January MAR as of 01/15/25 1400 [2:00 PM] reflected the following: Suction Q shift & PRN. Report abnormal secretions to MD every shift related to TRACHEOSTOMY STATUS. Verify the following emergency supplies are at the bedside (above the HOB): Ambu bag Obturator Water-soluble lubricant, Trach in the size ordered, Trach in a size below and size above (preferably), E- cylinder at the bedside for emergency O2 use. every shift for Presence of Trach Interview on 01/15/25 at 2:29 PM with ADON A revealed she was the ADON assigned to the North Station where Resident #67 resided. She stated she was unsure why Resident #67's trach care orders were not showing. She stated she could assure that Resident #67 had trach care physician orders and did not understand how they could disappear from the system. She stated it was the responsibility of the admitting nurse to put in orders. She stated during morning stand up the DON and the ADONs audit physician orders upon return from the hospital. She stated she was unsure if the physician orders were put in the system. However, she had seen the orders prior to today (01/15/25). ADON A stated Resident #67 had been receiving trach care every shift and PRN . She stated there was no potential risk if they did not have any physician orders due to the resident continued to receive care. Interview on 01/16/25 at 2:17 PM with RNC revealed her expectations were for the nurses to obtain physician orders and put them in the system. She stated Resident #67 should have had orders for trach care. She stated she was unaware Resident #67 did not have any physician orders. She stated it was the responsibility of the DON and the ADON to ensure physician orders were obtained. She stated the potential risk of not having physician orders could lead to resident trach care not getting done. Record review of the facility's Respiratory Care Services: Tracheostomy Care policy, review date 2020, reflected the following: To aseptically clean a tracheostomy site and trach tube free from mucous buildup, maintaining tube patency, reducing risk of infection and maintaining skin integrity at the stoma site. Tracheostomy care should be provided every 8 to 12 hours or as indicated by order of physician. 1. Verify physician's order, including: procedure to be done, frequency, physician's signature Record review of the facility's Following Physician Orders policy, dated 09/28/21, reflected the following: The policy provide guidance on receiving and following physician orders. .For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement physician orders.

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 4 of 5 rooms (Rooms 221, 225, 229, and 231) reviewed for environmental conditions. The facility failed to maintain Rooms 221, 225, 229, and 231 in a safe and sanitary condition. The failure placed residents at risk for infection and decreased quality of life. Findings included: Observation on 10/01/24 at 10:56 AM of room [ROOM NUMBER] revealed a vent cover measuring approximately 10 inches by 10 inches on the ceiling was covered with dark debris. When looking through the vent, it appeared to have thick black dust and debris. room [ROOM NUMBER] had a silver ceiling rail hanging from the ceiling. Observation on 10/01/24 at 11:21 AM of room [ROOM NUMBER] revealed a vent cover measuring approximately 10 inches by 10 inches on the ceiling over resident bed revealed the vent was completely covered with black debris identical to mold, dust and dirt. When looking through the vent, it appeared to have thick black dust and debris. Observation on 10/01/24 at 11:48 AM of room [ROOM NUMBER] revealed a vent cover measuring approximately 10 inches by 10 inches on the ceiling was covered with dark debris inside the vent, and the vent had dark dust outside the vent. Observation on 10/01/24 at 11:49 AM of room [ROOM NUMBER] revealed a vent cover measuring approximately 10 inches by 10 inches on the ceiling was covered with dark debris inside the vent, and the vent had dark dust fairies outside the vent. Interviewed residents revealed they did not have any concerns with the way vents the vents looked; however, they did not recall seeing staff cleaning the vents. Observation and interview on 10/01/24 at 12:08 PM with Housekeeper C revealed she was aware of the vents in resident Rooms 221, 225, 229 and 231 being dirty. Housekeeper C stated the vents had dark matter on them that looked like mold. Housekeeping C stated she had pointed the vents on another hall to the Maintenance Director about a month ago. She stated she thought since then he would have looked at all the vents in the facility. Housekeeper C stated she had not talked to anyone concerning the vents on Hall 200. Housekeeper C stated she was responsible for alerting the Maintenance Director so that he could clean the vents and not doing so placed the residents at risk of becoming sick or ill. Housekeeper C revealed she had not seen the silver rail measuring approximately 2.5 feet hanging from the ceiling, so she had not reported it to anyone. Housekeeper C stated the way it was hanging placed residents at risk of injury. Housekeeper C stated that she should report it to Maintenance Department to be repaired. Observation and interview on 10/01/24 at 12:26 PM with CNA A in Rooms 221, 225, 229 and 231 revealed she thought the vents had mold on them. CNA A stated she did enter the rooms daily to care for residents, but she never really looked up unless residents complained of being cold. While in room [ROOM NUMBER], a silver ceiling rail measuring approximately 2.5 feet was hanging from the ceiling. CNA A stated it was her responsibility to alert the Maintenance Director if there was a problem in the resident rooms, so they could provide maintenance or repairs. According to CNA A, residents were placed at risk when having dirty vents because they were breathing in what looked like mold which could cause breathing problems and infections. CNA A stated she had not seen the ceiling rail hanging prior to today, but it also placed residents and staff at risk for injury if it fell . Interview on 10/01/24 at 1:46 PM with LVN B revealed she was notified about the vents being dirty by CNA A. She stated she had not had a chance to observe the vents, but anyone that saw the vents dirty would report to the Maintenance Department. She stated anytime housekeeping came to clean the rooms they should be cleaning the vents as well. LVN B stated not doing so could place residents at risk for respiratory concerns. LVN B stated she had not received any concerns so far concerning breathing problems from Rooms 221, 225, 229 or 231. She stated she was also notified about the silver ceiling rail hanging in room [ROOM NUMBER], but when she went to observe the room the Maintenance Director was already in the room. She stated anyone who entered the room could be injured if the rail fell . She stated any staff that entered the room was responsible for notifying the nurse or Maintenance Department of the rail hanging, so that it could be repaired and to prevent injury. Interview on 10/01/24 at 2:57 PM with the Maintenance Director revealed he was notified of the ceiling vents and the hanging rail in resident rooms on Hall 200. He stated after observation of the vents today he ordered new vents. He stated last year he went through the entire building and cleaned the vents and after observing on 10/01/24 it looked like the vents just had a build-up of dust or dirt. He stated on a monthly basis while checking the light bulbs he did dust the vents and looked over resident rooms to see what all needed to be repaired. He stated it was the responsibility of the housekeepers to notify him of anything they saw in the resident rooms that need to be repaired. The Maintenance Director stated not alerting him of the dirty vents and the hanging rail placed residents at risk of developing allergies and breathing infections. He further stated there was not a risk of resident in room [ROOM NUMBER] being affected by the rail because he fixed it, and it was held on tightly by the end that has holding the rail to the ceiling. Interview on 10/01/24 at 3:37 PM with the Administrator revealed she ordered new vents. She stated the vents looked like they were all cleaned with degreaser and the paint was coming off. She stated the staff doing Angel Rounds should be looking over resident rooms and reporting any concerns. She stated some staff were out, and perhaps the people that were covering the Angel Rounds were just focusing on the resident needs. She stated anyone, who saw the vents or the rail hanging, was responsible for reporting it to the nurse, the maintenance department or herself. The Administrator stated leaving the items unattended placed the residents at risk of infection and injury if not addressed. Review of the facility's Housekeeping Standards policy, revised January 2024, reflected: The facility will provide a clean and sanitary living environment for the physical and emotional well being of the resident. The housekeeping program will address itself to the prevention of the spread of disease and infection through proper and effective disinfection procedures. Quality Control Monitoring Program - to establish a means of monitoring the quality of housekeeping services. Work Order System - to establish a means of written communication with all departments regarding discrepancies in quality control. Acquiring the proper chemicals, tools, equipment and supplies - to clean and disinfect

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for ADL care. The facility failed to provide Resident #1 assistance with timely incontinence care. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection. Findings included: Record review of Resident #1's face sheet, dated 10/01/24, reflected the resident was a [AGE] year-old female, admitted to the facility on [DATE], and readmitted on [DATE]. Resident #1's diagnoses included stroke, hypertension (high blood pressure), peripheral artery disease (disorder that causes abnormal narrowing of the arteries), hemiplegia (loss of the ability to move one entire side of the body), dementia (general decline in ability to perform everyday tasks), seizure disorder (uncontrolled shaking movements), and anxiety disorder (mental disorder of uncontrollable feelings). Record review of Resident #1's admission MDS assessment, dated 06/26/24, reflected Resident #1's BIMS score was 15 indicating her cognition was intact. Resident #1 was coded with frequently incontinent of bowel and bladder. Resident #1 required partial/moderate assistance with toileting, shower/bathing and personal hygiene. Record review of Resident #1's current, undated care plan reflected Resident #1 was incontinent of bowel/bladder related to weakness, and dementia. The care plan reflected: Goal: Resident will remain free from skin breakdown due to incontinence and brief use. Resident will be clean and odor free. Interventions: Incontinent: Check frequently for wetness and soiling, every two hours, and change as needed. Briefs or incontinence products as needed for protection. Apply barrier cream to skin after incontinence episodes. Resident wears extended wear/nighttime briefs at night to assist in preventing interrupted sleep for incontinence care. Assist to toilet as needed. Weekly skin checks and report any changes to physician. Observation and interview on 10/01/24 at 11:21 AM revealed Resident #1 was in bed. The resident stated she had been in her room in bed since the 6:00 AM-2:00 PM shift had started. She stated she ate breakfast and must had gone back to sleep. Resident #1 stated she was wet and was ready to be changed. She stated, I don't like to have this urine on me. Resident #1 stated the last time she was changed was prior to the 6:00 AM-2:00 PM shift, and no one had entered her room to ask her if she needed to be changed since early morning. The resident then activated her call light to request assistance. Observation on 10/01/24 at 11:50 AM revealed CNA A provided Resident #1 with incontinence care, and CNA A used proper technique throughout the procedure. Resident #1 expressed no discomfort, and no skin breakdown was noted. Resident #1's brief was soaked as well as her bedding. Resident #1 stated she was last changed just before day shift (6:00 AM-2:00 PM) came on duty today, so about 6 hours ago. Resident #1 stated she was a heavy wetter and staff usually had to change her linen when they changed her brief. Interview on 10/01/24 at 12:26 PM with CNA A revealed she was working with Resident #1 during 6:00 AM-2:00 PM shift today. CNA A stated she did rounds before and after breakfast, and Resident #1 stated she was okay. CNA A stated Resident #1 was a heavy wetter. CNA A stated the last time she checked on Resident #1 for incontinence care was around 10:00 AM, and the resident was sleeping at the time. According to CNA A, Resident #1 did not have any irritation and had not complained of her care. She stated Resident #1 was usually up and out of bed and able to alert staff when she had to go to the restroom. CNA A stated Resident #1 was soaked down to the bed when she completed the observed incontinence care. She stated she was surprised there was not a bed pad underneath the resident because she needed to have one. CNA A stated it was her responsibility to complete incontinence care rounds to ensure residents were clean and dry. She stated it was her responsibility to ensure the resident's bed was dry and clean. She stated not ensuring residents were clean and dry could cause residents to have skin damage and irritation. Interview on 10/01/24 at 1:46 PM with LVN B revealed she worked the 6:00 AM-2:00 PM shift Monday-Friday and cared for Resident #1 on her hall. She stated she was not sure why Resident #1 was soaked to the bed today. LVN B stated when Resident #1 was in bed, her call light was within reach, and she could alert staff to help her to the restroom. She stated Resident #1 was usually up and about the facility during the day. She stated she viewed Resident #1 as continent while the resident was up in her wheelchair because she was able to alert staff when she needed to go to the restroom, and staff would then assist her. LVN B stated it was the responsibility of the aide to complete incontinence care rounds every 2 hours and as needed. LVN B stated Resident #1 being wet placed her at risk of skin breakdown, falls if trying to change herself, and urinary tract infection. Interview on 10/01/24 at 3:25 PM with the DON revealed she was alerted to Resident #1 being soaked during an incontinence care observation. The DON stated CNAs were responsible for doing rounds every 2 hours on residents to ensure they were clean and dry. She stated nurses were also responsible for checking on their residents to ensure they are doing okay. She stated leaving Resident #1 wet placed her at risk of skin breakdown, infection, and pressure sores. The DON stated Resident #1 usually only required brief changes during the night hours because she alerted staff for assistance when she needed to go to the restroom during the day. She stated Resident #1 could alert staff when she needed to go to the restroom. Review of the facility's Incontinence Care policy, revised 02/14/20, reflected: Purpose: To outline a procedure for cleansing the perineum and buttocks after an incontinence episode. .Apply clean linen/under pad, brief or other incontinent products as needed. Reposition for comfort with call light in reach and provide additional care as needed as requested by patient. The policy revealed an outlined procedure for cleaning the perineum and buttocks after an incontinence episode. The policy included equipment and procedure to be used during incontinence care. The policy did not address how often to check on residents for incontinence care.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments for 1 of 4 (Medication Cart 1) medication carts reviewed for storage of medication. The facility failed to ensure that medications were secured inside the medication cart on 100 halls on 04/30/24. This failure could place residents at risk of overdosing and drug diversions by staff and visitors. Findings included: In an observation on 04/30/24 at 9:20 AM, the medication cart on the 100 halls was unlocked and unattended. Resident #3 was observed sitting in her wheelchair next to the unlocked medication cart, and Resident # 1 was observed independently propelling in his wheelchair a total of 3 times within 12 inches of the unlocked medication cart at 9:25 AM. The surveyor supervised the medication cart until assigned staff returned. At 9:28 AM the assigned medication person had not returned. The surveyor called for CNA L to assist with locating the person responsible for the care on the 100 halls. At 9:34 AM another employee (name unknown) approached and locked the medication cart, stating that ADON A was responsible for the medication cart located on the 100 halls. The staff said ADON A was on her way the cart. Resident #1 Record review of Resident #1's face sheet, dated 04/30/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: cerebral infarction (stroke), age related nuclear cataract (age related condition affects the lens of the eye), depression (mental state of low mood), and anxiety (fearful, worrying). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #1 had a resident mood interview severity score of 00, indicating the resident score did not identify mood concerns Review of MDS Behavior section reflected had physical and verbal toward behavior toward others 1 to 3 days. Resident #1 required supervision with ADLs of bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1's care plan, dated 12/30/23, revealed Resident #1 had ADL self-care Performance Deficit. requiring supervision and assistance from the staff. Resident requires the use of psychotropic medications antidepressant, antipsychotic for depression and anxiety. Resident #1 has behaviors toward others due to ineffective coping skills, including instigating and physical aggression toward others. Interventions were Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Arrange for psych consult, follow up as indicated, and Administer medications as ordered. Monitor/document for side effects and effectiveness. Interventions for Anti-anxiety medications include monitoring side effects of drowsiness, lack of energy, slow reflexes, slurred speech, confusion, depression, dizziness, impaired thinking and judgment, forgetfulness, gastric distress, and changes in vision. In an observation and attempted interview on 04/30/24 at 9:25 AM with Resident #1, revealed him waving at surveyor and stating, I was fine. Resident #1 was observed propelling independently in his wheelchair 12 inches from the unlocked medication cart 3 times. Resident #2 Record review of Resident #2's face sheet dated 04/30/24 reflected the resident was an [AGE] year-old female admitted on [DATE]. Her diagnoses included: unspecified dementia (decline in memory), psychotic disturbance (disorders affecting mental thoughts, perception, and reality, mood disturbance, lack of coordination age-related physical debility (physical decline in abilities due to age). Record review of Resident #2's quarterly MDS dated [DATE], reflected a BIMS score of 4 indicating severe cognitive impairment. Resident requires extensive assistance for bed mobility, always incontinent, and had vision impairment. In an observation of Resident #2 on 04/30/24 at 9:20 AM to 9:36 AM, the resident was asleep in her wheelchair next to an unlocked medication cart on the 100 halls. She was observed in and out of sleep, while moving her wheelchair closer to the medication cart. In an interview on 04/30/24 at 9:36 AM with ADON A, she stated she was summoned by the MD to access another resident's records and became distracted, thus leaving the medication cart unlocked outside room [ROOM NUMBER] and 116. ADON A stated medication carts should be locked when unattended to prevent staff, visitors, and residents from accessing patient medications. She said the risk of leaving the medication cart unlocked, could lead to patient's accessing medication and resulting in a negative or adverse reactions causing harm. In an interview on 04/30/24 at 3:02 PM with the DON, she stated she expected medication carts to be secured and locked when the certified staff walked away from the cart, to prevent uncertified staff, visitors, and residents from accessing the medications inside the cart. She stated the risk of leaving a medication cart unattended and unlocked included resident accessing medication, resident overdosing, and allergic reactions. The DON stated that it was the responsibility of the DON and ADON to monitor medication cart security and safety at the facility. Interview on 04/30/24 at 3:43 PM with the Administrator, she stated she expected all certified staff to know the location of their medication, cart, supplies on board the cart, location of residents, and ensure the medication carts were secure to prevent families from accessing. She was not concerned with resident's accessing unlocked medication carts. A medication cart security policy was requested from the DON and Administrator on 04/30/24 at 11:123 AM. The DON responded on 04/30/24 at 2:01 PM stating, Unfortunately, we do not have a med cart security policy.

Based on observation, interview, and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 3 residents (Resident #1) reviewed for Care Plans. The facility failed to ensure Resident #1's Care Plan was reviewed and updated quarterly, based on record reviews made on 04/30/24. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #1's face sheet, dated 04/30/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Cerebral infarction (stroke), age related nuclear cataract (age related condition affects the lens of the eye), Depression (mental state of low mood), anxiety (fearful, worrying). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #1 had a resident mood interview severity score of 00, indicating the resident score did not identify mood concerns Review of MDS Behavior section reflected had physical and verbal toward behavior toward others 1 to 3 days. Resident #1 required supervision with ADLs of bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1's care plan, dated 12/30/23, revealed Resident #1 had impaired cognition, visual impairment, ADL self-care performance deficit. Resident requires the use of psychotropic medications antidepressant, antipsychotic for depression and anxiety. Resident #1 has behaviors toward others due to ineffective coping skills, including instigating and physical aggression toward others. Interventions were Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Arrange for psych consult, follow up as indicated, and Administer medications as ordered. Monitor/document for side effects and effectiveness. Interventions for Anti-anxiety medications include monitoring side effects of drowsiness, lack of energy, slow reflexes, slurred speech, confusion, depression, dizziness, impaired thinking and judgment, forgetfulness, gastric distress, and changes in vision. Resident #1's care plan had not been updated as of 12/30/23. In an observation and attempted interview on 04/30/24 at 9:25 AM, Resident #1 was independently propelling back and forth on the 100 hall and throughout the facility. An attempted interview revealed Resident #1 waving at surveyor and stating, I'm fine. There were no concerns with ADL care. In an interview on 04/30/24 at 3:02 PM with the DON, she revealed she had been the assigned DON for 2 weeks. She stated that care plans were reviewed quarterly and as needed. She stated that Resident #1's should have had a quarterly update by 04/03/24. She stated the DON and MDS Nurse normally updated the care plan. She stated she had not been trained on facility process for updating care plans by the corporate nurse. The DON stated she was not familiar with the care plan process and would be trained tomorrow. At that training, she would be educated on how to monitor care plans. The MDS nurse was not interviewed on 04/30/24. Interview on 04/30/24 at 3:43 PM with the Administrator, she revealed she was aware there were a back log of quarterly care plans that were not updated from the previous DON and ADON, and she has since hired new nurse managers that were trained by the Regional Nurse Consultant. The Regional Nurse Consultant was scheduled to train new staff on 05/01/24. She stated she did not know the risk of care plans not being updated. Record review of the facility's Care Plan Guidelines policy, dated 05/06/16, reflected: All Admission and Significant Change care plans that are generated by the MDS-CAAs will be initiated by a Registered Nurse (RN). Care Plan Updates the IDT will review the care plans Annually, Quarterly, and as needed to ensure all goals and approaches are appropriate. The IDT will sign their designated sections of the care plan thereby signifying that they have reviewed their section of each care plan. The IDT will review the care plans Annually, Quarterly, and as needed to ensure all goals and approaches are appropriate. The IDT will sign their designated sections of the care plan thereby signifying that they have reviewed their section of each care plan. Meetings will be conducted within 21 days of admission to the facility and at least quarterly thereafter. A care plan meeting will be scheduled with any Significant Change MDS. The meetings will be scheduled by the Social Worker, or designee, following the schedule above (within 21 days of admission, at least quarterly and with any Significant Change MDS).

Based on interview and record review, the facility failed to ensure licensed nurses had the appropriate competencies and skills sets to provide nursing services to care for residents' needs and ensure resident safety, in accordance with professional standards of practice necessary for 1 of 5 residents (Resident #1) reviewed for nursing competencies. The facility failed to ensure LVN C was competent in medication administration when LVN C failed to ensure Resident #1 was administered nitroglycerin (medication used to prevent or relieve chest pain caused by coronary artery disease by relaxing blood vessels), as ordered by the physician on 02/04/24. LVN C dispensed an entire bottle of nitroglycerin, which consisted of 25 (0.4 mg) tablets, to Resident #1 when the physician order was for 1 (0.4 mg) tablet resulting in Resident #1 being sent to the emergency room . Resident #1's initial blood pressure at the ER was 86/42. The noncompliance was identified as PNC. The IJ began on 02/04/24 and ended on 02/05/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk to medication administration errors, not receiving the intended therapeutic effects of the medications, and could contribute to adverse reactions resulting in a decline in health, hospitalization , or death. The findings included: A record review of the American Heart Associations' guidance on Understanding Blood Pressure Readings, last reviewed on 05/30/23, reflected a normal blood pressure reading would be 120/80. Accessed on 02/16/24 from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings A record review of Resident #1's electronic Face Sheet dated 02/06/24 reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses that included need for assistance with personal care, muscle weakness, unsteadiness on feet, and atherosclerotic heart disease of native coronary artery (caused by plaque buildup in the wall of the arteries that supply blood to the heart). A record review of Resident #1's Optional State Assessment MDS, dated [DATE] indicated Resident #1 had a BIMS score of 11, which indicated the resident's cognition was moderately impaired. A record review of Resident #1's Physician Orders, dated 02/04/24, reflected Nitroglycerin Sublingual Tablet 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for chest pain x 3 does, if no relief call MD, send to ER for further Evaluation. A record review of Resident #1's Care Plan, dated 09/08/22, indicated a focus area of has altered cardiovascular (relating to the heart and blood vessels) status r/t ASHD/CAD and the interventions included .Monitor for complaint of chest pain. Enforce the need to call for assistance if pain starts .Monitor/document/report to MD PRN any s/sx of CAD: chest pain or pressure especially with activity, etc Further review of Resident #1's Care Plan indicated a focus on area of Hypertension (when the pressure in your blood vessels is too high), and an intervention included Administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate. A record review of Resident #1's Progress Notes, dated 02/04/24 at 2:27 PM, by LVN C, reflected Data: Resident complained of chest pain. Resident was observed sitting in his wheelchair, appeared not to be in any distress. Vital signs were taken and this nurse looked at resident's chart to see if anything was available to be given. Resident did not have an order for nitroglycerin. [Telehealth] was called. Action: Before Resident left he stated he was not having chest pain and that I'm alive. Response: Vitals signs taken BP 118/70 P (pulse) 78 O2 (oxygen) 97% Room Air. [Telehealth] gave an order to give Nitroglycerin 0.4mg 1 tablet sublingual (situated or applied under the tongue) every 5 minutes times 3 doses. If no relief to call 911. Medication retrieved from Nexsys (secure technology to manage controlled medications, STAT/first doses and electronic E-Kits). This nurse gave the entire bottle misinterpreting the order and thought that the whole bottle was 0.4mg. Then realizing the error, Assessed resident, vitals taken again BP 159/108 P 102, No SOB noted, No respiratory distress. Resident was alert and oriented at this time. This nurse then called 911 and then reported it to the DON and called [telehealth]. EMT's arrived, while being taken out on the stretcher, Resident was alert, stable and talking to the nurse and stated he was not having chest pain and that I'm alive. [telehealth MD] asked if Resident was alert and stable and if he was having any adverse reactions. Resident was stable and did not appear to have any adverse reactions. [telehealth MD] stated ok, it's good he went to the hospital and is not having any reactions. [FM] notified at [phone number]. Stated to let her know when we hear back from the hospital. A record review of Resident #1's hospital records, dated 02/04/24, reflected Resident #1 entered theER on [DATE] at 3:20 PM. The ER records reflected Chief Complaint Patient presents with Drug Overdose per EMS Accidental overdose of nitroglycerine, give 25 -0.4 mg nitro tablets by nursing home staff over a period of 20 minutes . Initial pressure 86 over 42 presently 115 over 68 after 1 liter of fluid. Sinus bradycardia (a slow heart rate) on the monitor at a rate of 56. Further review of the ER records reflected Resident #1 was given a physical exam and his cardiovascular rate and rhythm was Bradycardia present. The ER records reflected Resident #1's final diagnosis included acute chest pain, bradycardia, hypothyroidism, and overdose of nitroglycerin. Resident #1 was admitted to the hospital on 02/04/24 at 5:47 PM. In an interview on 02/06/24 at 9:10 AM, the DON stated on Sunday (02/04/24) she was contacted by the WCN and told that LVN C gave Resident #1 an entire bottle of nitroglycerin and was sent out to the hospital. The DON stated she went to the facility and LVN C told her that Resident #1 complained of chest pain, so she contacted the MD and was provided an order for 0.4 mg of nitroglycerin. The DON stated, LVN C told her she got confused and thought the entire bottle was 0.4mg and not each tablet. The DON stated LVN C told her she gave Resident #1 the entire bottle, which was 25 tablets. The DON stated the MD and Resident #1's FM were notified. The DON stated she in-serviced and suspended LVN C. She stated she ensured the other residents who had orders for nitroglycerin were not administered the medication and confirmed when they were administered nitroglycerin it was administered per the orders. The DON stated the ADONs audited the medication carts and found there were no issues. The DON stated following the incident, she immediately in-serviced staff on medication administration, nitroglycerin administration, and abuse & neglect. She stated staff were not able to start their shift until they were in-serviced. The DON stated all in-services were completed by 02/05/24. She stated LVN C would be terminated. The DON stated her expectation was for Med Aides and nurses to administer medications per the physician orders, and if they have questions about the orders or medications, they were supposed to get clarification before administering the medication. In an interview on 02/06/24 at 10:17 AM, LVN C stated on Sunday (02/04/24) about noon, Resident #1 started complaining of chest pain, so she notified the WCN, who was the charge nurse. LVN C stated the WCN told her to take Resident #1's vitals and contact the MD. LVN C stated she contacted the MD and was given an order for 0.4 mg of nitroglycerin and if resident continued to have chest pain, then she needed to send Resident #1 to the ER. LVN C stated the WCN pulled the medicine for the emergency kit. She stated the bottle was small and the pills were tiny, so she misinterpreted the dosage amount. LVN C stated she thought the entire bottle was 0.4 mg, so she gave the entire bottle to the Resident #1, which was 25 tablets. She stated it was her first-time administering nitroglycerin. LVN C stated as she was about to leave Resident #1's room, she realized her mistake, but the pills were in his mouth and dissolved. LVN C stated she notified the WCN of her mistake and was told to call 911. She stated 911 was called and she notified the MD and Resident #1's family of the incident. LVN C stated the EMS arrived about 10 minutes after they were contacted. She stated Resident #1's vitals were normal while he was at the facility. LVN C stated she was in-serviced and suspended. In an interview on 02/06/24 at 10:28 AM, the WCN stated on 02/04/24, Resident #1 was complaining of chest pain. The WCN stated LVN C contacted the MD and received an order for nitroglycerin. She stated she pulled the Nitroglycerin from Nexsys and told LVN C to put Resident #1's name and date on the bottle. The WCN stated she told her to give Resident #1 one tablet and then wait to see if the chest pain stopped. She stated about 30 minutes later, LVN C came to her office crying saying she messed up and gave Resident #1 the entire bottle. The WCN stated LVN C stated she thought the entire bottle was 0.4 mg. The WCN stated she told LVN C to call 911 and to take Resident #1's vitals. In a follow up interview on 02/06/24 at 5:11 PM, the DON stated LVN C was a new nurse and got her license in September 2023. The DON stated a licensed nurse skills competency was completed when LVN C was initially hired in October 2023. The DON stated medication administration is a skill that is observed and completed during the competency check. She stated she did not believe any other evaluations had been completed after her initial skills check in October 2023. A record review of the facility's policy titled Medication- Treatment Administration and Documentation Guidelines, dated 02/02/14, reflected Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Fundamental Information: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Point Click Care (PCC) times codes are assigned to medication in order to administer according to manufacturers' guidelines, physician orders or patient choice . Process: 1. Verify labels accurately reflect the physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the MAR three (3) times . 4. Administer the medication according to the physician orders . A policy regarding nursing competency was requested and the facility provided a policy titled Training Requirements, dated 11/29/22. A record review of the policy reflected Policy: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Policy Explanation and Compliance Guidelines: . 3. Competencies and skill set for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles . An IJ was identified to have existed from 02/04/24 through 02/05/24. On 02/06/24 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: A record review of the facility's document titled Associate Disciplinary Memorandum, dated 02/04/24 and completed by the DON, reflected LVN C was suspended due to medication error. A record review of the facility's document titled Termination Report, dated 02/06/24, reflected LVN C was terminated due to safety violations. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON A, reflected the medication carts for the 100 hall was audited and had no issues. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON B, reflected the medication carts for the 200 hall was audited and had no issues. A record review of the facility's in-services titled Medication Pass Policy and Nitroglycerin uses and directions, dated 02/04/24, reflected all Med Aides and nursing staff, were educated on the facility's policy titled Medication- Treatment Administration Documentation Guidelines, dated 02/02/14 and training document Nitroglycerin Oral: Uses, Side Effects, Interactions, Pictures, Warning & Dosing, undated. A record review of the facility's documents titled Validation Checklist Medication Pass, dated 02/04/24, reflected Purpose: To determine if the nurse is performing a medication pass procedure in accordance with the facility's standard of practice. Enter Nurse/Nurse Aide Initial Record observation below. Review findings with the nurse. Provide correction action as needed. The documents reflected ADON A and ADON B completed observations of medication pass on all Med Aides and nurses, which revealed there were no issues. A record review of the facility's in-services titled Abuse and Neglect, dated 02/04/24, reflected all staff were in-serviced on the facility's policy titled Abuse Policy, dated 02/01/21, and completed a posttest titled Resident Abuse Prevention and Reporting, which reflected no issues. Interviews were conducted from 02/06/24 between 11:40 AM and 2:20 PM to 02/07/24 between 10:10 and 10:30, with 3 Med Aides, 4 RNs, 5 LVNs, and two ADONs, from various shifts. The staff all stated they had been in-serviced on medication administration, nitroglycerin administration, and abuse and neglect. The staff were able to identify and define medication errors, and were knowledgeable on procedures for administering all medications, specifically nitroglycerin. The staff were knowledgeable of abuse & neglect policy and procedures.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident # 1) reviewed for significant medication errors. On 02/04/24, LVN C failed to ensure Resident #1 was administered nitroglycerin (medication used to prevent or relieve chest pain caused by coronary artery disease by relaxing blood vessels), as ordered by the physician. LVN C dispensed an entire bottle of nitroglycerin, which consisted of 25 (0.4 mg) tablets to Resident #1, when the physician order was for 1 (0.4 mg) tablet. Resident #1 was transferred to the emergency room , his initial blood pressure at the ER was 86/42. The noncompliance was identified as PNC. The IJ began on 02/04/24 and ended on 02/05/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health, hospitalization , or death. The findings included: A record review of the American Heart Associations' guidance on Understanding Blood Pressure Readings, last reviewed on 05/30/23, reflected a normal blood pressure reading would be 120/80. Accessed on 02/16/24 from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings A record review of Resident #1's electronic Face Sheet dated 02/06/24 reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses that included need for assistance with personal care, muscle weakness, unsteadiness on feet, and atherosclerotic heart disease of native coronary artery (caused by plaque buildup in the wall of the arteries that supply blood to the heart). A record review of Resident #1's Optional State Assessment MDS, dated [DATE] indicated Resident #1 had a BIMS score of 11, which indicated the resident's cognition was moderately impaired. A record review of Resident #1's Physician Orders, dated 02/04/24, reflected Nitroglycerin Sublingual Tablet 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for chest pain x 3 does, if no relief call MD, send to ER for further Evaluation. A record review of Resident #1's Care Plan, dated 09/08/22, indicated a focus area of has altered cardiovascular (relating to the heart and blood vessels) status r/t ASHD/CAD and the interventions included . Monitor for complaint of chest pain. Enforce the need to call for assistance if pain starts . Monitor/document/report to MD PRN any s/sx of CAD: chest pain or pressure especially with activity, etc. Further review of Resident #1's Care Plan indicated a focus on area of Hypertension (when the pressure in your blood vessels is too high), and an intervention included Administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate. A record review of Resident #1's Progress Notes, dated 02/04/24 at 2:27 PM, by LVN C, reflected Data: Resident complained of chest pain. Resident was observed sitting in his wheelchair, appeared not to be in any distress. Vital signs were taken and this nurse looked at resident's chart to see if anything was available to be given. Resident did not have an order for nitroglycerin. [Telehealth] was called. Action: Before Resident left he stated he was not having chest pain and that I'm alive. Response: Vitals signs taken BP 118/70 P (pulse) 78 O2 (oxygen) 97% Room Air. [Telehealth] gave an order to give Nitroglycerin 0.4mg 1 tablet sublingual (situated or applied under the tongue) every 5 minutes times 3 doses. If no relief to call 911. Medication retrieved from Nexsys (secure technology to manage controlled medications, STAT/first doses and electronic E-Kits). This nurse gave the entire bottle misinterpreting the order and thought that the whole bottle was 0.4mg. Then realizing the error, Assessed resident, vitals taken again BP 159/108 P 102, No SOB noted, No respiratory distress. Resident was alert and oriented at this time. This nurse then called 911 and then reported it to the DON and called [telehealth]. EMT's arrived, while being taken out on the stretcher, Resident was alert, stable and talking to the nurse and stated he was not having chest pain and that I'm alive. [telehealth MD] asked if Resident was alert and stable and if he was having any adverse reactions. Resident was stable and did not appear to have any adverse reactions. [telehealth MD] stated ok, it's good he went to the hospital and is not having any reactions. [FM] notified at [phone number]. Stated to let her know when we hear back from the hospital. A record review of Resident #1's hospital records, dated 02/04/24, reflected Resident #1 entered theER on [DATE] at 3:20 PM. The ER records reflected Chief Complaint Patient presents with Drug Overdose per EMS Accidental overdose of nitroglycerine, give 25 0.4 mg nitro tablets by nursing home staff over a period of 20 minutes . Initial pressure 86 over 42 presently 115 over 68 after 1 liter of fluid. Sinus bradycardia (a slow heart rate) on the monitor at a rate of 56. Further review of the ER records reflected Resident #1 was given a physical exam and his cardiovascular rate and rhythm was Bradycardia present. The ER records reflected Resident #1's final diagnosis included acute chest pain, bradycardia, hypothyroidism, and overdose of nitroglycerin. Resident #1 was admitted to the hospital on 02/04/24 at 5:47 PM. In an interview on 02/06/24 at 9:10 AM, the DON stated on Sunday (02/04/24) she was contacted by the WCN and told that LVN C gave Resident #1 an entire bottle of nitroglycerin and was sent out to the hospital. The DON stated she went to the facility and LVN C told her that Resident #1 complained of chest pain, so she contacted the MD and was provided an order for .4 mg of nitroglycerin. The DON stated, LVN C told her she got confused and thought the entire bottle was .4mg and not each tablet. The DON stated LVN C told her she gave Resident #1 the entire bottle, which was 25 tablets. The DON stated the MD and Resident #1's FM were notified. The DON stated she in-serviced and suspended LVN C. She stated she ensured the other residents who had orders for nitroglycerin were not administered the medication and confirmed when they were administered nitroglycerin it was administered per the orders. The DON stated the ADONs audited the medication carts and found there were no issues. The DON stated following the incident, she immediately in-serviced staff on medication administration, nitroglycerin administration, and abuse & neglect. She stated staff were not able to start their shift until they were in-serviced. The DON stated all in-services were completed by 02/05/24. She stated LVN C would be terminated. The DON stated her expectation was for Med Aides and nurses to administer medications per the physician orders, and if they have questions about the orders or medications, they were supposed to get clarification before administering the medication. In an interview on 02/06/24 at 10:17 AM, LVN C stated on Sunday (02/04/24) about noon, Resident #1 started complaining of chest pain, so she notified the WCN, who was the charge nurse. LVN C stated the WCN told her to take Resident #1's vitals and contact the MD. LVN C stated she contacted the MD and was given an order for .4 mg of nitroglycerin and if resident continued to have chest pain, then she needed to send Resident #1 to the ER. LVN C stated the WCN pulled the medicine for the emergency kit. She stated the bottle was small and the pills were tiny, so she misinterpreted the dosage amount. LVN C stated she thought the entire bottle was .4 mg, so she gave the entire bottle to the Resident #1, which was 25 tablets. She stated it was her first-time administering nitroglycerin. LVN C stated as she was about to leave Resident #1's room, she realized her mistake, but the pills were in his mouth and dissolved. LVN C stated she notified the WCN of her mistake and was told to call 911. She stated 911 was called and she notified the MD and Resident #1's family of the incident. LVN C stated the EMS arrived about 10 minutes after they were contacted. She stated Resident #1's vitals were normal while he was at the facility. LVN C stated she was in-serviced and suspended. In an interview on 02/06/24 at 10:28 AM, the WCN stated on 02/04/24, Resident #1 was complaining of chest pain. The WCN stated LVN C contacted the MD and received an order for nitroglycerin. She stated she pulled the Nitroglycerin from Nexsys and told LVN C to put Resident #1's name and date on the bottle. The WCN stated she told her to give Resident #1 one tablet and then wait to see if the chest pain stopped. She stated about 30 minutes later, LVN C came to her office crying saying she messed up and gave Resident #1 the entire bottle. The WCN stated LVN C stated she thought the entire bottle was .4 mg. The WCN stated she told LVN C to call 911 and to take Resident #1's vitals. A record review of the facility's policy titled Medication- Treatment Administration and Documentation Guidelines, dated 02/02/14, reflected Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Fundamental Information: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Point Click Care (PCC) times codes are assigned to medication in order to administer according to manufacturers' guidelines, physician orders or patient choice . Process: 1. Verify labels accurately reflect the physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the MAR three (3) times . 4. Administer the medication according to the physician orders . An IJ was identified to have existed from 02/04/24 through 02/05/24. On 02/06/24 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: A record review of the facility's document titled Associate Disciplinary Memorandum, dated 02/04/24 and completed by the DON, reflected LVN C was suspended due to medication error. A record review of the facility's document titled Termination Report, dated 02/06/24, reflected LVN C was terminated due to safety violations . A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON A, reflected the medication carts for the 100 hall was audited and had no issues. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON B, reflected the medication carts for the 200 hall was audited and had no issues. A record review of the facility's in-services titled Medication Pass Policy and Nitroglycerin uses and directions, dated 02/04/24, reflected all Med Aides and nursing staff, were educated on the facility's policy titled Medication- Treatment Administration Documentation Guidelines, dated 02/02/14 and training document Nitroglycerin Oral: Uses, Side Effects, Interactions, Pictures, Warning & Dosing, undated. A record review of the facility's documents titled Validation Checklist Medication Pass, dated 02/04/24, reflected Purpose: To determine if the nurse is performing a medication pass procedure in accordance with the facility's standard of practice. Enter Nurse/Nurse Aide Initial Record observation below. Review findings with the nurse. Provide correction action as needed. The documents reflected ADON A and ADON B completed observations of medication pass on all Med Aides and nurses, which revealed there were no issues. A record review of the facility's in-services titled Abuse and Neglect, dated 02/04/24, reflected all staff were in-serviced on the facility's policy titled Abuse Policy, dated 02/01/21, and completed a posttest titled Resident Abuse Prevention and Reporting, which reflected no issues. Interviews were conducted from 02/06/24 between 11:40 AM and 2:20 PM to 02/07/24 between 10:10 AM and 10:30 AM, with 3 Med Aides, 4 RNs, 5 LVNs, and two ADONs, from various shifts. The staff all stated they had been in-serviced on medication administration, nitroglycerin administration, and abuse and neglect. The staff were able to identify and define medication errors, and were knowledgeable on procedures for administering all medications, specifically nitroglycerin. The staff were knowledgeable of abuse and neglect policy and procedures.

Based on interviews and record reviews the facility failed to have evidence that all alleged violations were thoroughly investigated for 2of 6 residents (Resident # 1 and Resident #2) reviewed for investigations of abuse and neglect. 1. The facility failed to investigate an allegation of physical abuse for Resident #1 which placed the resident at higher risk for abuse and further injury. 2. The facility failed to investigate an allegation of abuse reported by Resident #2 which affected Resident #1. 3. The alleged perpetrator continued to work with Resident #1 after the allegation of abuse was reported. An Immediate Jeopardy (IJ) situation was identified on 07/08/22 at 4:38 PM. While the IJ was removed on 07/11/22, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not having allegations of abuse investigated which could cause further abuse and more serious harm. Findings include: 1. Review of Resident #1's MDS assessment dated [DATE], reflected the resident was a [AGE] year-old-female admitted to the facility on [DATE]. The resident had a memory problem and severely impaired cognitive skills for daily decision making. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan, dated 07/11/21, reflected : Resident had an activities of daily living care deficit and was totally dependent on staff for bed mobility and hygiene. Review of Resident #1's Nurse Note, dated 05/03/22 at 12:32 PM written by LVN B reflected: Nurse notified by the CNA (D) that resident has a black eye. Roommate said resident was hit by the CNA (A) when changing her. Resident is in no pain or distress, and her eye drops administered. ADON notified. Review of Resident #1's Nurse Note, dated 05/03/22 at 3:20 PM and written by LVN C reflected: Last night when CNA (A) was doing incontinent care on the resident; CNA (A) rolled resident toward the wall to the window to change resident. Then resident rolled over and her head went into the wall. Head to toe check without tears/abrasions. Family, ADON, NP notified. NP gave order for skull series (x-rays). Review of Resident #1's X-ray Report, dated 5/3/22, reflected: No evidence of skull fracture. Review of Resident #1's May 2022 Neurological assessments revealed no changes in neurological status. Review of Resident #1's Incident Report, dated 05/03/22, reflected: Discolored area bilateral upper eyelids, slight swelling right eyebrow area. Resident bumped into wall during incontinent care last night. Resident unable to give description. Neurological checks initiated. Witness CNA A Record reviews indicated there was no information to indicate the resident had a fall and/or allegation of abuse investigated. Review of Resident #1's Physician Note, dated 05/07/22 at 6:05 PM reflected: Resident was transferred to the emergency department following a change in status of being difficult to arouse and low blood pressure. An interview with the family of Resident #1 on 07/08/22 at 1:55 PM, revealed the resident passed away at the hospital following her transfer from the facility on 05/08/22. He said, she was sent to the hospital and placed in ICU. The facility said she hit the wall. The doctor at the hospital reported the resident was brain dead. Review of Resident #1's Hospital Records, dated 05/08/22, did not reveal evidence of head injury . 2. Review of Resident #2's MDS Assessment, dated 05/26/22, reflected the resident was a [AGE] year-old-female. The resident had the ability to understand others and make herself understood. Her BIMs score was 13 , cognitively intact. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Care Plan, dated 02/23/21, reflected the resident had delusions. An interview with Resident #2 (roommate to Resident #1) on 07/08/22 at 2:55 PM, revealed she was alert and oriented to person, place, and situation. She said on an unknown date, she heard Resident #1 grunt like she was hit. She said, The CNA (A) pulled her (Resident #1) out of the bed and the resident (Resident #1) hit the floor on the side of the bed closest to me (Resident #2). She (Resident #1) takes two people to get in bed, and the CNA (A) picked her up by her arm. I told the nurse about it, but no one ever came and talked to me about it. The CNA (A) did not stop working with her (Resident #1). I know that CNA (A) hurt her bad when she (Resident #1) hit that concrete floor. An interview on 07/08/22 at 2:35 PM with LVN B revealed she documented an allegation of abuse for Resident #1 on 05/03/22, but she did not investigate or report the allegation of abuse. She said I, saw the bruise on the eye on 05/03/22. I did not know if it was for real (the allegation of abuse), the roommate will go off sometimes. I explained to the 2:00 PM - 10:00 PM nurse what happened. I gave her the report of what the roommate said. I did not say anything to the Abuse Coordinator because I did not know if she (Resident #2) was for real when she said the CNA (A) hurt the resident. I told ADON (E) about the allegation of abuse the same day, and she told me to document it, so I did. LVN B said CNA D reported the allegation of abuse to her. LVN B said she did not speak to the roommate (Resident #2) about the allegation of abuse, because we were already going to the breakroom for lunch. An interview on 07/08/22 at 5:35 PM, CNA D revealed on 05/03/22, I went into the room to get her (Resident #1) ready and up to put her in the chair. When me and the CNA (unknown) put her in the chair, I noticed there was a bruise on her eye. The roommate (Resident #2) said that the resident (Resident #1) fell the day before during transition from wheelchair to bed. CNA D said there must have been a miscommunication because he (CNA D) did not tell LVN B that CNA A hit Resident #1. CNA D said, The black eye looked like a hit, but the roommate said she fell during transfer from the wheelchair to the bed. An interview on 07/08/22 at 2:20 PM, CNA A revealed on the night of 05/02/22, unknown time, she had the curtain closed and was changing Resident #1. CNA A said when she rolled the resident, the resident hit her face on the wall. CNA A said there were no bruises on her face, and the resident's face hit the wall first. CNA A said she did not report the incident because there was no injury. CNA A said Resident #2 (roommate) reported Resident #1 fell out of bed, but she did not. She (Resident #2) said I picked the resident up off the ground and put her back in bed. I did not do that. Review of CNA A's schedule for May 2022 reflected she was assigned to Resident #1 and Resident #2's room on 05/04/22 following the allegation of abuse. An interview was attempted with LVN C on 07/08/22 at 5:45 PM but she did not return the call of the Surveyor. An interview on 07/08/22 at 4:55 PM, ADON E revealed she was told Resident #1 had a black eye and the roommate (Resident #2) said the resident had fallen. ADON E said she spoke to Resident #2 and was told she did not see the fall but heard it. ADON E said Resident #2 reported the incident occurred in the evening, but she did not give the name of the CNA involved in the incident. ADON E said she thought Resident #1 had a fall from bed but when she spoke to the nurse, no one had reported a fall. She said CNA A said when she turned Resident #1 over, she could have hit her face on the wall. ADON E said CNA A continued to provide care to Resident #1 and no one monitored the care provided following the incident because everyone thought the injury was an accident. ADON E said when an allegation of abuse is reported, the Abuse Coordinator was supposed to be notified. An interview on 07/08/22 at 2:38 PM, the Abuse Coordinator revealed he was not notified of any physical abuse allegation with Resident #1. He said, I don't know who the roommate is. (DON) did the investigation. An interview on 07/08/22 at 2:40 PM, the DON revealed she did not know anything about Resident #1's death, hospitalization , or allegation of physical abuse. Review of the facility, Abuse Policy, dated 02/01/21, reflected: V. Investigation: B. The facility must have evidence that all violations, including allegations, are thoroughly investigated. Investigations are under the direction of the Abuse Coordinator . This was determined to be an Immediate Jeopardy (IJ) on 07/08/22 at 4:38 PM. The Administrator and DON were notified at 4:45 PM on 07/08/22. The Administrator was provided with the IJ template on 07/08/22 at 4:54 PM. The following Plan of Removal was submitted by the facility and was accepted on 07/11/22 at 7:44 AM, and reflected: 1. Immediate action(s) taken for the resident(s) found to have been affected include: o Facility reported allegation of abuse documented in the resident's chart to State Agency on 7/8/2022 at 6:30PM. o The resident that the abuse occurred to no longer resides in the facility. o On 7/8/2022 Facility suspended Charge Nurse, LVN pending investigation, who documented in the clinical record the allegation of abuse the CNA reported on 5/3/2022. o On 7/8/2022 Facility Administrator suspended, pending investigation the CNA that was assigned to the resident on 5/3/2022 6am-2pm. o On 7/8/2022 Facility Administrator or Designee immediately begin patient questionnaires to identify any unreported allegations of abuse from residents. o On 7/8/2022 Facility Administrator began conducting an Abuse allegation investigation for the allegation made on 5/3/2022. o On 7/8/2022 the DON or Designee immediately called and interviewed the staff members who worked the day of the allegation on made on 5/3/2022 and began interviewing other employees of their knowledge of other potential abuse situations. o On 7/8/2022 the charge nurses began conducting head to toe assessments on residents that resided on the North Hall, which are documented on skin observation worksheets. 2. Actions to Prevent Occurrence/Recurrence: o On 7/8/22 employees were in-serviced by the DON or designee and Post Test was given on Abuse Policy which includes: o All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administrator or the DON. o NOTE: If the alleged abuse/neglect involves the Administrator, report the incident immediately to the DON. If the DON is not available, report the incident immediately to the Regional Vice President or Regional Nurse Consultant. o If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge o The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. o No staff members will be allowed to work until they have received the Inservice and completed the post test. o In-servicing and posttest for Abuse will be completed by 7/9/2022 3. How the corrective action(s) will be monitored to ensure the practice will not recur: o Daily the ADONs and Charge nurses will supervise staff during rounds on the unit to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. o The department heads during quality-of-life rounds will talk to residents about staff practices during care such as inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, not answering call light, directing residents who need toileting assistance to urinate or defecate in their beds, and reporting skin alternations like bruises and skin tears . o All new employees will be trained on hire and annually on Abuse, Neglect, Misappropriation, and Reporting abuse practices such as: o How to report their knowledge of a suspicion of a crime, abuse, or witnessed abuse, neglect or misappropriation of resident property. o How to report a reasonable suspicion of a crime can be done without fear of retaliation. Employees may file a complaint with the state survey agency against any facility that retaliates against an employee who makes a report, causes a lawful report to be made, or who takes steps in assisting in the making of a report. o How to recognize signs of burnout, frustration and stress that may lead to abuse; and o What constitutes abuse, neglect and misappropriation of resident property? o Discuss behavioral interventions that can be used for inappropriate resident behaviors. o All allegations of Abuse, Neglect, Misappropriation will be reviewed and validated by the QAA committee monthly. Monitoring of the facility's Plan of Removal included the following: Record review of the in-services dated 07/08/22, reflected: The facility will provide a living environment that is free from abuse, neglect, or exploitation in accordance with facility policy and state guidelines. Any observation or infraction of this policy must be immediately reported to the Abuse Prevention Coordinator or the DON. Interviews and record reviews were conducted on 07/11/22 starting at 9:50 AM and continued through 07/11/22 at 2:50 PM. The staff members were able to verbalize their understanding that if they received any report of abuse, even if the allegation involved a staff member, the Abuse Coordinator had to be notified. The staff were able to verbalize the allegation had to be investigated. Interviewed staff members and shifts were: LVN G - worked day shift Hospitality Aide - worked day shift CNA I - worked all shifts CNA J - worked day shift LVN F - worked all shifts Hospitality Aide K - worked day and evening shift CNA A - worked evening and night shift CNA D - worked all shifts CNA L - worked all shifts CNA M - Worked day and evening shift SW - worked day shift Hospitality Aide N - worked day and night shift CNA O - worked day and evening shift LVN P - worked day and evening shift LVN B - worked all shifts ADON E - worked all shifts ADON Q - worked all shifts LVN R - worked day shift An interview with the DON on 07/11/22 at 2:25 PM, revealed her role in the Plan of Removal was to help with interventions and make sure everyone understood the in-service and were treating residents properly. She said if she received a report that a resident was abused, she would tell the nurses to make sure the resident was safe and the person (alleged perpetrator) was no longer with the resident, call the Abuse Coordinator, and speak to the alleged perpetrator to see what was going on. She said she did not know how many times CNA A worked with Resident #1 following the allegation because she was not suspended at the time of the allegation. She said going forward the alleged perpetrator would more than likely be suspended pending investigation. She said she would be using a monitoring tool to ensure allegations of abuse were investigated and reported. She said she did not identify any other allegations of abuse during the plan of removal process. An interview with the Administrator on 07/11/22 at 2:45 PM, revealed his role in the plan of removal was to make sure everything in the plan of removal was executed, and that staff were educated on the in-service prior to the start of their shift. He said if staff discovered an allegation of abuse, they were supposed to tell him immediately and if he was not available, they could tell the DON, SW, and call him again. He said for Resident #1, he did not start the investigation for the allegation of abuse until 07/08/22 and that LVN B should have notified him immediately with the allegation. (Surveyor entered on 07/08/22 and discovered the allegation) The Abuse Coordinator said they did not find any other allegations of abuse during the Plan of Removal process. He said at the time of this interview he spoke with Resident #2 who told him, CNA (A) actually pulled her (Resident #1) into the floor. She (CNA A) was mad because the resident (Resident #1) was difficult to change. CNA D went to get LVN B because he said it looks like she (Resident #1) was hit in the eye and the roommate (Resident #2) told him it was a fall. He said at that point in the investigation it looked like a miscommunication. He said he did not know how many times CNA A worked with Resident #1 following the allegation of abuse, but he could find out. The Administrator was informed that the Immediate Jeopardy was removed on 07/11/22 at 4:15 PM. The facility remained out of compliance at a severity of potential for no actual harm with the potential for more than minimal harm, and a scope of isolated Due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure treatment and care based on the comprehensive assessment and in accordance with standards of practice was provided for 1 (Resident #1) of 4 residents reviewed for change of condition. LVN A failed to properly recognize, assess, or respond when Resident #1 experienced a significant change of condition. Resident #1 was identified has having a gurgling sound coming from his gastrostomy tube, was lethargic, and had a reduce level of responsiveness. Resident #1 had a change of condition for approximately seven hours before he expired in the facility. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan or removal. This failure placed residents at risk for deteriorating health, serious illness and death. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated under Advance Directives that Resident was a full code. Review of Resident 1's admission Minimum Data Sets (MDS), dated [DATE], revealed Resident #1's [DIAGNOSES REDACTED].#1's cognitive skills for daily decision making were severely impaired. The MDS also revealed Resident #1 had an abdominal/nasogastric feeding tube. Review of Resident #1's care plan, dated [DATE] and updated on [DATE], revealed Resident #1 required the use of a feeding tube and was at risk for aspirations. The interventions included to check for tube placement and monitor gastric contents residual volume per facility protocol and d monitor/document/report to the physician as needed for complications related to tube feedings According to the National Institute of Health's [MEDICAL CONDITION] Institute a gastrostomy tube is a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient. Giving food through a gastrostomy tube is a type of enteral nutrition. Accessed on [DATE] from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrostomy-tube Review of Resident #1's nursing documentation revealed the following entries: -[DATE] at 6:04 AM completed by LVN H, revealed Patient is awake and alert and verbally responsive. Skin is warm and dry. Resident noted with episodes of labored breathing this shift. However, vital signs within normal limits, with oxygen saturation at 98% with oxygen 3L/min administered by nasal cannula. Patient does not appear to have labored breathing while sitting up in bed, positioned at 85 degrees. Hence, ensured CNAs kept patient positioned upright for effective breathing and to avoid [DEVICE] aspiration. All scheduled medication has been administered as ordered. Frequent visual monitoring given to resident throughout the shift. Will continue to monitor. - [DATE] at 11:30 PM completed by LVN A., EMTs left facility without giving Nurse time of death for resident .This nurse called 911 x2 before getting an official time . Per (EMS), Resident was pronounced dead at (10:06 PM ). [DATE] at 1:31 AM (Late entry by LVN A): .went to see (Resident #1) to check on resident's feeding .Upon arrival, resident looks pale and clammy .Resident felt cold and clammy . Resident was non responsive Writer called nurse to confirm unresponsiveness of resident .Nurse asked if resident was hospice or full code .Writer said resident was hospice .Writer looked for hospice phone number in chart and called DON .Writer and Nurse discovered resident was a full code Crash cart was taken to (Resident #1's room) .CPR initiated by writer .Nurse called code, called 911 During an interview on [DATE] at 12:31 PM, CNA I stated she worked the 2:00 PM- 10 PM shift on [DATE]. CNA I stated she checked in on Resident #1 between 2:15 PM - 2:30 PM and she noticed a rattling/gurgling noise coming from the resident's mouth that she wasn't used to hearing. CNA I stated when she walked into Resident #1's' room, she noticed his head of his bed was up ,[DATE] degrees. CNA I stated she immediately placed the head of the bed up higher more towards a 90 degree angle. CNA I stated Resident #1 was on a continuous tube feed and the feeding pump was running. CNA I stated she continued to hear the rattling noise coming from Resident #1 and immediately went to get LVN A. She stated she informed LVN A that Resident #1 was making noises that he usually didn't make. CNA I stated LVN A informed her he was probably making the noise because he may have been getting too much formula. CNA I stated both she and LVN A returned to Resident #1's room and LVN A stopped Resident #1's feeding pump. CNA I stated after LVN A stopped the feeding pump, she and LVN A were taking turns going in/out of the Resident #1's room to listen to see if he was still making rattling noises. CNA I stated the sound decreased a little bit over the course of the day but he was still making the rattling/gurgling noise. CNA I stated she provided incontinence care to resident later that day and noticed he didn't urinate very much, and his [MEDICAL CONDITION] bag had remained flat. She stated Resident #1's bag normally didn't stay flat but had some contents in it. CNA I stated she notified LVN A regarding Resident #1's [MEDICAL CONDITION] bag and the gurgling sound decreased but never went away. CNA I stated Resident #1 wasn't arousable but he would usually holler out in pain and that day he didn't. CNA I stated Resident #1 would usually lift his head and make noises but did not that day. CNA I stated sometimes it appeared that Resident #1 was getting too much formula and he would vomit it up but she had never heard him gurgle that way. CNA I stated during the time that Resident #1 was found unresponsive, she was in another resident's room with the door closed and did not hear the code being called. CNA I stated when she exited the other resident's room she noticed LVN A taking the crash cart to Resident '#1's room. During an interview with LVN A on [DATE] at 10:56 AM she stated she had received her nursing license in [DATE] and had been employed with the facility since [DATE]. She stated working at the facility was her first nursing job. LVN A stated that she worked double shifts on the weekends (6 AM- 2 PM and 2 PM-10 PM) and that she was assigned to provide care to Resident #1 during her shifts. LVN A stated on the day that Resident #1 was found unresponsive ([DATE]), CNA I reported to her, around 3:00 PM, that she had heard gurgling noises coming from the resident. LVN A stated that she went to Resident #1's room with CNA I and that she also heard the gurgling but that Resident #1 didn't appear to be in any distress. LVN A stated that because of the gurgling she decided to turn off resident's feeding due to concerns of possible formula coming up from the [DEVICE] into resident's mouth. LVN A stated that she checked on Resident #1 again about an hour and a half later and he wasn't responsive, LVN A clarified by stating that resident was known to not verbally communicate and look off into the ceiling. She stated she noticed some of the formula coming up in the tubing but the gurgling sound had subsided a little. LVN A stated she didn't notify anyone, nor gave a reason as to why she didn't notify anyone regarding the gurgling sound. LVN A stated she checked resident's vital signs and placement of the tubing, by listening over resident's stomach for sounds with her stethoscope, but she did not check resident's residual. LVN A stated once she turned the feeding pump off, she periodically went into Resident #1's room to check on him but she did not restart the feeding pump. LVN A stated that he was still gurgling but each time she went into the room it had lessened more and more. LVN A stated when she checked on him around 5pm/6pm the sound had lessened and once the gurgling stopped she planned on restarting the feeding pump. LVN A stated she walked past Resident #1's room a lot during her shifts and she would poke her head in his room. She stated she noticed his complexion was pale, but it always appeared pale, and he was non-responsive, staring at the ceiling, not making any verbal sounds or noises. LVN A stated she was doing rounds for the evening and she went into his room around 9:00 PM, she touched resident and his face was cold, and his arms were clammy, and resident was staring into space. LVN A stated she didn't have her stethoscope, so she couldn't check for a heartbeat but she checked for his pulse and breathing and that she was unable to find a pulse or respirations. She stated she left Resident #1's room, walked down the hall, and called for assistance from LVN B. LVN A stated LVN B checked Resident #1's pulse, temp, vitals and determined that Resident #1 had expired. LVN A stated she informed LVN B that Resident #1 was on hospice. LVN A stated she wasn't sure about Resident #1's code status, that she hadn't seen anything in resident's chart but assumed he was on hospice and a DNR (Do Not Resuscitate-DNR) due to his deteriorating health, receiving [MEDICAL TREATMENT], [DEVICE] feeding, and not being responsive to people or place. LVN A stated both she and LVN B left Resident #1's room to check for the contact information for the hospice nurse and upon opening resident's chart found that he was a full code. She stated she went to get the crash cart to perform CPR while LVN B called the code and contacted 911 During an interview on [DATE] at 10:19 AM, LVN B stated that on [DATE] she was working on the opposite end of the 200-Hall from LVN A. LVN B stated that she was not informed by LVN A about the gurgling sound that LVN A had heard coming from Resident #01 that day LVN B stated it was towards the end of the shift when LVN A came to her and asked her to come to Resident #1's room with her. LVN B stated that she checked resident's vitals and was unable to get a heartbeat, pulse, or respirations, and thus had pronounced that he had passed. LVN B stated after she arrived at the room, she asked if Resident #1 was on hospice and was informed by LVN A that he was. LVN B stated they left Resident #1's room to check the resident's record to get the hospice nurse's information and they realized the resident was a full code. LVN B stated at that time LVN A went to get the crash cart and initiated CPR while she called the code and contacted 911. LVN B stated she then went to Resident #1's room to assist and nursing staff continued to provide CPR until EMS came. LVN B stated she was not familiar with Resident #1's condition prior to him being found in his bed unresponsive as she wasn't tasked with taking care of him that day. LVN B stated the process for responding to a resident displaying noises such as gurgling who was receiving tube feeding was for nursing to turn off the feeding pump, assess the resident (check for residual) and notify the physician to determine the next step. . LVN A confirmed she did not notify the DON or the physician about Resident #1's change in condition, nor could not provide any reasoning why she didn't make the notifications. During an interview on [DATE] at 1:08 PM, the DON stated Resident #1 was alert and oriented to self, that he did not communicate verbally but that he would nod his head yes/no. DON stated that she was not made aware of Resident #1 gurgling or his change in condition. The DON stated the protocol for a change in patient condition was to assess the resident, notify the doctor, get orders and follow orders from there. She stated if need nurses could contact her to get assistance with assessment of patients. DON stated a change in condition assessment included: listening to lungs and heart, check for turgor [MEDICAL CONDITION] O2 saturations (sats), vitals, elevation of head, aspiration signs for [DEVICE] (gurgling, coughing, spike a temp). She stated nurses were to check residual- and hold feeding and notify the resident's physician when they saw a change in condition with a resident receiving [DEVICE] feeding. DON stated on [DATE] when Resident #1 was found unresponsive she had received a call from LVN A around 9:18 PM and was informed that LVN A went into resident's room and he wasn't responding. The facility's policy titled: A Notification of Changes, dated [DATE], indicated when to communicate acute changes in status to MD, NP, and/Responsible Party .of the following an accident resulting in injury to the resident that potentially requires physician intervention .the need to significantly alter the resident's treatment The facility's policy titled: A Verification of Placement of Feeding Tube policy, dated [DATE], indicated It is the practice of this facility to ensure proper placement of feeding tubes prior to .the facility will monitor resident for complications related to resident's feeding signs and symptoms of respirator distress .gagging, coughing, changes in rate and dept of respirations Immediately stop any feeding .notify immediate physician. The administrator and DON were notified on [DATE] at 5:31 PM that an Immediate Jeopardy was identified. The IJ template was provided to the administrator on [DATE] at 5:31 PM The facility's Plan of Removal was accepted on [DATE] at 2:06 PM and included: Immediate Action: All licensed nurses were educated in the center, in person, on 1) Notification of Change of Condition Policy and 2) Verification of Tube Feeding Policy by DON/designee starting [DATE] and completed [DATE]. No licensed nurse will be allowed to return to work until this education is completed. All licensed nurse completed a skills validation/verification on [DEVICE] that including monitoring for adverse signs and symptoms of [DEVICE]s. This was completed on [DATE] by (DON) and any license nurse that has not completed this skills validation will not be allowed to work until this is completed. Nurse aides were educated in the center, in person, on Notification of Change of Condition Policy by DON/designee starting [DATE]. Knowledge of training will be validated with a post-test. This education was completed on [DATE] and any Nurse aide who has not completed this education will not be allowed to work until this is completed. A Post Test was administered by the DON/designee for all License nurses on Tube feeding and Change of condition at completion of training to validate that nurse can recognize change of condition for residents with [DEVICE]s, and for any resident with a change in condition. New hires (licensed nurses and nurse aides, and PRN staff, will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly. Any licensed nurse, nurse aide or PRN staff, who has not received education on change of condition this in service will not be allowed to work until this is completed. Monitoring: The DON/designee will review and audit of the 24-hour report to monitor for change in resident condition. The DON/designee will sign the 24-hour as verification of review The DON/designee will also complete chart audits/health document assessment as follows: -Three residents weekly for four weeks then; -Two residents weekly for two weeks then; -Two residents a month for two months. The regional/corporate/consultant nurse will visit the facility weekly to provide general oversight and monitoring of the Plan of Removal. Monitoring of the plan of removal included the following: On [DATE] between 2:18 PM and 3:01 PM, individual interviews with four nurses (LVN A, LVN D, LVN J, and LVN K) representing multiple shifts (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m.) revealed they were in-serviced on placement of feeding tubes, documentation regarding tube feeding, Gastrostomy tube site care and changes of condition. Nursing staff stated that they were proficient in [DEVICE] feedings and noticing signs/symptoms of adverse tubing issues. They were able to identify examples of changes of condition. They said they would immediately assess a resident if they noticed a change of condition or if staff notified them of a change of condition. They said if a resident presented with changes of condition, they would assess the resident and call the Physician/NP and responsible party. They said they would document any changes of condition in the resident's clinical record and interventions that were put into place. No concerns were noted during the interviews Review of in-services dated [DATE] and [DATE] revealed nurses and CNA's were in-serviced on changes in condition. The in-service indicated when a nurse noticed a change in condition they were to assess the resident, notify the physician/NP or hospice if indicated, and document mental status changes, vital signs, refusal of medications/meals, and assess skin. The CNA in-service indicated that when a CNA noticed a change in resident condition, that they were to notify the resident's nurse immediately. On [DATE] between 2:18 PM and 3:01 PM, individual interviews with three CNAs (CNA L, CNA M, and CNA M), representing multiple shifts (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., and 10 p.m. to 6 a.m.) revealed they were in-serviced on changes of condition and were able to identify examples of changes of condition. CNAs stated that they would report any changes of condition to the resident's charge nurse immediately. No concerns were noted during the interviews. Review of document titled: Validation Checklist Feeding Tube dated [DATE], revealed that LVN A received training in feeding tube in accordance with facility policy and procedures. Additional review of the document acknowledged validation of competency by DON On [DATE] at 4:07 PM., the Administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan or removal.

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED].#1) of 76 residents reviewed for CPR. LVN A failed to immediately start and continuously provide CPR until the arrival of emergency medical personnel when she determined Resident #1 did not have a pulse or respirations on [DATE]. Due to confusion over Resident # 1's code status CPR was not started until at least 21 minutes after Resident #1 was found without a pulse or respiration. Resident #1 expired at the facility on [DATE]. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] until [DATE]. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. This failure placed residents at risk of not receiving necessary life-saving measures, which could result in death. Findings included: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet revealed Resident #1 was a full code. Review of Resident 1's admission Minimum Data Sets (MDS), dated [DATE], revealed Resident #1's [DIAGNOSES REDACTED].#1's cognitive skills for daily decision making were severely impaired. The MDS also revealed Resident #1 had an abdominal/nasogastric feeding tube. Review of Resident #1's physician orders, dated [DATE], indicated Resident #1 had an order for [REDACTED]. Review of care plan progress note, dated [DATE] and revised [DATE], revealed .Resident has confirmed with PCP that he wishes to maintain a Full Code status . and that Resident #1 was a full code with interventions that included to begin CPR after absence of vital signs, call 911, notify physician and notify family/responsible party. Review of Resident #1's nurses' notes revealed the only entries by LVN A regarding the incident: - [DATE] at 11:30 PM ., EMTs left facility without giving Nurse time of death for resident .This nurse called 911 x2 before getting an official time . Per (EMS), Resident was pronounced dead at (10:06 PM) . [DATE] at 1:31 AM (Late entry after the incident), .went to see (Resident #1) to check on resident's feeding .Upon arrival, resident looks pale and clammy .Resident felt cold and clammy . Resident was non responsive Writer called nurse to confirm unresponsiveness of resident Nurse asked if resident was hospice or full code .Writer said resident was hospice .Writer looked for hospice phone number in chart and called DON .Writer and Nurse discovered resident was a full code Crash cart was taken to (Resident #1's room) .CPR initiated by writer .Nurse called code, called 911 . During an interview with LVN A on [DATE] at 10:56 AM stated that she worked double shifts on the weekends (6 AM- 2 PM and 2 PM-10 PM) and that she was assigned to provide care to Resident #1 during her shifts. LVN A stated on the day that Resident #1 was found unresponsive ([DATE]), CNA I reported to her, around 3:00 PM, that she had heard gurgling noises coming from the resident. LVN A stated that she went to Resident #1's room with CNA I and that she also heard the gurgling but that Resident #1 didn't appear to be in any distress. LVN A stated that because of the gurgling she decided to turn off resident's feeding pump due to concerns of possible formula coming up from the [DEVICE] into resident's mouth. LVN A stated that she checked on Resident #1 again about an hour and a half later and he wasn't responsive. LVN A clarified by stating that resident was known to not verbally communicate and look off into the ceiling. She stated she noticed some of the formula coming up in the tubing but the gurgling sound had subsided a little. LVN A stated she didn't notify anyone, nor gave a reason as to why she didn't notify anyone regarding the gurgling sound. LVN A stated she was doing rounds for the evening and she went into his room around 9:00 PM, she touched resident and his face was cold, and his arms were clammy, and resident was staring into space. LVN A stated she didn't have her stethoscope, so she couldn't check for a heartbeat but she checked for his pulse and breathing, and that she was unable to find a pulse or respirations. She stated she left Resident #1's room, walked down the hall, and called for assistance from LVN B. LVN A stated LVN B checked Resident #1's pulse, temp, vitals and determined that Resident #1 had expired. LVN A stated she informed LVN B that Resident #1 was on hospice. LVN A stated she wasn't sure about Resident #1's code status, that she hadn't seen anything in resident's chart but assumed he was on hospice and a DNR (Do Not Resuscitate-DNR) due to his deteriorating health, receiving [MEDICAL TREATMENT], [DEVICE] feeding, and not being responsive to people or place. LVN A stated that she did not recall getting updates on resident code status during 24-hour nursing report. LVN A stated both she and LVN B left Resident #1's room to check for the contact information for the hospice nurse and upon opening resident's chart found that he was a full code. She stated she went to get the crash cart to perform CPR while LVN B called the code and contacted 911. LVN A stated while performing CPR she noticed something was coming up from Resident's mouth; Resident #1 was still lying at an angle when she began providing CPR. , LVN A stated she had forgotten the facility's protocol for finding a resident unresponsive. She stated upon contacting the DON, she found that she had done the procedure wrong. LVN A stated she believed with Resident #1 being found unresponsive and cold/clammy to touch that he had already passed away and she was unaware that she should have provided and continued to provide CPR. LVN A stated she now understood she should have called someone to find his code status (call code blue). LVNA stated from the time she found him unresponsive and checked his vitals, to starting CPR took approximately 21 minutes. She stated she should have known his code status, not left his side and called for assistance. LVN A stated since Resident #1 had already expired when she entered his room, her intervening would not have changed the outcome even if she had provided CPR quickly. LVN stated that the outcome in delay of providing CPR to a resident could lead to death. LVN A stated she had not had any other residents that were unresponsive since Resident #1 and that she received training regarding code status and providing CPR. LVN A stated she would conduct an assessment, yell for help, and then begin CPR immediately. During an interview on [DATE] at 10:20 AM, LVN B stated that she provided assistance to LVN A on [DATE]. She stated she assessed Resident #1 and was unable to get a heartbeat, pulse, or any respirations. LVN B stated she did not know the resident's code status because she was not Resident #1's nurse. LVN B stated LVN A informed her that Resident #1 was a hospice resident. LVN B stated she and LVN A left the room to go and locate hospice nurse information in Resident #1's chart. Upon reviewing Resident #1's chart, they found that he was a full code. LVN B stated that LVN A went to get the crash cart and began CPR while she called the code and dialed 911. LVN B stated the protocol for an unresponsive resident that was a full code was one person needed to stay with the resident while another staff called the code and 911. She stated if the resident was a hospice resident with a DNR that they were to leave the room and contact the hospice nurse. During an interview on [DATE] at 1:08 PM, the DON stated Resident #1 was alert and oriented to self, that he did not communicate verbally but that he would nod his head yes/no. DON stated her expectation a resident found unresponsive was for staff to call a code and stay in the room with the resident to assess. Once the code was called someone was to come in with the chart, find the code status, provide CPR and contact 911. DON stated the crash cart had code statuses of residents on them. DON stated on [DATE] when Resident #1 was found unresponsive she had received a call from LVN A, around 9:18 PM, and was informed that LVN A went into resident's room and he wasn't responding. The DON stated she asked LVN A if she had called the code and she was informed that LVN A, with the assistance of LVN B, was attempting to find the resident's code status. DON stated she informed LVN A to get off the phone and find resident's status. DON stated when LVN A called her LVN A thought resident was on hospice and a DNR. DON stated she reiterated to LVN A to get off the phone, ensure the correct status and call the code. DON stated that code statuses for all residents were communicated in the 24-hour report and in the resident's chart, as well as information regarding procedural steps as to what to do regarding if a resident was a full code or DNR. DON stated she expected staff to locate a resident's code status within less than a minute. She expected staff to call the code, get the chart, and then if red DNR and if green provide CPR immediately. DON stated that she was not aware that both nurses had left the room and she didn't understand why LVN A needed LVN B to assess behind her. The DON stated she was informed LVN A was not told by anyone nor did she read in Resident #1's chart that he was a hospice patient, but she just assumed he was due to him going in/out of the hospital, receiving [MEDICAL TREATMENT], O2, and being on a feeding tube. Regarding LVN A's failure to understand the appropriate code for the resident, the DON stated the failure could cause resident's to receive a delay in life sustaining measures and possibly die. DON acknowledged that after the incident, that the facility ensured they had copies of all CPR cards for nurses currently certified, set up classes to get those who were not certified, conducted mock code status drills for 2 weeks, provided in-services regarding documentation, and continual education as well to ensure that facility staff were aware of code status, and advance directives Further interview with DON on [DATE] at 1:08 PM revealed two other residents at the facility had coded on [DATE] and [DATE] respectively and nursing staff were able to follow the policy and procedures regarding CPR and code status without incident. The facility's policy titled: A Cardiopulmonary Resuscitation Advanced Directives Policy, dated [DATE] and revised [DATE] indicated: .When a patient is found to be without a heartbeat or respirations by any staff member the patient Medical record must be checked to ensure that the .If there are no Advanced Directives or a Full Code Status the licensed staff will start CPR .CPR will continue until EMS arrives The facility's policy titled A Emergency Management: Identification of Code Status Policy, dated [DATE], indicated: Prior to the arrival of EMS, licensed nursed trained in CPR must provide basic life support .An Advanced Direction chart tab or section at the front of each patient chart is designated to file advance directive, code status . The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ and retrieved on [DATE] reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. The administrator was notified on [DATE] at 5:30 PM that a Past Noncompliance Immediate Jeopardy existed from [DATE] until [DATE]. The facility's action plan to address the deficient practice included the following: All nurses will receive in service on CPR-Advanced Directives Policy, Advance Care Planning and Identification of Code Status with posttest. 100% chart audit of all charts to validate code status of all residents and the code status system by DON/designee. DON/Designee will validate code status paperwork is completed upon admission. Respirations All staff received in service on abuse and neglect, with posttest. Mock drills to be conducted monthly regarding code status and facility policy/procedures regarding CPR DON/Designee will validate CPR certification of all nurses The above in services and validation, as well as posttest, were completed for all staff as of [DATE]. DON/Designee will continue to utilize the Advanced Directive QAPI tool for all new or readmissions to validate that code status system is in place. DON/Designee will continue to utilize QAA audit tool-mock drill privileged document on a monthly basis to ensure nursing staff is knowledgeable about CPR procedures and timelines. Interviews on [DATE] between 11:54 AM and 12:20 PM with staff members representing multiple shifts revealed they had received training in CPR, identification of code status, and the facility's abuse policy. All staff were knowledgeable regarding the facility's protocol for CPR, including staying with the resident, checking code status on the resident chart or the resident code status list on the crash cart, and calling 911). The interviewed staff included LVN C, LVN D, LVN E, LVN F and CNA G. No concerns were noted during the interviews. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] until [DATE]. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation.

Based on interview and record review the facility failed to implement written policies and procedures to prohibit abuse, neglect, and/or misappropriation for four (CNA A, CNA B, CNA C and CNA D) of seven personnel files reviewed for abuse protocol. 1. The facility failed to implement their policies on hiring staff with convictions that bar employment and running annual background checks for CNA [NAME] CNA A was convicted on one assault charge for causing bodily harm/injury to a family member. The arrest date was 07/20/15. The level and degree of the offense was a misdemeanor - class [NAME] An Immediate Jeopardy was identified on 10/10/19. While the Immediate Jeopardy was removed on 10/11/19, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated due to monitoring the implementation of the plan of Removal. 2. The facility failed to search the employee misconduct registry/nurse aide registry (EMR/NAR) annually to determine if staff were employable for CNA A, CNA B, CNA C and CNA D. These failures placed residents at risk of serious adverse outcomes of abuse or neglect and residents being cared for by staff that were not employable. Findings included: Review of the facility's abuse policy, revised 09/13/17, reflected: .Screen potential employees for a history of abuse, neglect, or mistreating residents. This includes attempting to obtain information from previous employers and /or current employers, and checking with the appropriate licensing boards and registries B. Obtain criminal background check. C. Verify with the state licensing authorities that licensed professionals are in good standing with the licensure board. D. Verify with the Nurse Aid Registry and Misconduct Registry for all non-licensed staff, including C.N.A and CMA, that potential employee is not listed on either registry . [NAME] The facility will not employ or otherwise engage individuals who-have been found guilty of abuse, neglect exploitation, misappropriation of property, or mistreatment by a court of law . 1. Review of CNA A's personnel file reflected CNA A was hired on 08/19/18 with a criminal background check dated 08/08/18. The background check reflected CNA A was convicted on one assault charge for causing bodily harm/injury to a family member. The arrest date was 07/20/15. The level and degree of the offense was a misdemeanor - class [NAME] Review of the Penal Code, Chapter 22, Section 22.01, not dated, reflected: (b) A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of: (1) an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony; Interview with the Payroll Coordinator on 10/10/19 at 11:01 AM revealed CNA A had a bar to employment on his criminal background check. The Payroll Coordinator stated he was not aware CNA A had the criminal charge on his background check. Interview with the DON on 10/10/19 at 11:30 AM revealed CNA A was a PRN employee at the facility and he was an active employee in their system. The DON stated criminal background checks were conducted annually. The DON stated she was not aware CNA A had a criminal charge which would bar him from employment. 2. Review of CNA B's personnel file reflected CNA B was hired on 08/19/18 and an EMR/NAR (Employee Misconduct Registry/Nurse Aide Registry) search was completed on 08/08/18 with no negative findings. There was no evidence an EMR/NAR search was completed after 08/08/18 for CNA B. Review of CNA C's personnel file reflected CNA C was hired on 04/06/15 and had an EMR/NAR search completed on 10/13/17, which had no negative findings. There was no evidence an EMR/NAR search was completed after 10/13/17 for CNA C. Review of CNA D's personnel file reflected CNA D was hired on 08/03/15 and had an EMR/NAR search completed on 10/13/17 and 12/10/17, which had no negative findings. There was no evidence an EMR/NAR search was completed after 12/10/17 for CNA D. Interview with the Payroll Coordinator on 10/09/19 at 3:31 PM revealed EMR/NAR checks were completed at the beginning of the year in January. The Payroll Coordinator stated he was not aware EMR/NAR checks were supposed to be completed annually based on the hire date. Interview with the Payroll Coordinator on 10/09/19 at 3:56 PM revealed EMR/NAR checks were out of date for CNA A, CNA B, CNA C and CNA D. He stated there were no EMR/NAR checks for the years (YEAR) or 2019 for CNA C or CNA D. He did not know why the EMR/NAR checks were not completed. Interview with the Administrator on 10/09/19 at 4:14 PM revealed he thought EMR/NAR checks were run annually. An Immediate Jeopardy was identified on 10/10/19. The Administrator, DON and Regional Nurse Consultant were informed of the Immediate Jeopardy on 10/10/19 at 3:45 PM and a Plan or Removal was requested at that time. The facility's Plan of Removal, dated and accepted on 10/11/19 at 2:25 PM, reflected: 1. Immediate action(s) taken for the employee(s) found to have been affected include: CNA A was contacted by Administrator and terminated on 10/10/19. The employee was hired 8/9/18 with a bar to employment and worked for one year until pointed out by the survey team. A new criminal background check was not conducted on his anniversary in accordance to facility policy. 2. Actions taken/systems put into place to reduce the risk of future occurrence include: On 10/10/2019 Payroll Coordinator has conducted a 100% validation of all employee background checks and professional registry checks. The results of the audit were validated by Administrator and documented on an active employee roster. No bars to employment were found. Additionally, any employee identified with a bar to employment will be immediately terminated by the Administrator. The Administrator contacted all contract employee supervisors including Regional Director with Rehab (Rehab company name), Regional Director with (Food Service Company name) and District Director who will conduct criminal background and professional registry checks if applicable immediately. The findings will be submitted to the Administrator who will validate background information submitted via an active employee roster. The audit will commence on 10/10/19 and will conclude 10/11/19. An in-service education program will be conducted by VP of Human Resources for (Company Name) with Payroll Coordinator and all department managers on 10/11/2019 regarding the employee background and registry check system. A post-test will be used for follow up and validation of understanding of the background training. VP of Operations is with the corporate office and is not directly responsible for oversight of facility personnel. An Outlook calendar will be set up month by month to remind the Payroll Coordinator to run the annual employee background and registry checks. The last working day of every month, the Payroll Coordinator will run a hire date list form the scheduling software each month. 3. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator will review all new employee background, employee misconduct registry, and nurse aide registry checks to validate for no bar of employment. The Administrator will monitor corrective actions by using an active employee roster with hire dates monthly. The monthly annual employee background checks are filed in an employee binder. The Administrator will validate employee background checks prior to hire, annually and when an employee is named in a facility investigation. 4. New backgrounds from the facility and all contract employees including Rehab (Company name), (Company Name) and (Food Service Company Name) will be submitted to the Administrator and validated for no bar to employment via active employee roster. If they are unable to provide criminal background checks they will be required to submit dates the background checks were conducted in writing. The annual registry check and criminal background check findings will be submitted to the QAPI Committee by the Payroll Coordinator. The plan of removal will be monitored monthly at the QAPI Committee meeting to validate substantial compliance has been met. Monitoring of the Plan of Removal revealed: Interviews were conducted with the following staff: Administrator, DON and Payroll Coordinator on 10/11/19 from 3:16 PM through 5:07 PM. The staff were able to confirm they had been in-serviced on performing and reviewing background checks of staff upon hire and annually. An Immediate Jeopardy was identified on 10/10/19. While the Immediate Jeopardy was removed on 10/11/19 at 5:18 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated due to monitoring the implementation of the plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of four residents reviewed for inappropriate Hoyer lift transfers. 1. CNA A failed to obtain assistance to complete a mechanical lift transfer for Resident #1 on 05/31/19 as was required by the resident's care plan and the mechanical lift's operation manual. 2. CNA A failed to utilize the appropriate sling for an above-the-knee [MEDICAL CONDITION] during Resident #1's mechanical lift transfer on 05/31/19. As a result of these failures, Resident #1 slid out of the mechanical lift sling during the inappropriate single-person transfer on 05/31/19, hit the back of his head on the railing of his bed, and was sent to the emergency room for evaluation and treatment of [REDACTED]. These failures could affect residents by placing them at risk for serious injuries which could result in a decreased quality of life and physical functioning. Findings include: Review of Resident #1's Face Sheet dated 06/04/19 revealed a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, Section G Functional Status B. Transfer from bed chair. Total Dependence (Full staff performance every time during the entire 7-day period and Two+ persons physical assist. Review of Resident #1's Fall assessment dated [DATE] revealed a score of 17 (High Risk) for falls due to Resident #1's having three or more predisposing diseases present. Review of Resident #1's Pain Flow Assessment records from 03/20/19 revealed the resident did not have any symptoms of pain until 05/31/19 which was a score level 4 (moderate). Review of Resident #1's Care Plans, date initiated 02/05/19, revealed: Transfers: x2 person hoyer lift and falls: anticipate and meet the resident's needs . Review of the Resident Care Tool undated revealed Resident #1 level of asst. staff 2 and lift sling size/color: blue large. Review of Resident #1's Witness Fall Incident Report dated 05/31/19 by LVN C revealed: Incident description: This writer was notified of resident fall in the room during a transfer. Resident found lying down facing up, Hoyer lift and wheelchair next to resident .Immediate Action Taken: Assessed resident head to toe. Resident bleeding copious (large) blood to the occipital area and hematoma noted. Pressure applied to the hematoma area until the bleeding stopped. Bruising and swelling to the left scapular area noted .(emergency services) arrived at 12:50 PM and resident transferred to hospital for further treatment and evaluation .injuries observed: Abrasion of left shoulder and hematoma back of head .Level of Pain: 4 (moderate) . Review of Resident #1's Hospital records dated 05/31/19 revealed: Chief Complaint: Patient presents with a Fall .he was being transferred from bed to wheelchair and was dropped and hit the back of his head on the bed rail .physical exam Head: Normocephalic. Head is with contusion (hematoma to L posterior head) .C collar in place . In an interview on 06/04/19 at 9:56 AM, Resident #2 said around lunch time on 05/31/19, he saw two staff getting Resident #1 ready for an appointment and saw him slide out of the sling. Resident #2 said the staff dropped Resident #1 on his head, while they were transferring him to his wheelchair. Resident #2 said the staff called the paramedics and he heard the paramedics saying Resident #1 probably had a head injury because he was nauseated and had vomited, then the paramedics took Resident #1 to the hospital. In an interview on 06/04/19 at 11:14 AM, ADON [NAME] stated last Friday (05/31/19) CNA A told her she was getting Resident #1, a resident with a left (AKA) above the knee amputation, ready for an appointment. CNA A said HA B was also in the room during Resident #1's transfer and during the process of his hoyer lift transfer from his bed to his wheelchair he fell out of the sling and hit the floor. CNA A reported she had him in the orange Combi - body sling. ADON [NAME] said CNA A should have known (HA) Hospitality Aides were not supposed to assist CNAs, but CNA A asked HA B to assist her with Resident #1's hoyer transfer. ADON [NAME] stated she was not sure why CNA A did not get another CNA, but CNA A told her she felt comfortable with HA B, so she asked her to come into the room for Resident #1's hoyer transfer. In an interview on 06/04/19 at 12:00 PM, CNA A said she had an incident with Resident #1, he had a fall. She said It was like a freakish accident that happened last Friday (05/31/19) around noon before Resident #1 was on his way to an appointment. CNA A said she did not know she could not have a Hospitality Aide help her with a transfer, because the other staff was assisting other residents, so she asked HA B to help spot her. She said she had already changed him before HA B came into the resident's room, the Combi sling was already under him and positioned properly. CNA A said she was raising Resident #1 off the bed and working the hoyer lift and as she lifted him up, while guiding him to the wheelchair and he just fell out of the sling and hit the floor. He bumped his head and had a knot and a small amount of blood, but it was not bleeding profusely. He was talking and not in distress or pain, and he vomited a small amount. CNA A said she transferred Resident #1 properly CNA A said the nurses came to assess him and he went to the hospital. In an interview on 06/04/19 at 12:19 PM, the Administrator said Resident #1 fell last Friday 05/31/19, and the information he got was CNA A transferred Resident #1 in the hoyer lift and he slipped out of the sling and sustained a cut to his head. They sent him out to the hospital for an evaluation. In an interview on 06/04/19 at 5:06 PM, HA B stated last Friday (05/31/19) LVN F said they did not have enough staff that day then a PRN (as needed) CNA A asked her to go in a room to watch her transfer Resident #1. CNA A put the hoyer sling under the resident, who was in a Combi sling and as CNA A turned on the hoyer control button, the resident started sliding out of it. HA B said she saw his leg hanging down, and as soon as the lift started moving, he fell and hit the back of his head. HA B said Resident #1 said his head hurt. and then she saw blood coming from the back of his head. Then they got the nurse and the nurse assessed then sent him to the hospital. In an interview on 06/04/19 at 5:32 PM, CNA A stated the Resident Care tool sheets let direct care staff know whether the residents were incontinent or continent or a 1-person or 2-person Hoyer lift She added she knew Resident #1 required a two-person hoyer transfer. In an interview on 06/05/19 at 9:28 AM, LVN C stated last Friday (05/31/19) Resident #1 was about to go to an appointment around 12:00 PM and CNA A said Resident #1 slid from the hoyer lift sling. She said he had just fallen, and HA B was also in the room. She saw the hoyer lift and Resident #1 was on the floor next to the head of the bed, and his feet were close to the wheelchair and hoyer lift. LVN C said she assessed and checked his vital signs and did not see the blood until she assessed the back of his head and saw his head bleeding and swelling. She said she applied pressure to his head to stop it from bleeding, which was coming out slowly, and once the bleeding was under control she noticed a laceration about two centimeters in length on the back of his head and his left shoulder was bruised and swollen. She kept the towel in place behind his head while he was on his back. He had also vomited before the paramedics came and took him to the hospital. LVN C said for hoyer lift transfers she knew they were supposed to have two staff for safety. In an interview on 06/05/19 at 11:08 AM, CNA D stated Resident #1 was a regular hoyer lift resident who she transferred with a full body sling. They were not supposed to use a Combi sling on an [MEDICAL CONDITION]. If a Combi sling was used, there would not be enough support on the side of the missing limb, and said she was afraid of using the Combi sling for that reason. CNA D said the Combi slings were used for residents who had both limbs but said she did not feel safe using it on them either and did not use the Combi sling at all for any of her group of residents. CNA D said they went by the Resident Care Tool Sheet each aide had to carry with them which told them whether the resident required one or two-person assistance. CNA D said she worked last Friday (05/31/19) and CNA A did not ask her to assist with Resident #1's hoyer lift transfer. CNA D said All hoyer lift transfers are two-person transfers, I had no problems getting a second qualified person and they have enough staff working here. In an interview on 06/06/19 at 10:23 AM, CNA A stated she was educated and would no longer use the Combi sling for Resident #1 but would use the regular full body sling. She said Resident #1 normally used the orange Combi sling, and on 05/31/19 she did not look at the resident care tool sheet to see he was to use the blue large Combi sling. She said from now-on she would check the resident care tool sheet first. She normally did not have a hard time getting a second qualified staff to help her, but on 05/31/19 at around 12:00 PM it was busy, and she was trying to make sure Resident #1 made it to his appointment on time. CNA A said HA B was close enough and she saw her giving ice to another resident. She said she asked HA B, Hey can you come real quick to help me, and HA B said sure. CNA A said she felt really bad about Resident #1 falling. In an interview on 06/06/19 at 1:44 PM, the DON stated Resident #1 fell last Friday (05/31/19). The DON said the orange Combi sling was the one CNA A used that was incorrect, and she should have used the blue colored sling for Resident #1's hoyer lift transfer. She said after Resident #1 fell she spoke to CNA A about her using the wrong sling during Resident #1's hoyer transfer and was unsure why she used the wrong sling. DON said she also spoke to CNA about making sure she had the proper nursing staff for a hoyer transfer by looking at the resident care tool sheet. In an interview on 06/06/19 at 2:34 PM, the Administrator stated he was not at work on 05/31/19 but was aware CNA A did an improper transfer and stated it was tough that it happened and could have been avoided. He said CNA A should have known better because she had been trained in the past when she was hired. Review of the facility's Lifting Procedure Acknowledgement form signed by CNA A and dated 03/27/19 revealed: .3. Give the most support to the heaviest parts of resident's body 4. Hold the resident close to your body for the best support. Use smooth, steady, not jerky motions .7. When using the Hoyer lift, always be sure to have help. Never use the Hoyer lift alone, as it takes two (2) people for safety. Review of Hoyer lift sling user manual dated 12/2018 reflected: .Reusable combi sling Six Strap Reference Guide Lifting bed to chair: .2. Bring padded legs of sling under each leg and up between legs of patient ensuring padded part of sling legs are flat under legs .Warnings: Do not use Combi Sling for above the knee [MEDICAL CONDITION]. Use only in reclined position for those with poor upper body strength. Use correct size at all times. Review of the hoyer lift Series Owner's Manual, dated (YEAR), revealed: General Information - Safety Information: Warning: untrained operators can cause injury or be injured. Permit only trained personnel to operate the lift. Improper operation can cause injury. Operate the lift only as described in this manual. .Lifting a patient: Important: Wrong sling size can allow patients to fall out. Important: Read separate sling user guide for information on selecting, attaching and using lift with slings. Transporting a patient: 2. Have an attendant steady the resident during transport. 3. Move the lift by grasping the push handles and pushing in the desired direction. 6. Slings are supplied with side handles to aid in stabilizing during transporting. Review of the Facility's Job Description of a Hospitality Aide, undated, revealed: To provide non-professional support duties under the supervision of licensed nursing personnel; and to assist in maintaining a position of a physical and psychosocial environment for the residents. Review of the Facility's Job Description of Certified Nursing Aide - CNA dated 09/18/17: General purpose: To provide non-professional direct care duties under the supervision of licensed nursing personnel, and to assist in maintaining a positive physical and psychosocial environment for the residents .Essential Duties and responsibilities: Personal care, nursing care, and food service functions: .Reads and follows daily care plans . Review of the Facility's Hydraulic Lift (Hoyer Lift) policy, undated, revealed: Responsibility: Licensed Nurse and Nursing Assistant Note: Follow Manufacturer Recommendations. Review of the Facility's Fall Management System Policy dated 01/03/17 revealed: Policy - It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs. Review of the Facility's Abuse Policy, revision date 12/05/16 and 09/13/17, revealed: Policy - The resident has the right to be from abuse, neglect. In an interview on 06/04/19 at 12:19 PM, the Administrator said Resident #1 fell last Friday 05/31/19, and the information he got was CNA A transferred Resident #1 in the hoyer lift and he slipped out of the sling and sustained a cut to his head. They sent him out to the hospital for an evaluation. In an interview on 06/04/19 at 5:06 PM, HA B stated last Friday (05/31/19) LVN F said they did not have enough staff that day then a PRN (as needed) CNA A asked her to go in a room to watch her transfer Resident #1. CNA A put the hoyer sling under the resident, who was in a Combi sling and as CNA A turned on the hoyer control button, the resident started sliding out of it. HA B said she saw his leg hanging down, and as soon as the lift started moving, he fell and hit the back of his head. HA B said Resident #1 said his head hurt. and then she saw blood coming from the back of his head. Then they got the nurse and the nurse assessed then sent him to the hospital. In an interview on 06/04/19 at 5:32 PM, CNA A stated the Resident Care tool sheets let direct care staff know whether the residents were incontinent or continent or a 1-person or 2-person Hoyer lift She added she knew Resident #1 required a two-person hoyer transfer. In an interview on 06/05/19 at 9:28 AM, LVN C stated last Friday (05/31/19) Resident #1 was about to go to an appointment around 12:00 PM and CNA A said Resident #1 slid from the hoyer lift sling. She said he had just fallen, and HA B was also in the room. She saw the hoyer lift and Resident #1 was on the floor next to the head of the bed, and his feet were close to the wheelchair and hoyer lift. LVN C said she assessed and checked his vital signs and did not see the blood until she assessed the back of his head and saw his head bleeding and swelling. She said she applied pressure to his head to stop it from bleeding, which was coming out slowly, and once the bleeding was under control she noticed a laceration about two centimeters in length on the back of his head and his left shoulder was bruised and swollen. She kept the towel in place behind his head while he was on his back. He had also vomited before the paramedics came and took him to the hospital. LVN C said for hoyer lift transfers she knew they were supposed to have two staff for safety. In an interview on 06/05/19 at 11:08 AM, CNA D stated Resident #1 was a regular hoyer lift resident who she transferred with a full body sling. They were not supposed to use a Combi sling on an [MEDICAL CONDITION]. If a Combi sling was used, there would not be enough support on the side of the missing limb, and said she was afraid of using the Combi sling for that reason. CNA D said the Combi slings were used for residents who had both limbs but said she did not feel safe using it on them either and did not use the Combi sling at all for any of her group of residents. CNA D said they went by the Resident Care Tool Sheet each aide had to carry with them which told them whether the resident required one or two-person assistance. CNA D said she worked last Friday (05/31/19) and CNA A did not ask her to assist with Resident #1's hoyer lift transfer. CNA D said All hoyer lift transfers are two-person transfers, I had no problems getting a second qualified person and they have enough staff working here. In an interview on 06/06/19 at 10:23 AM, CNA A stated she was educated and would no longer use the Combi sling for Resident #1 but would use the regular full body sling. She said Resident #1 normally used the orange Combi sling, and on 05/31/19 she did not look at the resident care tool sheet to see he was to use the blue large Combi sling. She said from now-on she would check the resident care tool sheet first. She normally did not have a hard time getting a second qualified staff to help her, but on 05/31/19 at around 12:00 PM it was busy, and she was trying to make sure Resident #1 made it to his appointment on time. CNA A said HA B was close enough and she saw her giving ice to another resident. She said she asked HA B, Hey can you come real quick to help me, and HA B said sure. CNA A said she felt really bad about Resident #1 falling. In an interview on 06/06/19 at 1:44 PM, the DON stated Resident #1 fell last Friday (05/31/19). The DON said the orange Combi sling was the one CNA A used that was incorrect, and she should have used the blue colored sling for Resident #1's hoyer lift transfer. She said after Resident #1 fell she spoke to CNA A about her using the wrong sling during Resident #1's hoyer transfer and was unsure why she used the wrong sling. DON said she also spoke to CNA about making sure she had the proper nursing staff for a hoyer transfer by looking at the resident care tool sheet. In an interview on 06/06/19 at 2:34 PM, the Administrator stated he was not at work on 05/31/19 but was aware CNA A did an improper transfer and stated it was tough that it happened and could have been avoided. He said CNA A should have known better because she had been trained in the past when she was hired. Review of the facility's Lifting Procedure Acknowledgement form signed by CNA A and dated 03/27/19 revealed: .3. Give the most support to the heaviest parts of resident's body 4. Hold the resident close to your body for the best support. Use smooth, steady, not jerky motions .7. When using the Hoyer lift, always be sure to have help. Never use the Hoyer lift alone, as it takes two (2) people for safety. Review of Hoyer lift sling user manual dated 12/2018 reflected: .Reusable combi sling Six Strap Reference Guide Lifting bed to chair: .2. Bring padded legs of sling under each leg and up between legs of patient ensuring padded part of sling legs are flat under legs .Warnings: Do not use Combi Sling for above the knee [MEDICAL CONDITION]. Use only in reclined position for those with poor upper body strength. Use correct size at all times. Review of the hoyer lift Series Owner's Manual, dated (YEAR), revealed: General Information - Safety Information: Warning: untrained operators can cause injury or be injured. Permit only trained personnel to operate the lift. Improper operation can cause injury. Operate the lift only as described in this manual. .Lifting a patient: Important: Wrong sling size can allow patients to fall out. Important: Read separate sling user guide for information on selecting, attaching and using lift with slings. Transporting a patient: 2. Have an attendant steady the resident during transport. 3. Move the lift by grasping the push handles and pushing in the desired direction. 6. Slings are supplied with side handles to aid in stabilizing during transporting. Review of the Facility's Job Description of a Hospitality Aide, undated, revealed: To provide non-professional support duties under the supervision of licensed nursing personnel; and to assist in maintaining a position of a physical and psychosocial environment for the residents. Review of the Facility's Job Description of Certified Nursing Aide - CNA dated 09/18/17: General purpose: To provide non-professional direct care duties under the supervision of licensed nursing personnel, and to assist in maintaining a positive physical and psychosocial environment for the residents .Essential Duties and responsibilities: Personal care, nursing care, and food service functions: .Reads and follows daily care plans . Review of the Facility's Hydraulic Lift (Hoyer Lift) policy, undated, revealed: Responsibility: Licensed Nurse and Nursing Assistant Note: Follow Manufacturer Recommendations. Review of the Facility's Fall Management System Policy dated 01/03/17 revealed: Policy - It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs. Review of the Facility's Abuse Policy, revision date 12/05/16 and 09/13/17, revealed: Policy - The resident has the right to be from abuse, neglect.

Based on interview and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical and nursing needs identified in the comprehensive assessment for one (Resident #1) of four residents reviewed for Care Plans. CNA A failed to implement Resident #1's care plan which dictated the resident required a 2 (or more) person transfer with a mechanical lift. As a result, the resident fell during an improper, single-person mechanical lift transfer on 05/31/19, hit the back of his head on the railing of his bed, and was sent to the emergency room for evaluation and treatment of [REDACTED]. This failure placed the residents at risk of not having their individual needs met which could lead to injury. Findings include: Review of Resident #1's Face Sheet dated 06/04/19 revealed a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Section G Functional Status B. Transfer from bed chair. Total Dependence (Full staff performance every time during the entire 7-day period and Two+ persons physical assist. Review of Resident #1's Care Plans with date initiated 02/05/19 revealed: Transfers: x2 person hoyer lift and falls: anticipate and meet the resident's needs . Review of Resident #1's Witness Fall Incident Report dated 05/31/19 by LVN C revealed: Incident description: This writer was notified of resident fall in the room during a transfer. Resident found lying down facing up, Hoyer lift and wheelchair next to resident .Immediate Action Taken: Assessed resident head to toe. Resident bleeding copious (large) blood to the occipital area and hematoma noted. Pressure applied to the hematoma area until the bleeding stopped. Bruising and swelling to the left scapular area noted .(emergency services) arrived at 12:50 PM and resident transferred to hospital for further treatment and evaluation .injuries observed: Abrasion of left shoulder and hematoma back of head .Level of Pain: 4 (moderate) . Review of the Resident Care Tool, undated, revealed: Resident #1 level of asst. staff 2 and lift sling size/color: blue large. In an interview on 06/04/19 at 12:00 PM, CNA A said she had an incident with Resident #1, he had a fall. She said It was like a freakish accident that happened last Friday (05/31/19) around noon before Resident #1 was on his way to an appointment. CNA A said she did not know she could not have a Hospitality Aide help her with a transfer, because the other staff was assisting other residents, so she asked HA B to help spot her. She said she had already changed him before HA B came into the resident's room, the Combi sling was already under him and positioned properly. CNA A said she was raising Resident #1 off the bed and working the hoyer lift and as she lifted him up, while guiding him to the wheelchair and he just fell out of the sling and hit the floor. He bumped his head and had a knot and a small amount of blood, but it was not bleeding profusely. He was talking and not in distress or pain, and he vomited a small amount. CNA A said she transferred Resident #1 properly CNA A said the nurses came to assess him and he went to the hospital. In an interview on 06/04/19 at 5:06 PM, HA B stated last Friday (05/31/19) LVN F said they did not have enough staff that day then a PRN (as needed) CNA A asked her to go in a room to watch her transfer Resident #1. CNA A put the hoyer sling under the resident, who was in a Combi sling and as CNA A turned on the hoyer control button, the resident started sliding out of it. HA B said she saw his leg hanging down, and as soon as the lift started moving, he fell and hit the back of his head. HA B said Resident #1 said his head hurt. and then she saw blood coming from the back of his head. Then they got the nurse and the nurse assessed then sent him to the hospital. In an interview on 06/04/19 at 5:06 PM, HA B stated last Friday (05/31/19) LVN F said they did not have enough staff that day then CNA A asked her to go into the room to watch her transfer Resident #1. CNA A put the hoyer sling under the resident, who was in a Combi sling. HA B said as CNA A turned on the hoyer lift button, the resident started sliding out of the sling. She saw his leg hanging down, and as soon as the lift started moving, he fell and hit the back of his head. Then, they got the nurse. HA B said Resident #1 hit the back of his head and he said his head hurt, then she saw blood coming from the back of his head. The nurse came to assess him, then they sent him to hospital. In an interview on 06/04/19 at 5:32 PM, CNA A stated the Resident Care Tool let staff know whether the residents were incontinent or continent and required 1 person or 2-person assistance with the Hoyer lift. She added she knew Resident #1 was a two-person hoyer transfer, which was why she got HA B. In an interview on 06/05/19 at 9:28 AM, LVN C stated last Friday (05/31/19) Resident #1 was about to go to an appointment around 12:00 PM and CNA A said Resident #1 slid from the hoyer lift sling. She said he had just fallen, and HA B was also in the room and saw the hoyer lift. Resident #1 was on the floor next to the head of the bed, and his feet were close to the wheelchair and hoyer lift. LVN C said she assessed and checked his vitals and did not see the blood until she assessed the back of his head and saw his head bleeding and swelling. LVN C said for hoyer lift transfers she knew there were supposed to have two staff for safety. In an interview on 06/06/19 at 1:44 PM, the DON stated Resident #1 fell last Friday (05/31/19). The DON said the orange sling was the one CNA A used, but she should have used the blue colored sling for Resident #1's hoyer lift transfer. They spoke to CNA A about her using the wrong sling during Resident #1's hoyer transfer and were unsure why she used the wrong sling. The DON stated the Resident Care Tool information was based on the residents' care plans and had the resident's individual ADL needs in a nutshell in a pocket care tool sheet. The CNAs carried the care tools with them in their pockets as a quick reference guide. In an interview on 06/06/19 at 2:34 PM, the Administrator stated he was not at work on 05/31/19 but was aware CNA A did an improper transfer. He said they were in the process of re-training the staff to use the plan of care also known as the pocket care tool sheets for determining the resident's care needs. Review of the Facility's Care Plans and Care Area Assessments (CAA) dated 05/06/16 revealed: Guideline It is the intent of the Corporate Company to meet and abide by all State and Federal regulations that pertain to resident care plans and subsequent Care Area Assessments CAAs completion. Purpose: The purpose of the guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CAT) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident .

Based on observations, interviews, and record reviews, the facility failed to ensure that nurse aides were able to demonstrate competency in skill and techniques necessary to care for the resident's needs, as identified through resident assessments and described in the plan of care for one (Resident #1) of four residents reviewed for nursing services. CNA A failed to demonstrate competency in skills and techniques she had been previously trained in when she did not utilize two qualified staff members to complete a mechanical lift transfer for Resident #1, as was dictated in the resident's care plan and the mechanical lift's user manual. As a result of these failures, Resident #1 slid out of the mechanical lift sling during the inappropriate single-person transfer on 05/31/19, hit the back of his head on the railing of his bed, and was sent to the emergency room for evaluation and treatment of [REDACTED]. This failure has the potential risk of resulting in harm and could decrease the residents' quality of life. Findings include: Review of Resident #1's Face Sheet dated 06/04/19 revealed a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Section G Functional Status B. Transfer from bed chair. Total Dependence (Full staff performance every time during the entire 7-day period and Two+ persons physical assist. Review of Resident #1's Care Plans with date initiated 02/05/19 revealed: Transfers: x2 person hoyer lift and falls: anticipate and meet the resident's needs . Review of Resident #1's Witness Fall Incident Report dated 05/31/19 by LVN C revealed: Incident description: This writer was notified of resident fall in the room during a transfer. Resident found lying down facing up, Hoyer lift and wheelchair next to resident .Immediate Action Taken: Assessed resident head to toe. Resident bleeding copious (large) blood to the occipital area and hematoma noted. Pressure applied to the hematoma area until the bleeding stopped. Bruising and swelling to the left scapular area noted .(emergency services) arrived at 12:50 PM and resident transferred to hospital for further treatment and evaluation .injuries observed: Abrasion of left shoulder and hematoma back of head .Level of Pain: 4 (moderate) . Review of Resident #1's Hospital records dated 05/31/19 revealed: Chief Complaint: Patient presents with a Fall .he was being transferred from bed to wheelchair and was dropped and hit the back of his head on the bed rail .physical exam Head: Normocephalic. Head is with contusion (hematoma to L posterior head) .C collar in place . Review of the Resident Care Tool, undated, revealed: Resident #1 level of asst. staff 2 and lift sling size/color: blue large. In an interview on 06/04/19 at 12:00 PM, CNA A said she had an incident with Resident #1, he had a fall. She said It was like a freakish accident that happened last Friday (05/31/19) around noon before Resident #1 was on his way to an appointment. CNA A said she did not know she could not have a Hospitality Aide help her with a transfer, because the other staff was assisting other residents, so she asked HA B to help spot her. She said she had already changed him before HA B came into the resident's room, the Combi sling was already under him and positioned properly. CNA A said she was raising Resident #1 off the bed and working the hoyer lift and as she lifted him up, while guiding him to the wheelchair and he just fell out of the sling and hit the floor. He bumped his head and had a knot and a small amount of blood, but it was not bleeding profusely. He was talking and not in distress or pain, and he vomited a small amount. CNA A said she transferred Resident #1 properly CNA A said the nurses came to assess him and he went to the hospital. In an interview on 06/04/19 at 5:06 PM, HA B stated last Friday (05/31/19) LVN F said they did not have enough staff that day then a PRN (as needed) CNA A asked her to go in a room to watch her transfer Resident #1. CNA A put the hoyer sling under the resident, who was in a Combi sling and as CNA A turned on the hoyer control button, the resident started sliding out of it. HA B said she saw his leg hanging down, and as soon as the lift started moving, he fell and hit the back of his head. HA B said Resident #1 said his head hurt. and then she saw blood coming from the back of his head. Then they got the nurse and the nurse assessed then sent him to the hospital. In an interview on 06/04/19 at 5:32 PM, CNA A stated the Resident Care Tool sheets let staff know whether the residents were incontinent or continent and required 1 person or 2-person assistance with the Hoyer lift. She added she knew Resident #1 was a two-person hoyer transfer. In an interview on 06/05/19 at 11:08 AM, CNA D said they went by the Resident Care Tool Sheet each aide had to carry with them which told them whether the resident required one or two-person assistance. CNA D said All hoyer lift transfers are two-person transfers, I had no problems getting a second qualified person and they have enough staff working here. In an interview on 06/05/19 at 9:28 AM, LVN C stated last Friday (05/31/19) Resident #1 was about to go to an appointment around 12:00 PM and CNA A said Resident #1 slid from the hoyer lift sling. She said he had just fallen, and HA B was also in the room and saw the hoyer lift. Resident #1 was on the floor next to the head of the bed, and his feet were close to the wheelchair and hoyer lift. LVN C said she assessed and checked his vitals and did not see the blood until she assessed the back of his head and saw his head bleeding and swelling. In an interview on 06/06/19 at 10:23 AM, CNA A stated she was educated and would no longer use the Combi sling for Resident #1 but would instead use the regular full body sling and would ensure she had another CNA or nurse to assist with hoyer transfers. In an interview on 06/06/19 at 1:44 PM, the DON stated Resident #1 fell last Friday (05/31/19). The DON said the orange Combi sling was the one CNA A used that was incorrect, and she should have used the blue colored sling for Resident #1's hoyer lift transfer. She said after Resident #1 fell she spoke to CNA A about her using the wrong sling during Resident #1's hoyer transfer and was unsure why she used the wrong sling. DON said she also spoke to CNA about making sure she had the proper nursing staff for a hoyer transfer by looking at the resident care tool sheet. In an interview on 06/06/19 at 2:34 PM, the Administrator stated he was not at work on 05/31/19 but was aware CNA A did an improper transfer. He said the measures to prevent this type of incident from happening were by re-education of the staff, which they started Friday (05/31/19), skills check with return demonstrations, and in-service training on the proper protocol with handling Hoyer Lifts. The Administrator said Resident #1's fall could have been avoided and CNA A should have known better because she had been trained when she was first hired. And said after Resident #1 fell they re-trained the staff to use the plan of care also known as pocket care tool sheets they were supposed to go by and told them if they needed help they could only seek assistance from another CNA, nurse or medication aide. And if they were not available, they would have to wait until a second person was available. Review of CNA A's employee records revealed she signed on 03/27/19 of being educated on safe hoyer lift transfers. Review of CNA A's Nursing Assistant Skills Review Checklist dated 03/27/19 revealed she was trained by ADON [NAME] on Transfers: body mechanics .1-2 person lifts and ADL Care tracker trainings on 04/03/19. Review of the facility's Lifting Procedure Acknowledgement form signed by CNA A and dated 03/27/19 revealed: .3. Give the most support to the heaviest parts of resident's body 4. Hold the resident close to your body for the best support. Use smooth, steady, not jerky motions .7. When using the Hoyer lift, always be sure to have help. Never use the Hoyer lift alone, as it takes two (2) people for safety. Review of the Facility's Job Description of Certified Nursing Aide - CNA dated 09/18/07 reflected: General purpose: To provide non-professional direct care duties under the supervision of licensed nursing personnel, and to assist in maintaining a positive physical and psychosocial environment for the residents .Essential Duties and responsibilities: Personal care, nursing care, and food service functions: Reads and follows daily care plans .In-service functions: Attend orientation and in-service as required by the state .Staff Development Function: Attend and participate in training, educational activities and staff meetings; assist with orientation and training other staff. Review of the Facility's Hydraulic Lift (Hoyer Lift) policy undated revealed Responsibility: Licensed Nurse and Nursing Assistant .Note: Follow Manufacturer Recommendations.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for incidents and accidents. 1. CNA A failed to obtain assistance to complete a mechanical lift transfer for Resident #1 on 05/31/19 as was required by the resident's care plan and the mechanical lift's operation manual. 2. CNA A failed to utilize the appropriate sling for an above-the-knee [MEDICAL CONDITION] during Resident #1's mechanical lift transfer on 05/31/19. As a result of these failures, Resident #1 slid out of the mechanical lift sling during the inappropriate single-person transfer on 05/31/19, hit the back of his head on the railing of his bed, and was sent to the emergency room for evaluation and treatment of [REDACTED]. This failure placed residents at risk for serious bodily harm or [MEDICATION NAME] physical impairment. Findings include: Review of Resident #1's Face Sheet dated 06/04/19 revealed a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, Section G Functional Status B. Transfer from bed chair. Total Dependence (Full staff performance every time during the entire 7-day period and Two+ persons physical assist. Review of Resident #1's Fall assessment dated [DATE] revealed a score of 17 (High Risk) for falls due to Resident #1 having three or more predisposing diseases present. Review of Resident #1's Pain Flow Assessment records from 03/20/19 revealed the resident did not have any symptoms of pain until 05/31/19 which was a score level 4 (moderate). Review of Resident #1's Care Plans, date initiated 02/05/19, revealed: Transfers: x2 person hoyer lift and falls: anticipate and meet the resident's needs . Review of the Resident Care Tool undated revealed Resident #1 level of asst. staff 2 and lift sling size/color: blue large. Review of Resident #1's Witness Fall Incident Report dated 05/31/19 by LVN C revealed: Incident description: This writer was notified of resident fall in the room during a transfer. Resident found lying down facing up, Hoyer lift and wheelchair next to resident .Immediate Action Taken: Assessed resident head to toe. Resident bleeding copious (large) blood to the occipital area and hematoma noted. Pressure applied to the hematoma area until the bleeding stopped. Bruising and swelling to the left scapular area noted .(emergency services) arrived at 12:50 PM and resident transferred to hospital for further treatment and evaluation .injuries observed: Abrasion of left shoulder and hematoma back of head .Level of Pain: 4 (moderate) . Review of Resident #1's Hospital records dated 05/31/19 revealed: Chief Complaint: Patient presents with a Fall .he was being transferred from bed to wheelchair and was dropped and hit the back of his head on the bed rail .physical exam Head: Normocephalic. Head is with contusion (hematoma to L posterior head) .C collar in place . In an interview on 06/04/19 at 9:56 AM, Resident #2 said around lunch time on 05/31/19, he saw two staff getting Resident #1 ready for an appointment and saw him slide out of the sling. Resident #2 said the staff dropped Resident #1 on his head, while they were transferring him to his wheelchair. Resident #2 said the staff called the paramedics and he heard the paramedics saying Resident #1 probably had a head injury because he was nauseated and had vomited, then the paramedics took Resident #1 to the hospital. In an interview on 06/04/19 at 11:14 AM, ADON [NAME] stated last Friday (05/31/19) CNA A told her she was getting Resident #1, a resident with a left (AKA) above the knee amputation, ready for an appointment. CNA A said HA B was also in the room during Resident #1's transfer and during the process of his hoyer lift transfer from his bed to his wheelchair he fell out of the sling and hit the floor. CNA A reported she had him in the orange Combi - body sling. ADON [NAME] said CNA A should have known (HA) Hospitality Aides were not supposed to assist CNAs, but CNA A asked HA B to assist her with Resident #1's hoyer transfer. ADON [NAME] stated she was not sure why CNA A did not get another CNA, but CNA A told her she felt comfortable with HA B, so she asked her to come into the room for Resident #1's hoyer transfer. In an interview on 06/04/19 at 12:00 PM, CNA A said she had an incident with Resident #1, he had a fall. She said It was like a freakish accident that happened last Friday (05/31/19) around noon before Resident #1 was on his way to an appointment. CNA A said she did not know she could not have a Hospitality Aide help her with a transfer, because the other staff was assisting other residents, so she asked HA B to help spot her. She said she had already changed him before HA B came into the resident's room, the Combi sling was already under him and positioned properly. CNA A said she was raising Resident #1 off the bed and working the hoyer lift and as she lifted him up, while guiding him to the wheelchair and he just fell out of the sling and hit the floor. He bumped his head and had a knot and a small amount of blood, but it was not bleeding profusely. He was talking and not in distress or pain, and he vomited a small amount. CNA A said she transferred Resident #1 properly CNA A said the nurses came to assess him and he went to the hospital. In an interview on 06/04/19 at 12:19 PM, the Administrator said Resident #1 fell last Friday 05/31/19, and the information he received was CNA A transferred Resident #1 in the hoyer lift and he slipped out of the sling and sustained a cut to his head. They sent him out to the hospital for an evaluation. In an interview on 06/04/19 at 5:06 PM, HA B stated last Friday (05/31/19) LVN F said they did not have enough staff that day then a PRN (as needed) CNA A asked her to go in a room to watch her transfer Resident #1. CNA A put the hoyer sling under the resident, who was in a Combi sling and as CNA A turned on the hoyer control button, the resident started sliding out of it. HA B said she saw his leg hanging down, and as soon as the lift started moving, he fell and hit the back of his head. HA B said Resident #1 said his head hurt. and then she saw blood coming from the back of his head. Then they got the nurse and the nurse assessed then sent him to the hospital. In an interview on 06/04/19 at 5:32 PM, CNA A stated the Resident Care tool sheets lets the direct care staff know whether the residents were incontinent or continent or a 1-person or 2-person Hoyer lift She added she knew Resident #1 required a two-person hoyer transfer which was why she got HA B, but CNA A said HA B did not provide care. In an interview on 06/05/19 at 9:28 AM, LVN C stated last Friday (05/31/19) Resident #1 was about to go to an appointment around 12:00 PM and CNA A said Resident #1 slid from the hoyer lift sling. She said he had just fallen, and HA B was also in the room. She saw the hoyer lift and Resident #1 was on the floor next to the head of the bed, and his feet were close to the wheelchair and hoyer lift. LVN C said she assessed and checked his vital signs and did not see the blood until she assessed the back of his head and saw his head bleeding and swelling. She said she applied pressure to his head to stop it from bleeding, which was coming out slowly, and once the bleeding was under control she noticed a laceration about two centimeters in length on the back of his head and his left shoulder was bruised and swollen. She kept the towel in place behind his head while he was on his back. He had also vomited before the paramedics came and took him to the hospital. LVN C said for hoyer lift transfers she knew they were supposed to have two staff for safety. In an interview on 06/05/19 at 11:08 AM, CNA D stated Resident #1 was a regular hoyer lift resident who she transferred with a full body sling. They were not supposed to use a Combi sling on an [MEDICAL CONDITION]. If a Combi sling was used, there would not be enough support on the side of the missing limb, and said she was afraid of using the Combi sling for that reason. CNA D said the Combi slings were used for residents who had both limbs but said she did not feel safe using it on them either and did not use the Combi sling at all for any of her group of residents. CNA D said they went by the Resident Care Tool Sheet each aide had to carry with them which told them whether the resident required one or two-person assistance. CNA D said she worked last Friday (05/31/19) and CNA A did not ask her to assist with Resident #1's hoyer lift transfer. CNA D said All hoyer lift transfers are two-person transfers, I had no problems getting a second qualified person and they have enough staff working here. In an interview on 06/06/19 at 10:23 AM, CNA A stated she was educated and would no longer use the Combi sling for Resident #1 but would use the regular full body sling. She said Resident #1 normally used the orange Combi sling, and on 05/31/19 she did not look at the resident care tool sheet to see he was to use the blue large Combi sling. She said from now-on she would check the resident care tool sheet first. She normally did not have a hard time getting a second qualified staff to help her, but on 05/31/19 at around 12:00 PM it was busy, and she was trying to make sure Resident #1 made it to his appointment on time. CNA A said HA B was close enough and she saw her giving ice to another resident. She said she asked HA B, Hey can you come real quick to help me, and HA B said sure. CNA A said she felt really bad about Resident #1 falling. In an interview on 06/06/19 at 1:44 PM, the DON stated Resident #1 fell last Friday (05/31/19). The DON said the orange Combi sling was the one CNA A used that was incorrect, and she should have used the blue colored sling for Resident #1's hoyer lift transfer. She said after Resident #1 fell she spoke to CNA A about her using the wrong sling during Resident #1's hoyer transfer and was unsure why she used the wrong sling. DON said she also spoke to CNA about making sure she had the proper nursing staff for a hoyer transfer by looking at the resident care tool sheet. In an interview on 06/06/19 at 2:34 PM, the Administrator stated he was not at work on 05/31/19 but was aware CNA A did an improper transfer and stated it was tough that it happened and could have been avoided. He said CNA A should have known better because she had been trained in the past when she was hired. Review of the facility's Lifting Procedure Acknowledgement form signed by CNA A and dated 03/27/19 revealed: .3. Give the most support to the heaviest parts of resident's body 4. Hold the resident close to your body for the best support. Use smooth, steady, not jerky motions .7. When using the Hoyer lift, always be sure to have help. Never use the Hoyer lift alone, as it takes two (2) people for safety. Review of Hoyer lift sling user manual dated 12/2018 reflected: .Reusable combi sling Six Strap Reference Guide Lifting bed to chair: .2. Bring padded legs of sling under each leg and up between legs of patient ensuring padded part of sling legs are flat under legs .Warnings: Do not use Combi Sling for above the knee [MEDICAL CONDITION]. Use only in reclined position for those with poor upper body strength. Use correct size at all times. Review of the hoyer lift Series Owner's Manual, dated (YEAR), revealed: General Information - Safety Information: Warning: untrained operators can cause injury or be injured. Permit only trained personnel to operate the lift. Improper operation can cause injury. Operate the lift only as described in this manual. .Lifting a patient: Important: Wrong sling size can allow patients to fall out. Important: Read separate sling user guide for information on selecting, attaching and using lift with slings. Transporting a patient: 2. Have an attendant steady the resident during transport. 3. Move the lift by grasping the push handles and pushing in the desired direction. 6. Slings are supplied with side handles to aid in stabilizing during transporting. Review of the Facility's Job Description of a Hospitality Aide, undated, revealed: To provide non-professional support duties under the supervision of licensed nursing personnel; and to assist in maintaining a position of a physical and psychosocial environment for the residents. Review of the Facility's Job Description of Certified Nursing Aide - CNA dated 09/18/17: General purpose: To provide non-professional direct care duties under the supervision of licensed nursing personnel, and to assist in maintaining a positive physical and psychosocial environment for the residents .Essential Duties and responsibilities: Personal care, nursing care, and food service functions: .Reads and follows daily care plans . Review of the Facility's Hydraulic Lift (Hoyer Lift) policy, undated, revealed: Responsibility: Licensed Nurse and Nursing Assistant .Note: Follow Manufacturer Recommendations. Review of the Facility's Fall Management System Policy dated 01/03/17 revealed: Policy - It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs. Review of the Facility's Abuse Policy, revision date 12/05/16 and 09/13/17, revealed: Policy - The resident has the right to be from abuse, neglect. Review of the facility's Incident/Accident Policy dated (MONTH) (YEAR) revealed: Policy .Appropriate authorities will be notified in a timely manner for all reportable incidents and accidents .Fundamental Information - Definitions: Incident: an unusual or unexpected event that is not consistent with the routine operation of the facility or the routine care of the resident .This includes incidents that occur involving a resident, visitor, employee, volunteer, or other non-employee .

Based on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit neglect of residents for three (Residents #1, #3, and #4) 14 residents who smoked. 1) Resident #1 had a history of [REDACTED]. Resident #1 sustained three second [MEDICAL CONDITION] she smoked unsupervised with her oxygen tank on her wheelchair and her nasal cannula still in her nose on 01/10/12. The facility continued to allow Resident #1 to smoke with her oxygen tank on her wheelchair. Resident #1 was outside with her oxygen tank on her wheelchair smoking with the assistance of Housekeeper B on 01/26/12. Resident #1 put her extinguished cigarette (half of a cigarette) in her purse after a smoke break. 2) Resident #4 also smoked with her oxygen tank on the back of her wheelchair. 3) Resident #3 was able to retrieve a cigarette from the "smoke box" (a box that contained the smoking paraphernalia) during a supervised smoke break. 4) The facility decided it was safe for residents to smoke with their oxygen tanks on the back of their wheelchairs as long as the tank was turned off. An Immediate Jeopardy (IJ) was identified on 01/26/12 at 4:59 PM. While the IJ was removed on 01/27/12, the facility remained out of compliance at a scope of "pattern" and severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the 14 residents, including Residents #1, #4, and #3, who smoked, by placing them at risk [MEDICAL CONDITION] small flash fires. Findings included: 1) During a confidential interview, a concern was voiced regarding residents who smoked and also used oxygen. The interviewee stated a resident had recently sustained a burn while smoking with oxygen and the resident continued to smoke while the oxygen tank was attached to the wheelchair. The interviewee identified Resident #1 as the resident who sustained the burns. 2) Resident #1's Admission Record dated 03/16/11 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also included the following Diagnoses: [REDACTED]. A Safe Smoking assessment dated [DATE] reflected Resident #1 was able to indicate she understood the facility smoking policy and rules. The assessment reflected she was assessed as a "Safe Smoker." Resident #1's Social Progress Notes dated 09/17/11 reflected, "Resident has been counseled several times by myself and the Administrator. She continues to be seen on the smoking patio with her oxygen tank attached to the back of her wheelchair and smoking. If resident continues her behavior, further action may have to be taken." Resident #1's Social Progress Notes dated 09/20/11 reflected a quarterly assessment. The Notes reflected the resident continued to be active in activities, helped fell ow residents, was very alert and oriented with no mood problems. Further review of the Notes revealed Resident #1 continued to have the behavior of smoking with her oxygen tank attached to her wheelchair. The Social Progress Notes also reflected Resident #1 had breathing difficulties and required oxygen on a daily basis. Resident #1's care plan dated 10/12/11 reflected the resident had oxygen therapy. The goal was for Resident #1 not to have any signs or symptoms of poor oxygen absorption through the review date. One of the interventions on the care plan was for her to have a portable oxygen apparatus. Resident #1's Social Progress Notes dated 10/28/11 reflected, "Resident has been warned numerous times about going outside and smoking with her oxygen tank on...It was explained to resident by myself and administrator that if she is caught outside on the smoking patio with her oxygen tank on even if it is turned off she could or can get a 30 day notice." Resident #1's care plan dated 11/01/11 reflected the resident had a behavior problem of smoking on the patio with her oxygen tank and had been counseled several times and asked not to do that. The care plan reflected the resident continued with the behavior. The goals of the care plan were the resident would have fewer episodes of smoking on the patio with her oxygen tank and would show less signs of behavior. The approaches were to anticipate and meet her needs, explain all procedures before starting and allow resident to adjust to changes, and "If reasonable, discuss resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable." Resident #1's MDS assessment dated [DATE] reflected she was cognitively intact and was able to express her needs. The MDS assessment reflected Resident #1 did not exhibit any behaviors during the assessment period. A review of Resident #1's current physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Resident #1's Nurse's Notes dated 01/10/12 reflected at 9:35 PM the resident was out on the smoking patio and she still had her oxygen on and her nasal cannula caught on fire. The Notes also reflected Resident #1 [MEDICAL CONDITION] her right wrist and a burn to her lateral left ankle. The Notes reflected Resident #1's smoking materials were confiscated. The Notes also reflected the nurse contacted Resident #1's physician's assistant about the injuries. The Notes reflected the physician's assistant ordered [MEDICAL CONDITION] be cleaned with normal saline and apply Silva cream daily and wrap with gauze. The facility's Provider Investigation Report dated 01/11/12 reflected Resident #1 suffered three second [MEDICAL CONDITION] a small flash fire. The Report reflected the resident was outside smoking without staff supervision or staff's knowledge. The Report also reflected, "The only way this could be prevented was if resident would have turned in her cigarettes when they were obtained by an outside source." An interview was conducted with the DON on 01/27/12 at 12:12 PM. The surveyor asked if they had discussed the oxygen and smoking problems, following the incident with Resident #1 when she sustained second degree burns. He said they did and they came to the decision that residents who required oxygen, could still smoke as long as the oxygen was turned off. An interview was conducted with Resident #1 on 01/26/12 at 3:05 PM. The surveyor asked her to explain what happened on the day she sustained her burns. Resident #1 told the surveyor she was out in the smoking area. The resident stated she bent down to extinguish her cigarette on the cement patio. Resident #1 said she then turned around to turn on her oxygen, when the cannula pulled out of her nose and dropped to the ground. She said she believed there was just enough residual oxygen in the tubing and it caught fire. She said CNA D pulled the cannula off her, and as she did, it hit her ankle. 3) A review of Resident #4's Admission Record dated 08/02/11 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record included the following Diagnoses: [REDACTED]. Resident #4's smoking assessment dated [DATE] reflected she was a safe smoker but unable to make decisions regarding tasks of a daily life. Resident #4's MDS assessment dated [DATE] reflected she was cognitively intact and able to express her needs. The assessment reflected Resident #4 did not have any behaviors, during the assessment period. Resident #4's physician's orders [REDACTED]. 4) Resident #3's Smoking assessment dated [DATE] reflected he was determined to be an unsafe smoker. The assessment also reflected Resident #3 needed "Occasional" supervision when he was smoking. An undated handwritten entry on this assessment reflected Resident #3's cigarettes were held by the facility for designated smoking times. A review of Resident #3's Admission Record dated 01/27/12 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. The Admission Record also reflected his original admitted was 12/22/09. Resident #3's MDS assessment dated [DATE] reflected his cognitive skills were moderately impaired, he could make concrete requests and he could respond adequately to simple, direct communication only. The assessment reflected Resident #3 did not have any behaviors during the assessment period. 5) On 01/26/12, the surveyor conducted observations during the 9:00 AM smoke break. Resident #1 was observed to self-propel her wheelchair onto the patio area (the designated smoking area.) A portable oxygen tank (E-tank) was attached to the back of her wheelchair. Resident #1 removed the oxygen tubing from her nose and propelled her wheelchair to a table. The oxygen tank was turned off. Housekeeper B then assisted Resident #1 to a chair at the table at 9:05 AM and positioned her wheelchair approximately fifteen feet from Resident #1. Housekeeper B was then observed to return the wheelchair to Resident #1, who had a lit cigarette between her lips at 9:07 AM. Resident #1 was observed to transfer herself from the chair and back into the wheelchair, while she had a lit cigarette hanging from her lips. Shortly after she transferred herself back into the chair, she was observed to extinguish her cigarette and leave the designated smoking area. At approximately 9:10 AM on 01/26/12, Resident #1 was observed as she propelled her wheelchair past the surveyor. Half of an extinguished cigarette was observed in plain view in the top of her purse. The surveyor asked Resident #1 if there was a reason she had the cigarette in her purse. Resident #1 said she usually only smoked half of the cigarette because she was trying to quit smoking. On 01/26/12 at 9:20 AM during the smoking break, Housekeeper B was observed to step over to assist Resident #2. At the time Housekeeper B was assisting Resident #2, Resident #3 was observed to reach into the box that contained the smoking materials and remove a cigarette. An interview was conducted with Housekeeper B on 01/26/12 at 9:20 AM. The surveyor asked Housekeeper B how Resident #3 was able to obtain the cigarette. Housekeeper B told the surveyor she (Housekeeper B) got distracted. 6) An interview with the AD on 01/26/12 at 10:30 AM revealed the staff member who was supervising the smoke break lit the cigarettes for the residents. She stated it was hard to verify if a resident had a lighter because they did not search residents. She also stated Resident #9 was allowed to keep his pipe because he was upset and did not want to turn it in because he was afraid it would get lost. The AD stated Resident #9 was not allowed to keep tobacco or a lighter. She also stated she was not sure if she should be turning off oxygen tanks. 7) An interview was conducted with Housekeeper E on 01/26/12 at 11:10 AM. He identified himself as the individual who had been assigned to supervise the smoke break on 01/26/12 at 11:00 AM. The surveyor asked him who was responsible for turning off the oxygen when a resident came out to smoke. He said, "The nurses." Housekeeper E said he was in housekeeping and did not know anything about oxygen. Housekeeper E said Resident #4 used oxygen and she came out earlier to smoke. He said he asked her to sit in a regular chair, so the oxygen was not on the chair, but she wanted to sit in her wheelchair. He stated Resident #4 turned off her oxygen, but the oxygen tank was still on her chair. 8) An interview was conducted with Housekeeper B on 01/26/12 at 11:20 AM. The surveyor asked Housekeeper B who was responsible for ensuring the residents' oxygen was turned off before the residents began to smoke. Housekeeper B said she did not mind doing it, but the nurses were supposed to take the oxygen off. Housekeeper B said if the nurses did not turn it off, she would just transfer the resident out of the chair. Housekeeper B stated at that time Resident #4 came out with her oxygen on today, (01/26/12), and she (Housekeeper B) asked Resident #4 if she was supposed to be out in the smoking area with her oxygen. According to Housekeeper B, Resident #4 said she could be out in the smoke area, as long as the oxygen was turned off. Housekeeper B said she checked with the DON and he told her it was okay as long as the oxygen was on zero. Housekeeper B expressed a concern about being responsible for the residents. She said she was not a nurse and even if the tank was on zero, she was afraid the oxygen might still leak out, or the resident might turn it back on. The surveyor asked Housekeeper B to identify residents who smoked. She identified Residents #1, #4 and #5. The surveyor asked Housekeeper B, during this same interview on 01/26/12 at 11:20 AM, if she routinely supervised residents during the smoke break. She said someone else had previously been assigned to supervise the smokers, but she had been assigned the duty at 9:00 AM and 11:00 AM for quite some time. The surveyor asked Housekeeper B if she was aware of any other resident who used oxygen and smoked. She identified Resident #1 and Resident #5. 9) Resident #1 was observed on 01/26/12 at 12:58 PM. Resident #1's oxygen tank was positioned on the back of her wheelchair. Maintenance C held the door open for Resident #1 as she approached the smoking area, with her oxygen tank still on the back of her chair. The AD then entered the smoking area on 01/26/12 at approximately 1:00 PM. Resident #1 remained in her wheelchair with the oxygen on the back of the chair and the AD lit Resident #1's cigarette at that time. The surveyor observed the oxygen tank was turned off and the AD told the surveyor she turned it off. Then the AD came back and had Resident #1 move to a regular chair and the wheelchair was approximately 15 feet away from the resident. Further observation on 01/26/12 at 1:04 PM of the smoke break revealed the AD assisted Resident #1 back into her wheelchair and propelled Resident #1 within 10 feet of another resident who was smoking. 10) An interview with the Social Worker on 01/26/12 at 1:17 PM revealed she was not assigned to supervise the residents with smoking. She stated the Administrator, DON and AD decided the residents could smoke outside with their oxygen tanks turned off. The Social Worker also stated she determined Resident #1 was a safe smoker prior to the incident on 01/10/12. She stated she had not reassessed the smokers since the incident. The Social Worker stated now all the residents were supervised. She stated the smokers needed to be reassessed. When asked if she knew of any other residents with burns, she stated Resident #7 had holes in his pants and now he was a supervised smoker. 11) The Social Worker was observed on 01/26/12 at 2:00 PM. She was standing in front of three H (Helium) tanks and one tank labeled compressed Helium. Staff A was observed smoking a cigarette. Staff A replied, "You caught me." The surveyor asked if there was a reason she was smoking in a non-designated smoking area. Staff A said, "I'm not supposed to be, you just caught me." Ten cigarette butts were observed in a pile on the grass at the corner of the building within 10 feet of the H tanks. 12) An interview with CNA I on 01/26/12 at 2:59 PM revealed she supervised the final smoke break at 9:00 PM. She stated she was to make sure the oxygen tank was at zero before she gave them a cigarette. She stated Resident #1 had oxygen and Resident #5 had oxygen. CNA I stated Resident #4 had her oxygen tank turned off, but the tank was on her wheelchair. 13) An interview was conducted with the Administrator on 01/26/12 at 3:19 PM. The surveyor asked him who was responsible for ensuring the oxygen was turned off before residents smoked. The Administrator said the person assigned to the smoke break and who maintained the smoke box. The surveyor asked the Administrator if he had any concerns about residents who were seated in their wheelchairs and smoking with the oxygen tank still attached to the back of the wheelchair, or within close proximity to the residents. The Administrator said he was not aware of any specific distance requirements and the tanks were to be turned off while smoking. The surveyor asked the Administrator if staff, who were designated as the person responsible to ensure oxygen was turned off, had been trained on how to turn off the oxygen tank. The Administrator said he would not know the answer to that question. The surveyor asked who would have the responsibility to ensure they had been trained. He said ultimately it would be his responsibility, but he would have to trust his staff. During this same interview with the Administrator, he also informed the surveyor the facility determined all residents were required to be supervised during smoking, since the incident occurred on 01/10/12 with Resident #1. 14) A review of the facility's current smoking policy dated December 2011 revealed, "This facility shall provide an environment where residents who smoke may do so safely and shall include safety awareness assessments on admission, quarterly as needed to determine smoking privileges and/or restrictions." The policy reflected, "Smoking restrictions shall be used for the safety and well being of the residents and not for staff convenience. Smoking shall not be allowed at any time in a resident's room, bed, or un-designated areas. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for 'no smoking.' 3. The designated smoking monitor must be able to respond quickly in the event of an emergency and must supervise the smokers throughout the entire smoking period. 4. Residents who smoke shall not be permitted to retain cigarettes, pipes, tobacco, lighters, lighter fluids, and butane gas; other forms for gas or fluids nor matches at any time. 5. Residents assesses (sic) as safe smokers will be allowed to check out smoking material but must smoke only in the facility's designated smoking area. 6. Residents who smoke will be required to sign a smoking contract. Exchange of any type of smoking paraphernalia from resident to resident will not be allowed. Failure to comply can lead up to immediate discharge from the facility...." 15) Review of the facility's current Abuse Prohibition Policy and Procedures dated January 2007 revealed the definition of Neglect was, "A deprivation of life's necessities, of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident." 16) An IJ was identified on 01/26/12 at 4:59 PM in the area of Resident Behavior Facility Practices. The Administrator and the DON were informed at that time. A Plan of Removal was requested at that time. 17) Resident #6's Record of admitted d 01/27/12 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also reflected her [DIAGNOSES REDACTED]. Resident #6's MDS assessment dated [DATE] reflected her cognitive skills were moderately impaired, but she was able to express her needs. The MDS assessment also reflected Resident #6 did not exhibit any behaviors during the assessment period. Resident #6's physician's orders [REDACTED]. Resident #6 was observed on 01/27/12 at 11:06 AM. She was seated in a chair in the designated smoking area. The cigarette she held in her right hand was observed with the ashes extended out and then were observed to drop onto her pajama pants. 18) http://rotech.com/respiratory/documents/STAY_SAFE_WHEN_USING_OXYGEN.pdf, reflected, "Three things are necessary for a fire. First, a combustible material (i.e. something that will burn); secondly, an ignition source (i.e. a spark, flame, or high temperature to get the fire going); and thirdly, oxygen. While oxygen itself is not flammable, oxygen must be present for a fire to occur. When higher concentrations of oxygen are present (such as when using oxygen therapy), the result is: Easier ignition of combustible material Much higher flame temperatures Extremely fast flame spread Thus, when a patient is using oxygen, combustibles that are in close contact with the oxygen (e.g. clothing, oxygen tubing, hair, pillow, blanket, a cigarette) are more prone to catching on fire, and if they ignite, they will burn hotter and the flame will spread faster. To use oxygen safely, maintain a safe distance (at least 15 feet) between all oxygen equipment (including tubing) and any flame or other potential source of ignition. Other potential ignition sources include cook stoves, heating stoves, fireplaces, gas hot water heaters, and candles...." (Retrieved on 02/07/12). 19) Review of the Plan of Removal, dated 01/27/12 and accepted at 4:40 PM revealed: "Immediate Action 1. No O2 (oxygen) tanks will be allowed on the smoking patio. All tanks will be removed from the resident chairs prior to exiting the building by the smoking supervisor or designated monitor effective 01/26/12 at 2100 (9:00 PM). 2. ADONs will monitor each smoke break to ensure that no tanks are on the smoking patio beginning 01/26/12 at 2100 (9:00 PM) and on-going until policy is being complied with and spot checks thereafter. 3. ADONs will monitor smoking supervisors to ensure that all resident are being monitored for safety and that the supervisor is on the patio during the entire smoke break effective 01/26/12 at 2100 (9:00 PM) until the policy is being complied with and spot checks thereafter. 4. SSW will ensure that all smoking assessments on all residents that are smokers. Completed 01/26/12 at 2000 (8:00 PM). 5. SSW will ensure that all smokers will have care plans in place to reflect that they are smokers and require supervision. Completed 01/26/12 at 2000 (8:00 PM). 6. One designated staff member will be assigned to watch the smoking patio and doors to ensure that residents do not attempt to smoke without supervision effective 01/26/12 at 2000 (8:00 PM). 7. All ash trays will be emptied by housekeeping after each smoke break to prevent residents from taking cigarette stubs from the trays effective 01/27/12 at 0930 (9:30 AM). 8. Administration and nursing administration will ensure that all staff will be re-educated on the smoking policy especially in regard to use of O2 while smoking. Beginning 01/26/12 at 2000 (8:00 PM) and completed by 01/30/12 then on-going. 9. All staff will be in-serviced on the reporting of unusual events e.g..[MEDICAL CONDITION] unknown origin to administration. Beginning 01/27/12 and completed by 01/30/12 then on-going. 10. If smoking materials are noted to be in a residents possession the staff nurse will confiscate the materials and place the resident on Q 15 minute checks until administration is available effective 01/27/12 at 1200 (12:00 PM). 11. Smoking schedules will be modified to include the level of supervision required for each resident so that staff will be aware of the residents special needs for supervision. Effective 01/27/12. 12. Smoking policy will be in force immediately and on-going. 13. All staff will be instructed to smoke only in the designated smoking area. Effective 01/27/12. 14. All staff will be in-serviced in the reporting mechanism for unusual occurrences as per #9. The immediate supervisor must be notified then the DON/Administrator or designee will be notified. Beginning 01/27/12 and completed by 01/30/12 then on-going. The appropriate personnel e.g.. DON, Administrator, Social Worker will then assess the resident/situation and determine what actions to take e.g.. appropriate interventions to ensure resident safety while smoking,, (sic) report to regulatory bodies, etc." 20) Interviews after the Plan of Removal was accepted: An interview was conducted with Housekeeper C on 01/28/12 at 10:20 AM. He told the surveyor they were told the doors would be monitored at all times. He stated the housekeeping and laundry staff would no longer be assigned to monitor the residents at smoke break. He said they would be required to empty the ashtrays and ensure no residents had access to any cigarette butts. Housekeeper C also stated the residents would be provided individual approved ashtrays. An interview conducted with LVN G on 01/27/12 at 8:00 PM revealed she worked the night shift. She confirmed she received an inservice that informed staff no resident was to smoke unsupervised. LVN G also stated no resident was to attend smoke break with oxygen in use. She stated they were also instructed to confiscate any smoking material from any resident who was found with smoking paraphernalia in their possession. An interview was conducted with LVN J on 01/28/12 at 11:30 AM. She confirmed she was inserviced regarding residents who smoked. She stated no resident was to attend the smoke break with an oxygen tank. LVN J stated all residents would be supervised. She stated residents who were seen with smoking paraphernalia would have it confiscated. LVN J also stated residents could only smoke at the designated smoking times. An interview was conducted with LVN K on 01/28/12 at 11:58 AM. She identified herself as the weekend nurse who worked 16 hour shifts. She confirmed she was provided an inservice regarding residents who smoked. She said residents could only smoke at the designated times and had to be supervised by the staff. LVN K stated they had a specific person assigned to sit at the doors to ensure no residents smoked at times other than the designated smoking times. She stated staff had to take lighters and cigarettes from the residents if they were seen with them. The DON provided the schedule of specific staff who were assigned to sit at the doors of the designated smoking area for all three shifts. The DON also provided a document which identified each resident who smoked, and the level of supervision they required. An interview was conducted with Resident #8 on 01/28/12 at 12:00 PM.. She informed the surveyor she had to sign a smoking contract and was again informed about the smoking policy. She said that the residents could only smoke with staff supervision and at the designated smoking times. 21) While the IJ was removed on 01/27/12, at 4:40 PM the facility remained out of compliance at a scope of "pattern" and severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. 22) The AD provided a list which identified 14 residents who smoked.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for three (Residents #1, #3, and #4) of 14 residents who smoked. 1) Resident #1 had a history of [REDACTED]. Resident #1 sustained three second [MEDICAL CONDITION] she smoked unsupervised with her oxygen tank on her wheelchair and her nasal cannula still in her nose on 01/10/12. The facility continued to allow Resident #1 to smoke with her oxygen tank on her wheelchair. Resident #1 was outside with her oxygen tank on her wheelchair smoking with the assistance of Housekeeper B on 01/26/12. Resident #1 put her extinguished cigarette (half of a cigarette) in her purse after a smoke break. 2) Resident #4 also smoked with her oxygen tank on the back of her wheelchair. 3) Resident #3 was able to retrieve a cigarette from the "smoke box" (a box that contained the smoking paraphernalia) during a supervised smoke break. 4) The facility decided it was safe for residents to smoke with their oxygen tanks on the back of their wheelchairs as long as the tank was turned off. 5) The Social Worker was smoking in front of Helium tanks which was a prohibited smoking area. An Immediate Jeopardy (IJ) was identified on 01/26/12 at 4:59 PM. While the IJ was removed on 01/27/12, the facility remained out of compliance at a scope of "pattern" and severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the 14 residents, including Residents #1, #4, and #3, who smoked, by placing them at risk [MEDICAL CONDITION] small flash fires. Findings included: 1) Review of the facility's current Abuse Prohibition Policy and Procedures dated January 2007 revealed the definition of Neglect was, "A deprivation of life's necessities, of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident." 2) During a confidential interview, a concern was voiced regarding residents who smoked and also used oxygen. The interviewee stated a resident had recently sustained a burn while smoking with oxygen and the resident continued to smoke while the oxygen tank was attached to the wheelchair. The interviewee identified Resident #1 as the resident who sustained the burns. 3) Resident #1's Admission Record dated 03/16/11 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also included the following Diagnoses: [REDACTED]. A Safe Smoking assessment dated [DATE] reflected Resident #1 was able to indicate she understood the facility smoking policy and rules. The assessment reflected she was assessed as a "Safe Smoker." Resident #1's Social Progress Notes dated 09/17/11 reflected, "Resident has been counseled several times by myself and the Administrator. She continues to be seen on the smoking patio with her oxygen tank attached to the back of her wheelchair and smoking. If resident continues her behavior, further action may have to be taken." Resident #1's Social Progress Notes dated 09/20/11 reflected a quarterly assessment. The Notes reflected the resident continued to be active in activities, helped fell ow residents, was very alert and oriented with no mood problems. Further review of the Notes revealed Resident #1 continued to have the behavior of smoking with her oxygen tank attached to her wheelchair. The Social Progress Notes also reflected Resident #1 had breathing difficulties and required oxygen on a daily basis. Resident #1's care plan dated 10/12/11 reflected the resident had oxygen therapy. The goal was for Resident #1 not to have any signs or symptoms of poor oxygen absorption through the review date. One of the interventions on the care plan was for her to have a portable oxygen apparatus. Resident #1's Social Progress Notes dated 10/28/11 reflected, "Resident has been warned numerous times about going outside and smoking with her oxygen tank on...It was explained to resident by myself and administrator that if she is caught outside on the smoking patio with her oxygen tank on even if it is turned off she could or can get a 30 day notice." Resident #1's care plan dated 11/01/11 reflected the resident had a behavior problem of smoking on the patio with her oxygen tank and had been counseled several times and asked not to do that. The care plan reflected the resident continued with the behavior. The goals of the care plan were the resident would have fewer episodes of smoking on the patio with her oxygen tank and would show less signs of behavior. The approaches were to anticipate and meet her needs, explain all procedures before starting and allow resident to adjust to changes, and "If reasonable, discuss resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable." Resident #1's MDS assessment dated [DATE] reflected she was cognitively intact and was able to express her needs. The MDS assessment reflected Resident #1 did not exhibit any behaviors during the assessment period. A review of Resident #1's current physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Resident #1's Nurse's Notes dated 01/10/12 reflected at 9:35 PM the resident was out on the smoking patio and she still had her oxygen on and her nasal cannula caught on fire. The Notes also reflected Resident #1 [MEDICAL CONDITION] her right wrist and a burn to her lateral left ankle. The Notes reflected Resident #1's smoking materials were confiscated. The Notes also reflected the nurse contacted Resident #1's physician's assistant about the injuries. The Notes reflected the physician's assistant ordered [MEDICAL CONDITION] be cleaned with normal saline and apply Silva cream daily and wrap with gauze. The facility's Provider Investigation Report dated 01/11/12 reflected Resident #1 suffered three second [MEDICAL CONDITION] a small flash fire. The Report reflected the resident was outside smoking without staff supervision or staff's knowledge. The Report also reflected, "The only way this could be prevented was if resident would have turned in her cigarettes when they were obtained by an outside source." An interview was conducted with the DON on 01/27/12 at 12:12 PM. The surveyor asked if they had discussed the oxygen and smoking problems, following the incident with Resident #1 when she sustained second degree burns. He said they did and they came to the decision that residents who required oxygen, could still smoke as long as the oxygen was turned off. An interview was conducted with Resident #1 on 01/26/12 at 3:05 PM. The surveyor asked her to explain what happened on the day she sustained her burns. Resident #1 told the surveyor she was out in the smoking area. The resident stated she bent down to extinguish her cigarette on the cement patio. Resident #1 said she then turned around to turn on her oxygen, when the cannula pulled out of her nose and dropped to the ground. She said she believed there was just enough residual oxygen in the tubing and it caught fire. She said CNA D pulled the cannula off her, and as she did, it hit her ankle. 4) A review of Resident #4's Admission Record dated 08/02/11 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record included the following Diagnoses: [REDACTED]. Resident #4's smoking assessment dated [DATE] reflected she was a safe smoker but unable to make decisions regarding tasks of a daily life. Resident #4's MDS assessment dated [DATE] reflected she was cognitively intact and able to express her needs. The assessment reflected Resident #4 did not have any behaviors, during the assessment period. Resident #4's physician's orders [REDACTED]. 5) Resident #3's Smoking assessment dated [DATE] reflected he was determined to be an unsafe smoker. The assessment also reflected Resident #3 needed "Occasional" supervision when he was smoking. An undated handwritten entry on this assessment reflected Resident #3's cigarettes were held by the facility for designated smoking times. A review of Resident #3's Admission Record dated 01/27/12 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. The Admission Record also reflected his original admitted was 12/22/09. Resident #3's MDS assessment dated [DATE] reflected his cognitive skills were moderately impaired, he could make concrete requests and he could respond adequately to simple, direct communication only. The assessment reflected Resident #3 did not have any behaviors during the assessment period. 6) On 01/26/12, the surveyor conducted observations during the 9:00 AM smoke break. Resident #1 was observed to self-propel her wheelchair onto the patio area (the designated smoking area.) A portable oxygen tank (E-tank) was attached to the back of her wheelchair. Resident #1 removed the oxygen tubing from her nose and propelled her wheelchair to a table. The oxygen tank was turned off. Housekeeper B then assisted Resident #1 to a chair at the table at 9:05 AM and positioned her wheelchair approximately fifteen feet from Resident #1. Housekeeper B was then observed to return the wheelchair to Resident #1, who had a lit cigarette between her lips at 9:07 AM. Resident #1 was observed to transfer herself from the chair and back into the wheelchair, while she had a lit cigarette hanging from her lips. Shortly after she transferred herself back into the chair, she was observed to extinguish her cigarette and leave the designated smoking area. At approximately 9:10 AM on 01/26/12, Resident #1 was observed as she propelled her wheelchair past the surveyor. Half of an extinguished cigarette was observed in plain view in the top of her purse. The surveyor asked Resident #1 if there was a reason she had the cigarette in her purse. Resident #1 said she usually only smoked half of the cigarette because she was trying to quit smoking. On 01/26/12 at 9:20 AM during the smoking break, Housekeeper B was observed to step over to assist Resident #2. At the time Housekeeper B was assisting Resident #2, Resident #3 was observed to reach into the box that contained the smoking materials and remove a cigarette. An interview was conducted with Housekeeper B on 01/26/12 at 9:20 AM. The surveyor asked Housekeeper B how Resident #3 was able to obtain the cigarette. Housekeeper B told the surveyor she (Housekeeper B) got distracted. 7) An interview with the AD on 01/26/12 at 10:30 AM revealed the staff member who was supervising the smoke break lit the cigarettes for the residents. She stated it was hard to verify if a resident had a lighter because they did not search residents. She also stated Resident #9 was allowed to keep his pipe because he was upset and did not want to turn it in because he was afraid it would get lost. The AD stated Resident #9 was not allowed to keep tobacco or a lighter. She also stated she was not sure if she should be turning off oxygen tanks. 8) An interview was conducted with Housekeeper E on 01/26/12 at 11:10 AM. He identified himself as the individual who had been assigned to supervise the smoke break on 01/26/12 at 11:00 AM. The surveyor asked him who was responsible for turning off the oxygen when a resident came out to smoke. He said, "The nurses." Housekeeper E said he was in housekeeping and did not know anything about oxygen. Housekeeper E said Resident #4 used oxygen and she came out earlier to smoke. He said he asked her to sit in a regular chair, so the oxygen was not on the chair, but she wanted to sit in her wheelchair. He stated Resident #4 turned off her oxygen, but the oxygen tank was still on her chair. 9) An interview was conducted with Housekeeper B on 01/26/12 at 11:20 AM. The surveyor asked Housekeeper B who was responsible for ensuring the residents' oxygen was turned off before the residents began to smoke. Housekeeper B said she did not mind doing it, but the nurses were supposed to take the oxygen off. Housekeeper B said if the nurses did not turn it off, she would just transfer the resident out of the chair. Housekeeper B stated at that time Resident #4 came out with her oxygen on today, (01/26/12), and she (Housekeeper B) asked Resident #4 if she was supposed to be out in the smoking area with her oxygen. According to Housekeeper B, Resident #4 said she could be out in the smoke area, as long as the oxygen was turned off. Housekeeper B said she checked with the DON and he told her it was okay as long as the oxygen was on zero. Housekeeper B expressed a concern about being responsible for the residents. She said she was not a nurse and even if the tank was on zero, she was afraid the oxygen might still leak out, or the resident might turn it back on. The surveyor asked Housekeeper B to identify residents who smoked. She identified Residents #1, #4 and #5. The surveyor asked Housekeeper B, during this same interview on 01/26/12 at 11:20 AM, if she routinely supervised residents during the smoke break. She said someone else had previously been assigned to supervise the smokers, but she had been assigned the duty at 9:00 AM and 11:00 AM for quite some time. The surveyor asked Housekeeper B if she was aware of any other resident who used oxygen and smoked. She identified Resident #1 and Resident #5. 10) Resident #1 was observed on 01/26/12 at 12:58 PM. Resident #1's oxygen tank was positioned on the back of her wheelchair. Maintenance C held the door open for Resident #1 as she approached the smoking area, with her oxygen tank still on the back of her chair. The AD then entered the smoking area on 01/26/12 at approximately 1:00 PM. Resident #1 remained in her wheelchair with the oxygen on the back of the chair and the AD lit Resident #1's cigarette at that time. The surveyor observed the oxygen tank was turned off and the AD told the surveyor she turned it off. Then the AD came back and had Resident #1 move to a regular chair and the wheelchair was approximately 15 feet away from the resident. Further observation on 01/26/12 at 1:04 PM of the smoke break revealed the AD assisted Resident #1 back into her wheelchair and propelled Resident #1 within 10 feet of another resident who was smoking. 11) An interview with the Social Worker on 01/26/12 at 1:17 PM revealed she was not assigned to supervise the residents with smoking. She stated the Administrator, DON and AD decided the residents could smoke outside with their oxygen tanks turned off. The Social Worker also stated she determined Resident #1 was a safe smoker prior to the incident on 01/10/12. She stated she had not reassessed the smokers since the incident. The Social Worker stated now all the residents were supervised. She stated the smokers needed to be reassessed. When asked if she knew of any other residents with burns, she stated Resident #7 had holes in his pants and now he was a supervised smoker. 12) The Social Worker was observed on 01/26/12 at 2:00 PM. She was standing in front of three H (Helium) tanks and one tank labeled compressed Helium. Staff A was observed smoking a cigarette. Staff A replied, "You caught me." The surveyor asked if there was a reason she was smoking in a non-designated smoking area. Staff A said, "I'm not supposed to be, you just caught me." Ten cigarette butts were observed in a pile on the grass at the corner of the building within 10 feet of the H tanks. 13) An interview with CNA I on 01/26/12 at 2:59 PM revealed she supervised the final smoke break at 9:00 PM. She stated she was to make sure the oxygen tank was at zero before she gave them a cigarette. She stated Resident #1 had oxygen and Resident #5 had oxygen. CNA I stated Resident #4 had her oxygen tank turned off, but the tank was on her wheelchair. 14) An interview was conducted with the Administrator on 01/26/12 at 3:19 PM. The surveyor asked him who was responsible for ensuring the oxygen was turned off before residents smoked. The Administrator said the person assigned to the smoke break and who maintained the smoke box. The surveyor asked the Administrator if he had any concerns about residents who were seated in their wheelchairs and smoking with the oxygen tank still attached to the back of the wheelchair, or within close proximity to the residents. The Administrator said he was not aware of any specific distance requirements and the tanks were to be turned off while smoking. The surveyor asked the Administrator if staff, who were designated as the person responsible to ensure oxygen was turned off, had been trained on how to turn off the oxygen tank. The Administrator said he would not know the answer to that question. The surveyor asked who would have the responsibility to ensure they had been trained. He said ultimately it would be his responsibility, but he would have to trust his staff. During this same interview with the Administrator, he also informed the surveyor the facility determined all residents were required to be supervised during smoking, since the incident occurred on 01/10/12 with Resident #1. 15) A review of the facility's current smoking policy dated December 2011 revealed, "This facility shall provide an environment where residents who smoke may do so safely and shall include safety awareness assessments on admission, quarterly as needed to determine smoking privileges and/or restrictions." The policy reflected, "Smoking restrictions shall be used for the safety and well being of the residents and not for staff convenience. Smoking shall not be allowed at any time in a resident's room, bed, or un-designated areas. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for 'no smoking.' 3. The designated smoking monitor must be able to respond quickly in the event of an emergency and must supervise the smokers throughout the entire smoking period. 4. Residents who smoke shall not be permitted to retain cigarettes, pipes, tobacco, lighters, lighter fluids, and butane gas; other forms for gas or fluids nor matches at any time. 5. Residents assesses (sic) as safe smokers will be allowed to check out smoking material but must smoke only in the facility's designated smoking area. 6. Residents who smoke will be required to sign a smoking contract. Exchange of any type of smoking paraphernalia from resident to resident will not be allowed. Failure to comply can lead up to immediate discharge from the facility...." 16) An IJ was identified on 01/26/12 at 4:59 PM in the area of Resident Behavior Facility Practices. The Administrator and the DON were informed at that time. A Plan of Removal was requested at that time. 17) Resident #6's Record of admitted d 01/27/12 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also reflected her [DIAGNOSES REDACTED]. Resident #6's MDS assessment dated [DATE] reflected her cognitive skills were moderately impaired, but she was able to express her needs. The MDS assessment also reflected Resident #6 did not exhibit any behaviors during the assessment period. Resident #6's physician's orders [REDACTED]. Resident #6 was observed on 01/27/12 at 11:06 AM. She was seated in a chair in the designated smoking area. The cigarette she held in her right hand was observed with the ashes extended out and then were observed to drop onto her pajama pants. 18) http://rotech.com/respiratory/documents/STAY_SAFE_WHEN_USING_OXYGEN.pdf, reflected, "Three things are necessary for a fire. First, a combustible material (i.e. something that will burn); secondly, an ignition source (i.e. a spark, flame, or high temperature to get the fire going); and thirdly, oxygen. While oxygen itself is not flammable, oxygen must be present for a fire to occur. When higher concentrations of oxygen are present (such as when using oxygen therapy), the result is: Easier ignition of combustible material Much higher flame temperatures Extremely fast flame spread Thus, when a patient is using oxygen, combustibles that are in close contact with the oxygen (e.g. clothing, oxygen tubing, hair, pillow, blanket, a cigarette) are more prone to catching on fire, and if they ignite, they will burn hotter and the flame will spread faster. To use oxygen safely, maintain a safe distance (at least 15 feet) between all oxygen equipment (including tubing) and any flame or other potential source of ignition. Other potential ignition sources include cook stoves, heating stoves, fireplaces, gas hot water heaters, and candles...." (Retrieved on 02/07/12). 19) Review of the Plan of Removal, dated 01/27/12 and accepted at 4:40 PM revealed: "Immediate Action 1. No O2 (oxygen) tanks will be allowed on the smoking patio. All tanks will be removed from the resident chairs prior to exiting the building by the smoking supervisor or designated monitor effective 01/26/12 at 2100 (9:00 PM). 2. ADONs will monitor each smoke break to ensure that no tanks are on the smoking patio beginning 01/26/12 at 2100 (9:00 PM) and on-going until policy is being complied with and spot checks thereafter. 3. ADONs will monitor smoking supervisors to ensure that all resident are being monitored for safety and that the supervisor is on the patio during the entire smoke break effective 01/26/12 at 2100 (9:00 PM) until the policy is being complied with and spot checks thereafter. 4. SSW will ensure that all smoking assessments on all residents that are smokers. Completed 01/26/12 at 2000 (8:00 PM). 5. SSW will ensure that all smokers will have care plans in place to reflect that they are smokers and require supervision. Completed 01/26/12 at 2000 (8:00 PM). 6. One designated staff member will be assigned to watch the smoking patio and doors to ensure that residents do not attempt to smoke without supervision effective 01/26/12 at 2000 (8:00 PM). 7. All ash trays will be emptied by housekeeping after each smoke break to prevent residents from taking cigarette stubs from the trays effective 01/27/12 at 0930 (9:30 AM). 8. Administration and nursing administration will ensure that all staff will be re-educated on the smoking policy especially in regard to use of O2 while smoking. Beginning 01/26/12 at 2000 (8:00 PM) and completed by 01/30/12 then on-going. 9. All staff will be in-serviced on the reporting of unusual events e.g..[MEDICAL CONDITION] unknown origin to administration. Beginning 01/27/12 and completed by 01/30/12 then on-going. 10. If smoking materials are noted to be in a residents possession the staff nurse will confiscate the materials and place the resident on Q 15 minute checks until administration is available effective 01/27/12 at 1200 (12:00 PM). 11. Smoking schedules will be modified to include the level of supervision required for each resident so that staff will be aware of the residents special needs for supervision. Effective 01/27/12. 12. Smoking policy will be in force immediately and on-going. 13. All staff will be instructed to smoke only in the designated smoking area. Effective 01/27/12. 14. All staff will be in-serviced in the reporting mechanism for unusual occurrences as per #9. The immediate supervisor must be notified then the DON/Administrator or designee will be notified. Beginning 01/27/12 and completed by 01/30/12 then on-going. The appropriate personnel e.g.. DON, Administrator, Social Worker will then assess the resident/situation and determine what actions to take e.g.. appropriate interventions to ensure resident safety while smoking,, (sic) report to regulatory bodies, etc." 20) Interviews after the Plan of Removal was accepted: An interview was conducted with Housekeeper C on 01/28/12 at 10:20 AM. He told the surveyor they were told the doors would be monitored at all times. He stated the housekeeping and laundry staff would no longer be assigned to monitor the residents at smoke break. He said they would be required to empty the ashtrays and ensure no residents had access to any cigarette butts. Housekeeper C also stated the residents would be provided individual approved ashtrays. An interview conducted with LVN G on 01/27/12 at 8:00 PM revealed she worked the night shift. She confirmed she received an inservice that informed staff no resident was to smoke unsupervised. LVN G also stated no resident was to attend smoke break with oxygen in use. She stated they were also instructed to confiscate any smoking material from any resident who was found with smoking paraphernalia in their possession. An interview was conducted with LVN J on 01/28/12 at 11:30 AM. She confirmed she was inserviced regarding residents who smoked. She stated no resident was to attend the smoke break with an oxygen tank. LVN J stated all residents would be supervised. She stated residents who were seen with smoking paraphernalia would have it confiscated. LVN J also stated residents could only smoke at the designated smoking times. An interview was conducted with LVN K on 01/28/12 at 11:58 AM. She identified herself as the weekend nurse who worked 16 hour shifts. She confirmed she was provided an inservice regarding residents who smoked. She said residents could only smoke at the designated times and had to be supervised by the staff. LVN K stated they had a specific person assigned to sit at the doors to ensure no residents smoked at times other than the designated smoking times. She stated staff had to take lighters and cigarettes from the residents if they were seen with them. The DON provided the schedule of specific staff who were assigned to sit at the doors of the designated smoking area for all three shifts. The DON also provided a document which identified each resident who smoked, and the level of supervision they required. An interview was conducted with Resident #8 on 01/28/12 at 12:00 PM.. She informed the surveyor she had to sign a smoking contract and was again informed about the smoking policy. She said that the residents could only smoke with staff supervision and at the designated smoking times. 21) While the IJ was removed on 01/27/12, at 4:40 PM the facility remained out of compliance at a scope of "pattern" and severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. 22) The AD provided a list which identified 14 residents who smoked.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for three (Residents #1, #3, and #4) of 14 residents who smoked. 1) Resident #1 had a history of [REDACTED]. On 01/10/12, Resident #1 was smoking unsupervised with her oxygen nasal cannula in her nose, and her oxygen tank on her wheelchair. Resident suffered three second degree burns from a flash fire. The facility continued to allow Resident #1 continued to smoke with her oxygen tank on her wheelchair. Resident #1 put her extinguished cigarette (half of a cigarette) in her purse after a smoke break. 2) Resident #4 also smoked with her oxygen tank on the back of her wheelchair. 3) Resident #3 was able to retrieve a cigarette from the "smoke box" (a box that contained the smoking paraphernalia) during a supervised smoke break. 4) The Social Worker was smoking in front of Helium tanks which was an area that prohibited smoking. An Immediate Jeopardy (IJ) was identified on 01/26/12. While the IJ was removed on 01/27/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because the facility was still monitoring the Plan of Removal. These failures could affect the 14 residents, including Residents #1 and #4, who smoked, by placing them at risk for flash fires and burns. Findings included: 1) During a confidential interview, a concern was voiced regarding residents who smoked and also used oxygen. The interviewee stated a resident had recently sustained a burn while smoking with oxygen and the resident continued to smoke while the oxygen tank was attached to the wheelchair. The interviewee identified Resident #1 as the resident who sustained the burns. 2) Resident #1's Admission Record dated 03/16/11 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also included the following Diagnoses: [REDACTED]. A Safe Smoking assessment dated [DATE] reflected Resident #1 was able to indicate she understood the facility smoking policy and rules. The assessment reflected she was assessed as a "Safe Smoker." Resident #1's Social Progress Notes dated 09/17/11 reflected, "Resident has been counseled several times by myself and the Administrator. She continues to be seen on the smoking patio with her oxygen tank attached to the back of her wheelchair and smoking. If resident continues her behavior, further action may have to be taken." Resident #1's Social Progress Notes dated 09/20/11 reflected a quarterly assessment. The Notes reflected the resident continued to be active in activities, helped fell ow residents, was very alert and oriented with no mood problems. Further review of the Notes revealed Resident #1 continued to have the behavior of smoking with her oxygen tank attached to her wheelchair. The Social Progress Notes also reflected Resident #1 had breathing difficulties and required oxygen on a daily basis. Resident #1's care plan dated 10/12/11 reflected the resident had oxygen therapy. The goal was for Resident #1 not to have any signs or symptoms of poor oxygen absorption through the review date. One of the interventions on the care plan was for her to have a portable oxygen apparatus. Resident #1's Social Progress Notes dated 10/28/11 reflected, "Resident has been warned numerous times about going outside and smoking with her oxygen tank on...It was explained to resident by myself and administrator that if she is caught outside on the smoking patio with her oxygen tank on even if it is turned off she could or can get a 30 day notice." Resident #1's care plan dated 11/01/11 reflected the resident had a behavior problem of smoking on the patio with her oxygen tank and had been counseled several times and asked not to do that. The care plan reflected the resident continued with the behavior. The goals of the care plan were the resident would have fewer episodes of smoking on the patio with her oxygen tank and would show less signs of behavior. The approaches were to anticipate and meet her needs, explain all procedures before starting and allow resident to adjust to changes, and "If reasonable, discuss resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable." Resident #1's MDS assessment dated [DATE] reflected she was cognitively intact and was able to express her needs. The MDS assessment reflected Resident #1 did not exhibit any behaviors during the assessment period. A review of Resident #1's current physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Resident #1's Nurse's Notes dated 01/10/12 reflected at 9:35 PM the resident was out on the smoking patio and she still had her oxygen on and her nasal cannula caught on fire. The Notes also reflected Resident #1 had burns to her right wrist and a burn to her lateral left ankle. The Notes reflected Resident #1's smoking materials were confiscated. The Notes also reflected the nurse contacted Resident #1's physician's assistant about the injuries. The Notes reflected the physician's assistant ordered the burns to be cleaned with normal saline and apply Silva cream daily and wrap with gauze. The facility's Provider Investigation Report dated 01/11/12 reflected Resident #1 suffered three second degree burns from a small flash fire. The Report reflected the resident was outside smoking without staff supervision or staff's knowledge. The Report also reflected, "The only way this could be prevented was if resident would have turned in her cigarettes when they were obtained by an outside source." An interview was conducted with the DON on 01/27/12 at 12:12 PM. The surveyor asked if they had discussed the oxygen and smoking problems, following the incident with Resident #1 when she sustained second degree burns. He said they did and they came to the decision that residents who required oxygen, could still smoke as long as the oxygen was turned off. An interview was conducted with Resident #1 on 01/26/12 at 3:05 PM. The surveyor asked her to explain what happened on the day she sustained her burns. Resident #1 told the surveyor she was out in the smoking area. The resident stated she bent down to extinguish her cigarette on the cement patio. Resident #1 said she then turned around to turn on her oxygen, when the cannula pulled out of her nose and dropped to the ground. She said she believed there was just enough residual oxygen in the tubing and it caught fire. She said CNA D pulled the cannula off her, and as she did, it hit her ankle. 3) A review of Resident #4's Admission Record dated 08/02/11 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record included the following Diagnoses: [REDACTED]. Resident #4's smoking assessment dated [DATE] reflected she was a safe smoker but unable to make decisions regarding tasks of a daily life. Resident #4's MDS assessment dated [DATE] reflected she was cognitively intact and able to express her needs. The assessment reflected Resident #4 did not have any behaviors, during the assessment period. Resident #4's physician's orders [REDACTED]. 4) Resident #3's Smoking assessment dated [DATE] reflected he was determined to be an unsafe smoker. The assessment also reflected Resident #3 needed "Occasional" supervision when he was smoking. An undated handwritten entry on this assessment reflected Resident #3's cigarettes were held by the facility for designated smoking times. A review of Resident #3's Admission Record dated 01/27/12 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. The Admission Record also reflected his original admitted was 12/22/09. Resident #3's MDS assessment dated [DATE] reflected his cognitive skills were moderately impaired, he could make concrete requests and he could respond adequately to simple, direct communication only. The assessment reflected Resident #3 did not have any behaviors during the assessment period. 5) On 01/26/12, the surveyor conducted observations during the 9:00 AM smoke break. Resident #1 was observed to self-propel her wheelchair onto the patio area (the designated smoking area.) A portable oxygen tank (E-tank) was attached to the back of her wheelchair. Resident #1 removed the oxygen tubing from her nose and propelled her wheelchair to a table. The oxygen tank was turned off. Housekeeper B then assisted Resident #1 to a chair at the table at 9:05 AM and positioned her wheelchair approximately fifteen feet from Resident #1. Housekeeper B was then observed to return the wheelchair to Resident #1, who had a lit cigarette between her lips at 9:07 AM. Resident #1 was observed to transfer herself from the chair and back into the wheelchair, while she had a lit cigarette hanging from her lips. Shortly after she transferred herself back into the chair, she was observed to extinguish her cigarette and leave the designated smoking area. At approximately 9:10 AM on 01/26/12, Resident #1 was observed as she propelled her wheelchair past the surveyor. Half of an extinguished cigarette was observed in plain view in the top of her purse. The surveyor asked Resident #1 if there was a reason she had the cigarette in her purse. Resident #1 said she usually only smoked half of the cigarette because she was trying to quit smoking. On 01/26/12 at 9:20 AM during the smoking break, Housekeeper B was observed to step over to assist Resident #2. At the time Housekeeper B was assisting Resident #2, Resident #3 was observed to reach into the box that contained the smoking materials and remove a cigarette. An interview was conducted with Housekeeper B on 01/26/12 at 9:20 AM. The surveyor asked Housekeeper B how Resident #3 was able to obtain the cigarette. Housekeeper B told the surveyor she (Housekeeper B) got distracted. 6) An interview with the AD on 01/26/12 at 10:30 AM revealed the staff member who was supervising the smoke break lit the cigarettes for the residents. She stated it was hard to verify if a resident had a lighter because they did not search residents. She also stated Resident #9 was allowed to keep his pipe because he was upset and did not want to turn it in because he was afraid it would get lost. The AD stated Resident #9 was not allowed to keep tobacco or a lighter. She also stated she was not sure if she should be turning off oxygen tanks. 7) An interview was conducted with Housekeeper E on 01/26/12 at 11:10 AM. He identified himself as the individual who had been assigned to supervise the smoke break on 01/26/12 at 11:00 AM. The surveyor asked him who was responsible for turning off the oxygen when a resident came out to smoke. He said, "The nurses." Housekeeper E said he was in housekeeping and did not know anything about oxygen. Housekeeper E said Resident #4 used oxygen and she came out earlier to smoke. He said he asked her to sit in a regular chair, so the oxygen was not on the chair, but she wanted to sit in her wheelchair. He stated Resident #4 turned off her oxygen, but the oxygen tank was still on her chair while she smoked. 8) An interview was conducted with Housekeeper B on 01/26/12 at 11:20 AM. The surveyor asked Housekeeper B who was responsible for ensuring the residents' oxygen was turned off before the residents began to smoke. Housekeeper B said she did not mind doing it, but the nurses were supposed to take the oxygen off. Housekeeper B said if the nurses did not turn it off, she would just transfer the resident out of the chair. Housekeeper B stated at that time Resident #4 came out with her oxygen on today, (01/26/12), and she (Housekeeper B) asked Resident #4 if she was supposed to be out in the smoking area with her oxygen. According to Housekeeper B, Resident #4 said she could be out in the smoke area, as long as the oxygen was turned off. Housekeeper B said she checked with the DON and he told her it was okay as long as the oxygen was on zero. Housekeeper B expressed a concern about being responsible for the residents. She said she was not a nurse and even if the tank was on zero, she was afraid the oxygen might still leak out, or the resident might turn it back on. The surveyor asked Housekeeper B to identify residents who smoked. She identified Residents #1, #4 and #5. The surveyor asked Housekeeper B, during this same interview on 01/26/12 at 11:20 AM, if she routinely supervised residents during the smoke break. She said someone else had previously been assigned to supervise the smokers, but she had been assigned the duty at 9:00 AM and 11:00 AM for quite some time. The surveyor asked Housekeeper B if she was aware of any other resident who used oxygen and smoked. She identified Resident #1 and Resident #5. 9) Resident #1 was observed on 01/26/12 at 12:58 PM. Resident #1's oxygen tank was positioned on the back of her wheelchair. Maintenance C held the door open for Resident #1 as she approached the smoking area, with her oxygen tank still on the back of her chair. The AD then entered the smoking area on 01/26/12 at approximately 1:00 PM. Resident #1 remained in her wheelchair with the oxygen on the back of the chair and the AD lit Resident #1's cigarette at that time. The surveyor observed the oxygen tank was turned off and the AD told the surveyor she turned it off. Then the AD came back and had Resident #1 move to a regular chair and the wheelchair was approximately 15 feet away from the resident. Further observation on 01/26/12 at 1:04 PM of the smoke break revealed the AD assisted Resident #1 back into her wheelchair and propelled Resident #1 within 10 feet of another resident who was smoking. 10) An interview with the Social Worker on 01/26/12 at 1:17 PM revealed she was not assigned to supervise the residents with smoking. She stated the Administrator, DON and AD decided the residents could smoke outside with their oxygen tanks turned off. The Social Worker also stated she determined Resident #1 was a safe smoker prior to the incident on 01/10/12. She stated she had not reassessed the smokers since the incident. The Social Worker stated now all the residents were supervised. She stated the smokers needed to be reassessed. When asked if she knew of any other residents with burns, she stated Resident #7 had holes in his pants and now he was a supervised smoker. 11) The Social Worker was observed on 01/26/12 at 2:00 PM. She was standing in front of three H (Helium) tanks and one tank labeled compressed Helium. Staff A was observed smoking a cigarette. Staff A replied, "You caught me." The surveyor asked if there was a reason she was smoking in a non-designated smoking area. Staff A said, "I'm not supposed to be, you just caught me." Ten cigarette butts were observed in a pile on the grass at the corner of the building within 10 feet of the H tanks. 12) An interview with CNA I on 01/26/12 at 2:59 PM revealed she supervised the final smoke break at 9:00 PM. She stated she was to make sure the oxygen tank was at zero before she gave them a cigarette. She stated Resident #1 had oxygen and Resident #5 had oxygen. CNA I stated Resident #4 had her oxygen tank turned off, but the tank was on her wheelchair. 13) An interview was conducted with the Administrator on 01/26/12 at 3:19 PM. The surveyor asked him who was responsible for ensuring the oxygen was turned off before residents smoked. The Administrator said the person assigned to the smoke break and who maintained the smoke box. The surveyor asked the Administrator if he had any concerns about residents who were seated in their wheelchairs and smoking with the oxygen tank still attached to the back of the wheelchair, or within close proximity to the residents. The Administrator said he was not aware of any specific distance requirements and the tanks were to be turned off while smoking. The surveyor asked the Administrator if staff, who were designated as the person responsible to ensure oxygen was turned off, had been trained on how to turn off the oxygen tank. The Administrator said he would not know the answer to that question. The surveyor asked who would have the responsibility to ensure they had been trained. He said ultimately it would be his responsibility, but he would have to trust his staff. During this same interview with the Administrator, he also informed the surveyor the facility determined all residents were required to be supervised during smoking, since the incident occurred on 01/10/12 with Resident #1. 14) A review of the facility's current smoking policy dated December 2011 revealed, "This facility shall provide an environment where residents who smoke may do so safely and shall include safety awareness assessments on admission, quarterly as needed to determine smoking privileges and/or restrictions." The policy reflected, "Smoking restrictions shall be used for the safety and well being of the residents and not for staff convenience. Smoking shall not be allowed at any time in a resident's room, bed, or un-designated areas. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for 'no smoking.' 3. The designated smoking monitor must be able to respond quickly in the event of an emergency and must supervise the smokers throughout the entire smoking period. 4. Residents who smoke shall not be permitted to retain cigarettes, pipes, tobacco, lighters, lighter fluids, and butane gas; other forms for gas or fluids nor matches at any time. 5. Residents assesses (sic) as safe smokers will be allowed to check out smoking material but must smoke only in the facility's designated smoking area. 6. Residents who smoke will be required to sign a smoking contract. Exchange of any type of smoking paraphernalia from resident to resident will not be allowed. Failure to comply can lead up to immediate discharge from the facility...." 15) Review of the facility's current Abuse Prohibition Policy and Procedures dated January 2007 revealed the definition of Neglect was, "A deprivation of life's necessities, of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident." 16) An IJ was identified on 01/26/12 at 4:59 PM in the area of Resident Behavior Facility Practices. The Administrator and the DON were informed at that time. A Plan of Removal was requested at that time. 17) Resident #6's Record of admitted d 01/27/12 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also reflected her [DIAGNOSES REDACTED]. Resident #6's MDS assessment dated [DATE] reflected her cognitive skills were moderately impaired, but she was able to express her needs. The MDS assessment also reflected Resident #6 did not exhibit any behaviors during the assessment period. Resident #6's physician's orders [REDACTED]. Resident #6 was observed on 01/27/12 at 11:06 AM. She was seated in a chair in the designated smoking area. The cigarette she held in her right hand was observed with the ashes extended out and then were observed to drop onto her pajama pants. 18) http://rotech.com/respiratory/documents/STAY_SAFE_WHEN_USING_OXYGEN.pdf, reflected, "Three things are necessary for a fire. First, a combustible material (i.e. something that will burn); secondly, an ignition source (i.e. a spark, flame, or high temperature to get the fire going); and thirdly, oxygen. While oxygen itself is not flammable, oxygen must be present for a fire to occur. When higher concentrations of oxygen are present (such as when using oxygen therapy), the result is: Easier ignition of combustible material Much higher flame temperatures Extremely fast flame spread Thus, when a patient is using oxygen, combustibles that are in close contact with the oxygen (e.g. clothing, oxygen tubing, hair, pillow, blanket, a cigarette) are more prone to catching on fire, and if they ignite, they will burn hotter and the flame will spread faster. To use oxygen safely, maintain a safe distance (at least 15 feet) between all oxygen equipment (including tubing) and any flame or other potential source of ignition. Other potential ignition sources include cook stoves, heating stoves, fireplaces, gas hot water heaters, and candles...." (Retrieved on 02/07/12). 19) Review of the Plan of Removal, dated 01/27/12 and accepted at 4:40 PM revealed: "Immediate Action 1. No O2 (oxygen) tanks will be allowed on the smoking patio. All tanks will be removed from the resident chairs prior to exiting the building by the smoking supervisor or designated monitor effective 01/26/12 at 2100 (9:00 PM). 2. ADONs will monitor each smoke break to ensure that no tanks are on the smoking patio beginning 01/26/12 at 2100 (9:00 PM) and on-going until policy is being complied with and spot checks thereafter. 3. ADONs will monitor smoking supervisors to ensure that all resident are being monitored for safety and that the supervisor is on the patio during the entire smoke break effective 01/26/12 at 2100 (9:00 PM) until the policy is being complied with and spot checks thereafter. 4. SSW will ensure that all smoking assessments on all residents that are smokers. Completed 01/26/12 at 2000 (8:00 PM). 5. SSW will ensure that all smokers will have care plans in place to reflect that they are smokers and require supervision. Completed 01/26/12 at 2000 (8:00 PM). 6. One designated staff member will be assigned to watch the smoking patio and doors to ensure that residents do not attempt to smoke without supervision effective 01/26/12 at 2000 (8:00 PM). 7. All ash trays will be emptied by housekeeping after each smoke break to prevent residents from taking cigarette stubs from the trays effective 01/27/12 at 0930 (9:30 AM). 8. Administration and nursing administration will ensure that all staff will be re-educated on the smoking policy especially in regard to use of O2 while smoking. Beginning 01/26/12 at 2000 (8:00 PM) and completed by 01/30/12 then on-going. 9. All staff will be in-serviced on the reporting of unusual events e.g.. burns of unknown origin to administration. Beginning 01/27/12 and completed by 01/30/12 then on-going. 10. If smoking materials are noted to be in a residents possession the staff nurse will confiscate the materials and place the resident on Q 15 minute checks until administration is available effective 01/27/12 at 1200 (12:00 PM). 11. Smoking schedules will be modified to include the level of supervision required for each resident so that staff will be aware of the residents special needs for supervision. Effective 01/27/12. 12. Smoking policy will be in force immediately and on-going. 13. All staff will be instructed to smoke only in the designated smoking area. Effective 01/27/12. 14. All staff will be in-serviced in the reporting mechanism for unusual occurrences as per #9. The immediate supervisor must be notified then the DON/Administrator or designee will be notified. Beginning 01/27/12 and completed by 01/30/12 then on-going. The appropriate personnel e.g.. DON, Administrator, Social Worker will then assess the resident/situation and determine what actions to take e.g.. appropriate interventions to ensure resident safety while smoking,, (sic) report to regulatory bodies, etc." 20) Interviews after the Plan of Removal was accepted: An interview was conducted with Housekeeper C on 01/28/12 at 10:20 AM. He told the surveyor they were told the doors would be monitored at all times. He stated the housekeeping and laundry staff would no longer be assigned to monitor the residents at smoke break. He said they would be required to empty the ashtrays and ensure no residents had access to any cigarette butts. Housekeeper C also stated the residents would be provided individual approved ashtrays. An interview conducted with LVN G on 01/27/12 at 8:00 PM revealed she worked the night shift. She confirmed she received an inservice that informed staff no resident was to smoke unsupervised. LVN G also stated no resident was to attend smoke break with oxygen in use. She stated they were also instructed to confiscate any smoking material from any resident who was found with smoking paraphernalia in their possession. An interview was conducted with LVN J on 01/28/12 at 11:30 AM. She confirmed she was inserviced regarding residents who smoked. She stated no resident was to attend the smoke break with an oxygen tank. LVN J stated all residents would be supervised. She stated residents who were seen with smoking paraphernalia would have it confiscated. LVN J also stated residents could only smoke at the designated smoking times. An interview was conducted with LVN K on 01/28/12 at 11:58 AM. She identified herself as the weekend nurse who worked 16 hour shifts. She confirmed she was provided an inservice regarding residents who smoked. She said residents could only smoke at the designated times and had to be supervised by the staff. LVN K stated they had a specific person assigned to sit at the doors to ensure no residents smoked at times other than the designated smoking times. She stated staff had to take lighters and cigarettes from the residents if they were seen with them. The DON provided the schedule of specific staff who were assigned to sit at the doors of the designated smoking area for all three shifts. The DON also provided a document which identified each resident who smoked, and the level of supervision they required. An interview was conducted with Resident #8 on 01/28/12 at 12:00 PM.. She informed the surveyor she had to sign a smoking contract and was again informed about the smoking policy. She said that the residents could only smoke with staff supervision and at the designated smoking times. 21) While the IJ was removed on 01/27/12, at 4:40 PM the facility remained out of compliance at a scope of "pattern" and severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. 22) The AD provided a list which identified 14 residents who smoked.

Based on observation, interview and record review, the Administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident for three (Residents #1, #3, and #4) of 14 residents who smoked. 1. The Administrator failed to implement the facility's smoking policies in order to ensure safe smoking and monitor residents and staff smoking to ensure compliance and failed to train staff regarding handling oxygen when residents were smoking. Resident #1 had a history of [REDACTED]. After the incident, the facility continued to allow Resident #1 to smoke with her oxygen tank on the back of her wheelchair. 2) Resident #4 also smoked with her oxygen tank on the back of her wheelchair. 3) Resident #3 was able to retrieve a cigarette from the "smoke box" (a box that contained the smoking paraphernalia) during a supervised smoke break. 4) The Social Worker was smoking in front of Helium tanks which was an area that prohibited smoking. An Immediate Jeopardy (IJ) was identified on 01/26/12. While the IJ was removed on 01/27/12, the facility remained out of compliance at a scope of "pattern" and severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" because the facility was still monitoring the Plan of Removal. These failures could affect the 14 residents, including Residents #1 and #4, who smoked by placing them at risk for flash fires and burns. Findings included: 1) During a confidential interview, a concern was voiced regarding residents who smoked and also used oxygen. The interviewee stated a resident had recently sustained a burn while smoking with oxygen and the resident continued to smoke while the oxygen tank was attached to the wheelchair. The interviewee identified Resident #1 as the resident who sustained the burns. 2) Resident #1's Admission Record dated 03/16/11 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also included the following Diagnoses: [REDACTED]. A Safe Smoking assessment dated [DATE] reflected Resident #1 was able to indicate she understood the facility smoking policy and rules. The assessment reflected she was assessed as a "Safe Smoker." Resident #1's Social Progress Notes dated 09/17/11 reflected, "Resident has been counseled several times by myself and the Administrator. She continues to be seen on the smoking patio with her oxygen tank attached to the back of her wheelchair and smoking. If resident continues her behavior, further action may have to be taken." Resident #1's Social Progress Notes dated 09/20/11 reflected a quarterly assessment. The Notes reflected the resident continued to be active in activities, helped fell ow residents, was very alert and oriented with no mood problems. Further review of the Notes revealed Resident #1 continued to have the behavior of smoking with her oxygen tank attached to her wheelchair. The Social Progress Notes also reflected Resident #1 had breathing difficulties and required oxygen on a daily basis. Resident #1's care plan dated 10/12/11 reflected the resident had oxygen therapy. The goal was for Resident #1 not to have any signs or symptoms of poor oxygen absorption through the review date. One of the interventions on the care plan was for her to have a portable oxygen apparatus. Resident #1's Social Progress Notes dated 10/28/11 reflected, "Resident has been warned numerous times about going outside and smoking with her oxygen tank on...It was explained to resident by myself and administrator that if she is caught outside on the smoking patio with her oxygen tank on even if it is turned off she could or can get a 30 day notice." Resident #1's care plan dated 11/01/11 reflected the resident had a behavior problem of smoking on the patio with her oxygen tank and had been counseled several times and asked not to do that. The care plan reflected the resident continued with the behavior. The goals of the care plan were the resident would have fewer episodes of smoking on the patio with her oxygen tank and would show less signs of behavior. The approaches were to anticipate and meet her needs, explain all procedures before starting and allow resident to adjust to changes, and "If reasonable, discuss resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable." Resident #1's MDS assessment dated [DATE] reflected she was cognitively intact and was able to express her needs. The MDS assessment reflected Resident #1 did not exhibit any behaviors during the assessment period. A review of Resident #1's current physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Resident #1's Nurse's Notes dated 01/10/12 reflected at 9:35 PM the resident was out on the smoking patio and she still had her oxygen on and her nasal cannula caught on fire. The Notes also reflected Resident #1 [MEDICAL CONDITION] her right wrist and a burn to her lateral left ankle. The Notes reflected Resident #1's smoking materials were confiscated. The Notes also reflected the nurse contacted Resident #1's physician's assistant about the injuries. The Notes reflected the physician's assistant ordered [MEDICAL CONDITION] be cleaned with normal saline and apply Silva cream daily and wrap with gauze. The facility's Provider Investigation Report dated 01/11/12 reflected Resident #1 suffered three second [MEDICAL CONDITION] a small flash fire. The Report reflected the resident was outside smoking without staff supervision or staff's knowledge. The Report also reflected, "The only way this could be prevented was if resident would have turned in her cigarettes when they were obtained by an outside source." An interview was conducted with the DON on 01/27/12 at 12:12 PM. The surveyor asked if they had discussed the oxygen and smoking problems, following the incident with Resident #1 when she sustained second degree burns. He said they did and they came to the decision that residents who required oxygen, could still smoke as long as the oxygen was turned off. An interview was conducted with Resident #1 on 01/26/12 at 3:05 PM. The surveyor asked her to explain what happened on the day she sustained her burns. Resident #1 told the surveyor she was out in the smoking area. The resident stated she bent down to extinguish her cigarette on the cement patio. Resident #1 said she then turned around to turn on her oxygen, when the cannula pulled out of her nose and dropped to the ground. She said she believed there was just enough residual oxygen in the tubing and it caught fire. She said CNA D pulled the cannula off her, and as she did, it hit her ankle. 3) A review of Resident #4's Admission Record dated 08/02/11 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record included the following Diagnoses: [REDACTED]. Resident #4's smoking assessment dated [DATE] reflected she was a safe smoker but unable to make decisions regarding tasks of a daily life. Resident #4's MDS assessment dated [DATE] reflected she was cognitively intact and able to express her needs. The assessment reflected Resident #4 did not have any behaviors, during the assessment period. Resident #4's physician's orders [REDACTED]. 4) Resident #3's Smoking assessment dated [DATE] reflected he was determined to be an unsafe smoker. The assessment also reflected Resident #3 needed "Occasional" supervision when he was smoking. An undated handwritten entry on this assessment reflected Resident #3's cigarettes were held by the facility for designated smoking times. A review of Resident #3's Admission Record dated 01/27/12 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. The Admission Record also reflected his original admitted was 12/22/09. Resident #3's MDS assessment dated [DATE] reflected his cognitive skills were moderately impaired, he could make concrete requests and he could respond adequately to simple, direct communication only. The assessment reflected Resident #3 did not have any behaviors during the assessment period. 5) On 01/26/12, the surveyor conducted observations during the 9:00 AM smoke break. Resident #1 was observed to self-propel her wheelchair onto the patio area (the designated smoking area.) A portable oxygen tank (E-tank) was attached to the back of her wheelchair. Resident #1 removed the oxygen tubing from her nose and propelled her wheelchair to a table. The oxygen tank was turned off. Housekeeper B then assisted Resident #1 to a chair at the table at 9:05 AM and positioned her wheelchair approximately fifteen feet from Resident #1. Housekeeper B was then observed to return the wheelchair to Resident #1, who had a lit cigarette between her lips at 9:07 AM. Resident #1 was observed to transfer herself from the chair and back into the wheelchair, while she had a lit cigarette hanging from her lips. Shortly after she transferred herself back into the chair, she was observed to extinguish her cigarette and leave the designated smoking area. At approximately 9:10 AM on 01/26/12, Resident #1 was observed as she propelled her wheelchair past the surveyor. Half of an extinguished cigarette was observed in plain view in the top of her purse. The surveyor asked Resident #1 if there was a reason she had the cigarette in her purse. Resident #1 said she usually only smoked half of the cigarette because she was trying to quit smoking. On 01/26/12 at 9:20 AM during the smoking break, Housekeeper B was observed to step over to assist Resident #2. At the time Housekeeper B was assisting Resident #2, Resident #3 was observed to reach into the box that contained the smoking materials and remove a cigarette. An interview was conducted with Housekeeper B on 01/26/12 at 9:20 AM. The surveyor asked Housekeeper B how Resident #3 was able to obtain the cigarette. Housekeeper B told the surveyor she (Housekeeper B) got distracted. 6) An interview with the AD on 01/26/12 at 10:30 AM revealed the staff member who was supervising the smoke break lit the cigarettes for the residents. She stated it was hard to verify if a resident had a lighter because they did not search residents. She also stated Resident #9 was allowed to keep his pipe because he was upset and did not want to turn it in because he was afraid it would get lost. The AD stated Resident #9 was not allowed to keep tobacco or a lighter. She also stated she was not sure if she should be turning off oxygen tanks. 7) An interview was conducted with Housekeeper E on 01/26/12 at 11:10 AM. He identified himself as the individual who had been assigned to supervise the smoke break on 01/26/12 at 11:00 AM. The surveyor asked him who was responsible for turning off the oxygen when a resident came out to smoke. He said, "The nurses." Housekeeper E said he was in housekeeping and did not know anything about oxygen. Housekeeper E said Resident #4 used oxygen and she came out earlier to smoke. He said he asked her to sit in a regular chair, so the oxygen was not on the chair, but she wanted to sit in her wheelchair. He stated Resident #4 turned off her oxygen, but the oxygen tank was still on her chair while she smoked. 8) An interview was conducted with Housekeeper B on 01/26/12 at 11:20 AM. The surveyor asked Housekeeper B who was responsible for ensuring the residents' oxygen was turned off before the residents began to smoke. Housekeeper B said she did not mind doing it, but the nurses were supposed to take the oxygen off. Housekeeper B said if the nurses did not turn it off, she would just transfer the resident out of the chair. Housekeeper B stated at that time Resident #4 came out with her oxygen on today, (01/26/12), and she (Housekeeper B) asked Resident #4 if she was supposed to be out in the smoking area with her oxygen. According to Housekeeper B, Resident #4 said she could be out in the smoke area, as long as the oxygen was turned off. Housekeeper B said she checked with the DON and he told her it was okay as long as the oxygen was on zero. Housekeeper B expressed a concern about being responsible for the residents. She said she was not a nurse and even if the tank was on zero, she was afraid the oxygen might still leak out, or the resident might turn it back on. The surveyor asked Housekeeper B to identify residents who smoked. She identified Residents #1, #4 and #5 who smoked. The surveyor asked Housekeeper B, during this same interview on 01/26/12 at 11:20 AM, if she routinely supervised residents during the smoke break. She said someone else had previously been assigned to supervise the smokers, but she had been assigned the duty at 9:00 AM and 11:00 AM for quite some time. The surveyor asked Housekeeper B if she was aware of any other resident who used oxygen and smoked. She identified Resident #1 and Resident #5. 9) Resident #1 was observed on 01/26/12 at 12:58 PM. Resident #1's oxygen tank was positioned on the back of her wheelchair. Maintenance C held the door open for Resident #1 as she approached the smoking area, with her oxygen tank still on the back of her chair. The AD then entered the smoking area on 01/26/12 at approximately 1:00 PM. Resident #1 remained in her wheelchair with the oxygen on the back of the chair and the AD lit Resident #1's cigarette at that time. The surveyor observed the oxygen tank was turned off and the AD told the surveyor she turned it off. Then the AD came back and had Resident #1 move to a regular chair and the wheelchair was approximately 15 feet away from the resident. Further observation on 01/26/12 at 1:04 PM of the smoke break revealed the AD assisted Resident #1 back into her wheelchair and propelled Resident #1 within 10 feet of another resident who was smoking. 10) An interview with the Social Worker on 01/26/12 at 1:17 PM revealed she was not assigned to supervise the residents with smoking. She stated the Administrator, DON and AD decided the residents could smoke outside with their oxygen tanks turned off. The Social Worker also stated she determined Resident #1 was a safe smoker prior to the incident on 01/10/12. She stated she had not reassessed the smokers since the incident. The Social Worker stated now all the residents were supervised. She stated the smokers needed to be reassessed. When asked if she knew of any other residents with burns, she stated Resident #7 had holes in his pants and now he was a supervised smoker. 11) The Social Worker was observed on 01/26/12 at 2:00 PM. She was standing in front of three H (Helium) tanks and one tank labeled compressed Helium. Staff A was observed smoking a cigarette. Staff A replied, "You caught me." The surveyor asked if there was a reason she was smoking in a non-designated smoking area. Staff A said, "I'm not supposed to be, you just caught me." Ten cigarette butts were observed in a pile on the grass at the corner of the building within 10 feet of the H tanks. 12) An interview with CNA I on 01/26/12 at 2:59 PM revealed she supervised the final smoke break at 9:00 PM. She stated she was to make sure the oxygen tank was at zero before she gave them a cigarette. She stated Resident #1 had oxygen and Resident #5 had oxygen. CNA I stated Resident #4 had her oxygen tank turned off, but the tank was on her wheelchair. 13) An interview was conducted with the Administrator on 01/26/12 at 3:19 PM. The surveyor asked him who was responsible for ensuring the oxygen was turned off before residents smoked. The Administrator said the person assigned to the smoke break and who maintained the smoke box. The surveyor asked the Administrator if he had any concerns about residents who were seated in their wheelchairs and smoking with the oxygen tank still attached to the back of the wheelchair, or within close proximity to the residents. The Administrator said he was not aware of any specific distance requirements and the tanks were to be turned off while smoking. The surveyor asked the Administrator if staff, who were designated as the person responsible to ensure oxygen was turned off, had been trained on how to turn off the oxygen tank. The Administrator said he would not know the answer to that question. The surveyor asked who would have the responsibility to ensure they had been trained. He said ultimately it would be his responsibility, but he would have to trust his staff. During this same interview with the Administrator, he also informed the surveyor the facility determined all residents were required to be supervised during smoking, since the incident occurred on 01/10/12 with Resident #1. 14) A review of the facility's current smoking policy dated December 2011 revealed, "This facility shall provide an environment where residents who smoke may do so safely and shall include safety awareness assessments on admission, quarterly as needed to determine smoking privileges and/or restrictions." The policy reflected, "Smoking restrictions shall be used for the safety and well being of the residents and not for staff convenience. Smoking shall not be allowed at any time in a resident's room, bed, or un-designated areas. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for 'no smoking.' 3. The designated smoking monitor must be able to respond quickly in the event of an emergency and must supervise the smokers throughout the entire smoking period. 4. Residents who smoke shall not be permitted to retain cigarettes, pipes, tobacco, lighters, lighter fluids, and butane gas; other forms for gas or fluids nor matches at any time. 5. Residents assesses (sic) as safe smokers will be allowed to check out smoking material but must smoke only in the facility's designated smoking area. 6. Residents who smoke will be required to sign a smoking contract. Exchange of any type of smoking paraphernalia from resident to resident will not be allowed. Failure to comply can lead up to immediate discharge from the facility...." 15) Review of the facility's current Abuse Prohibition Policy and Procedures dated January 2007 revealed the definition of Neglect was, "A deprivation of life's necessities, of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident." 16) An IJ was identified on 01/26/12 at 4:59 PM in the area of Resident Behavior Facility Practices. The Administrator and the DON were informed at that time. A Plan of Removal was requested at that time. 17) Resident #6's Record of admitted d 01/27/12 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The Record also reflected her [DIAGNOSES REDACTED]. Resident #6's MDS assessment dated [DATE] reflected her cognitive skills were moderately impaired, but she was able to express her needs. The MDS assessment also reflected Resident #6 did not exhibit any behaviors during the assessment period. Resident #6's physician's orders [REDACTED]. Resident #6 was observed on 01/27/12 at 11:06 AM. She was seated in a chair in the designated smoking area. The cigarette she held in her right hand was observed with the ashes extended out and then were observed to drop onto her pajama pants. 18) http://rotech.com/respiratory/documents/STAY_SAFE_WHEN_USING_OXYGEN.pdf, reflected, "Three things are necessary for a fire. First, a combustible material (i.e. something that will burn); secondly, an ignition source (i.e. a spark, flame, or high temperature to get the fire going); and thirdly, oxygen. While oxygen itself is not flammable, oxygen must be present for a fire to occur. When higher concentrations of oxygen are present (such as when using oxygen therapy), the result is: Easier ignition of combustible material Much higher flame temperatures Extremely fast flame spread Thus, when a patient is using oxygen, combustibles that are in close contact with the oxygen (e.g. clothing, oxygen tubing, hair, pillow, blanket, a cigarette) are more prone to catching on fire, and if they ignite, they will burn hotter and the flame will spread faster. To use oxygen safely, maintain a safe distance (at least 15 feet) between all oxygen equipment (including tubing) and any flame or other potential source of ignition. Other potential ignition sources include cook stoves, heating stoves, fireplaces, gas hot water heaters, and candles...." (Retrieved on 02/07/12). 19) Review of the Plan of Removal, dated 01/27/12 and accepted at 4:40 PM revealed: "Immediate Action 1. No O2 (oxygen) tanks will be allowed on the smoking patio. All tanks will be removed from the resident chairs prior to exiting the building by the smoking supervisor or designated monitor effective 01/26/12 at 2100 (9:00 PM). 2. ADONs will monitor each smoke break to ensure that no tanks are on the smoking patio beginning 01/26/12 at 2100 (9:00 PM) and on-going until policy is being complied with and spot checks thereafter. 3. ADONs will monitor smoking supervisors to ensure that all resident are being monitored for safety and that the supervisor is on the patio during the entire smoke break effective 01/26/12 at 2100 (9:00 PM) until the policy is being complied with and spot checks thereafter. 4. SSW will ensure that all smoking assessments on all residents that are smokers. Completed 01/26/12 at 2000 (8:00 PM). 5. SSW will ensure that all smokers will have care plans in place to reflect that they are smokers and require supervision. Completed 01/26/12 at 2000 (8:00 PM). 6. One designated staff member will be assigned to watch the smoking patio and doors to ensure that residents do not attempt to smoke without supervision effective 01/26/12 at 2000 (8:00 PM). 7. All ash trays will be emptied by housekeeping after each smoke break to prevent residents from taking cigarette stubs from the trays effective 01/27/12 at 0930 (9:30 AM). 8. Administration and nursing administration will ensure that all staff will be re-educated on the smoking policy especially in regard to use of O2 while smoking. Beginning 01/26/12 at 2000 (8:00 PM) and completed by 01/30/12 then on-going. 9. All staff will be in-serviced on the reporting of unusual events e.g..[MEDICAL CONDITION] unknown origin to administration. Beginning 01/27/12 and completed by 01/30/12 then on-going. 10. If smoking materials are noted to be in a residents possession the staff nurse will confiscate the materials and place the resident on Q 15 minute checks until administration is available effective 01/27/12 at 1200 (12:00 PM). 11. Smoking schedules will be modified to include the level of supervision required for each resident so that staff will be aware of the residents special needs for supervision. Effective 01/27/12. 12. Smoking policy will be in force immediately and on-going. 13. All staff will be instructed to smoke only in the designated smoking area. Effective 01/27/12. 14. All staff will be in-serviced in the reporting mechanism for unusual occurrences as per #9. The immediate supervisor must be notified then the DON/Administrator or designee will be notified. Beginning 01/27/12 and completed by 01/30/12 then on-going. The appropriate personnel e.g.. DON, Administrator, Social Worker will then assess the resident/situation and determine what actions to take e.g.. appropriate interventions to ensure resident safety while smoking,, (sic) report to regulatory bodies, etc." 20) Interviews after the Plan of Removal was accepted: An interview was conducted with Housekeeper C on 01/28/12 at 10:20 AM. He told the surveyor they were told the doors would be monitored at all times. He stated the housekeeping and laundry staff would no longer be assigned to monitor the residents at smoke break. He said they would be required to empty the ashtrays and ensure no residents had access to any cigarette butts. Housekeeper C also stated the residents would be provided individual approved ashtrays. An interview conducted with LVN G on 01/27/12 at 8:00 PM revealed she worked the night shift. She confirmed she received an inservice that informed staff no resident was to smoke unsupervised. LVN G also stated no resident was to attend smoke break with oxygen in use. She stated they were also instructed to confiscate any smoking material from any resident who was found with smoking paraphernalia in their possession. An interview was conducted with LVN J on 01/28/12 at 11:30 AM. She confirmed she was inserviced regarding residents who smoked. She stated no resident was to attend the smoke break with an oxygen tank. LVN J stated all residents would be supervised. She stated residents who were seen with smoking paraphernalia would have it confiscated. LVN J also stated residents could only smoke at the designated smoking times. An interview was conducted with LVN K on 01/28/12 at 11:58 AM. She identified herself as the weekend nurse who worked 16 hour shifts. She confirmed she was provided an inservice regarding residents who smoked. She said residents could only smoke at the designated times and had to be supervised by the staff. LVN K stated they had a specific person assigned to sit at the doors to ensure no residents smoked at times other than the designated smoking times. She stated staff had to take lighters and cigarettes from the residents if they were seen with them. The DON provided the schedule of specific staff who were assigned to sit at the doors of the designated smoking area for all three shifts. The DON also provided a document which identified each resident who smoked, and the level of supervision they required. An interview was conducted with Resident #8 on 01/28/12 at 12:00 PM.. She informed the surveyor she had to sign a smoking contract and was again informed about the smoking policy. She said that the residents could only smoke with staff supervision and at the designated smoking times. 21) While the IJ was removed on 01/27/12, at 4:40 PM the facility remained out of compliance at a scope of "pattern" and severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. 22) The AD provided a list which identified 14 residents who smoked.

Based on observation, interview, and record review, it was determined the facility failed to ensure three (Resident #1, #3, and #6) of seven residents reviewed for pressure ulcers received the necessary care and services to prevent the development of new pressure ulcers, prevent the worsening of current pressure ulcers, promote the healing of current pressure ulcers and ensure the accurate assessment and documentation of the pressure ulcers. 1) Resident #3 had a history of [REDACTED]. Resident #3's feet were not off-loaded and were in direct contact with the mattress. LVN A and LVN E reported the resident had no skin breakdowns. Resident #3 was found with an unstageable pressure ulcer on her left foot and a stage II pressure ulcer on her right hand. Resident #3 was prescribed [MEDICATION NAME] (antibiotic) 500 mg without a culture. None of the facility staff were aware of the resident's skin breakdowns. These failures resulted in Resident #3 having two infected pressure ulcers, which placed her at risk for pain, worsening of the current Pressure Ulcers, development of further pressure ulcers [MEDICAL CONDITION]. 2) Resident #1 had a Pressure Ulcer which increased in depth from 2.0 cc on 10/19/11 to a variance of 2.1 cc to 3.0 cc on 11/02/11. LVN E did not accurately measure the pressure ulcer as she was not aware of what tunneling or undermining was in regard to the pressure ulcer. These failures resulted in a decline in the resident's pressure ulcer and presented an inaccurate picture of the pressure ulcer and caused a potential delay in the treatment required by Resident #1 and placed her at risk for continued pain and decline in the healing of her pressure ulcer. 3) Resident #6 had two pressure ulcers on her right foot. Documentation by LVN E was for one pressure ulcer only. On 11/02/11, one pressure ulcer was approximately 3 cm by 6 cm, unstageable, with black eschar on the right heel and the other pressure ulcer was approximately 3 cm by 6 cm, Stage IV, on the right posterior ankle. There was no treatment order for Resident #6's Stage IV and no evidence of an assessment. These failures resulted in Resident #6 having a pressure ulcer being treated without a physician's order, not being assessed to determine whether it was healing or further declining since it was a Stage IV and further placed Resident #6 at risk for Pain, Infection [MEDICAL CONDITION]. These failures placed the facility's eight residents, including Residents #1, #3 and #6, at risk for the development of pressure ulcers, the decline of current pressure ulcers, increased pain, the need for debridement, the development of infection [MEDICAL CONDITION] and the potential for admission to a wound care facility. Findings included: 1) Review of Resident #3's most current annual MDS assessment dated [DATE] revealed diagnosds which included [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITIONS] Disorder, Arthritis, [MEDICAL CONDITIONS], Dementia, [MEDICAL CONDITION], Reflux Esophagitis, and Dysphagia. The surveyor observed Resident #3 during initial rounds on 11/01/11 at 9:40 a.m. LVN W stated Resident #3 was bedfast, incontinent of bowel and bladder, alert and oriented with confusion and aphasic, was on [DEVICE] feedings and required total care with her ADL needs. Resident #3 was observed asleep in bed in her room. LVN W stated she was not sure if Resident #3 had any skin problems presently, but she was seen by the wound care nurse as needed. Review of a care plan dated 07/18/11 and 08/01/11 revealed Resident #3 had Pressure Ulcers on her left upper foot and right and left heel areas. Review of the most current care plan dated 08/30/11 revealed Resident #3 had the potential for Pressure Ulcer development related to her immobility. The approaches identified were: Bathe per schedule, Float heels, Reposition at least every two hours, more often as needed or requested, Monitor and report to MD (medical doctor) as needed for changes in skin status: appearance, color, impaired skin; Pressure relieving/reducing devices on bed/chair; Administer medications as ordered. The surveyor asked LVN E on 11/02/11 at 2:30 p.m. to assist the surveyor with observing Resident #3's skin. LVN E told the surveyor Resident #3 had no open areas. She stated the resident had healed areas on her heels. LVN E contacted LVN A to find assistance for the observation. LVN A stated Resident #3 did not have any open areas she was aware of. LVN A called CNAs BB and CC to assist the surveyor and provide Resident #3 with incontinent care. Review of a Non-Pressure Skin Condition Report for Resident #3 revealed an area on the right inner heel was "healed" on 10/26/11. There were no additional skin assessments after that date. The surveyor observed CNA BB and CC on 11/02/11 at 2:50 p.m. providing Resident #3 incontinent care. Resident #3 had hand rolls in both hands a foul odor emanating from the right hand area. Resident #3's feet were observed in direct contact with the air mattress. The right foot was intact, however the left planter foot under the left foot big toe area had a Stage III open area with a thick, soft brown slough in the middle, surrounded by white tissue. The Pressure Ulcer was approximately 3.0 cm x 3.0 cm. This area had no dressing covering it. CNAs BB and CC told the surveyor they had never seen the area before. They stated Resident #3 was a hospice resident and was seen by hospice aides. After providing Resident #3 incontinent care, the CNAs left Resident #3 with her wound area still in direct contact with the mattress. On 11/03/11 at 12:15 p.m., the surveyor observed LVN E with Resident #3. Resident #3 was observed in bed at that time with her feet in direct contact with the mattress. They were not off-loaded (elevated to prevent friction) with the bed. The Pressure Ulcer on Resident #3's left planter big toe area was open and in contact with a towel under her feet. The towel had a moderate amount of thick, serous drainage on it. The pressure ulcer did not have a protective covering to prevent infection. The surveyor observed the brown slough (from the observation on 11/02/11 at 2:50 p.m.) was no longer in the wound bed and there was now a small amount of yellow slough in the wound bed. LVN E stated she had completed a head-to-toe assessment on Resident #3 on 11/02/11 after she was told by the DON Resident #3 had an open area. During the assessment she also identified a Stage II open area on Resident #3's right hand. Observation of the fifth digit area with LVN E revealed there was no dressing on the site. The finger was so contracted it was digging and rubbing into the palm of the right hand. LVN E stated she had the measurement of the Pressure Ulcer documented in the Weekly Pressure Ulcer Healing Record. Review of the Weekly Pressure Ulcer Healing Record for Resident #3 revealed an assessment dated [DATE] for her fifth digit. The measurement was 1.4 cm x 1.1 cm with small serosanguineous drainage, and slight odor. Another Weekly Pressure Ulcer Healing Record also reflected an assessment for Resident #3's "left foot-under." The document reflected the area was unstageable, measured 2.0 cm x 1.7 cm with no depth, had a small amount of serosanguineous drainage, a slight odor and the wound bed had slough. On 11/03/11 at 12:30 p.m., the surveyor asked LVN E why she staged Resident #3's left foot area with slough and drainage as an "Unstageable" wound. (The Weekly Pressure Ulcer Healing Record reflected a Stage III was "Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.") LVN E stated the slough covered most of the wound bed even though there was an opening and draining area in the wound bed. Later the surveyor observed the document had been changed from unstageable to Stage II. Review of Resident #3's physician's telephone order dated 11/02/11 revealed an order for [REDACTED]." There was no order given to culture the wound prior to the administration of the antibiotic. At 1:00 p.m. on 11/02/11 the surveyor asked LVN E if Resident #3's wound had been cultured. LVN E told the surveyor the physician assistant (PA) observed the wound and wrote the order for the antibiotics. LVN E stated the PA sometimes ordered antibiotics without culturing the wound and/or drainage. During the interview with the DON on 11/04/11 at 2:30 p.m., he was queried regarding his involvement in the skin system processs. He responded "I look at the schedule of assessments. I recently reviewed some of the wounds over the last month." The DON gave the names of three residents he had reviewed. When asked if there were any changes in treatment or care for the residents he had reviewed the DON responded, "No Mamm, the assessments were correct." When asked how he identified and tracked skin issues, the DON replied, "I routinely look when I visit the residents, the aides use the Skin Identification Tool and complete a form for each resident and the nurses conduct a weekly head to toe assessment. I also get a schedule of assessments from (ADON V) and I rely on the Hospice Aide and Hospice Nurse for reports on their residents." 2) Resident #1 was observed during the initial rounds on 11/01/11 at 9:43 a.m. LVN W stated Resident #1 was alert and oriented to person, place and time. He was mobile in the facility via his wheelchair. Resident #1 had a Foley catheter, required assistance with ADLs, fed himself, was Paraplegic, had a wound VAC and was seen by the wound care nurse (LVN E) in the facility. Resident #1 was resting in bed in his room. Resident #1 was observed with a PICC line to the right upper arm area. Review of Resident #1's November 2011 consolidated physician's orders revealed diagnoses, which included Pressure Ulcer Buttock, Muscular Wasting and Disuse Atrophy, [MEDICAL CONDITIONS] Reflux, Depression, [MEDICAL CONDITION], and Venous [MEDICAL CONDITION] and Embolism. Review of the initial MDS assessment dated [DATE] for Resident #1 revealed diagnoses, which included Urinary Tract Infection, Wound Infection, Arthritis, and [MEDICAL CONDITION]. The MDS assessment also reflected Resident #1 had one Stage III pressure ulcer. The dimensions were: length 7.0 cm, width 6.0 cm with depth 2.0 cm. The surveyor observed LVN E on 11/02/11 at 1:45 p.m. providing wound care treatment to Resident #1. LVN E pulled her treatment cart to the resident's room. LVN E opened the cart and obtained 4 x 4 gauze, paper,wound cleanser, black foam dressing, gloves, wound vac tubing and closure dressing clear tape. LVN E cleaned Resident #1's overbed table with antimicrobial wipes. While still wet, she placed the supplies on the parchment paper (used for cooking) on the wet table. LVN E went to the cart again to obtain more gloves and a red bag for trash. LVN E placed the red bag in the trash can at the foot of the bed. LVN E, without washing her hands, opened the individual packets of 4 x 4 gauze. She took the gauze out of the packets and placed them on the wet parchment paper. She also opened the Kerlix gauze and placed it on the parchment paper. LVN E donned gloves, obtained scissors from her jacket pocket, cleaned them with the alcohol wipe pad and placed them on the parchment paper. She opened the foam wound vac dressing, cutting out a size to match the wound, clamped the wound vac tubing and disconnected the wound vac. LVN E removed the old dressing from the wound. LVN E was asked when she measured the wound last. LVN E stated she measured the Pressure Ulcer last Wednesday, 10/26/11. LVN E offered to measure the Pressure Ulcer at that time. LVN E removed her gloves and went into the treatment cart without washing her hands or using a sanitizer to clean her hands. LVN E came back to the room with measuring paper tape and Q-tip. LVN E positioned the resident and the overbed table. The right Ischium had an opened area with a very strong, foul smell. LVN E washed her hands and donned gloves. The following was the measurement obtained: Length 6.0 cm Width 5.5 cm Depth at 12 o'clock 3.0 cm At 3:00 o'clock 2.1 cm and At 9:00 o'clock 2.8 cm. LVN E stated during the measurements she was not aware of checking the pressure ulcer for undermining or tunneling. The depth she was measuring was the depth of the wound from the edge to the base of the wound. Undermining is when the wound is is larger than appears, and extends underneath the skin and wound edges. Tunneling is a canal or tunnel that extends into a wound deeper than the majority of the base of the wound. This information was retrieved on 11/21/11 from medicaledu.com. LVN E picked up 4 x 4 gauze, and the Saf Cleans spray bottle. She sprayed the wound cleanser into the wound bed and cleaned with the 4 x 4 gauze twice. LVN E then switched the Saf Cleans to her right hand, which was the contaminated gloved hand and sprayed the wound bed twice, switching between the 4 x 4 and the Saf Cleans, thus contaminating the Saf Cleans bottle. After cleaning the wound bed, she placed the contaminated Saf Cleans spray bottle on the parchment paper on the overbed table. LVN E picked up more 4 x 4 gauze and dried the Pressure Ulcer bed. The wound bed was red and clean with a very strong, foul odor emanating from the wound. LVN E removed her gloves, donned clean gloves, cleaned her scissors with alcohol, removed the gloves and donned clean gloves. LVN E took the foam dressing and cut a piece the size of the Pressure Ulcer. She covered the wound bed with the foam dressing and reconnected the wound vac with thick, serous/yellow drainage in the vacuum bag. After completing the dressing changes, LVN E removed her gloves, picked up the left over items and the Saf Cleans bottle. She placed the contaminated Saf Cleans spray bottle into the general use treatment cart. LVN E came back into the room and washed her hands. After observing LVN E perform the wound care treatment, the surveyor asked the LVN what kind of infection Resident #1 had. LVN E stated she did not know what type infection Resident #1 had. The surveyor interviewed the DON on 11/02/11 at 3:10 p.m. The DON stated he did not know what organism or infection Resident #1 had been treated for [REDACTED]. An interview with the DON on 11/04/11 at 2:30 p.m. revealed Resident #1 had a wound on his coccyx and a wound vac was in place. When queried regarding involvement of the MD in the assessment and progression of the resident's wound, the DON responded, "his recommendations would be in the Progress Notes and Physician's Orders. I don't know if he (MD) has actually seen the wound. He would look at reports by the treatment nurse and assess the wound as issues arise." The DON stated LVN E changed the resident's wound vac weekly on Wednesdays. When advised there was no initial or subsequent assessment in place to determine a baseline in order to evaluate if the wound was worse or better, the DON stated, "I have not had the opportunity to see the wound yet to determine any necessary changes." The DON also stated Resident #1's physician and had not yet observed the wound on the resident. Review of laboratory reports from Resident #1's hospital transfer records, reflected a report for the "superficial wound culture" dated 10/06/11. The final report reflected "...4+ mixed flora consisting of Staphylococcus species... and Corynebacterium species...." Resident #1 was admitted from an area hospital with antibiotics [MEDICATION NAME] 3.375 gram/50 ml IVPB to end 11/17/11. Review of a telephone order dated 10/19/11 at 5:00 p.m., revealed order for, "(1) Clean wound (R) Ischium with wound cleaner pat dry. Apply wound vac to area M-W-F and prn." Review of the care plan for Resident #1 revealed a care plan dated 10/20/11 for wound care. The approaches identified were: 1. Assess the wound daily for signs and symptoms of infection (i.e. [DIAGNOSES REDACTED], [MEDICAL CONDITION], drainage, eccymosis (sic), or poor approximation of wound edges. 2. Turn and reposition Q (every) 2 hours and prn (as needed). 3. Encourage increase fluid and intake 4. Consult ET nurse as needed and 5. Administer medications as ordered. Review of the weekly pressure ulcer healing record for the right Ischium dated 10/26/11 for Resident #1 revealed the measurements at that time were length 6.5 cm x width 5.5 cm and depth 1.8 with serosanguineous odorless, small drainage. On 11/04/11 at 3:30 p.m. the facility DON presented the surveyor with a new care plan for Resident #1. Review of the care plan revealed there was no care plan specifically for the pressure ulcer. The care plan also revealed Resident #1 required IV antibiotic therapy for treatment of [REDACTED]." 3) Resident #6's quarterly MDS assessment dated [DATE] reflected [DIAGNOSES REDACTED]. The resident scored a one out of 15 total points on the Brief Interview for Mental Status which indicated the resident was cognitively impaired. The resident was incontinent of bowel/bladder and totally dependent on others for all activities of daily living. Resident #6's Nurses Notes on 08/31/11 reflected the resident sustained [REDACTED]. The resident was transferred to the hospital and returned the same day with an immobilizer. Resident #6's Nurses Notes on 09/22/11 at 7:45 a.m. reflected "...pressure sore from brace/immobilizer noted on back of right ankle above the heel and bruise to inner back of knee...Treatment nurse notified/ADON for further evaluation...." Resident #6's Physician's Telephone Orders dated 09/22/11 reflected, "Clean wound right heel with wound cleaner pat dry. Apply Triple Antibiotic ointment and [MEDICATION NAME] Spray and cover with dry dressing and [MEDICATION NAME]." The Physician Telephone Order did not include the frequency or how often to provide the wound care or address the wound on the back of the ankle. (Note: Wound care was being provided on a daily basis to both the right heel and the back of the right ankle, per an interview with LVN E on 11/04/11 at 3:30 p.m.) Resident #6's Weekly Pressure Ulcer Healing Record dated 10/04/11 and signed by LVN E reflected the resident had a deep tissue injury measuring 7 cm by 3.5 cm with serosanguineous exudate, surrounding skin color normal for skin, and no culture was sent. There was not a site of the wound documented. Resident #6's Weekly Pressure Ulcer Healing Record dated 10/13/11 and signed by LVN E reflected the resident had a "2.5 cm by 3 cm wound with serosanguineous exudate, no odor, scant exudate amount, wound bed black/brown (eschar), surrounding skin color normal for skin, and no culture sent." The site and stage of the pressure ulcer was not documented and there was only one pressure ulcer. Resident #6's Weekly Pressure Ulcer Healing Record dated 10/19/11 and signed by LVN E revealed the resident had a "2.5 cm by 2.5 cm wound with serosanguineous exudate, no odor, small exudate amount, wound bed black/brown (eschar), surrounding skin color normal for skin, and no culture sent." The site and stage of the pressure ulcer was not documented and there was only one pressure ulcer. LVN E was observed providing wound care to Resident #6 on 11/02/11 at 10:15 a.m. It was observed at that time the resident had two pressure ulcers on the right foot: one approximately 3 cm by 6 cm, unstageable, black eschar on the heel; and one approximately 3 cm by 6 cm, Stage IV, on the right posterior ankle. The surveyor continued to watch as LVN E provided wound care to both pressure ulcers. LVN E stated Resident #3's pressure ulcers "started with a sheer. The brace had slid down and the heel was purple." Resident #6's Physician's Telephone Orders dated 10/27/11 reflected, "Clean wound right heel with wound cleaner pat dry. Apply [MEDICATION NAME] AG and cover with dry dressing daily. Revaluate in two weeks." The Physician's Telephone Order did not address the pressure ulcer on the back of the ankle. In an interview on 11/04/11 at 3:30 p.m. the surveyor asked the DON if the wounds, which LVN E was providing care to, should have a Physician Order to reflect the treatment provided. The DON stated, "Yes." The surveyor informed the DON Resident #3 had two pressure ulcers on her right foot,which LVN E was providing wound care for on a daily basis with orders for only one pressure ulcer. 4) Review of the facility policy "Pressure Ulcer Prevention & Skin Care Management dated December 2003 revealed the facility shall identify residents that are at risk for alteration in skin integrity, provide interventions to reduce the risk of pressure ulcer development, prevent infection and further skin breakdown and provide treatment and services that promote healing, prevent infection and further skin breakdown. The policy also reflected the following: - A licensed nurse shall complete a weekly skin assessment on each resident. - During routine daily care, the CNA shall observe the resident 's skin and report changes to the LN utilizing the skin identification tool. - Proper positioning devices shall be utilized between bony prominences and to off-load heel pressure while in bed and wheel/Geri-chair. - The Interdisciplinary Team shall develop a resident specific care plan for prevention of loss of skin integrity and revise according to resident needs. 5) The computer generated Form CMS-672, completed and signed by the DON on 11/01/11, reflected eight residents had pressure ulcers.