Accordius Health At Midwood, Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services for 1 of 3 residents (Resident #32) reviewed for beneficiary notification. The findings included: Resident #32 was admitted to the facility on [DATE] and Medicare Part A services began on 12/20/24. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was issued on 3/02/25 to Resident #32 which explained Medicare Part A coverage for skilled services would end on 3/04/25. Resident #32 remained in the facility. A review of the medical record revealed a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided to Resident #32. An interview conducted with the Business Office Manager (BOM) on 8/05/25 at 1:10 PM revealed she was responsible for issuing the CMS-10055 ABN and CMS-10123 NOMNC when a resident's Medicare Part A benefit was ending. She stated her employment at the facility did not begin until 3/10/25 and the Former Social Worker was issuing the ABN and NOMNC forms when Resident #32's Part A benefit ended. The BOM stated Resident #32 was issued the CMS-10123 NOMNC but not the CMS-10055 ABN. She revealed because Resident #32 remained in the facility both the CMS-10123 NOMNC and CMS-10055 ABN should have been issued. A phone interview with the Former Social Worker on 8/07/25 at 10:53 AM indicated while employed at the facility, the BOM was responsible for issuing the CMS-10123 NOMNC and CMS-10055 ABN when Medicare Part A benefits were ending and he did not recall a time when he was responsible for issuing the forms. During an interview with the Administrator on 8/07/25 at 3:27 PM she stated at the beginning of March 2025 they were in the process of hiring a new BOM and the Former Social Worker was responsible for issuing beneficiary notifications. The Administrator indicated when a resident's Medicare Part A benefit was ending, and they remained in the facility, both the CMS-10123 NOMNC and CMS-10055 ABN should be issued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to revise a resident's care plan with current cardiopulmonary resuscitation code status for 1 of 21 residents (Resident #64) reviewed for care plans. The findings included:Resident #64 was admitted to the facility on [DATE]. Her diagnoses included myasthenia gravis, diabetes mellitus, and essential primary hypertension. A review of Resident #64's care plan last revised on [DATE] indicated cardiopulmonary resuscitation (CPR)/Full Code status with a goal initiation date of [DATE], a goal revision date of [DATE] and a goal target date of [DATE]. Resident #64's most recent quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and revealed she was cognitively intact. A review of Resident #64's electronic medical record (EMR) social work progress note dated [DATE] revealed the Social Worker (SW) reviewed Resident #64's advanced directives with her and her code status was changed from a CPR/Full Code to Do Not Resuscitate (DNR) on the same date.A review of Resident #64's physical Medical Orders for Scope of Treatment (MOST) form, indicating DNR status, revealed the form was signed on [DATE]. An interview with the SW occurred on [DATE] at 12:36 PM. The SW explained Resident #64 indicated in a conversation about advanced directives that she wanted to change her code status from a CPR/Full Code to DNR. The SW recalled Resident #64 had two different MOST forms on file and she verified Resident #64's code status in the conversation. The SW stated code status changes were discussed during the facility's morning standup meeting and the MDS Nurse was tasked with making changes in the care plan.An interview was completed with the MDS Nurse on [DATE] at 12:44 PM. The MDS Nurse revealed she did not know Resident #64's code status from CPR/Full Code to DNR had changed. The MDS Nurse stated code status changes were typically discussed in clinical or standup meetings and the change in code status must have fallen through the cracks. The MDS Nurse indicated she would update the care plan with the correct code status.An interview with the Director of Nursing (DON) on [DATE] at 1:03 PM revealed Resident #64's code status change from CPR/Full Code to DNR should have been discussed in the morning standup meeting and the care plan should have been updated. The DON stated she was unsure why the code status change was not discussed in the morning stand up meeting.An interview with the Administrator on [DATE] at 1:17 PM revealed code status changes were discussed in their daily clinical meetings and discussed in their weekly risk management meetings. The Administrator was unsure how Resident #64's code status from CPR/Full Code to DNR was missed but she expected Resident #64's care plan to be updated timely.

Based on observations, record review and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities resulting in a medication error rate of 8% for 1 of 5 residents observed during medication administration observation (Resident #6). Findings included: On 08/06/2025 at 9:07 AM, Nurse #3 was observed and interviewed as he prepared to administer medication to Resident #8. He stated Resident #8 had a gastrostomy tube (g-tube) as indicated on his medication sheet located on the top of the medication cart. Nurse #3 obtained the medication aspirin 81 milligrams (mg) and losartan 50mg from the medication cart and proceeded to crush the medication and place it into a cup. Upon entrance into the resident room, Resident #8 was observed lying in bed as well as her roommate Resident #6. Resident #8 did not have a g-tube, and Resident #6 did have a g-tube. Nurse #3 was observed administering the medication prescribed to Resident #8 to Resident #6 during the medication pass observation. A review of Resident #8's medication orders revealed the resident had a current order initiated on 04/17/25 for losartan potassium oral tablet 50 mg give one tablet by mouth one time a day related to hypertension. Resident #8 also had an order initiated on 04/17/25 for aspirin oral tablet 81 mg by mouth one time a day related to hemiplegia (muscle weakness or partial paralysis on one side of the body). The medication error was identified during the surveyor's record review immediately following administration of the medication. On 08/06/25 at 9:55 AM an interview was conducted with Nurse #3. During the interview the surveyor notified Nurse #3 that he had administered Resident #8's medication to Resident #6. Nurse #3 immediately reviewed his medication sheet located on the top of the medication cart and showed the surveyor the sheet had Resident #8 as having a g-tube. He stated, I accidently got the two residents mixed up. Nurse #3 stated he had not realized he had made a medication error until the surveyor notified him. The interview revealed Nurse #3 was agency staff and did not work in the facility very often. He stated he was not familiar with the residents and had never worked on the assigned hall before. Nurse #3 immediately checked on Resident #6 and went to notify Nurse Practitioner #1. Nurse #3 stated after administering medication to Resident #6 he was then called to another room down the hall to administer medication and he had not administered any medication to Resident #8. On 08/06/25 at 11:00 AM an interview was conducted with Unit Manager #1. During the interview she stated Nurse #3 had come to her and notified her of the situation. Unit Manager #1 stated she had notified Nurse Practitioner #1 who was on her way to the facility, the Medical Director and Resident #6's Responsible Party (RP). On 08/06/25 at 11:14 AM an interview was conducted with Nurse Practitioner (NP)# 1. During the interview she stated she was notified by Unit Manager #1 that Nurse #3 had administered the incorrect medication to Resident #6. NP #1 stated anytime a resident received the wrong medication it was an issue however after her assessment of Resident #6 she was not experiencing any adverse reaction to the medication so far. She stated she gave the facility orders to obtain the residents blood pressure every 2 hours for a duration of 24 hours. The interview revealed she typically did not receive calls from the facility stating medication errors had occurred, so it was an unusual situation. NP #1 explained Resident #6 had received all of her scheduled medications following identification of the medication error and her medications included midodrine HCL oral tablet 5 mg ordered on 06/10/25 for low blood pressure. She stated because Resident #6 had received Resident #8's blood pressure medication there was a chance her blood pressure could drop, however Resident #6 was already prescribed a medication to help keep her blood pressure stable. On 08/06/25 at 11:26 AM a follow up interview was conducted with Nurse #3. During the interview he stated after realizing he had administered the wrong medication to Resident #6 he went to the nurse's station and told Unit Manager #1 who then called Nurse Practitioner #1 and the Medical Director. The interview revealed Resident #6's blood pressure was 92/60 and he received orders to check it every 2 hours. Nurse #3 stated he felt terrible about the situation, but it was hard because he didn't know the residents well in the facility and he saw g-tube listed by her name on the medication sheet located on the top of the medication cart, so he followed it. On 08/07/25 at 3:09 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated all nurses in the facility should be following the 6 rights of medication administration including right patient, right medication, right dose, right route, right time and right documentation. The DON stated the nurses on the hall had created a report sheet as a guide for agency staff and they had updated it as needed. Resident #8 had a g-tube at one time however it had been removed and the only resident in the room with a g-tube was Resident #6. She stated regardless of the paper on the top of the medication cart Nurse #3 should have been checking the electronic charting system to verify he had the correct resident prior to administration of the medication. She stated if he had a question, her office was right down the hall, and he could have asked for assistance. On 08/07/25 at 10:53 AM an interview was conducted with the Administrator. During the interview she stated the medication error occurred due to Nurse #3 not following the rights of medication administration. She stated the nurse had utilized a report sheet created by fellow nurses instead of using the residents Medication Administration Record (MAR). The report sheet showed Resident #8 had a g-tube and when he walked into the room, he saw Resident #6 had a g-tube and got the two residents confused. The Administrator stated Resident #6 was monitored closely during the day and through the night to ensure she had no adverse reaction to receiving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews with Registered Dietitian, Speech Therapist, and staff, the facility failed to modify a resident's diet order to meet her individual needs for 1 of 5 residents reviewed for nutrition (Resident #47).Findings included:Resident #47 was admitted to the facility 02/20/25 with a diagnosis including malnutrition. Hospital records revealed Resident #47 had a hospital stay on 03/30/25 due to shortness of breath. She was discharged back to the facility on [DATE].Review of Resident #47's physician orders revealed an order dated 04/07/25 for a regular diet. A Nurse Practitioner note dated 06/11/25 revealed Resident #47 was evaluated for a nursing request for medication and lab review. It was the Nurse Practitioner's initial encounter with Resident #47. Resident #47 expressed during the evaluation that she was concerned her dentures were missing. The Nurse Practitioner had a discussion with the Director of Nursing regarding the resident's lost dentures, and the DON was aware of the situation. Resident #47 went to the hospital with her dentures however when she returned the hospital did not send the dentures back with her. A dental examination note dated 06/23/25 revealed Resident #47 was evaluated on this date by the facility dentist. The note revealed Resident #47 did not have dentures at the time of the evaluation and the treatment plan included completing denture impressions on the next visit to the facility. Resident #47 was noted to have an atrophic lower ridge and was not a candidate for a lower denture. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. No nutritional approaches were documented during the assessment period. Review of Resident #47's weights revealed the following:- 05/16/25: 128.2 pounds- 06/07/25: 130 pounds- 07/07/25: 124.6 pounds On 08/04/25 at 11:28 AM an interview was conducted with Resident #47. Resident #47 stated she had lost her upper dentures the month prior and was having a difficult time eating her meals at the facility. She stated the facility continued to serve her a regular diet which included corn on the cob. Resident #47 stated she could not eat a lot of the meals provided by the facility and had told staff members (name she could not recall) that she was having difficulty eating. An observation of Resident #47's lunch meal ticket on 08/05/25 at 12:45 PM revealed she was to receive a regular diet. An observation of Resident #47's meal tray at the same time and date revealed she received two large kielbasa sausages with cabbage, canned sliced peaches and a roll. Resident #47 was observed cutting the sausages into smaller bites and attempting to chew the meat. An observation of Resident #47's lunch meal ticket on 08/06/25 at 12:30 PM revealed she was to receive a regular diet. An observation of Resident #47's meal tray at the same time and date revealed she received a slice of ham, mashed potatoes, corn on the cob and a cookie. An interview was conducted with Resident #47 at the time of the observation. Resident #47 stated, See it happens every day, I get food a cannot eat because I have no teeth. She stated she had told staff members she was unable to eat corn on the cob however nobody would ever change anything. She stated, I don't understand why they couldn't give me creamed corn, it makes me feel stupid. On 08/06/25 at 12:35 PM an interview was conducted with Nurse #4. The surveyor explained Resident #47 wanted a substitute for corn on the cob served for the lunch meal. Nurse #4 stated she was agency staffing and it was her first day in the facility. She stated she was not familiar with the resident, nor did she know if the resident had dentures. Nurse #4 stated she would go to the kitchen to see if they had a substitute for the corn served. On 08/06/25 at 1:03 PM an observation was conducted of Resident #47 with a bowl of creamed corn. An interview conducted with Resident #47 at the same date and time revealed Nurse #4 had provided her with the bowl of corn. Resident #47 stated, It is so good, I don't understand why they can't do this all of the time. On 08/06/25 at 2:59 PM an interview was conducted with Nurse Aide #3. During the interview she stated she had never heard Resident #47 complain about not having dentures but had heard her complain once about her diet. NA #3 stated Resident #47 had said to her, look at my mouth, my diet should be puree its hard for me to eat. NA #3 stated she went to the kitchen to get the resident an alternative meal she could eat and told the Nurse on duty (whose name she could not recall). On 08/06/25 at 3:07 PM an interview was conducted with the Speech Therapist. During the interview she stated she had never worked with Resident #47 because nobody from the nursing staff had mentioned she was experiencing difficulty eating her prescribed diet. The Speech Therapist explained if a resident was having any issues eating the assigned diet nursing staff could downgrade the diet themselves or send a referral for therapy to see if the need for a diet change was there. On 08/07/25 at 2:46 PM an interview was conducted with the Dietitian. She stated she came into the building weekly on Thursdays and had evaluated Resident #47 in the past. She stated Resident #47 had a slight decrease in weight since April 2024 but overall, her weight had maintained consistently 123 pounds to 124 pounds. The Dietitian stated issues with Resident #47's diet had not been voiced prior to 08/07/25 and that nursing staff could have downgraded her diet at any time. On 08/07/25 at 3:09 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Resident #47's dentures had been lost by the hospital during an admission. The DON explained Resident #47 had been seen by dental services and they were working on getting Resident #47 a new set of dentures. She stated she was unaware of any issues with the resident being unable to eat her meals. She stated if she was having issues, she would expect nursing staff to let the Dietitian or Speech therapist know and to downgrade her diet. The DON stated she had seen Resident #47 eating her meals without difficulty and that the resident had never expressed to her she was having issues. On 08/07/25 at 10:34 AM an interview was conducted with the Administrator. During the interview she stated the Social Worker had put in a request for new dentures for Resident #47. She stated if Resident #47 was experiencing an issue with her diet or meals, nursing staff should let them know and her diet could be adjusted.

Based on observations, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Nurse #2 did not doff her gloves, perform hand hygiene and don clean gloves prior to cleaning wound and applying new wound dressing to Resident #31's sacrum. Additionally, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 did not don a gown during a high contact care activity which included dressing Resident #31 who had a chronic wound and feeding tube. The deficient practice occurred for 2 of 5 staff members observed for infection control practices (Nurse #1 and Nurse #2).The findings included:
A. The Hand Hygiene policy without revision date, revealed hand hygiene means to clean one’s hands with either a sanitizer product or with soap and water and glove use was not a substitute for hand hygiene. The policy also revealed staff were to perform hand hygiene for the following:
- During all care activities and while working in all locations within the facility.
- Before and after wearing gloves.
- After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings.
An observation was conducted on 8/7/2025 at 10:59 AM while Resident #31 received wound care. Nurse #2 was observed entering Resident #31’ts room wearing a gown, then applied gel hand sanitizer, and donned gloves. Next Nurse #2 removed the soiled dressing from Resident #31’s sacrum and placed soiled dressing in the trash. Nurse # 2, without changing gloves cleaned the wound on Resident #31’s sacrum and placed a clean dressing on the wound. Nurse #2 cleaned the workstation, removed gloves and gown. Nurse #2 used gel hand sanitizer prior to exiting Resident #31’s room.
An interview was conducted on 8/7/2025 at 11:40 AM with Nurse #2. Nurse #2 stated she did not sanitize or wash her hands between removing the old dressing, cleaning the wound, and placing the new dressing on Resident #31’s wound because she had forgotten and stated, “maybe I could have double gloved and removed a pair of gloves after removing the dirty dressing.” The interview revealed that Nurse #2 completed wound care in the facility throughout the week for her assigned residents that required wound care.
An interview was conducted on 8/7/2025 at 2:28 PM with the Director of Nursing (DON). The DON stated she served as the Infection Control Nurse for the facility since April of 2022. The DON stated staff received education about infection control during orientation and annually. The DON reported that when staff performed wound care, they should wash their hands and change gloves before removing the old dressing and then perform hand hygiene and change gloves in between wound care steps because of the contact with body fluids and non-intact skin. The DON stated Nurse #2 should have changed gloves and performed hand hygiene after she removed the dirty dressing, after cleaning the wound, and before applying a new dressing.
B. The facility's policy for Enhanced Barrier Precautions (EBP) revised on 3/27/24 read in part: EBP refer to infection control interventions designed to reduce the transmission of multidrug-resistant organisms which employs targeted gown and gloves use during high contact resident care activities for residents with wounds and/or indwelling medical devices. High contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube and tracheostomy, and wound care: any skin opening requiring a dressing.
An observation conducted on 8/04/25 at 11:33 AM revealed Resident #31 had personal protective equipment (PPE) including gowns and gloves available in a caddy hanging on the door to her room. Nurse Aide (NA) #1 and Nurse #1 were observed entering Resident #31’s room to reposition her in bed. NA #1 donned a gown and gloves and Nurse #1 donned gloves. Upon entering Resident #31’s room EBP signage was observed on the closet door instructing staff to wear a gown and gloves during high contact care activities which included bathing, dressing and transfers. Resident #31 was lying flat in bed covered with a sheet and had a feeding tube in place. NA #1 and Nurse #1 used a draw sheet to pull Resident #31 up in the bed and then elevated the head of the bed to approximately 45 degrees. Nurse #1 assisted NA #1 to dress Resident #31 in a shirt and then disposed of her gloves, performed hand hygiene and exited the room.
During a phone interview with Nurse #1 on 8/07/25 at 2:14 PM she revealed Resident #31 was on EBP due to having a wound and a feeding tube. Nurse #1 indicated she was unaware of the EBP signage posted in Resident #31’s room however the PPE caddy hanging on the room door indicated that EBP was in place. Nurse #1 revealed she wore a gown and gloves when providing care related to Resident #31’s wound or feeding tube. Nurse #1 stated she did not think a gown was required when putting Resident #31’s shirt on because it was not involving her wound or feeding tube.
An interview conducted with the Director of Nursing (DON) on 8/07/25 at 3:13 PM indicated she was also the facility's Infection Preventionist (IP). She stated EBP were implemented for residents with an open wound and/or indwelling medical device such as a feeding tube or urinary catheter. She revealed residents on EBP had a PPE caddy containing gowns and gloves hanging on their door and EBP signage was posted inside their room. She stated when staff provided high contact care for a resident on EBP which included bathing, dressing and transfers they should wear a gown and gloves.
During an interview with the Administrator on 8/07/25 at 3:20 PM she revealed staff providing high contact care for a resident on EBP such as bathing, dressing and transfers, should wear a gown and gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, responsible person (RP) and Medical Director (MD) interviews, the facility failed to notify the MD when multiple doses of significant morning medications (seizure medication, insulin, depression medication, and chronic kidney and heart failure medication) were not administered due to Resident #20 being out of facility for dialysis treatment and not administered her morning medications. There was a high likelihood of failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. Additionally, the facility failed to notify the Responsible Person (RP) for Resident #66 when Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with handle. This deficient practice affected two of three sampled residents reviewed for notification (Resident #20 and #66).
Immediate jeopardy began on 4/02/24 when the facility failed to notify the physician when medications scheduled for morning administration (a seizure medication, insulin, a depression medication, and a chronic kidney and heart failure medication) were not administered on multiple occasions to Resident #20. Immediate jeopardy was removed on 4/28/24 when the facility implemented an acceptable credible allegations of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective.
Example #2 for Resident #66 was cited at a scope and severity of D.
Findings included:
1. Resident #20 was admitted to the facility on [DATE] with diagnoses to include renal dialysis dependence, heart failure, seizure disorder, depression, and diabetes. Resident #20 also received scheduled dialysis treatments outside of the facility on Tuesday, Thursday, and Saturday and would leave the facility for these treatments at 5:30 AM and return to the facility at 10:30 AM.
Review of physician orders for significant medication for Resident #20 are as follows:
Escitalopram 20 milligrams (MG), give 1 tablet by mouth one time a day related to depression;
Keppra 24 hour extended release 500 MG, give 1 tablet by mouth one time a day related to epilepsy;
Ozempic 1 MG solution pen-injector, inject subcutaneously (beneath the skin) 1 time a day every Thursday related to type 2 diabetes;
Carvedilol 25 MG, give 1 tablet by mouth 2x's daily for hypertensive heart disease and chronic kidney disease with heart failure; and
Humalog 100-unit/ milliliter (ML) solution pen- injector, inject subcutaneously per sliding scale before meals and at bedtime related to type 2 diabetes.
Review of the Medication Administration Record (MAR) dated April 2024 revealed dates of Resident #20 not receiving significant morning medications due to being out of the facility for scheduled dialysis treatments. Per Resident #20's April 2024 MAR, missed doses of scheduled significant morning medication are as follows:
Escitalopram (9 AM) - Tuesday 4/02, Thursday 4/11, Tuesday 4/16
Keppra (8 AM) - Tuesday 4/02, Tuesday 4/09, Thursday 4/11, Tuesday 4/16
Ozempic (9 AM) - Thursday 4/11
Carvedilol (7:30 AM) - Tuesday 4/02, Tuesday 4/09, Thursday 4/11, Tuesday 4/16
Humalog and blood sugars (7:30 AM) - Tuesday 4/02, Tuesday 4/09, Thursday 4/11, Saturday 4/13, Tuesday 4/16
Per the manufacturer label warnings, failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, increased blood pressure and heart rate which could lead to stroke and cardiac complications, anxiety, and irritability.
Review of Resident #20's April 2024 nursing progress notes revealed no documentation of the MD being notified of the missed medications.
A telephone interview was conducted with the MD on 04/17/24 at 4:24 PM. The MD revealed that he had not been made aware of Resident #20 not receiving her morning medications on the days she received dialysis. He stated all dialysis residents should be administered any medications missed while at dialysis upon their return. The MD also stated that he would have expected the facility to notify him if a resident's dialysis treatments were conflicting with when a medication was ordered to be administered so he could adjust the medications and their times to be administered. Due to having no knowledge of Resident #20 not being administered morning medications on days where she had received dialysis treatments, he was not able to comment on any outcome it caused or could have caused and whether those would have been significant or not.
An interview was conducted with the Administrator and Director of Nursing (DON) on 04/18/24 at 12:20 PM revealed they were not aware Resident #20 had missed her medications. The Administrator stated nursing staff had been educated that anytime a medication is not administered to a resident for whatever reason they were to notify the physician, the supervisor and document. The DON revealed all dialysis residents should be administered their scheduled medications upon their return to the facility and any issues with not being able to administer those medications should be reported immediately to the physician for recommendations on how to proceed, the nursing supervisor and documented.
The Administrator was notified of immediate jeopardy on 04/26/24 at 1:07 PM.
The facility provided the following plan for IJ removal.
Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
The facility failed to notify the Medical Director of missed/omitted significant medications prescribed for Resident #20 to treat diabetes, epilepsy and hypertensive heart disease and chronic kidney disease with heart failure, and depression. Nurse #13 and Nurse #15 did not notify the medical provider of the missed/omitted significant medications.
On 4/18/24 Nurse #13 received verbal 1 on 1 education by Director of Nursing (DON) on policy regarding notification of provider and resident representative promptly upon any resident change in condition, clinical complications, or need to alter treatment significantly. Education also included notifying the medical provider regarding missed significant medications when a resident is out of the facility when these medications are due to be administered. Nurse #13 verbalized understanding of re-education.
On 4/18/24 facility Medical Director (MD) was notified by DON of Resident #20's identified medication omissions. An order was obtained from MD to administer all prescribed medications upon return from dialysis for all residents in the facility who receive dialysis treatment.
The DON completed an audit on 4/18/24 of all residents receiving dialysis services back 4/1/24 to ensure no other significant medication errors. Any errors identified were reported to MD.
On 4/27/24 DON completed an audit of all residents' Medication Administration Records back to 4/1/24 for med errors/omissions and reviewed incident reports to ensure notification of responsible party/family and MD was completed. The Director of Nursing reviewed electronic health care record dashboard back to 4/1/24, which reflects resident's changes in conditions, new medication orders, omitted medications as well as risk management dashboard for incidents and accidents to ensure notification to resident's responsible party and the medical practitioner.
Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.
4/24/24 Quality Assurance Performance Improvement (QAPI) meeting was held by Administrator (LNHA) with all department heads on policy regarding notification of provider and resident representative promptly upon any resident change in condition, clinical complications, or need to alter treatment significantly and MD via phone. Notification Policy was reviewed during QAPI. Education/audits/monitoring were discussed. MD and Department Heads verbalized understanding. The Notification Policy did not require revisions at this time.
On 4/24/24 in person education began with all licensed nurses (including Nurse #15) and medication aides including agency nurses and medication aides by DON/ Assistant DON (ADON)/Nurse Managers on policy regarding notification of medical provider and resident representative promptly upon any resident change in condition, clinical complications, or need to alter treatment significantly, including medications missed/omitted. Education also included notification to medical provider for all missed or omitted medications for residents out of the facility and/or on leave of absence. All staff verbalized understanding. Education to all remaining licensed nurses and medication aides was completed by DON on 4/24/24 via phone and/or in person. All staff not educated on 4/24/24 will be educated by DON/ADON/Nurse Manger prior to the start of their next shift. The DON will be responsible for maintaining an employee tracking log to identify staff that still require education. All newly hired nurses and medication aides, including agency nurses and medication aides, will receive this education from the DON/ADON during the orientation process. The Nurse Manager on duty will provide verbal education to any agency staff member that works after 4/24/24 prior to accepting shift assignment. DON/ADON/Nurse Managers were made aware of this responsibility by the Administrator on 4/24/24. The DON will notify the Nurse Managers when there is a new agency nurse or medication aide that requires the education.
Alleged date of immediate jeopardy removal: 4/28/24
A validation of immediate jeopardy removal was conducted on 05/07/24. The audit of all dialysis residents was reviewed and verified that each resident that received dialysis had an ordered entered into their medical record that indicated all prescribed medications were to be given upon return from dialysis treatment. Each resident's care plan was also updated and verified as a part of the removal verification process. Staff in-service records and interviews with nursing staff confirmed they were educated on the requirement of notification to the medical provider and responsible party when medications were missed or omitted. The facility's QA committee met on 04/24/24 and reviewed the policy on notification which did not require any revisions. The QA verbalized understanding of the policy and requirement. Audits completed from 04/28/24 through 05/06/24 were reviewed with no new issues identified. The facility's removal date of 04/28/24 was validated.
2. Resident #66 was admitted to the facility on [DATE] with diagnosis that included a left arm fracture and dementia.
An interview with Nursing Assistant (NA) #6 on 4/17/24 at 9:00 AM revealed she had been employed at the facility since August 2023 and was familiar with Resident #66. She stated on 2/21/24 she was walking up the resident 200 hall and observed Resident #66 standing right outside of the maintenance room (located at the top of the 200 hall between the utility room and beauty parlor), the door was unlocked and cracked open. Resident #66 had a long ridged knife with a handle in her right hand and using a back-and-forth motion was attempting to cut off the cast located on her left arm. The NA stated she assumed Resident #66 had gotten the knife from inside the maintenance room since that was where she was standing. NA #6 revealed she asked Resident #66 to hand her the knife, which she did with no issues and placed it back inside the maintenance room and shut the door. She assessed Resident #66's body for any injuries, and walked her back to her room where she assessed her again for any injuries and did not observe any visible injuries and Resident #66 had no complaints of pain. NA #6 stated she did not recall if she informed any of the nurses on the hall but did report the incident to the DON. She revealed Resident #66 had a history of wandering all the halls in the facility and would stop at each room and try and turn all the door handles to see if they would open. She stated she had no knowledge of what occurred after she notified the DON of the incident, and she did not lock the maintenance door back and was not aware if anyone else locked the maintenance door after the incident or why the maintenance door had been unlocked in the first place.
Review of Resident #66 progress notes from February 2024 to present revealed no documentation of incident or notification of incident to Resident #66's Responsible Party (RP) or the Medical Director.
An interview with Resident #66's RP on 04/17/24 at 10:45 AM revealed she had not been notified of the incident with Resident #66 standing outside of the unlocked maintenance room attempting to cut the cast off of her left arm with a ridged knife on 2/21/24. She stated she would have liked to have been notified of the incident so that she could have come to the facility to assess Resident #66 herself, address any issues and make sure that Resident #66 was safe and unharmed.
A telephone interview was conducted with the MD on 04/17/24 at 4:24 PM. The MD revealed that he had not been made aware of the incident with Resident #66 that occurred on 2/21/24 and would have preferred the facility to notify him or the nurse practitioner about the incident so they could have discussed any change in behavior or condition, possible treatments, or medication changes.
An interview with the Administrator and Director of Nursing (DON) on 04/18/24 at 12:20 PM revealed the Administrator had not been made aware of the incident and the DON did not recall being notified of the incident with Resident #66. The Administrator stated anytime an event such as a behavioral incident or accident occurs with a resident, nursing staff should notify their supervisors immediately and document the event so they can investigate the incident properly, provide notifications to the residents' RP and family, and make sure the correct precautions or treatment are put into place. The Administrator and DON revealed Resident #66's RP should have been notified of the incident when it occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family, and staff interview the facility failed to protect Resident #172's private health information when her insulin pen was left at the bedside of another resident for 1 of 2 residents reviewed for privacy and confidentiality.
The findings included:
Resident #171 was admitted to the facility on [DATE] and was discharged on 09/06/23. Resident #171's diagnoses included diabetes mellitus.
Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #171 was cognitively intact.
Resident #171 was interviewed via phone on 04/15/24 at 4:31 PM. Resident #171 stated that on 07/10/23 at 6:06 PM Nurse #10 came into her room to give her an insulin shot. She stated Nurse #10 had laid the cap to the insulin pen on her bedside table and after she had given the insulin shot to Resident #171, she (Resident #171) noted that the label that was on the insulin pen cap had Resident #172's name on it.
A picture provided by Resident #171 on 04/15/24 at 4:59 PM revealed an Insulin Pen with a label that contained Resident #172's name, room number, type of insulin, prescription number and fill date. The type of insulin was Lispro insulin (fast acting insulin).
Resident #171's family member was interviewed via phone on 04/16/24 at 5:03 PM. The family member stated that Resident #171 had called and had sent her a picture of the insulin pen belonging to Resident #172. The family member stated she reported the issue to the Director of Nursing (DON) in July after the incident occurred.
The DON was interviewed on 04/18/24 at 2:47 PM. The DON stated that all staff were responsible for ensuring the protection of protected health information. And in this situation the prudent thing to have done was ensure that no protected health information was left for another resident to see it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interviews the facility failed to protect a resident's right to be free from inappropriate physical contact by a staff member. On 4/1/24 Nurse Aide (NA) #1 was observed lying in bed with Resident #46. This deficient practice occurred for 1 of 5 residents reviewed for abuse, neglect, and exploitation.
The findings included:
The facility Abuse/ Neglect and Exploitation Policy read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion.
The initial allegation report dated 4/10/24 included in part, It was reported that an agency Nurse Aide #1, got into the bed with Resident #46 and allowed him to touch on her. Nurse Aide #1 has been suspended pending investigation.
Resident #46 was readmitted to the facility on [DATE] with diagnoses that included depression and legal blindness.
A quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #46 was cognitively intact, and severely impaired vision/ legally blind.
During an interview on 4/15/24 at 2:25 pm Resident #46 indicated at about 2:00 am a few weeks prior (couldn't recall exact date) he was awakened to a voice and believed the person may have been on the phone. Resident #46 stated he was blind and did not know who the person was. Resident #46 stated he did not know for sure if the person was in his bed with him or if the person was sitting on the bed. He stated the person who he later identified as NA #1, was also talking to another NA (NA #3) who was with his roommate. Resident #46 recalled NA #1 called him (Resident #46's) by name and stated, I'm sorry am I waking you up? Resident #46 stated he told NA #1 no. Resident #46 stated he never touched NA #1 intentionally and NA #1 never touched him.
During a follow up interview on 4/17/24 at 2:34 pm Resident #46 revealed he may have touched NA#1 on her thigh and quickly removed it when he realized there was someone in or on his bed. Resident #46 recalled NA #1 was talking to a NA on the other side of the room when he was awakened, then inadvertently touched NA #1 on the thigh and NA #1 stated I'm sorry, did I wake you? Resident #46 stated he was not bothered that NA #1 was in his bed and indicated that she may have been lying down at first.
During a phone interview on 4/17/24 at 3:06 pm NA #1 revealed she worked from 11:00 pm on 3/31/24 to 7:00 am on 4/1/24 and was assigned to Resident #46 as the one-to-one sitter. NA #1 stated Resident #46 was asleep when she arrived for her shift, and she relieved the previous sitter. NA #1 stated NA #3 took breaks during the night and she monitored his resident who was also on one-to-one. NA #1 stated throughout her shift, she sat in a chair at the foot of Resident #46's bed and that Resident #46 awakened about 2-3 times during the night to request ice water. NA #1 stated she never sat on or laid in Resident #46's bed, she never touched Resident #46, she was never talking on her cell phone, and she never asked Resident #46 if she woke him up. NA #1 stated numerous people told her that a rumor was going around that she was in bed with Resident #46, and they were touching each other. NA #1 further revealed she did not know why NA #3 and Resident #46 would have made those statements. NA #1 also stated she had never been accused of sleeping on her shift.
During a telephone interview on 4/17/24 at 1:35 pm Nurse Aide (NA) #3 revealed worked a double shift (3pm -11pm and 11pm- 7am) on 3/31/24 and was he was assigned as the one-to-one sitter (11pm- 7am shift) for Resident #46's roommate who occupied bed A (which was closest to the door), and the privacy curtain was pulled between the beds to allow privacy of both residents as they slept. NA #3 stated NA #1 was assigned as the one-to-one sitter for Resident #46. NA #3 further revealed between 1:30 am and 2:00 am he stood up from his chair, walked around the privacy curtain and was about to ask NA #1 to monitor the bed A resident while he (NA #3) went on break when he observed NA #1 lying in bed with Resident #46. NA #3 stated he observed NA #1 lying on her back with eyes closed and Resident #46 also appeared to be asleep. Resident #46's had his right hand resting under NA #1's breasts. NA #3 indicated he stated to NA #1 Girl, what are you doing? and NA #1 opened her eyes and did not respond verbally. Instead, she shrugged her shoulders and propped her arm behind her head. NA #3 stated he left the room to go on break, stopped at the nurse's station and stated to Nurse #13, Yall need to go check on Resident #46. NA #3 recalled Nurse #13 responded Why what's wrong with him? NA #3 stated he informed Nurse #13 there was nothing wrong with Resident #46, but NA #1 was lying in bed with him. NA #3 stated when he returned to Resident #46's room, NA #1 was sitting in the chair next to bed A, then got up, returned to Resident #46's side of the room (bed B), sat in a chair and did not say anything further to him (NA#3).
During an interview on 4/18/24 at 2:45 pm Nurse #13 indicated she worked 3/31/24 to 4/1/24 (11pm -7am shift). On 4/1/24, she overheard NA #3 talking about NA #1 lying in bed with Resident #46 and when she went to see herself, NA #1 was sitting in a chair in Resident #46's room. Nurse #13 further indicated she asked NA #1 if everything was okay and did not specifically ask NA #1 if she had been lying in bed with Resident #46.
During a telephone interview on 4/17/24 at 5:51 pm Unit Manager #1 indicated on 4/10/24, she overheard staff talking about NA #1 lying in the bed with Resident #46 on the overnight shift on 4/1/24. Unit Manager #1 further indicated she reported the incident to the DON on 4/10/24.
During an interview on 4/18/24 at 3:30 pm the DON revealed she was made aware of the incident that involved Resident #46 and NA #1 on 4/10/24. The DON stated her expectation was for all residents to be protected from abuse, neglect, exploitation, and inappropriate physical contact was not acceptable. The DON further stated staff have been educated on the abuse policy.
During an interview on 4/18/24 at 3:25 pm the Administrator indicated she had not been made aware of the incident that occurred between NA #1 and Resident #46 until 4/10/24 and that the incident took her by surprise because staff were always calling her about everything else that occurred in the facility. The Administrator further indicated she expected all residents to be free from abuse, neglect, exploitation, misappropriation, and inappropriate physical contact was not acceptable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews and staff interviews the facility failed to follow their policy in the areas of reporting and protection. The facility failed to immediately report inappropriate staff to resident physical contact when Nurse Aide (NA) #1 was observed by another staff member (NA #3) lying in bed with Resident #46. NA #1 continued to work shifts on 4/1/24, 4/5/24, 4/6/24, 4/7/24. One of 5 residents were reviewed for abuse.
The findings included:
The facility Abuse/ Neglect and Exploitation Policy read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. The facility shall have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within 2 hours after the allegation is made if the allegation involved abuse or resulted in serious bodily injury or no later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury.
Resident #46 was readmitted to the facility on [DATE] with diagnoses that included depression, type 2 diabetes, bilateral glaucoma, legal blindness, and dependence on renal dialysis.
A quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #46 was cognitively intact, independent of care needs, had adequate hearing, clear speech, and severely impaired vision/ legally blind.
During an interview on 4/15/24 at 2:25 pm Resident #46 indicated he heard a lot of people stated he was in bed with a staff member. He further indicated about 2:00 am a few weeks prior (couldn't recall exact date) when he had planned to go to dialysis the following morning, he was awakened to a voice and believed the person may have been on the phone. Resident #46 stated he was blind and did not know who the person was. Resident #46 stated he did not know for sure if the person was in his bed with him or if the person was sitting on the bed while he laid in the bed. He stated the person who he later identified as a female, was also talking to another NA who was with the resident in bed A. Resident #46 recalled NA #1 called him (Resident #46's) by name and stated, I'm sorry am I waking you up? Resident #46 stated he told NA #1 no. Resident #46 stated he never touched NA #1 intentionally and NA #1 never touched him. Resident #46 stated NA #1 was sat on his bed for 10-15 minutes.
During a follow up interview on 4/17/24 at 2:34 pm Resident #46 revealed he may have touched NA#1 on her thigh and quickly removed it when he realized there was someone in or on his bed. Resident #46 recalled NA #1 was talking to a NA on the other side of the room when he was awakened, then inadvertently touched NA #1 on the thigh and NA #1 stated I'm sorry, did I wake you? Resident #46 stated he was not bothered that NA #1 was in his bed and that she may have been lying down at first.
During a telephone interview on 4/17/24 at 1:35 pm NA #3 revealed he worked a double shift (3pm -11pm and 11pm- 7am) on 3/31/24 and was he was assigned as the one-on-one sitter (11pm- 7am shift) for Resident #46's roommate who occupied the first bed (bed A). NA #3 stated NA #1 was assigned to one-on-one sitter for Resident #46. NA #3 further revealed between 1:30 am and 2:00 am he stood up from his chair, walked around the privacy curtain and was about to ask NA #1 to monitor the bed A resident while he (NA #3) went on break when he observed NA #1 lying in bed with Resident #46. NA #3 stated he observed NA #1 lying on her back with eyes closed and Resident #46 also appeared to be asleep as his right hand rested under NA #1's breasts. NA #3 indicated he stated to NA #1 Girl, what the hell are you doing? and NA #1did not respond verbally. Instead, she shrugged her shoulders as if she did not care and propped her arm behind her head. NA #3 stated he left the room to go on break, stopped at the nurse's station and stated Yall need to go check on Resident #46. NA #3 recalled Nurse #13 responded Why what's wrong with him? NA #3 stated he informed Nurse #13 there was nothing wrong with Resident #46 but NA #1 was lying in bed with him. NA #3 stated when he returned from his smoke break, Nurse #13 stated she observed Nurse Aide #1 sitting on the side of the resident's bed and did not observe her lying in the bed with the resident. NA #3 stated since he was the only one who observed NA #1 in the bed with the resident, he figured it would be viewed as his word against NA #1's word. NA #3 stated when he returned to Resident #46's room, NA #1 was sitting in the chair next to bed A, then got up, returned to Resident #46's side of the room (bed B), sat in a chair and did not say anything further to him (NA#3). NA #3 stated the next morning (4/1/24) he told a few other staff who worked that night, about the incident but was unsure who he told. NA #3 stated when he returned to work another shift on 4/1/24 (3p-11p), Resident #46 was on the smoking patio talking/ joking about the incident and how he thought he was dreaming that there was someone in his bed the previous night, until he felt breasts and that's when he (Resident #46) knew there really was someone in his bed. NA #3 stated he reported the incident to Nurse #13 and did not report the incident to the assigned nurse, Director of Nursing, or the Administrator because he thought the supervisors already knew about it.
During an interview on 4/17/24 at 3:47 pm NA #4 revealed she overheard other staff talking about the NA #1 being observed asleep in bed with Resident #46 and thought it was a joke, although she reported it to the assigned nurse (Nurse #14).
Attempts to contact Nurse #14 were unsuccessful.
During a telephone interview on 4/17/24 at 5:51 pm Unit Manager #1 indicated on 4/10/24 she overheard staff talking about the incident from 3/31/24 whereas NA #1 was observed lying in bed with Resident #46. Unit Manager #1 further indicated she reported the incident to the DON on 4/10/24.
During an interview on 4/18/24 at 2:45 pm Nurse #13 indicated she overheard NA #3 talking about the incident on 3/31/24 (11 pm- 7 am shift) and when she went to see herself, NA #1 was sitting in a chair in Resident #46's room. Nurse #13 further indicated she asked NA #1 if everything was okay and did not specifically ask if NA #1 was asleep in bed with Resident #46. Nurse #13 stated she felt there was nothing to report to her supervisor since she did not observe NA #1 in asleep in bed with Resident #46. Nurse #13 explained the next day 4/1/24, she heard more rumors about NA #1 being in bed with Resident #46 and thought the supervisors and/ or Director of Nursing (DON) were already aware of the incident. Nurse #13 stated she was just realizing that she could have reported the incident to the DON or Administrator instead of assuming the rumor was a joke or that leadership had already been made aware of the incident.
During an interview on 4/17/24 at 3:47 pm NA #4 revealed she overheard other staff talking about the NA #1 being observed asleep in bed with Resident #46 on 4/1/24 and thought it was a joke. NA #1 further revealed she reported the incident to the assigned nurse (Nurse #14) during the overnight shift 3/31/24 to 4/1/24.
Attempts to contact Nurse #14 were unsuccessful.
A review of the Facility Reported Incident investigation file dated 4/10/24 and NA #1's timecard indicated NA #1 continued to work shifts on 4/1/24, 4/4/24, 4/6/24 and 4/7/24 after the incident occurred and was reported on 3/31/24 (11pm- 7am shift).
During an interview on 4/18/24 at 3:30 pm the DON revealed on 4/10/24 she was made aware of the incident that involved Resident #46 and NA #1. The DON further revealed the facility submitted an initial allegation report and NA #1 was suspended. The DON stated her expectation was for all residents to be protected from abuse, neglect, and exploitation. The DON further stated all staff who were made aware of the incident since 4/1/24 should have reported it immediately to their supervisor and/or the Administrator.
During an interview on 4/18/24 at 3:25 pm the Administrator indicated she had not been made aware of the abuse incident until 4/10/24 and that the incident took her by surprise because staff were always calling her about everything else that occurred in the facility. She further indicated although the DON was on vacation during the week the incident occurred, the incident should have been reported to her (the Administrator) immediately. The Administrator stated she would have submitted an initial report, suspended the accused staff, and initiated a 5-day investigation to be sent to the State, according to the facility's abuse policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to refer two new residents with serious mental health diagnoses, and one resident with a new mental health diagnosis for Preadmission Screening and Resident Review (PASRR) level II for 3 of 3 residents reviewed for PASRR (Resident #4, #19, and #54).
The findings include:
1. Review of Resident #4's medical record revealed the resident had a PASRR level I determination completed prior to his admission and was admitted to the facility on [DATE]. The resident had been diagnosed with post-traumatic stress disorder (PTSD) and mental disorder during his admission. No PASRR level II referral documentation had been observed in Resident #4's medical records.
An interview on 04/17/24 at 9:26 AM with the Social Worker (SW) revealed he had been employed as the facility SW since March 2024 and had received training on how to complete PASRR paperwork for residents. He stated he was not aware of Resident #4's mental health diagnosis or that a PASRR level II referral had not been completed. The SW revealed that based on the PASRR training he had received a PASRR level II referral should be completed upon resident admission with a serious mental health diagnosis, when there was a change in condition or behavior, and when a resident had received a new mental health diagnosis. He also revealed that based on Resident #4's diagnosis of PTSD and mental disorder, the referral for a PASRR level II referral should have been completed.
An interview on 4/11/24 at 5:35 PM with the Administrator revealed a PASRR level II should be completed for a resident with a serious mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #4's admission diagnosis of PTSD and mental disorder, a PASRR level II referral should have been completed.
2. Review of Resident #19's medical record revealed the resident had a PASRR Level I determination completed prior to his admission and was admitted to the facility on [DATE]. The resident had been diagnosed with psychotic disorder with hallucinations as part of his admission. No PASRR level II referral documentation had been observed in Resident #19's medical records.
During an interview on 04/17/24 at 9:26 AM with the Social Worker (SW) revealed he had been employed as the facility SW since March 2024 and had received training on how to complete PASRR paperwork for residents. He stated he was not aware of Resident #19 mental health diagnosis or that a PASRR level II referral had not been completed. The SW revealed that based on the PASRR training he had received a PASRR level II referral should be completed upon resident admission with a serious mental health diagnosis, when there was a change in condition or behavior, and when a resident had received a new mental health diagnosis. He also revealed that based on Resident #19's admission diagnosis of psychotic disorder with hallucinations, paperwork for a PASRR level II referral should have been completed.
An interview on 4/11/24 at 5:35 PM with the Administrator revealed a PASRR level II should be completed for a resident with a serious mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #19 admission diagnosis of psychotic disorder with hallucinations a PASRR level II referral should have been completed.
3. Review of Resident #54's medical record revealed the resident had a PASRR level I completed prior to her admission and was admitted to the facility on [DATE]. The resident had been diagnosed with adjustment disorder with mixed anxiety and depressed mood on 6/2/23 and depression disorder on 6/2/23 during her admission and received a new diagnosis of bipolar disorder on 09/01/23. No PASRR level II referral documentation had been observed in Resident #54's medical records.
During an interview on 04/17/24 at 9:26 AM with the Social Worker (SW) revealed he had been employed as the facility SW since March 2024 and had received training on how to complete PASRR paperwork for residents. He stated he was not aware of Resident #4 mental health diagnosis or that a PASRR level II referral had not been completed. The SW revealed that based on the PASRR training he had received a Level II PASRR should be completed upon resident admission with a serious mental health diagnosis, when there was a change in condition or behavior, and when a resident had received a new mental health diagnosis. He also revealed that based on Resident #54's diagnosis of adjustment disorder with mixed anxiety and depressed mood, depression disorder, bipolar disorder, paperwork for a PASRR level II referral should have been completed.
During an interview on 4/18/24 at 12:15 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a serious mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #54 admission diagnosis of adjustment disorder with mixed anxiety and depressed mood, depression disorder and added diagnosis of bipolar disorder a PASRR level II should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 5 of 5 residents reviewed for activities (Residents #203, #102, #114 #216 and #46). The residents expressed not being able to leave the facility made them feel frustrated, awful, forgotten about, hemmed in, angry, and mad. The residents further stated they hated being stuck in the building all the time and once you get here, they won't let you leave.
The findings included:
A review of the January, February, March, April 2024 activity calendars revealed activities for inside of the facility during the week and on the weekends. There were no activities scheduled for outside of the facility.
Review of Resident Council Meeting minutes from April 2023 through March 2024 residents had voiced the desire to go on outings occasionally during the June 2023 and September 2023 meetings. The residents were not named but it was documented they wanted to go shopping and out to eat.
During a Resident Council Meeting conducted on April 17, 2024, at 3:05 PM Residents #203, #102, #114, #108, and #216 did have a desire to go out of the building. They reported they would like to go shopping and go out to eat, others suggested sporting events. The residents reported they really want to go out but were never offered any outings as an activity. The residents stated they felt like once they were admitted that they were not allowed to leave again. The residents stated they had asked before to go on outings, but there was never a response to their request. The Administrator was present during the meeting at the residents' request and stated she was aware of the desire to go out, but that without transportation this was not possible. The Administrator told the residents she was working on trying to figure out a way to get them out but did not have a timeline.
a.
Resident # 203 was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #203 felt that it was somewhat important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #203 was cognitively intact.
An interview as conducted with Resident #203 (Resident Council President) on 04/18/24 11:35 AM. The resident stated he wished they could go out on group outings and other residents have expressed the same to him. Resident #203 indicated he had reported this to the Administrator, but the residents had still not been offered an outing. Resident #203 further stated he could go out to the courtyard and visit, but he does not like not being able to go out of the facility for an activity. The resident reported that since he was admitted he has not been taken out of the facility for any activities and the only people that get to go out is people with families that take them out. Resident #203 said he was just frustrated because getting to go on outings should not be so hard.
b.
Resident #102 was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #102 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #102 was cognitively intact.
An interview was conducted with Resident #102 on 4/18/24 at 10:13 AM revealed that she felt hemmed in, would like to go out shopping, to Walmart or to eat at Cracker Barrel. Resident #102 stated it would make her feel happy. The interview further revealed she had mentioned this before during a resident council meeting however, they had not been out of the facility since the discussion. Resident #102 stated she had not been out of the facility for an activity since admission.
c.
Resident #114 was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #114 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #104 was cognitively intact.
An interview was conducted with Resident #114 on 04/18/24 at 10:15 AM revealed she would enjoy going out of the facility but wouldn't want to go out unless the facility was paying for the trip and meal. Resident #114 stated she had not been out of the facility on an outing since she was admitted to the facility. The resident reported that she hated being stuck in the building all the time and wished there were more chances to leave.
d.
Resident #216 was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #216 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #216 was cognitively intact.
An interview was conducted with Resident #216 on 04/18/24 at 09:53 AM. Resident #216 stated he felt angry and mad about being stuck in the nursing home and never having the opportunity to do things in the community. Resident #216 explained there were many pro football and pro basketball teams nearby that would probably donate tickets or food to the facility for the publicity. Resident #216 indicated he would even be willing to make the phone calls to make it happen. He further stated, once you get here, they won't let you leave. Resident #216 revealed he had not been on an outing since he was admitted to the facility.
e. Resident #46 was readmitted to the facility on [DATE].
A quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #46 was cognitively intact and had severely impaired vision/ legal blindness. The assessment further indicated doing favorite activities and doing things in a group setting were very important to Resident #46.
A revised care plan dated 12/12/23 indicated Resident #46 would attend/ participate in activities of choice through the next review period with interventions that included enjoying fresh air outside.
During an interview on 4/15/24 at 03:51 pm Resident #46 indicated he attended the bingo activity offered by the facility, however there were no planned activities outside of the facility because there was no transportation van for outings. Resident #46 further indicated there had not been a transportation for almost 2 years. Resident #46 stated he would like to participate in activities outside the facility such as the arcade or any place else, away from the facility.
During an interview on 4/17/24 at 9:39 am Nurse Aide (NA) #6 revealed she could not recall seeing the residents going on activities off the facility property and the facility did not have a van for transportation. NA #6 could not recall how long the facility had been without a transportation van and how long residents had not attended activities outside the facility. NA #6 further revealed she could recall the facility offered activities such as coffee times in the morning and bingo.
During a follow-up interview on 4/18/24 at 11:35 am Resident #46 stated not going on group outings made him feel awful, forgotten and that the facility did not have activities for a blind person to participate in. He further stated he would enjoy going to the arcade, the park to cook out when the weather was nice.
During an interview on 4/18/24 at 2:25 pm the Activity Director indicated Resident #46 attended in-house activities such as bingo and due to his blindness, Resident #46 would receive assistance from staff during the activity. She was not aware how long the facility had been without a van and could only state there was no van since she started 5 months ago. The Activity Director stated Resident #46 attends an activity at a local blind services agency once a month and that agency provides transportation.
An interview on 04/18/24 at 02:16 PM with the Activity Director (AD) revealed she had been in current position for five months. The AD stated she has been told by the Administrator she had to wait for outings outside of the building until they got a van. The AD further stated that residents had requested to go out, but since the facility did not have a van for transportation, they had not been able to leave the facility. The Activity Director indicated she was not the staff member who does the shopping for the residents, but she did go on Wednesday afternoon and pick up the smokers' cigarettes for the week. The AD stated that residents had told her they would like to leave the facility for an activity, but she stated that the Administrator told her it was not an option right now so that was what she had reported to the residents. She reported that the residents told her they would like to go shopping and out to eat.
An interview with the Director of Nursing (DON) on 4/17/24 at 3:33 pm reported that the facility did not have an activity van. The DON stated they used a contracted transportation company, but this was only used for resident medical appointments. She was not sure when or if the facility would be buying a van.
An interview with the Administrator on 4/17/24 at 3:45 PM revealed the facility did not have a van for transportation. The Administrator reported they were working on getting a van but was not sure when the corporate office was going to okay a new van. The Administrator stated she attends all the resident council meetings and was aware that residents wanted to go on outings, but she could not give a timeline as to when the facility might get a van. The interview further revealed the Administrator still had not come up with a way to meet this want. The Administrator indicated the facility used a contracted transportation company for transporting residents to and from medical appointments, but they did not use them for resident outings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews the facility failed to maintain an environment free of accident hazards for 1 of 5 residents (Resident #66) reviewed for supervision to prevent accidents. On 2/21/24, Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with a handle. Resident #66 was unattended in the hallway outside of the maintenance room, the door was unlocked and partially open. NA #6 asked Resident #66 to hand her the long ridged knife with handle which she did with no issues, placed the knife back inside the maintenance room and shut the door without locking the door. The maintenance room was observed on 4/17/24 to be unlocked. This practice has a high likelihood that residents could access materials that could cause serious harm or injury.
Immediate Jeopardy began on 2/21/24 when Resident #66 accessed a long rigid knife with a handle and was attempting to use it to cut her cast off. The immediate jeopardy was removed on 4/28/24 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective.
The findings included:
Resident #66 was admitted to the facility on [DATE]. Her admission diagnoses included fracture of left arm and dementia.
Review of admission nursing progress note dated 02/16/24 read in part, Resident #66 history of dementia, alert and oriented to person, pleasantly confused and forgetful. Hospital diagnosis included fall with left wrist fracture with cast in place.
Resident #66's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #66 was also assessed as being ambulatory with assistance of a walker or wheelchair, wandering with the significant risk of getting to a potentially dangerous place.
Review of admission care plan dated 2/22/24 revealed Resident #66 had an approach for wandering with a goal to reduce exit seeking behaviors. Interventions included wandering alarm bracelet located on Resident #66 left ankle, check wandering alarm bracelet every evening to ensure working properly, anticipate and meet resident needs in a prompt manner, notify MD and family of any changes in behavior, and monitor/ document/ report each shift and as needed any exit seeking behaviors or changes in behaviors.
Review of facility incident report log for February 2024 revealed no incident reports for Resident #66.
An interview with Nursing Assistant (NA) #6 on 4/17/24 at 9:00 AM revealed she had been employed at the facility since August 2023 and was familiar with Resident #66. She stated on 2/21/24 she was walking up the resident 200 hall and observed Resident #66 standing right outside of the maintenance room (located at the top of the 200 hall between the utility room and beauty parlor), the door was unlocked and cracked open with a long ridged knife with a handle in her right hand and using a back and forth motion was attempting to cut off the cast located on her left arm. The NA stated she assumed Resident #66 had gotten the knife from inside the maintenance room since that was where she was standing. She revealed she asked Resident #66 to hand her the knife which she did with no issues, placed it back inside the maintenance room and shut the door, assessed Resident #66 body for any injuries, and walked her back to her room where she assessed her again for any injuries and did not observe any visible injuries and Resident #66 had no complaints of pain. NA #6 stated she did not recall if she informed any of the nurses on the hall but did report the incident to the DON. She revealed Resident #66 had a history of wandering all the halls in the facility and would stop at each room and try and turn all the door handles to see if they would open. She stated she had no knowledge of what occurred after she notified the DON of the incident, and she did not lock the maintenance door back and was not aware if anyone else locked the maintenance door after the incident or why the maintenance door had been unlocked in the first place.
An observation on 04/17/24 at 9:45 AM revealed a room door at the beginning of the resident 200 hall with no signage. The room was located between the utility room and the beauty salon. The door handle to the room had a keyhole on the front and lock on the back. After knocking on the door with no answer, the surveyor placed hand on the door handle to check if the door was locked and the door easily opened without the handle having to be turned. An observation of the inside of the room revealed access to tools such as a hammer, sharp screw drivers, screws and nails lying on the desk and in the floor, filing cabinets, computer system on the desk, a television propped against wall at the door, and papers lying on top of the desk and in the floor. The Regional Nursing Educator Consultant approached surveyor as the observation of maintenance room was being made from doorway and when asked about the incident stated she had no knowledge of the incident but that the door should be locked at all times to prevent residents from entering.
An interview was conducted with the Regional Maintenance Director on 04/17/24 at 10:40 AM revealed the previous Maintenance Director had left at the end of February 2024 and he had been filling the role since the first of March. He also revealed no knowledge of the incident with Resident #66 but stated the door to the room maintenance room should always be locked due to the tools and materials kept inside. He stated the maintenance room was used to store maintenance tools and equipment and to send and receive work orders from the computer located in the room. When asked if he was aware that the maintenance room door was currently unlocked, he stated he was not aware and that he had not been in the room on this date or the day prior and was not aware of how long the door had been unlocked. He revealed he had a key to the maintenance room door but was not aware of who else in the facility had access to the room and could have left it unlocked.
A telephone interview with the previous Maintenance Director on 4/17/24 at 11:47 AM revealed he had previously been employed with the facility in different roles but had worked as the Maintenance Director for several months prior to leaving at the end of February 2024. He stated he had no knowledge of the incident involving Resident #66 but was sure there had been times the maintenance room door could have been left unlocked and therefore residents could have had access to items in the room used for maintenance work such as knives or sharp tools. He revealed when he originally started as the Maintenance Director the room had a keypad lock but he would sometimes forget the code to unlock it so he changed the door lock to a regular door handle like the ones located on resident's rooms that could be locked from the inside and would require a key to open. The previous Maintenance Director stated he had a key to the lock but could not recall who else in the facility had a key and that the maintenance room door should have been locked at all times to prevent residents from entering the room.
An interview with the Administrator and DON on 4/18/24 at 12:20 PM revealed the Administrator had no knowledge of the incident with Resident #66 until yesterday and the DON stated she did not recall being informed by NA #6 of the incident either. They both revealed the maintenance door should have been locked at all times to prevent residents and other staff from having access to the room and staff should have reported the incident immediately and documented the details of the incident.
The Administrator was notified of immediate jeopardy on 4/26/24 at 11:02 AM.
The facility provided the following plan for immediate jeopardy (IJ) removal.
Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
The facility failed to maintain an environment free of accident hazards for vulnerable residents by not maintaining locked maintenance office door, located in hall of resident, enabling her to enter and obtain the knife. On 2/21/24 Resident #66 was observed by Nurse Aide (NA) #6 to have a ridged knife in her hand attempting to cut off her cast. NA #6 removed knife from resident, secured maintenance door. NA #6 did not note any injuries or cuts on the cast.
Administration was not aware of the incident with Resident #66 that occurred on 2/21/24 until 4/17/24.
The physician or family wasn't made aware of the incident that occurred with Resident #66 on 2/21/24.
Resident #66 cast was removed on 3/20/24.
Resident #66 discharged from the facility on 4/23/24.
On 4/17/24 the maintenance office door was observed unlocked by a member of the survey team and notified the Regional Nurse. The Regional Nurse immediately notified the Administrator that the door was unlocked. The Administrator immediately informed the Maintenance Director who changed the lock out for a keypad security lock which allows door to lock automatically when shut on 4/17/24.
The root cause analysis determined that the Maintenance Director failed to manually lock the maintenance office door with a key upon exit on 2/21/24 and 4/17/24.
On 4/17/2024 the Administrator provided Maintenance Director with one-on-one education on the requirement for the facility to maintain an environment that is free of accident hazards by keeping all areas of the facility secure including housekeeping storage, kitchen entrance, and all other high-risk areas that residents have the potential to enter.
All residents residing in the facility can be affected by the deficient practice.
On 4/17/24 an audit of all doors to high-risk areas including kitchen entrance, shower rooms, housekeeping storage rooms was completed by the Administrator to ensure all had keypad security locks in place.
On 4/17/24 administrative staff were instructed by the Administrator to monitor and ensure all high-risk areas of entry are secured and halls are free of clutter. Any issues identified will be corrected and reported to the Administrator immediately.
On 4/27/24 the Administrator, DON and the Maintenance Director met to identify any high-risk areas in the facility and reviewed accidents/incidents including resident falls, injuries, and resident transportation back to April 1, 2024, to determine if there were any that were avoidable accidents or incidents. The review of the accidents/incidents did not determine the need for further analysis, education, or monitoring.
Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.
On 4/23/24, a QAPI meeting was held with all facility department heads at which time all were educated on potential accidents and hazards related to residents accessing hazardous materials and requirement for these items to be secure at all times by the Administrator.
On 4/24/24 in person education began with all staff, including agency staff, by Director of Nursing (DON) on maintaining an environment free of accidents, hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. Education included ensuring high risk areas of entry are secured at all times, halls are free of clutter. All staff not educated on 4/24/24 will be educated by DON or Assistant Director of Nursing (ADON prior to the start of their next shift. The Administrator will be responsible for maintaining employee log to identify staff that may still require education. Upon review of staff log, the Administrator will notify DON/ADON of any staff requiring education. All new hires, including maintenance staff and agency staff will be educated during the orientation process by DON/ ADON. The DON and ADON were made aware of this responsibility on 4/24/24 by the Administrator.
Alleged date of immediate jeopardy removal: date 4/28/24
A validation of immediate jeopardy removal was conducted on 05/07/24. The maintenance office door was noted to be closed, locked, and secured on 05/07/24 along with the other doors in the facility that potentially had hazardous chemicals or equipment in them. The doors include the spa doors located on each hallway, the maintenance office door, the kitchen doors, the supply room, the oxygen storage room, the housekeeping closet, and any other ancillary room that was identified by the facility, all were locked and secured. Interviews with administrative staff revealed that they had been educated on the need for continued monitoring of the doors to ensure that they were locked and secured to ensure resident safety. In-service records and interviews with all staff across all departments revealed that they had been educated on ensuring resident safety by keeping hallways clutter free and ensuring doors to potentially hazardous areas, chemicals, and equipment were always secure and if not to ensure no resident was in the area, secure the area and notify the administrator. The facility's QA committee met on 04/23/24 and conducted a root cause analysis which was reviewed as part of the removal process. Audits conducted daily from 04/17/24 through 05/07/24 were reviewed with no issues. The facility's removal date of 04/28/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, and staff interviews the facility failed to stop wound care when Resident #1 complained of pain of a 7 on a scale of 1-10 and address her pain before finishing the wound care for 1 of 1 residents reviewed for pain.
The findings included:
Resident #1 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident #1's diagnoses included pressure ulcer of right hip and chronic pain syndrome.
A physician's order dated 01/10/24 read, Acetaminophen-Codeine Orla 300-30 give one tablet by mouth every 6 hours as needed for pain related to chronic pain syndrome not to exceed 3 grams (gm) of acetaminophen in a 24-hour period.
Review of a physician's order dated 01/10/24 read, Acetaminophen 325 milligrams (mg) give 2 tablets by mouth every 6 hours as needed for pain not to exceed 3 grams of acetaminophen in a 24-hour period.
The significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was moderately cognitively impaired and had one unstageable pressure ulcer that was not present on admission. The MDS also indicated that Resident #1 received pressure ulcer care during the assessment reference period and had taken an opioid medication.
A pain care plan that was revised on 03/25/24 read; the resident has chronic pain related to mobility and aging process. The goal read; the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions included administer analgesia as ordered, anticipate the residents needs for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, monitor and report loss of appetite, monitor and report to nurse complaints of pain, notify physician if interventions are unsuccessful, and observe and report changes in sleep pattern.
Review of the Medication Administration Record (MAR) dated April 2024 revealed that on 04/17/24 Resident #1 had received Acetaminophen-Codeine Orla 300-30 at 9:49 AM for pain in her back that was rated a 6 on a pain scale of 1-10.
Further review of the MAR revealed that on 04/17/24 Resident #1 received Acetaminophen 325 mg 2 tablets by mouth at 3:47 PM for a headache that was rated a 3 on pain scale of 1-10.
An observation of wound care was conducted on 04/17/24 at 2:46 PM with Nurse #8 and Nurse #9. Nurse #9 was observed to transfer Resident #1 from her wheelchair to her bed and while Nurse #8 stood next to Resident #1, Nurse #9 washed and dried her hands and donned clean gloves. Nurse #9 was observed to remove a dirty dressing from Resident #1's mid chest and clean the wound with wound cleaner and then doffed her gloves, washed her hands, and again donned clean gloves. Resident #1 was then asked to turn onto her left side and once her pants were pulled down there was dressing noted to her right hip that was dated 04/16/24, Nurse #9 removed the old dressing and discarded it then cleaned the wound on the right hip with wound cleaner. She removed her gloves and washed her hands and donned clean gloves. Resident #1 then stated that she was hurting right there on that spot referring to the wound on her right hip. When asked what level her pain was, she replied it is a 7. Nurse #9 stated that she would get her something for pain as soon as she was done with wound care. Nurse #9 applied zinc oxide as prescribed to the peri wound, and Resident #1 stated that hurt. Nurse #9 gently laid a piece of medi-honey (honed soaked dressing) on top of the wound and covered the wound with adhesive dressing. Nurse #9 then removed her gloves and washed her hands again. While still resting in bed Resident #1 again stated that she hurt in her right hip and her head. Nurse #8 and Nurse #9 transferred Resident #1 to her wheelchair before exiting her room. Resident #1 was not crying and did not appear anxious at the time of the wound care. Nurse #9 asked her if she wanted something for pain and Resident #1 stated yes.
Nurse #9 was interviewed on 04/17/24 at 3:04 PM, she stated Resident #1 had never complained of pain during wound care before. She explained that she was usually anxious and wanted something for her nerves but had not complained of pain. Nurse #9 reviewed Resident #1's medical record and stated that she had Acetaminophen-Codeine at 9:49 AM and it would not be due again until 3:49 PM. Nurse #9 stated if Resident #1 had been complaining of pain directly on the wound she would have gone and asked the nurse for pain medication. Nurse #9 added that all residents were asked about pain every shift and if they reported pain, they were given something for their pain. Nurse #9 added that if Resident #1 was in pain she would tell me but most of the time she reported being anxious.
A follow up interview with Nurse #8 and Nurse #9 was conducted on 04/17/24 at 3:39 PM. Both Nurse #8 and Nurse #9 confirmed that Resident #1 complained of pain in her right hip that was a 7 on a pain scale and also complained of pain in her head.
The Administrator was interviewed on 04/18/24 at 12:00 PM. The Administrator stated wound care should have been stopped and Resident #1's pain addressed.
The Director of Nursing (DON) was interviewed on 04/18/24 at 2:49 PM who stated, pain was subjective and when a resident complains of pain we handle it. The staff assessed pain every shift and as needed. When Resident #1 complained of pain during wound care, the staff should have stopped the wound care and completed a full pain assessment and if she had nothing that could be given for pain the medial provider should have contacted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews the facility failed to provide breakfast, a bagged meal or snack for 2 of 2 residents (Resident #20 and #21) reviewed for dialysis.
The findings included:
a. Resident #20 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes and end stage renal disease.
A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #20 was cognitively intact.
An interview with Resident #20 on 4/15/24 at 4:00 PM revealed she did not always receive a meal when she went to dialysis and would have to wait until she returned from her treatments around lunch time before she was able to eat. She stated she attended dialysis three times a week from 5:30 AM to 10:30 AM and the facility was supposed to provide her with a bagged lunch that contained a sandwich, snacks, and drink but for the past several months she had not received her bagged lunch, or it would be missing the sandwich and drink. She stated this past weekend the Administrator had to bring the bagged lunched to the facility because they were not available when they left for their treatments. Resident #20 stated that she would like to have her bagged meal with her at dialysis so that she can have a little something to eat and to have in case her blood sugars were ever to drop while receiving her treatments.
b. Resident #21 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes and end stage renal disease.
A quarterly MDS dated [DATE] indicated Resident #21 was cognitively intact.
An interview with Resident #21 on 4/15/24 at 11:21 AM revealed he did not always receive a meal when he went to dialysis and would have to wait until lunch time before he could eat. Resident #21 reported he attended dialysis three times a week from 5:30 AM to 10:30 AM and the facility was supposed to provide him with a bagged meal he could take with him that should contain a sandwich, snacks and a drink. He stated for the past several months he either not received his bagged meal when leaving for dialysis, the bagged meal has missing items such as no sandwich and no drink, or the Administrator has had to bring them their bagged meal to the dialysis facility. Resident #21 stated although he had not suffered from any low blood sugar from missing out on his bagged meal, he still gets hungry and would like to have his bagged meal or at least a snack to take with him.
An interview with Dietary Manager (DM) #1 on 04/16/24 at 2:15 PM revealed she had been employed at the facility for about a month and when she came there were issues with the dialysis bags (sandwich/2 snacks/ drink) not being available for residents in nourishment rooms for the residents that leave early and nursing staff not being able to access them in kitchen or dietary staff not fixing them for the next morning. She stated dietary staff are responsible for preparing and labeling the bagged meals the night before and placing them in the nourishment room for the dialysis residents who leave the facility prior to breakfast being served. DM #1 revealed she was not aware there had not been any bagged meals left for dialysis residents over the past weekend until yesterday, so she made sure all dietary staff were educated on making sure the dialysis bagged meals were prepared and labeled each night and placed in the nourishment room.
An interview with the Nutritional Manager on 04/16/24 at 3:16 PM revealed no knowledge of dialysis residents who leave the facility prior to receiving breakfast not receiving their bagged meals to take with them to treatment. She stated dietary staff should be preparing those bagged meals each evening and placing them in the nourishment room where they are available for staff to give to dialysis residents prior to them leaving. She revealed the bagged meals are provided to dialysis residents due to them leaving prior to breakfast being served and also to provide them with some nutrition to prevent low blood sugar or nausea.
An interview with Nursing Assistant (NA) #6 on 04/17/24 at 9:05 AM revealed she had worked at facility since August 2023 both 1st and 2nd shift and was familiar with dialysis residents bagged meals not being available for those that leave early in the mornings. She stated dietary staff were not preparing the bagged meals and leaving them in the nourishment room and nursing staff were unable to access the kitchen to be able to receive or prepare the bagged meal. She revealed that she had seen an improvement over the past week or so with dietary staff preparing and labeling bagged meals and placing them in the nourishment rooms.
An interview with Unit Manager #1 on 04/17/24 at 5:40 PM revealed there had been past issues with dialysis residents who leave prior to breakfast not receiving their bagged meals to take with them due to dietary staff not preparing the meals or nursing staff not having access to the kitchen to receive the bagged meals. She stated recently dietary and nursing staff were educated on the importance of dietary residents receiving their bagged meals prior to their treatments and she felt like the issue had improved and to her knowledge there had been no further issues.
An interview with the Administrator on 4/18/24 at 4:45 PM revealed she expected the bagged meals for dialysis residents to be prepared and labeled the prior evening, so they were accessible to those residents who leave prior to breakfast being served. The Administrator further revealed she was aware of issues with the bagged meals not being prepared prior to dialysis residents leaving for their treatment and she has had to wait on dietary staff to prepare the bagged meals and deliver them to the dialysis facility herself. The Administrator stated dietary and nursing staff have been educated on the importance of dialysis residents having their bagged meals with them during their treatments to help prevent side effects such as low blood sugar or nausea.

Based on observations, record review and staff interview the facility failed to verify [NAME] #1's competencies and certifications for food production and meal service prior to first day of employment.
The findings included:
An interview on 04/16/24 at 02:05 PM with Dietary Manager (DM) #1 revealed new employees should be signed off on competencies before they are left on their own to work. DM #1 explained the kitchen had a checklist of competencies for the cook/chef staff, but DM #1 stated [NAME] #1 was assigned to another staff member for training on his first day (4/15/24). DM #1 revealed that she thought DM #2 from another facility was training [NAME] #1 that day (4/16/24) and she was not aware that DM #2 was not told that she was responsible for training [NAME] #1. DM #1 stated she should have ensured that DM #2 knew she was responsible for training [NAME] #1 on 04/16/24. DM #2 was not given [NAME] #1's checklist on 04/16/24. DM #1 reported that [NAME] #1 had not received food temperature training yet because that training was done on the second day. DM #1 reported she was responsible for the hiring process in the kitchen and reported she interviewed [NAME] #1 and took him at his word he had Servsafe certification (certificate proving completion of program to handle and serve food in a safe manner to prevent foodborne diseases), and culinary school training.
During an interview on 04/17/24 at 2:43 PM DM #1 stated she had to call [NAME] #1 on 04/17/24 and request that he call back so they could get copies of his Servsafe certification and culinary degree. DM #1 stated she should have verified his certifications before hire.
An interview on 04/16/24 at 02:40 PM with [NAME] #1 revealed he had not had any training from the facility, and no one was training him on 04/16/24 because they were short, so he just jumped in and went to prepare food. [NAME] #1 confirmed his first day at the facility was 04/15/24. [NAME] #1 stated he had completed the ServSafe certification and course and had gone to culinary school. [NAME] #1 confirmed no one asked him for certificates at the time of hire. [NAME] #1 revealed that he provided his Servsafe certificate to the Regional Director of Operations (RDO) for Dietary for the food service provider on 04/18/24 after she called and asked him to produce the certificate.
A review of [NAME] #1's competency checklist revealed at the top of the sheet there was a start date for evaluation, and it was dated 04/14/2024 and then a line that stated completion date of evaluation period of 04/15/24 even though all competencies below had not been completed. A review of the competency checklist revealed that cooking food temps were dated as completed on 04/15/24 for poultry, stuffed food, ground meat, fish, and other meats. All these food temps' categories were dated 04/14/24 and were signed off by DM #1.
During an interview on 04/18/24 at 10:58 AM the Regional Director of Operations (RDO) for Dietary provided a Servsafe certification for [NAME] #1 with expiration date of 10/27/26 and a copy of a screen shot dated 2013 that [NAME] #1 had been accepted to culinary school but was unable to verify completion. She also produced [NAME] #1's competencies for training for a cook/chef which were dated 04/14/2024 and 04/15/2024 and signed off by Dietary Manager #1. The RDO stated that the DM #1 was responsible for the hiring process for the kitchen staff, and she was not involved in the hiring for individual buildings. The RDO stated that the DM #1 was responsible for verifying competencies and certification for any new staff hired to the department,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff, and Medical Doctor (MD) interview the facility failed to prevent a significant medication error by failing to administer morning medications for a dialysis resident (Resident #20) for 1 of 3 residents reviewed for assuring the facility was free of medication errors. Resident #20 attended dialysis treatments on Tuesday, Thursday, and Saturday from 5:30 AM to 10:30 AM and was not administered her significant morning medications. Per the manufacturer label warnings, failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications.
Immediate jeopardy began on 04/02/24 when the facility failed to administer Resident #20's morning medications. Immediate jeopardy was removed on 04/27/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective.
The findings included:
Resident #20 was admitted to the facility on [DATE]. Resident #20's diagnoses included dependence on renal dialysis, seizures, type 2 diabetes, depression, chronic kidney and heart failure.
Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively intact and was assessed for receiving dialysis treatments.
Review of current physician order revealed Resident #20 was to receive scheduled dialysis treatments outside of facility every Tuesday, Thursday, and Saturday. Pick up time at 5:30 AM from the facility.
Review of physician orders for significant medication for Resident #20 are as follows:
Escitalopram Oxalate Tablet 20 milligrams (MG), give 1 tablet by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER
Keppra XR Oral Tablet Extended Release 24 Hour 500 MG (Levetiracetam), give 1 tablet by mouth one time a day related to EPILEPSY
Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-injector 4 MG/3 milliliter (ML) (Semaglutide) Inject 1 mg subcutaneously (beneath skin) one time a day every Thu related to TYPE 2 DIABETES
Carvedilol Oral Tablet 25 MG (Carvedilol), give 1 tablet by mouth two times a day related to HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE
HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale:
if 0 - 150 = 0 Units Notify Provider if less than 60;
151 - 200 = 2 Units;
201 - 250 = 4 Units;
251 - 300 = 6 Units;
301 - 350 = 8 Units;
351 - 400 = 10 Units;
401+ = 12 Units Notify provider if greater than 401, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high blood sugars).
Review of Medication Administration Record dated April 2024 revealed dates of Resident #20 not receiving significant morning medications due to being out of the facility for scheduled dialysis treatments. Nursing staff coded reason for not administering medications as #3 (resident on leave of absence). Per Resident #20 April 2024 MAR, missed doses of scheduled significant morning medication are as follows:
Escitalopram (9 AM) - Tuesday 4/02 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15)
Keppra (8 AM) - Tuesday 4/02 (Nurse #13), Tuesday 4/09 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15)
Ozempic (9 AM) - Thursday 4/11 (Nurse #13)
Carvedilol (7:30 AM) - Tuesday 4/02 (Nurse #13), Tuesday 4/09 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15)
Humalog and blood sugars (7:30 AM) - Tuesday 4/02 (Nurse #13), Tuesday 4/09 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15)
Review of Resident #20 progress notes for April 2024 revealed blood pressure and blood sugar were within normal limits.
An interview was conducted with Resident #20 on 04/16/24 at 4:54 PM revealed she had missed her morning medications on several occasions and although she could not recall the exact dates of when they were missed, she stated it usually occurred on the days she received her dialysis treatments. She stated to her knowledge she had not had any issues with her blood sugars or seizures from missing the medications but would like to receive her medications as ordered so that doesn't happen. She revealed she attends her dialysis treatments 3 days a week and leaves the facility at 5:30 AM and returns at 10:30 AM and sometimes nursing staff will give her medications to her with food when she returns and other times they don't. Resident #20 stated she had asked about not receiving her medications before and staff would tell her they could only be given at their scheduled time. She revealed she had not told anyone such as the Administrator or Director of Nursing (DON) about the missing medications.
A telephone interview was conducted with Nurse #15 on 04/18/24 at 12:20 PM revealed for the past several months she had worked both 1st and 2nd shift at the facility as an agency nurse and was typically assigned to work the medication carts on the resident halls. She stated she believed Resident #20 received dialysis treatments and on the days she received treatments she would leave the facility around 5 AM and return around 10:30 AM. Nurse #15 verified her initials listed for the MAR, the dates that she worked the medication cart for Resident #20 hall and on the dates Resident #20 had been at dialysis she was not able to administer her morning medications and did not administer them when she returned. She stated she was not aware that she was supposed to hold resident medications and wait to administer when they arrived back from dialysis and had coded the reason for not administering the medications as resident leave of absence because she did not know what other code to use for a resident out of facility for a treatment. She revealed she did not recall if Resident #20 asked about not receiving her medications.
An interview was conducted with Nurse #13 on 4/18/24 at 2:35 PM revealed for the past several months she had worked 1st shift at the facility as an agency nurse and was typically assigned to work the medication carts on resident halls. She stated she was familiar with Resident #20 and had administered her medications on several occasions. She also stated that Resident #20 received dialysis treatments 3x's a week and was usually gone for her treatments before she came into work and would return from them around 10:30 AM. Nurse #13 verified her initials listed for the MAR, the dates that she had worked the medication cart for Resident #20 hall. She admitted she had not administered Resident #20 her morning medications on the dates she had coded as resident leave of absence and was not aware that she was supposed to administer those medications when Resident #20 arrived back from treatments. She revealed she did not recall if Resident #20 asked about not receiving her medications.
A telephone interview was conducted with the MD on 04/17/24 at 4:24 PM. The MD revealed that he had not been made aware of Resident #20 not receiving her morning medications on the days she received dialysis. He stated all dialysis residents should be administered any medications missed while at dialysis upon their return. The MD also stated that he would expect to notify him if resident dialysis treatments were conflicting with when a medication was ordered to be administered so he could adjust the medications and their times to be administered. Due to having no knowledge of Resident #20 not being administered morning medications on days where she had received dialysis treatments, he was not able to comment on any outcome it caused or could have caused and whether those would have been significant or not.
An interview was conducted with the Administrator and Director of Nursing (DON) on 04/18/24 at 12:20 PM revealed they were not aware Resident #20 had missed her medications. The Administrator stated nursing staff had been educated that anytime a medication is not administered to a resident for whatever reason they were to notify the supervisor and document. The Administrator and DON revealed all dialysis residents should be administered their scheduled medications and any issues with not being able to administer those medications should be reported to the nursing supervisor immediately, the MD, and documented.
The Administrator was notified of immediate jeopardy on 04/26/24 at 1:07 PM.
The facility provided the following plan for IJ removal.
Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
The facility failed to prevent significant medication errors when Resident #20 was not administered medications as ordered by the physician prescribed to treat diabetes, epilepsy and hypertensive heart disease and chronic kidney disease with heart failure, and depression. Nurse #13 and Nurse #15 did not administer Resident #20 her morning medications when she returned to the facility from her dialysis treatments.
On 4/18/24 facility Medical Director (MD) was notified by the Director of Nursing (DON) of Resident #20's identified medication errors. An order was obtained from the MD to administer all prescribed medications upon return from dialysis for all residents in the facility who receive dialysis services. These orders were added to each resident's Medication Administration Record by Assistant Director of Nursing (ADON) on 4/18/24. On 4/18/24 Dialysis residents care plans were updated MDS Coordinator.
Nurse Practitioner assessed Resident #20 on 4/18/24. No new orders were received.
On 4/18/24 Nurse #13 received verbal 1 on 1 education by Director of Nursing (DON) on 6 rights of medication administration, potential adverse effects of missed medications, documentation requirements regarding omissions, significant medication errors, and administering medications upon resident return from dialysis. Nurse #13 verbalized understanding of re-education.
4/26/24 DON audited all current residents' Medication Administration Records back to 4/1/24 for any potential significant medication errors including missed/omitted medications or those marked as leave of absence. No additional significant medication errors were noted.
Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.
On 4/24/24 a Quality Assurance Performance Improvement (QAPI) meeting was held by the Administrator (LNHA) with all department heads and MD via phone regarding identification of the significant medication error. Education/audits/monitoring were discussed. Department Heads and MD verbalized understanding of education, audits and ongoing monitoring.
On 4/24/24 in person education began with all licensed nurses (including Nurse #15) and medication aides, including agency nurses or med aides, by DON/ Assistant Director of Nursing (ADON)/Nurse Managers on 6 rights of medication administration, potential adverse effects of missed medications, documentation requirements regarding omissions, significant medication errors, and administering medications upon resident return from dialysis or leave of absence. All staff verbalized understanding. Education to all remaining licensed nurses and medication aides was completed by DON on 4/26/24 via phone and/or in person. All newly hired nurses and medication aides, including agency nurses and medication aides, will receive this education from the DON/ADON during the orientation process. Nurse Manager on duty will provide verbal education to any agency staff member that works after 4/26/24 prior to accepting shift assignment. The Nurse Managers were notified of this responsibility on 4/24/24. The DON will notify the Nurse Managers when there is a new agency nurse or medication aide that requires the education.
Alleged date of immediate jeopardy removal: 4/27/24
A validation of immediate jeopardy removal was conducted on 05/07/24. The audit of all dialysis residents was reviewed and verified that each resident that received dialysis had an ordered entered into their medical record that indicated all prescribed medications were to be given upon return from dialysis treatment. Each resident's care plan was also updated and verified as a part of the removal verification process. Staff in-service records and interviews with nursing staff confirmed they were educated on the requirement of notification to the medical provider and responsible party when medications were missed or omitted. The facility's QA committee met on 04/24/24 and reviewed the policy on notification which did not require any revisions. The QA verbalized understanding of the policy and requirement. Audits completed from 04/28/24 through 05/06/24 were reviewed with no new issues identified. The facility's removal date of 04/27/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews the facility failed to provide evening snacks to residents when requested for 4 of 4 residents (Resident #9, #20, #21, and #171) reviewed for frequency of snacks. This practice had the potential to affect other residents who requested evening snacks.
The findings included:
a. Resident #9 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and heart failure.
A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #9 was cognitively intact.
An interview with Resident #9 on 4/15/24 at 4:31 PM revealed since he had been at the facility he might have received an evening snack maybe once or twice but not on a consistent basis. He stated he did not have the money to be able to purchase his own snacks all of the time and felt the facility should be able to provide him with an evening snack when requested. Resident #9 revealed when he would ask staff about receiving an evening snack, they would tell him there were no snacks available in the nourishment room for them to give to him and they did not have access to get snacks from the kitchen.
b. Resident # 171 was admitted to the facility on [DATE] and discharged on 9/16/23. She was cognitively intact with diagnosis that included type 2 diabetes and congestive heart failure.
A quarterly MDS dated [DATE] indicated Resident #171 was cognitively intact.
A telephone interview with Resident #171 on 4/15/24 at 4:31 PM revealed during her stay at the facility she might have received an evening snack maybe once or twice but not on a consistent basis. She stated she would have her sister bring her snacks or buy them herself. Resident #171 revealed when she would ask staff about receiving an evening snack, they would tell her there were no snacks available for them to give to her.
c. Resident #20 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and end stage renal disease.
A quarterly MDS dated [DATE] indicated Resident #20 was cognitively intact.
An interview with Resident #20 on 4/15/24 at 4:00 PM revealed during her stay at the facility she had never received an evening snack on a consistent basis. She stated when she has requested an evening snack from nursing staff, they have told her that there were no snacks available or all of them were passed on another hall and they had ran out for the evening and did not have access to the kitchen to refill their snacks.
d. Resident #21 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and end stage renal disease.
A quarterly MDS dated [DATE] indicated Resident #21 was cognitively intact.
An interview with Resident#21 on 4/15/24 at 11:21 AM revealed since he had been at the facility he had never received an evening snack or been offered an evening snack consistently. He stated sometimes nursing staff will ask if you want a snack and other times you have to request it and when you do the staff will usually come back and say they couldn't find any snacks in the nourishment room and they were not able to access the kitchen for more snacks.
An observation of nourishment room on 04/15/24 at 03:05 PM with Unit Manager #1 revealed the refrigerator to be empty except for two thickened liquid juices. There were five bagged snacks and two snack cakes located in the cabinet of the room. When the Unit Manager #1 was asked about why there were no snacks, sandwiches, or drinks available in the nourishment rooms she stated dietary staff were supposed to stock the nourishment rooms daily and she was not aware until now of there not being any snacks or drinks available.
An interview with Dietary Manager #1 on 04/16/24 at 2:15 PM revealed been here for about a month and was aware of issues with no snacks being available in the nourishment rooms for residents and nursing staff not having access to snacks from the kitchen. She stated she was not aware until yesterday of dietary staff not stocking the nourishment room, so she stocked the nourishment room herself last night and informed nursing staff that it had been stocked and was available for residents. She also stated she had educated dietary staff on making sure the nourishment room was stocked with snacks, sandwiches, and drinks to be available for residents and staff.
An interview with Nursing Assistant (NA) #6 on 04/17/24 at 9:05 AM revealed she had worked at facility since August 2023 both 1st and 2nd shift and was familiar with resident complaints of not receiving their evening snacks. She stated there have been times when she has gone to the nourishment room and there were no snacks available, no sandwiches, and no drinks and she informed dietary staff of the issue. NA #6 stated recently there have been more snacks available and residents are able to receive their evening snacks when requested.
An interview with the Administrator on 4/18/24 at 4:45 PM revealed she expected there to always be snacks available for residents. The Administrator further revealed dietary staff should be stocking enough snacks, sandwiches, and drinks for residents and nursing staff should have notified dietary staff, nursing supervisors, the DON or herself if there was an issue with not having evening snacks available for residents. The Administrator indicated nursing staff could have asked the Director of Nursing or Unit Managers for the codes to the nourishment rooms. She stated that she orders an overabundance of snacks each month to make sure residents have a variety of options for their snacks and there was no reason why residents should not be receiving their evening snacks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff, resident, Registered Dietitian, and Food Service Provider Representative interviews the facility failed to ensure that fried chicken was completely cooked before serving to residents on lunch trays by 1 of 2 cooks (Cook #1). Undercooked fried chicken was served to 15 of 69 residents and 5 of 15 residents consumed the undercooked fried chicken. Resident #54, Resident #21, Resident #37, Resident #51, and Resident #45 were noted as having consumed the undercooked fried chicken. This unsafe food handling practice had a high likelihood for food borne illness for residents. In addition, the facility failed to have food items labeled with a use by or expiration date and discard food items by the use by date in the dry storage room. Food items were left open to air in 1 of 1 walk-in freezer and a food item was not discarded by the use by date in the reach in refrigerator.
Immediate Jeopardy began on 04/16/24 when residents were served undercooked fried chicken for lunch. The immediate jeopardy was removed on 04/19/24 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective.
Example #2 is cited at a lower scope and severity of a D.
The findings included:
1. An interview was conducted on 04/17/24 9:30 AM with Nursing Assistant (NA) #6 revealed she was present during lunchtime in the dining room yesterday (4/16/24) and had observed the undercooked chicken served to residents. She stated she was assisting Resident #54 and when she cut further into the resident's chicken towards the bone the chicken was pink, bloody, and appeared undercooked. When NA #6 looked at the plate further, she observed blood on the plate underneath the chicken. NA #6 stated she immediately picked up Resident #54's plate and took it into the kitchen and showed it to the Dietary Manager (DM) #1 and informed her the chicken was undercooked. NA #6 stated Dietary Manager #1 took Resident #54's plate with a look of shock on her face and stated the chicken was not cooked. NA #6 explained after that they were told by the Administrator and DM #1 to pull all the residents trays out of the dining room and off the halls and they would provide them with all new trays. She stated she observed other residents in the dining room had eaten some of the chicken on their plates prior to them pulling them and she just informed them that they would be bringing them a fresh tray shortly.
On 04/16/24 at 12:15 PM an observation was conducted of the 200 halls during the lunch meal. Staff were observed passing trays to 4 residents. Staff were observed immediately removing two of the trays from (Resident #5 and Resident #6). The other two residents on the hall had received a mechanical soft diet with precooked chopped chicken and their meals were left in the rooms. The Administrator was observed pushing the meal cart back towards the kitchen.
A continuous observation of the kitchen that included interviews occurred on 04/16/24 from 12:10 PM until 1:45 PM. The door to the kitchen was propped open by a meal cart with several other meal carts in the kitchen, all with resident trays. DM #1, Clinical Nutrition Manager, Dietary Aide (DA) #1 and [NAME] #1 were observed looking at a piece of fried chicken that had been cut in to and the meat was pink and red colored juices on the plate. DM #1 was asked what was going on and she replied they were having to pull all the fried chicken because it was undercooked and bloody. DM #1 explained the Administrator made the decision to remove all the fried chicken from the residents for safety reasons and a different meal had to be prepared. Dietary Aide (DA) #1 and DA #2 were removing trays from tray carts, and dumping the food into the trash can. Two other dietary aids were running all plates, silverware, plate warmers, lids, and trays through the dishwasher. [NAME] #1 was clearing all the food off the serving line and then began preparing new side items. It was confirmed by DM #1 that 5 of the 15 residents that had been served the undercook chicken had eaten part of the chicken provided to them. The fried chicken that was being discarded into the trash can included breasts, wings, thighs, and legs and some of the chicken pieces had been partially consumed and others had not been touched. During the continuous observation pieces of the fried chicken that were sent back to the kitchen were cut into by [NAME] #1. The fried chicken was observed to be pink and undercooked in the middle and close to the bone and had red colored juices flowing from the chicken onto the meal plate. There was an observation of plates that had red colored juices on the plate that had seeped into the vegetables and sides on the plates on the counter tops in the kitchen. According to DM #1 all carts had been sent out and returned to the kitchen. Then [NAME] #1 removed an additional tray of fried chicken from the oven and temped chicken with a thermometer that was given to him by DM #2 and the temperature was 137 degrees Fahrenheit. This fried chicken was discarded. It was observed that the temperature on the oven was set at 170 degrees Fahrenheit. The Administrator was observed bringing fried chicken from a local fast-food restaurant and placing it on the kitchen counter. Dietary staff were then observed preparing new meal trays for residents that had their meal trays pulled.
Review of the food temperature sheet revealed a temperature of 168 degrees Fahrenheit was entered for the fried chicken on 4/16/24.
An interview on 04/16/24 at 2:40 PM with [NAME] #1 revealed this was only his second day working at the facility. [NAME] #1 stated that when he had questions about cooking fried chicken, that DM #2 showed him the recipe for fried chicken, and he followed the instructions. [NAME] #1 revealed that he had chicken breast, thighs, legs, and wings to prepare for the lunch meal. [NAME] #1 revealed that Dietary Manager #2 was working on the sides while he worked on preparing the chicken. [NAME] #1 reported that the chicken was cooked for 15 minutes in the [NAME], but then moved it to the oven because he felt the grease was old and dark and did not want the chicken to become too dark, so the chicken was placed in the oven to finish cooking. [NAME] #1 also reported he did not have a 2-inch pan, so he had to put all the chicken in a 4-inch pan instead, so the chicken pieces were piled on top of each other. He explained using a 2-inch pan would have allowed the chicken to be spread out and not sitting on top of each other so it would have cooked better in the oven. [NAME] #1 stated he believed since the chicken was piled on top of each other was why the top layer of chicken pieces were cooked but the chicken in the middle and lower layers was not cooked. He reported that the first time he pulled the chicken out of the oven it was not done, and he asked DA #1 who told him the chicken was not done after she cut into it and told him to put it back into the oven. [NAME] #1 indicated he failed to take the temperature of the chicken the second time it was taken out of the oven and reported he knew better and should have checked the temperature of the fried chicken pieces before sending food out. [NAME] #1 also stated he knew better than to leave the oven at 170 degrees Fahrenheit knowing that would not cook the chicken, but only keep it warm. The food temperature sheet was reviewed during the interview and [NAME] #1 confirmed there was an entry for the fried chicken on 4/16/24 of 168 degrees Fahrenheit but [NAME] #1 stated he did not write that temperature down.
An interview on 04/16/24 at 02:05 PM with DM #1 revealed the menu being served that day for lunch included fried chicken. The Dietary Manager explained the chicken had been thawed the prior evening, marinated and was dredged in flour and fried that morning prior to being served. When asked to clarify the type of chicken that had been prepared and served, she stated it was frozen, raw chicken that had been thawed. DM #1 also stated that this was a common recipe she had seen used at several of the facilities she had worked at prior. DM #1 indicated DA#1 reported to her the fried chicken was returned to the oven because it was not fully cooked the first time it was removed from the oven. DM #1 stated that a temperature of 168 had been documented on the food temperature sheet for the fried chicken but she did not know who had written that temperature down and [NAME] #1 denied writing it down. DM #1 revealed that [NAME] #1 stated he did not check the temperature of the fried chicken the second time the chicken was removed from the oven. DM #1 indicated [NAME] #1 was responsible for checking the temperature of the food before it was served to the residents on 4/16/24. Dietary Manager #1 reported she became aware of the fried chicken not being fully cooked when NA #6 came to the kitchen door and told them a resident had raw chicken. DM #1 then notified the Administrator of the issue with the fried chicken not being [NAME] cooked. DM #1 further stated that she was going to adjust dinner time since lunch was not served until 1:30 PM. DM #1 also stated that all new sides were prepared, and the Registered Dietician had approved all changes to the menu. She indicated she had only been working at the facility for a month and was always short-staffed. Dietary Manager #1 stated she thought Dietary Manager #2, who was from another facility, and [NAME] #1 were working together.
An interview was conducted with DM #2 on 04/16/2024 at 3:00 PM. DM #2 stated she was from another facility and had been called in to help due to the facility not having enough kitchen staff. DM #2 stated she was asked to come and support DM #1 since she was new and was short staffed. DM#2 revealed that [NAME] #1 asked her about the chicken and DM #2 reported getting him the recipe for cooking fried chicken and told him to follow the recipe. DM #2 stated she was not with [NAME] #1 when he checked the temperature of the fried chicken, and she was not aware that the first time it was taken out of the oven it was not cooked all the way. DM #2 further added that if she had known the chicken was not cooked thoroughly, she would have provided [NAME] #1 with more assistance. DM #2 also revealed she was helping the best she could, but she felt like the kitchen was in chaos when she arrived at the facility, and she felt bad for the new employee (Cook #1). DM #2 also stated that when she started looking into the chicken situation, she noted that [NAME] #1 had turned the temperature on the oven to 170 degrees, so it was too low to cook the chicken.
A review of the recipe for fried chicken provided by Dietary Manager #2 revealed:
1.
Wash and drain the raw chicken, and season with salt and pepper.
2.
Combine eggs and milk in large mixing bowl and dip chicken in milk mixture.
3.
Season flour with salt and paprika, and dredge chicken in season flour.
4.
Melt shortening in a large skillet or pan and place chicken in hot grease and cook until golden brown on both sides and the internal temperature is reached. Hazard Analysis and Critical Control Point (HACCP). [NAME] to an internal temperature of 165 degrees Fahrenheit. And HACCP: hold food at 135 degrees Fahrenheit.
Interview on 04/16/24 at 3:15 PM with [NAME] #2 revealed she usually cooked for the facility, but they were short of staff today, so she was not cooking but working as a dietary aide on the serving line. [NAME] #2 stated since she was not cooking, she had not been responsible for temping the food and had not temped any of the food that was prepared. She further stated when [NAME] #1 had removed the chicken from the fryer after 15 minutes he asked her to check the chicken to see if it was done. [NAME] #2 said she cut into the chicken and told [NAME] #1 that it was not done so he had put the chicken into the oven to finish cooking. She indicated when the trays started coming back into the kitchen due to the undercooked chicken, she and the other dietary aide began tearing everything down, discarding all the food items and washing and sanitizing everything that had encountered the undercooked chicken.
An interview on 04/16/24 at 02:00 PM with DA #1 revealed she was not involved with the cooking process on 04/16/24 and [NAME] #1 was responsible for checking and writing down temperatures for the fried chicken. DA #1 further stated she had not temped any of the food during the meal preparation and she was not sure who had checked the temperature of the fried chicken prior to it being served to the residents. DA #1 recalled she did not know there was a problem with the fried chicken being undercooked until trays started being returned to the kitchen. She indicated once the issue was identified she began cleaning and washing all the service items that had been returned so they could prepare new trays for the residents.
An interview conducted with Resident #5 and Resident #6 on 04/16/24 at 12:20 PM revealed they had been told the chicken they received that day was undercooked. The interview revealed neither of the residents had time to remove the lid of the plate before staff came and removed the tray from the room.
An interview was conducted on 04/16/24 4:20 PM with Resident #54. Her most recent Minimum Data Set Assessment noted she had intact cognition. She stated she had been eating lunch around noon in the dining room and was served a fried chicken thigh on her plate. She revealed she had begun eating her chicken and the closer she got to the bone of the chicken she noticed the chicken appeared pink and bloody and there was blood on her plate underneath the chicken. Resident #54 stated NA #6 who was also in the dining room saw her chicken and the blood on her plate and immediately removed the plate from her and took the plate into the kitchen and informed her they would bring her a new tray shortly.
An interview was conducted with Resident #21 on 04/16/24 at 04:23 PM. His most recent Minimum Data Set Assessment (MDS) noted he had intact cognition. Resident #21 revealed he had eaten the top half of the fried chicken provided to him in his room on 04/16/24 at lunch time and staff returned to the room and removed the rest of his chicken telling him there was a problem, and he would get a different tray shortly. Resident #21 stated he was upset because the first half of the fried chicken he had eaten tasted good, and their chicken is usually not good at all.
An interview was conducted with Resident #37 on 04/16/24 at 04:41 PM. Her most recent MDS noted she had intact cognition. Resident #37 revealed on 4/16/24 she was eating lunch in the dining room and had been served a fried chicken thigh and she first noticed the skin on the chicken was very brown and dark. The resident peeled the chicken skin back and took a few bites of the chicken and realized that it did not taste right. The chicken was chewy and appeared pink like it wasn't fully cooked. Resident #37 stated she stopped eating the chicken and NA #6 removed her tray and informed her they would bring her a fresh tray.
An interview was conducted with Resident # 51 on 04/16/24 at 04:45 PM. His most recent MDS noted he had intact cognition. Resident #51 revealed he had been served two fried chicken thighs for the lunch meal (4/16/24). He stated he ate the first thigh which did not appear to be pink on the inside however the texture tasted, off. The interview revealed when he took a bite of the second chicken thigh it was red and bloody on the inside, which dripped onto his plate. He stated staff removed the plate and eventually he was provided with a new meal tray.
An interview was conducted with Resident #45 on 04/16/24 at 03:37 PM. Her most recent MDS noted she had moderately impaired cognition. Resident #45 revealed on 04/16/24 she was eating in the dining room for lunch and was served fried chicken. She stated she had been served a leg piece but reported it was not good so after the first bite she did not eat the chicken anymore. Resident #45 reported that NA# 6 came and removed her tray with everyone else's and eventually brought her a new lunch tray.
Interview on 04/16/24 at 3:45 PM with the Assistant Director of Nursing revealed she had been instructed to contact the Medical Director regarding the five residents who had been served the undercooked chicken.
An interview on 04/16/24 at 03:20 PM with the Clinical Nutrition Manager for the food service provider revealed Dietary Manager #2 stated that staff in the dining room were the ones who discovered the undercooked fried chicken and let the kitchen know there was a problem with the chicken. The interview further revealed there were plenty of pans in the kitchen, so she had no idea why [NAME] #1 said there were not enough pans to spread the chicken out instead of piling it on top of each other. Dietary Manager #2 further stated that [NAME] #1 should have checked the temperature of the chicken right before the serving line was started and if the chicken was not done it should have been cooked longer even if lunch had to be a little late.
An interview on 04/16/24 at 03:45 PM with the Registered Dietician (RD) revealed NA #6 showed her the undercooked fried chicken that day. The RD reported that she observed the piece of fried chicken that NA #6 identified as undercooked and reported she did see the red liquid on the plate. The RD stated the fried chicken was slightly bloody and it was immediately pulled from the dining room. The RD further stated all trays had been delivered to the halls, but not all had been delivered to residents when the issue with the undercooked fried chicken was identified. Then the Administrator instructed staff to pull all trays back to the kitchen. The RD indicated DM #1 had informed her that 5 residents had consumed the undercooked fried chicken. The RD denied being present during the preparation of the fried chicken and did not observe [NAME] #1 while he prepared or cooked the chicken. The RD was asked twice if the kitchen used raw chicken for its fried chicken recipe and she stated yes, both times. The RD further stated all her kitchens used raw chicken for their fried chicken recipe.
Review of nursing note written by Assistant Director of Nursing (ADON) on 4/16/24 at 12:15 PM revealed Resident #54 notified of undercooked chicken. Removed tray, replaced with another meal, notified provider and power of attorney (POA/ sister). Resident education done and if experience abdominal pain, nausea/ vomiting, chills, lightheadedness, diarrhea, gas, weakness, headaches, or anything abnormal to notify staff/nurse. Resident #54 indicated understanding by nodding her head up and down. Denies any symptoms at present. No orders received by provider. (This same nursing note was placed in Resident #21, #23, and #51 electronic chart).
An interview and review of a purchase order was completed on 04/18/24 at 10:58 AM with the Regional Director of Operations (RDO) for Dietary with the food service provider. The RDO stated the facility had previously used raw bone-in chicken but had just recently switched to using the frozen precooked breaded chicken and there was no way that the fried chicken on 4/16/24 could have been undercooked. She supplied a purchase order with a delivery date of 04/14/24 for precooked breaded chicken. The RDO stated that the fried chicken could not be undercooked because it was a precooked product. She reported they had just switched from frozen raw chicken to precooked frozen chicken. The RDO also stated she felt the dietary staff were confused about what they were cooking and that it was precooked chicken. When the RDO was asked about the recipe instructions for fried chicken using raw chicken, she stated she did not know why the recipe was written the way it was since they no longer ordered raw chicken, so they needed to update the recipe. The RDO stated the [NAME] #1, Dietary Manager #1, and Dietary Manager #2 had since calmed down and she reported that their stories had changed and [NAME] #1 had checked the temperature of the fried chicken the second time it was pulled from the oven and the temperature was 168 degree Fahrenheit. The RDO was asked why the Registered Dietician would have confirmed the recipe was prepared using raw chicken and by the fried chicken recipe on 4/16/24. The RDO stated they just switched to pre-cooked chicken and was not sure if there was still raw chicken in kitchen freezer, or maybe the supplier had sent the wrong product. The RDO stated she was not present in the facility on 4/16/24 and wished someone had taken a picture of the undercooked fried chicken and was unable to produce the packaging the chicken had come from.
An interview on 04/18/24 at 02:38 PM with the Administrator revealed food being served to the residents should have temperature checks and be in expected ranges before it is served to the residents. The Administrator stated that DM #1 reported the undercooked fried chicken to her immediately after DM #1 became aware (on 4/16/24) and she went to the kitchen to see the undercooked chicken. The interview revealed after the Administrator observed the fried chicken, the decision was made to remove and discard all the fried chicken. The Administrator reported she was happy about how all the staff handled the situation once the issue was identified. The Administrator stated that education had been started for all dietary employees concerning correct food temperatures.
A conference call on 04/18/24 at 4:10 PM with the survey team, Administrator, Clinical Educator, Director of Clinical Asset Management for the food service provider, Clinical Nutrition Manager for the food service provider, [NAME] President of Operations for the food service provider, [NAME] President of Operations for the facility, owner and Chief Executive Officer of facility, revealed the facility and the food service providers maintained the fried chicken on 4/16/24 could not have been undercooked because the product was in fact frozen precooked chicken that was prepared and served to the residents. The Director of Clinical Asset Management stated there was no raw chicken in the kitchen, only precooked chicken as indicated by the purchase order she had provided to the survey team. She also stated she had interviewed the 4 residents that were identified as having received undercooked fried chicken and they had denied being served undercooked chicken. The [NAME] President of Operations for the food service provider indicated [NAME] #1 had embellished what he had told the survey team about how he had prepared and cooked the fried chicken. The [NAME] President of Operations also stated what NA #6 had cut into in the dining room was the blood line of the chicken close to the bone and said it was always dark reddish in color. The [NAME] President of Operations further indicated the cook time for raw chicken should have been 15 to 30 minutes in the fryer per the guidelines and then held in the warmer or oven at 140 degrees Fahrenheit until ready for service. During the conference call the Administrator stated she had not actually laid eyes on the fried chicken so she could not speak to what it looked like.
The Administrator was notified of immediate jeopardy on 04/16/2024 at 05:25 PM.
The facility provided the following credible allegation of immediate jeopardy removal.
Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance.
On 4/16/2024 at about 11:30 am, a facility Certified Nursing Assistant assigned to the dining room observed undercooked chicken served to two residents in dining room at the beginning of lunch service. The Certified Nursing Assistant immediately removed trays from affected residents to prevent consumption of the undercooked chicken and informed the Nurses assigned to those residents to ensure safety.
On 4/16/2024 The [NAME] President of Human Resources was in dining room during the incident and immediately notified Administrator and Director of Nursing of observed undercooked chicken being served in the dining room. The Administrator and Director of Nursing immediately notified dietary staff and went to halls in which trays were being served, where trays had been delivered to 1 out of 3 halls. Administrator and Director of Nursing assisted Certified Nursing Assistants in removal of delivered trays containing chicken and tray carts to prevent any further tray deliveries.
On 4/16/2024 The Director of Nursing and Administrator identified 15 residents were served and 5 consumed the undercooked chicken.
On 4/16/2024 The Director of Nursing notified the Physician and Medical Director. The physician's order was to monitor the residents and report any gastrointestinal complaints including abdominal pain, nausea, vomiting or diarrhea.
On 4/16/2024, The kitchen staff discarded the chicken dinners, including fried chicken, macaroni, cheese, and spinach. The trays were cleaned using sanitizer and high temperature. An alternative meal was prepared and served to residents in accordance with the facilities' food preparation policy. The facility management bought chicken from a local fast-food restaurant and new side items were prepared in the kitchen.
Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.
On 4/16/2024 the Administrator notified Regional Dietary Manager of the situation and she informed administrator she was in route to the building. Dietary Manager re-educated immediately by Regional Dietary Manager on safe food handling, potential food borne illnesses and proper cooking temperatures on 4/16/2024.
On 4/16/2024, The facility cook informed the Administrator and Regional Dietary Manager that temperature of 168 degrees Fahrenheit was obtained from top layer of prepared chicken prior to serving lunch service. The temperature log was also reviewed by the Administrator and confirmed the documented chicken temperature of 168 degrees Fahrenheit.
On 4/17/2024, all dietary staff were re-educated verbally by Regional Dietary Manager with reference to facility policy on food safety requirements and preparation guidelines. This included proper cooking temperatures and potential for food-borne illnesses and emphasized the importance of maintaining food temperature logs.
The Dietary Manager/designee will educate any dietary staff not educated on 4/17/2024 before their next scheduled shift. All newly hired dietary staff will be verbally educated upon hire by the Dietary Manager/Designee on food safety requirements and preparation guidelines, to include proper cooking temperatures and potential food borne illnesses. Employees must verbalize understanding and have required competencies including accurate thermometer readings.
On 4/17/2024, all staff including newly hired staff will be verbally educated by the Dietary Manager or Designee with reference to facility policy on food safety requirements and potential for food borne illness related to consuming undercooked chicken as well as proper procedure to immediately remove and report any identified undercooked food items to Dietary/Administrator/Director of Nursing/Designee. Any staff member who did not work on 4/17/2017 will receive the education from the Dietary Manager prior to the start of their next shift. Administrator/Vice President of Dietary Operations /Designee will monitor for 100% completion.
On 4/17/2024 the [NAME] President of Dietary Operations instructed dietary staff that a temperature check must be performed for at least 3 pieces of chicken per layer, followed by verification of temperature before serving. Dietary staff were also educated by Dietary Manager using approved recipe cards and food products.
On 4/16/2024, The Regional Dietary Manager provided one on one re-education with the facility cook on proper use of recipe cards, food products, and appropriate food temperatures and process.
Alleged date of immediate jeopardy removal: 04/19/24.
The immediate jeopardy removal plan was validated on 4/23/24. Review of education sign-in sheets revealed all dietary and facility staff were educated on signs and symptoms of foodborne illnesses, identifying undercooked food, and what to do in the event of finding undercooked food. The kitchen staff were able to describe the process of checking food temperatures and having another kitchen staff member to verify the temperature, as well as testing multiple areas of the food for temperature. Observations of the kitchen on 4/23/24 revealed no concerns with food preparation, checking food temperatures before plating or tray line. An Ad Hoc QAPI was conducted on 4/17/24. During an interview the Administrator confirmed they are putting a hold on purchasing raw chicken for residents until they were certain the corrections were sustained. The immediate jeopardy removal date of 4/19/24 was validated.
2. a. A tour of the kitchen was conducted with the Dietary Manager (DM) #1 on 04/15/2024 at 11:20 AM. Observations in the dry storage room revealed a plastic bin on a shelf that contained 10 to 15 bags of instant chocolate pudding bags. A crumbly dry substance was observed on and under the bags and there was no use by or expiration date on the bags of pudding. DM #1 could not identify what the substance was, but stated she would get it cleaned up. DM #1 stated the expiration date for the instant chocolate pudding was on the box they came in but that the boxes had been thrown away. In addition, there was an open bag of dried pasta with a use by date of 03/29/24. Dietary Manager #1 took the bag of dried pasta and removed it from dry storage.
b. Observation of the walk-in freezer on 04/15/2023 at 11:35 AM revealed an open box of bacon on a shelf. The plastic bag surrounding the bacon in the box was not sealed shut and the bacon was left open to air inside of the box. DM #1 was observed closing up the bacon, so it was no longer exposed. In addition, there was a package of sliced American cheese open to air with individual slices observed in other boxes on the same shelf. There was no date on the box of bacon or the package of cheese to indicate when they were opened. DM #1 took the cheese and removed it.
c. Observation of the reach-in refrigerator on 04/14/2024 at 11:42 revealed an unlabeled container of dried shredded cheese which DM #1 identified as parmesan cheese. It was noted on the container that the use by date was 04/09/2024. The Dietary Manager #1removed the container from the refrigerator and threw it away.
Interview with Dietary Manager #1 on 04/15/2024 at 11:50 AM revealed the cook for the day was responsible for checking dates before food was prepared. She also stated that all dietary employees were supposed to date all food items when they were opened and check products and to discard any expired food items. DM #1 stated was new to the position and is still trying to get things in order.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey that occurred on 12/16/21, the recertification and complaint investigation survey that occurred on 12/30/22 and the complaint investigation survey that occurred on 02/23/23. This failure was for one deficiency that was originally cited in the area of Free of Accidents Hazards/Supervision (F689). The recertification and complaint investigation survey that occurred on 12/16/21 and the recertification and complaint investigation survey that occurred on 12/30/22. This failure was for one deficiency that was originally cited in the area of Food Procurement, Store/Prepare/Serve Under Sanitary Conditions (F812) and this was subsequently recited on the current recertification and complaint investigation survey of 04/23/24. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program.
The findings included:
This tag is cross referred to:
F689: Based on observations, record reviews, and staff interviews the facility failed to maintain an environment free of accident hazards for 1 of 5 residents (Resident #66) reviewed for supervision to prevent accidents. On 2/21/24, Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with handle. Resident #66 was unattended in the hallway outside of the maintenance room, the door was unlocked and partially open. NA #6 asked Resident #66 to hand her the long ridged knife with handle which she did with no issues, placed the knife back inside the maintenance room and shut the door without locking the door. The maintenance room was observed on 4/17/24 to be unlocked. This practice has a high likelihood that residents could access materials that could cause serious harm or injury.
During the complaint investigation survey conducted 02/23/23, the facility failed to ensure the securement of the resident and her chair was according to the manufacturer's recommendations to provide a safe van transport for a resident reviewed for accidents/hazards.
During the recertification and complaint investigation survey conducted 12/30/22, the facility failed to provide care in a safe manner for residents and the facility failed to investigate the injury and complete a root cause analysis and as a result no plan was in place to prevent further injury to resident. In addition, the facility failed to complete accurate smoking assessments to provide a safe smoking environment for residents reviewed for smoking.
During the recertification and complaint investigation survey conducted 02/23/21, the facility failed to secure bleach used by a resident for personal for a resident reviewed for accidents/hazards.
F812: Based on record review, observations, and staff, resident, Registered Dietitian, and Food Service Provider Representative interviews the facility failed to ensure that fried chicken was completely cooked before serving to residents on lunch trays. Undercooked fried chicken was served to 15 of 69 residents and 5 of 15 residents consumed the undercooked fried chicken. Resident #54, Resident #21, Resident #37, Resident #51, and Resident #45 were noted as having consumed the undercooked fried chicken. This unsafe food handling practice had a high likelihood for food borne illness for residents. In addition, the facility failed to have food items labeled with a use by or expiration date and discard food items by the use by date in the dry storage room. Food items were left open to air in 1 of 1 walk-in freezer and a food item was not discarded by the use by date in the reach in refrigerator.
During the recertification and complaint investigation survey conducted 12/30/22, the facility failed to label, date, and seal open food items for use in the walk-in refrigerator and reach in cooler. This practice had the potential to affect the food served to residents.
During the recertification and complaint investigation survey conducted 12/16/21, the facility failed to label and date opened food items, failed to store food in closed containers, failed to remove dented cans, failed to keep floor in dry storage free of debris in the dry storage room reviewed for food storage.
An interview on 04/18/24 at 5:10 PM with the Administrator revealed their Quality Assurance and Process Improvement (QAPI) meetings were held monthly every 3rd Tuesday. She stated the department heads, Medical Director, pharmacist, and registered dietician attend the meetings. The Administrator further stated they had Process Improvement Plans in place for their renovations and physical plant operations and had completed plans for water temperatures and tracheostomy care. She indicated she felt like the repeat deficiencies were related to turnover in department heads and turnover of staff and because there were not systems in place for staff or accountability of staff and she was trying to get those things in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, picture, manufacturer's instructions, resident, family member #5, staff, consultant pharmacist, and Medical Director interviews the facility failed to ensure that single resident insulin pens were not shared between residents. On 07/10/23 Nurse #10 administered insulin to Resident #171 using Resident #172's insulin pen. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Regurgitation (emission) of blood into the insulin cartridge after injection will create a risk of bloodborne pathogen transmission if the pen is used for more than one resident, even when the needle is changed. This has the high likelihood to spread bloodborne pathogens such as human immunodeficiency virus (HIV), Hepatitis B and Hepatitis C. This affected 1 of 3 residents reviewed for infection control. The facility also failed to initiate Enhanced Barrier Precautions (EBP) for residents with medical devices and non-chronic wounds such as indwelling catheters and tracheostomies for 4 of 4 residents reviewed with medical devices and wounds (Resident #1, Resident #19, Resident #26, and Resident #57). The facility further failed to change gloves during incontinent care and before touching the resident's environment (Resident #35).
Immediate Jeopardy began on 07/10/23 when Nurse #10 administered insulin to Resident #171 using a pen that belonged to Resident #172. Immediate jeopardy was removed on 04/19/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal The facility will remain out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place.
Example #2 and #3 are being cited at a lower scope and severity of an E.
The findings included:
1.
Review of an article published on the National Library of Medicine website January 2008 read in part, the most common method of open loop insulin delivery is the subcutaneous insulin injection. In addition to the basal requirements the patient will inject insulin into subcutaneous tissue prior to meals. To provide rapid insulin during this situation a fast-acting insulin such as insulin aspart or insulin lispro is used.
Review of a facility policy dated 11/01/20 read in part, Insulin Pen: insulin pens contain multiple doses of insulin but are used for single residents only.
Review of manufacturer's instructions for Lispro insulin revised in July 2023 read in part, do not share your insulin Lispro (insulin in a pen form that has a reservoir that holds the insulin and a rubber end that is punctured when the small needle is applied to administer the insulin) pen with other people even if the needle has been changed. You may give other people a serious infection or get a serious infection from them.
Resident #171 was admitted to the facility on [DATE] and was discharged on 09/06/23. Resident #171's diagnoses included diabetes mellitus. Resident #171 resided on the 200 hall at the time of the incident.
Review of a physician's order dated 06/24/23 read, Admelog (Lispro insulin fast acting) for blood sugar 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units give subcutaneously three times a day for diabetes at 8:00 AM, 12:00 PM, and 4:00 PM.
An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #171 was cognitively intact.
Review of the Medication Administration Record (MAR) dated July 2023 revealed that on 07/10/23 Nurse #10 administered Admelog insulin at 8:00 AM, 12:00 PM, and 4:00 PM.
Review of a progress note for Resident #171 written by Nurse #11 dated 07/11/23 at 11:13 AM read; new insulin Lispro opened from e-kit. Reordered insulin Lispro from pharmacy. Will update as needed.
Resident #171 was interviewed via phone on 04/15/24 at 4:31 PM. She stated that she resided at the facility for a few months. Resident #171 stated that on 07/10/23 at 6:06 PM (time on her cell phone) Nurse #10 came into her room to give her an insulin shot. Resident #171 could not recall what her blood sugar was but stated that after Nurse #10 had checked her sugar, she required several units of insulin. She stated Nurse #10 had laid the cap to the insulin pen that she used to administer her insulin on her bedside table and after she had given the insulin shot to Resident #171, she (Resident #171) noted that the label that was on the insulin pen cap had Resident #172's name on it. Resident #171 stated she asked Nurse #10 about it, and she stated that it was left at the facility by another resident and was ok to use. Resident #10 stated that she reported the incident to Nurse #11 the next morning on 07/11/23 and to family member #5. She added she had no ill effects from receiving Resident #172's insulin
A cell phone picture provided by Resident #171 on 04/15/24 revealed an insulin pen with the red connector to the lower insulin reservoir noted with a label that contained Resident #172's name, room number, type of insulin, prescription number and fill date on the pens cap. The type of insulin was Lispro insulin (fast acting insulin).
Observations made on 04/17/24 at 2:38 PM of the medication carts revealed Lispro insulin pens for other residents that all contained the label and instructions on the cap of the pen. Each pen had a red connector that was attached to the pen reservoir and when removed the pen cap did not contain the red connector.
Family member #5 was interviewed via phone on 04/16/24 at 5:03 PM. The family member stated that Resident #171 had called her and told her a nurse had used another resident's insulin pen to administer insulin to her (Resident #171) and had sent her a picture of the insulin pen. The family member stated she reported the issue to the Director of Nursing (DON) in July 2023 after the incident occurred but had not heard anything back from her. The DON told the family member she would address it.
Resident #172 was admitted to the facility on [DATE] and was discharged on 08/09/23. Resident #172's diagnoses included diabetes mellitus. Resident #172 resided on the 300 hall at the time of the incident.
A physician's order dated 05/29/23 read, Lispro insulin for blood sugars 200-250=2 units, 251-300=4 units, 301-350=6 units, and 351-400= units subcutaneously before meals.
Nurse #10 was interviewed via phone on 04/16/24 at 5:10 PM. Nurse #10 confirmed she no longer worked at the facility. She stated when she did work at the facility, via an agency, she was a hall nurse and administered medications including insulin. Nurse #10 stated I have seen them share insulin pens there (at facility), but I have not done it because it messes up when they can get a refill. Nurse #10 stated she had never had to do that in this building referring to sharing insulin pens. Nurse #10 recalled Resident #171 but stated she did not recall giving her insulin from another resident's insulin pen. She added that the facility had availability issues with medications because the staff were not reordering them like they should.
Nurse #11 was interviewed via phone on 04/17/24 at 11:59 AM. Nurse #11 confirmed she no longer worked at the facility. Nurse #11 recalled that on 07/11/23 Resident #171 had reported to her that the cap from the insulin pen that was used the previous night was left at bedside and it was not her insulin. Nurse #11 stated she reported the issue to the DON. After she reported the incident to the DON, she was asked by the DON to educate all the nursing staff about insulin pens and how to use them, how to reorder them, and how to store them. Nurse #11 stated that was the only incident she heard about of staff sharing insulin pens and she was aware that you were not supposed to share insulin pens.
The Consultant Pharmacist was interviewed on 04/16/24 at 3:09 PM. The Pharmacist stated staff should not be sharing insulin pens, they are designed to be used multiple times by one resident only. She explained that when insulin pens first came out, they marketed the insulin pens as they could be used on multiple residents as long as you changed the needle between residents but then they discovered that those residents who shared insulin pens had Hepatitis C and the guidance was changed that you could not share the pens even if you changed the needle.
The DON was interviewed on 04/16/24 at 3:59 PM and again on 04/18/24 at 2:45 PM. The DON stated it was reported to her that there was an insulin pen cap found in Resident #171's room that did not belong to her. She stated she interviewed Resident #171 on 07/11/23, and she stated that the cap to the insulin pen that was used on her last evening had another resident's name on it. She also interviewed Nurse #10 who was certain that she had not shared the insulin pen. However, the DON stated on 07/11/23 she went through and made sure that each resident who was prescribed insulin had a supply of their prescribed insulin either on the medication cart or in the refrigerator. During the initial audit of the insulin, they discovered that some residents did not have a supply of insulin but Resident #171 was not one of those residents. The DON stated that she was instructed by the Administrator to replace everyone's insulin pen despite the high cost and all nursing staff were educated on the usage of insulin pens, how to reorder them and how to store them. The DON again stated she could not confirm that the insulin was given from another resident's pen, but they decided to put together a plan to correct any issue that they had. The DON was asked to run a report from July 2023 to October 2023 of residents that had diagnoses of bloodborne disease, and she stated she unable to do so.
The Administrator was interviewed on 04/18/24 at 11:54 AM, she stated she was aware of the insulin pen issue. From what she understood, it was just a cap that was discovered but she asked the DON to cover all the bases, and everyone got new insulin pens from the pharmacy. The Administrator stated she did not want any of her staff to share insulin pens as it is never appropriate to share the pens. She stated that the MD had stated to her that the insulin pens were a closed system as long as the needle was removed, and a new one put on.
The Medical Director (MD) was interviewed via phone on 04/17/24 at 4:20 PM. The MD stated that Lispro insulin and Admelog insulin were very similar and were in the same category of insulin and that there was no adverse effects from giving one or the other. The MD stated, it is not ideal to share insulin pens, but it can be done in certain circumstances because they are changing the needles, but it is better if you don't share them. The MD stated he had never heard of anyone at the facility sharing insulin pens and he only been the MD since October of 2023.
The Administrator was notified of Immediate Jeopardy on 04/18/24 at 11:09 AM.
The facility provided the following credible allegation of immediate jeopardy removal:
Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:
The facility failed to ensure that a single resident insulin pen was used for one resident (Resident #171). On 7/10/23 Nurse #10 used Resident #172's insulin pen to give short acting insulin to Resident #171
Nurse #10 is no longer employed at the facility.
The Director of Nursing notified the Medical Director and the Physician on 7/11/2023. There were no new orders. The Director of Nursing initiated an investigation and collected statements.
On 7/11/2023 the Director of Nursing notified the pharmacy of Resident #172's insulin pen used for Resident #171. The Director of Nursing ordered new insulin pens for all residents with a physician order for insulin.
The Insulin pen for Resident #172 was discarded, and new ones were ordered on 7/11/2023. Resident #172 did not receive insulin from the reused insulin pen. Resident #172 was discharged [DATE] and no longer resides in the facility.
Resident #171 notified the facility of deficient practice on July 11,2023. On 7/11/2023, new insulin pens were reordered, and the previously used pens were discarded. The Resident was assessed by the physician on 7/28/2023 with no new orders. The Resident was discharged from the facility on 9/6/2023.
The Director of Nursing reviewed residents who receive insulin via pen in July 2023. The Director of Nursing conducted an audit of all residents currently prescribed insulin to determine that all residents who receive insulin had a pen specific to the prescribed medication and dosage. On July 12 2023 All Residents who receive insulin via pen, received a new pen, labeled with their name, drug and dosage.
Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete:
On July 12,2023 Nurse #10 who was employed through agency contract was terminated.
On July 11, 2023, the Director of Nursing and Assistant Director of Nursing conducted an in person verbal in-service for 100% of nursing staff, including LPNs, RNs, and Medication Aides. The lesson plan covered the following topics:
-Insulin pens are Resident specific.
-Nurses may not exchange insulin pens for use with that of a different resident.
-If a resident does not have the required pen notify the supervisor, physician and pharmacy and medical director.
On July 11, 2023 all staff who received the in-service verbalized understanding.
The infection control policy was reviewed by the Director of Nursing and the Regional Nurse Consultant on July 11, 2023, to ensure it includes bloodborne pathogens and the use of insulin pens. No revisions were necessary.
On 7/11/2023, the Director of Nursing notified the Assistant Director of Nursing (who is responsible for staff education) to provide education on the policy prior to the start date for all new nursing hires (LPN, RN, Medication Aids).
On 4/17/24 the Director of Nursing notified the Health Department that on 7/11/2023 it was reported by Resident #171 that Nurse #10 administered insulin using a pen belonging to Resident #172
Immediate jeopardy removal date is 4/19/24
A validation of immediate jeopardy removal was conducted on 04/23/24. Interviews with nursing staff revealed they were aware to never share insulin pens, how to reorder them, how to store them, and how to utilize the backup medication system if a resident was out of their prescribed insulin. A medication pass was completed that included insulin administration with no issues noted and a medication error rate of 0%. The initial audit of all residents' insulin was reviewed as was the order form and confirmation from the pharmacy indicating that they had received the order for insulin pens for the residents that were in the building. Education sign in sheets were reviewed with no concerns noted. The DON verbally confirmed that the education was included in the new hire orientation program and that she had contact the health department to notify them of the reported incident. Attempts to notify the local health department of the incident were made on 04/17/24 and 04/18/24. The facility's removal date of 04/19/24 was validated.
2. Review of the facility's policy and procedure last updated and implemented on 04/01/24, entitled Enhanced Barrier Precautions read in part:
under Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Under Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Under Policy Explanation and Compliance Guidelines:
2. Initiation of Enhanced Barrier Precautions (EBP):
a. The facility will have the discretion in using EBP for residents who do not have a chronic
wound or indwelling medical device and are infected or colonized with a multi-drug-
resistant organism (MDRO) that is not currently targeted by the Centers for Disease Control
and Prevent (CDC).
b. An order for enhanced barrier precautions will be obtained for residents with any of the
following:
i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers,
unhealed surgical wounds, and chronic venous status ulcers) and/or indwelling
medical devices (e.g., central lines, urinary catheters, feeding tubes,
tracheostomy/ventilator tubes) even if the resident is not known to be infected or
colonized with a MDRO.
ii. Infection or colonization with a CDC-targeted MDRO when contact precautions
do not otherwise apply.
4. High contact resident care activities include:
a. Dressing
b. Bathing
c. Transferring
d. Providing hygiene
e. Changing linens
f. Changing briefs or assisting with toileting
g. Device care or use: central lines, urinary catheters, feeding tubes,
tracheostomy/ventilator tubes
h. Wound care: any skin opening requiring a dressing
a. Observation on 04/15/24 at 11:15 AM of Resident #57 revealed she had a gastrostomy tube for which she was receiving bolus feedings and she had a tracheostomy tube. There was no personal protective equipment (PPE) available outside her door.
b. Observation on 04/15/24 at 12:07 PM of Resident #1 revealed she had an indwelling urinary catheter and an unstageable wound to her right hip area. There was no personal protective equipment (PPE) available outside her door.
c. Observation on 04/15/24 at 12:30 PM of Resident #26 revealed he had an indwelling urinary catheter. There was no personal protective equipment (PPE) available outside his door.
d. Observation on 04/15/24 at 2:36 PM of Resident #19 revealed he had a stage III pressure ulcer on his left buttock. There was no personal protective equipment (PPE) available outside his door.
e. Observation on 04/16/24 at 4:00 PM of Resident #20 revealed she had chest catheter access for dialysis with a dressing on the catheter site. There was no personal protective equipment (PPE) available outside her door.
Interview on 04/18/24 at 2:55 PM with the Director of Nursing (DON) who was also the Infection Preventionist (IP) revealed she was aware of the new guidelines for placing residents with wounds and internal medical devices such as urinary catheters, gastrostomy tubes and tracheostomy tubes on Enhanced Barrier Precautions (EBP) effective 04/01/24. She stated they had not yet educated their staff on the procedures and had placed an order for caddies but had not received them and she had not implemented the guidelines. The DON/IP stated she was aware that it was supposed to be implemented effective 04/01/24 but she had not implemented the new guidelines at the facility and admitted the staff were not aware they needed to be wearing PPE during high contact resident care for residents with wounds, urinary catheters, feeding tubes, tracheostomy tubes and central catheters. She further stated that she should have already implemented the procedure at the facility effective 04/01/24.
3. Review of the facility's policy and procedure implemented on 11/01/20, entitled Hand Hygiene read in part:
under Policy Explanation and Compliance Guidelines:
3. Alcohol-based hand rub is the preferred method for cleaning hands in most clinical situations.
6. Additional considerations:
a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform
hand hygiene prior to donning gloves and immediately after removing gloves.
Hand Hygiene Table - use either soap and water or alcohol-based hand rub (ABHR is preferred)
After handling contaminated objects
When, during resident care, moving from a contaminated body site to a clean body site
After assistance with personal body functions (e.g., elimination, hair grooming, smoking)
When in doubt.
Observation on 04/15/24 at 11:27 AM revealed Nurse Aide (NA) #5 preparing to provide incontinence care to Resident #35. NA #5 donned her gloves and prepared wash cloths and wipes and proceeded to clean the resident on the front side from urine and then turned him on his right side and cleaned his back side and in between his buttocks from smears of stool. Once he was cleaned, with the same gloves on she placed a clean brief under the resident, opened his bedside drawer and removed a tube of barrier cream from the drawer, squirted it on her gloved hand and proceeded to rub the barrier cream on his buttocks. NA #5 then fastened his brief on the left side, turned him on his back and fastened the brief on the right side and adjusted his linens. NA #5 then doffed her gloves, sanitized her hands, and proceeded out of the room with a trash bag in her hand.
Telephone interview on 04/18/24 at 2:44 PM with NA #5 revealed she recalled caring for Resident #35 on 04/15/24. She stated she was nervous about being observed during resident care and forgot to doff her gloves after cleaning the resident and before applying barrier cream to his buttocks. She stated she knew the proper procedure for changing gloves when moving from a dirty to clean procedure but said she just forgot to do it because she was nervous about being watched.
Interview on 04/18/24 at 2:58 PM with the Director of Nursing (DON) who was also the Infection Preventionist (IP) revealed NA #5 should have doffed her gloves after cleaning the resident, sanitized her hands and donned clean gloves prior to touching the resident's bedside table and applying barrier cream to his buttocks. She stated she would provide additional education to NA #5 regarding hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 12/16/21. This was for 6 deficiencies that were cited in the areas of Resident Rights/Exercise of Rights (F550), Reasonable Accommodations of Needs/Preferences (F558), Care Plan Timing and Revision (F657), ADL (Activities of Daily Living) Care Provided for Dependent Residents (F677), Free of Accident Hazards/Supervision/Devices (F689) and Food Procurement, Storage/Preparation/Serve under Sanitary Conditions (F812) on 12/16/21 and recited on the current recertification and complaint survey of 12/15/22. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the complaint survey conducted on 4/8/22. This was evident for 1 deficiency in Safe/Clean/Comfortable/Homelike Environment (F584) originally cited on the complaint survey on 4/8/22 and recited on the current recertification and complaint survey of 12/15/22. The duplicate citations during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.
The findings included:
This tag is cross referenced to:
F550 - Based on observation, record review, resident, and staff interviews the facility failed to provide care in a manner that maintained the resident's dignity by not providing incontinence care when needed. This is evidenced by Resident #266 feeling violated. This occurred for 1 of 4 residents reviewed for dignity. (Resident #266)
During the recertification and complaint survey on 12/16/21, the facility failed to promote dignity by not providing colostomy care for 2 hours after leakage occurred, by not providing a privacy cover over a urinary drainage bag and by not ensuring a resident had a call bell in his room for 3 of 4 residents reviewed for dignity. In addition, the facility failed to promote a dignified dining experience by using styrofoam plates for 2 of 2 meals observed.
F558 - Based on record reviews, and interviews with family member, and staff, the facility failed to provide foot pedal on a wheelchair for a resident transported by the facility to a specialist appointment for one of one resident reviewed for accommodation of needs (Resident #114).
During the recertification and complaint survey on 12/16/21, the facility failed to ensure a resident had a call bell in his room and failed to keep a resident call bell within reach. This was for 2 of 2 residents reviewed for accommodation of needs.
F584 - Based on observations and resident and staff interviews, the facility failed to maintain home like environment and wall integrity in the residents' rooms for 2 of 9 sampled residents for rooms [ROOM NUMBERS] and 1 of 3 hallways.
During the complaint survey on 4/8/22, the facility failed to maintain clean floors in 3 of 3 hallways and in 2 of 15 resident rooms, ensure 1 of 2 handrails was secured to the wall on 200 hall, repair 5 of 5 drain covers on 200 hall, repair light fixture covers in 2 of 15 rooms and replace missing or damaged electrical wall plates in 2 of 15 rooms.
F657 - Based on record review and resident and staff interviews, the facility failed to invite a resident and/or her representative to participate and provide input in care planning for 1 of 3 sampled residents (Resident #18) and failed to update the care plan to reflect the current advance directive for 1 of 3 residents reviewed (Resident #13).
During the recertification and complaint survey on 12/16/21, the facility failed to review and revise a care plan in the areas of smoking, accidents, and nutrition. This was for 3 of 20 residents' care plans reviewed.
F677 - Based on observation, record review, resident, and staff interviews, the facility failed to provide incontinence care, which resulted in resident #266 feeling violated for 1 of 6 dependent residents reviewed for activities of daily living (ADL). (Resident #266)
During the recertification and complaint survey on 12/16/21, the facility failed to provide nail care and facial grooming for residents who required staff assistance with their activities of daily living (ADL). This was for 3 of 5 residents reviewed for ADL.
F689 - Based on record reviews, and interviews with resident, family member, staff, Nurse Practitioner and Medical Director, the facility failed to provide care in a safe manner for 2 of 6 residents reviewed for supervision to prevent accidents (Resident #114 and Resident #25). On 11/17/22, Resident #114's lower half of her body went off the other side of the bed during incontinence care resulting in a non-displaced, comminuted (bone that is broken in at least two places) proximal tibia-fibula (explain) fracture of the right leg. The facility failed to investigate the injury and complete a root cause analysis and as a result no plan was in place to prevent further injury to residents. On 11/25/22, Resident #25 who required two staff member assistance with bed mobility, fell out of a raised bed onto the floor during incontinence care which resulted in a closed fracture of the left tibial plateau, a closed fracture of the right femur, and a closed traumatic fracture of the left tibial plafond (end of the shin bone and involves the ankle joint). She complained of severe pain to both knees which was worsened by movement and alleviated by nothing. In addition, the facility failed to complete accurate smoking assessments to provide a safe smoking environment for 2 of 2 residents reviewed for smoking (Resident #16 and Resident #36).
During the recertification and complaint survey on 12/16/21, the facility failed to secure bleach used by a resident for personal use for 1 of 4 residents reviewed for accidents.
F812 - Based on observations and staff interview, the facility failed to label, date and seal open food items stored for use in 1 of 1 walk- in refrigerator and 1 of 1 reach in cooler. This practice had the potential to affect the food served to residents.
During the recertification and complaint survey on 12/16/21, the facility failed to label and date opened food items, failed to store food in closed containers, failed to remove dented cans, failed to keep floor in dry storage free of debris for 1 of 1 dry storage rooms reviewed for food storage.
An interview with the Administrator on 12/15/22 at 7:20 PM revealed the facility hadn't been able to implement procedures and monitor interventions put in place by the QAA committee due to changes in staffing and turn-over across all departments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with family member, and staff, the facility failed to provide foot pedal on a wheelchair for a resident transported by the facility to a specialist appointment for one of one resident reviewed for accommodation of needs (Resident #114).
The findings included:
Resident #114 was admitted to the facility on [DATE] and discharged to the hospital on [DATE].
Her admission diagnoses included left above the knee amputation, diabetes, and osteoporosis.
Resident #114's admission MDS dated [DATE] revealed she was moderately cognitively impaired but was alert and oriented to person, place and situation and was able to make all needs known. The MDS also revealed the resident required extensive assistance of 1 to 2 staff members for all activities of daily living (ADL) except eating.
Interview on 12/13/22 at 11:30 AM with Resident #114's family member revealed she met the resident at her specialist's appointment on 11/17/22. The family member stated Resident #114 had been transported to the appointment without a foot pedal on her wheelchair. The family member further stated she had to hold the resident's leg up with a towel because she was in pain with her leg not elevated and at rest on a foot pedal.
Interview on 12/14/22 at 9:11 AM with the Transporter revealed she remembered taking Resident #114 out for her specialist appointment but could not recall if the resident had a foot pedal on her wheelchair for her right leg. She stated she had never been told that residents going out in wheelchairs for appointments needed to have foot pedals on their wheelchairs. The Transporter further stated the resident had her own wheelchair and one that had been provided by the facility, but that morning neither of them could be found so she had to use another wheelchair to transport the resident.
Interview on 12/13/22 at 12:39 PM with Nurse #2 who was assigned to care for Resident #114 on 11/17/22 revealed she was not aware the resident had been sent out to her appointment without a foot pedal on her wheelchair. She stated she had not seen the resident when the Transporter took her out of the building for her appointment. Nurse #2 stated she thought all residents went out with foot pedals on their wheelchairs.
Interview on 12/14/22 at 10:42 AM with the Therapy Manager revealed if therapy was aware of resident's going out for appointments, they made sure their wheelchairs were equipped for their transport; however, she stated sometimes nursing made appointments they were not aware of and were not able to set their wheelchairs up with what they needed for transport. The Therapy Manager stated as she recalled Resident #114 was being seen by therapy for trunk weakness and said she would need a leg rest on her wheelchair when going out for appointments for her safety.
Interview on 12/15/22 at 5:33 PM with the Director of Nursing (DON) revealed she knew the resident had a specialist appointment and the facility Transporter took her to the appointment but stated she didn't know whether the resident had a footrest on her wheelchair when taken for her appointment. The DON stated the staff knew if the resident needed a footrest, one was to be attached to the wheelchair. She further stated the Transporter had been educated on the need for footrests on wheelchairs when transporting residents prior to this incident.
Interview on 12/15/22 at 7:02 PM with the Administrator revealed she would expect residents going out to appointments to have foot pedals on their wheelchairs. She stated the Transporter had been educated on the need for foot pedals on wheelchairs when transporting residents to appointments prior to this incident and they would provide more one on one education to her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation and interview was conducted on 12/12/22 at 12:03 PM with Resident #21 in room [ROOM NUMBER]. There were 2 large areas behind her bed (one area was 2 feet by 3 feet and the other area was 2 feet by 1 foot) that were patched with white material and had not been sanded and painted and the surfaces were uneven. The resident stated it had been that way for the past 3 years. She stated she had asked about getting it repaired and painted but it had not been done.
A list with no date was received from the Director of Nursing for repairs that had been identified as needed throughout the building on 12/15/22 at 9:50 AM was reviewed. room [ROOM NUMBER] was listed as needing to be painted.
Interview and observation on 12/15/22 at 2:50 PM with the Maintenance Director in room [ROOM NUMBER] revealed he was not aware of the holes in the wall that had been patched. He stated the room was on the list for painting but the areas behind the bed would require more patching, sanding, and painting. The Maintenance Director stated he had been given a priority list and room [ROOM NUMBER] had just been recorded as needing painting but he said he would need to make some repairs to the areas behind the bed before the room was painted.
Interview on 12/15/22 at 5:48 PM with the Director of Nursing (DON) revealed the list that was provided was developed by her and the Assistant Director of Nursing (ADON) going through the empty rooms on the 200 hall to identify what was needed to make them livable. She stated the goal was to move residents on the 300 hall to the 200 hall and renovate the 300 hall for new admissions. The DON further stated they had looked at whether the TV was in the room, proper functioning bed, bedside table and overbed tables were in the room and the overall aesthetics of the room such as paint in good condition, closets in good condition with locks on them, no holes in the wall, blinds in good condition, proper functioning toilet in the bathroom and working call lights in the room and bathrooms. The occupied rooms were not evaluated but the DON explained the nurses and nursing assistants were in those rooms on a daily basis and if there were issues, they should be identifying them and writing them in the book for maintenance.
Interview on 12/15/22 at 5:43 PM with the Regional Director of Clinical Services revealed they were trying to get 200 hall acceptable so they could move all the residents on the 300 hall onto the 200 hall and renovate the 300 hall for new admissions and then start working on the 200 hall. She stated they were getting rid of the popcorn ceilings, so she didn't want residents on the hall getting exposed to the dust. She further stated the 200 hall probably was not perfect in the real world but they were trying to make updates and identify issues to get started on repairs.
Interview on 12/15/22 at 7:07 PM with the Administer revealed their plan was to move the 300 hall residents to the 200 hall and renovate the 300 hall and when that was finished to renovate the 200 hall. She stated she was not aware of the condition of room [ROOM NUMBER] and said it should have been repaired before now if it had been that way for 3 years.
Based on observations and resident and staff interviews, the facility failed to maintain a home like environment and wall integrity in residents' rooms for 2 of 9 sampled residents (rooms [ROOM NUMBERS]) on 1 of 3 hallways.
The findings included:
1. Observation on 12/12/22 at 12:10 PM revealed the bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] was shared by three residents and had a light fixture wrapped in paper with blue paint tape, wet towel on the floor lying beside the toilet, the toilet paper holder was hanging off the wall with sharp edges showing, the light over the sink had dirt and dust in the light fixture, and the emergency call light cord had broken off with approximately 1 inch of the cord remaining. A roll of toilet paper was observed on the handrail near the toilet.
An observation and interview were conducted with Resident #40 on 12/13/22 at 11:45 am and revealed the light fixture wrapped in paper with blue paint tape, toilet paper holder was hanging off the wall with sharp edges showing, the light over the sink had dirt and dust in the light fixture, and the emergency call light cord had broken off with approximately 1 inch of the cord remaining. Resident #40 was cognitively intact and stated she felt that her bathroom had been yucky for several weeks and had reported the issues to staff but could not recall names. A roll of toilet paper was observed on the handrail near the toilet.
An interview with the facility Housekeeper on 12/13/22 at 3:00 PM revealed she had cleaned the bathroom to room [ROOM NUMBER] and #316 on 12/12/22 and 12/13/22. The Housekeeper further revealed she did not recall a towel on the floor on 12/12/22. The Housekeeper indicated she did not recall issues in the bathroom.
An observation and interview conducted with Maintenance Director on 12/13/22 at 2:50 PM revealed he had been working in the facility for three weeks and was not informed there were issues with the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER]. The Maintenance Director further revealed staff put a ticket in a binder at the nurses' station if there was an issue. The Maintenance Director observed the light fixture wrapped in paper with blue paint tape, the toilet paper holder was hanging off the wall with sharp edges showing, the light over the sink had dirt and dust in the light fixture, and the emergency call light cord had broken off with approximately 1 inch of the cord remaining. The Maintenance Director stated he normally checked the work binder daily and would also make daily rounds but was unable to since he had started. The Maintenance Director indicated the bathroom was not acceptable and should have been in better shape.
An interview conducted with the Director of Nursing (DON) on 12/15/22 at 5:50 PM revealed she had assisted a resident several times to the bathroom in room [ROOM NUMBER] and had observed the call light string to be broken, but it had worked. The DON further revealed she did not report this to maintenance and had gone through vacant rooms to check for issues but had not been through occupied rooms. The DON stated she expected for residents to be comfortable and be in a homelike environment.
Observation and interview were conducted with Administrator on 12/13/22 at 3:15 PM. The observation of the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] revealed the light fixture wrapped in paper with blue paint tape, the toilet paper holder was hanging off the wall with sharp edges showing, the light over the sink had dirt and dust in the light fixture, and the emergency call light cord had broken off with approximately 1 inch of the cord remaining. The Administrator stated the light fixture was covered with paper and tape from a paint job a few weeks ago and the facility had a plan to make improvements. The Administrator indicated the bathroom was not acceptable and the facility was working to make improvements throughout the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to invite a resident and/or her representative to participate and provide input in care planning for 1 of 3 sampled residents (Resident #18) and failed to update the care plan to reflect the current advance directive for 1 of 3 residents reviewed (Resident #13).
The findings included:
1. Resident #18 was admitted to the facility on [DATE].
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was moderately cognitively impaired.
A review of Resident #18's electronic medical record indicated the last documented care plan meeting was held on 5/31/22 with Resident #18's family member in attendance. Further review revealed no evidence of Resident #18, or her family member being invited to attend a care plan meeting to discuss and provide input regarding her plan of care following the completion of the quarterly MDS assessment dated [DATE].
An interview with Resident #18 on 12/12/22 at 11:38 AM revealed she had not been invited or participated in her care plan meetings.
An interview with the MDS Coordinator on 12/15/22 at 3:55 PM revealed care plan meetings were supposed to be done quarterly and they were supposed to be scheduled by the Social Worker. The Social Worker was supposed to be sending an invitation to the care plan meeting to both residents and family members. However, the facility had not had a Social Worker since December 2022.
An interview with the Regional Clinical Resident Coordinator on 12/15/22 at 6:35 PM revealed he was aware that the last care plan meeting for Resident #18 was held on 5/31/22 and she should have had at least two care plan meetings since then. He stated he identified an issue with care plan meetings not being scheduled in October 2022 and had started a plan to get care plan meetings scheduled. He did not know why Resident #18 still had not had a care plan meeting since. He further stated that since Resident #18 was not listed as responsible for herself, they normally invited just her responsible party to her care plan meetings.
An interview with the Administrator on 12/15/22 at 6:55 PM revealed she was aware that care plan meetings were not being held on a routine basis due to changes in staffing especially with the MDS Coordinator and Social Worker positions. She stated that residents and families should be invited to the care plan meetings regardless of who was listed as the responsible party. The residents needed to be involved in their care if they chose to do so.
2. Resident #13 was admitted to the facility on [DATE].
A DNR (Do Not Resuscitate) form dated 4/12/22 for Resident #13 was in the advance directive book at the nurses' station.
Resident #13's care plan last revised on 12/12/22 indicated Resident #13 and his family desired full code status at this time.
An interview with the MDS (Minimum Data Set) Coordinator on 12/15/22 at 2:56 PM revealed when she updated Resident #13's care plan 12/12/22, she overlooked his code status, and she should have updated his care plan to reflect his current code status.
An interview with the Director of Nursing (DON) on 12/15/22 at 5:26 PM revealed the MDS Coordinator was responsible for updating the care plans and she should have updated Resident #13's care plan to reflect his current advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, and staff interviews, the facility failed to provide incontinence care, which resulted in resident #266 feeling violated for 1 of 6 dependent residents reviewed for activities of daily living (ADL). (Resident #266)
The findings included:
Resident #266 was readmitted to the facility on [DATE] with diagnoses that included stroke, diabetes, muscle weakness, lack of coordination and major depressive disorder.
Resident #266's most recent Minimum Data Set, dated [DATE] revealed he was cognitively intact with no refusals of care. He required extensive assistance with bed mobility, toileting, and personal hygiene. He had functional limitations on one side for the upper and lower extremities. Resident #266 was frequently incontinent of bladder and always incontinent of bowel.
Review of Resident #266's was care plan revised on 12/12/22 revealed the following:
-Resident #266 had an ADL self-care deficit related to hemiplegia. The interventions included resident needs extensive 1 staff assist with bed mobility and resident uses the trapeze bar.
-Resident needs extensive 1 staff assist with personal hygiene and toileting. Encourage the resident to use the call bell for assistance.
-Resident #266 had a stroke affecting his right side. The interventions included, monitor, and document the resident's abilities for ADLs and assist as needed.
-Resident #266 had bowel and bladder incontinence. The interventions included cleanse peri-area with each episode of incontinence.
While touring the 200 hall on 12/12/22 at 10:15 AM there was a noticeable odor of feces when passing Resident #266's room. An observation was made from the hall revealed the resident's privacy curtains were pulled closed.
During an observation and interview with Resident #266 on 12/12/22 at 10:37 AM there was still a strong odor of feces in his room. Resident #266 revealed he was not having a good day because he had been waiting for 2 hours to be changed. He explained this occurs frequently, and he had waited up to 5 hours in the past. He further explained that staff would come in and turn off the call light and say they would be right back but would take a long time to return. He had reported this to the Director of Nursing (DON) in the past, but nothing had changed. Resident #266 stated he knew he had been waiting 2 hours because he always looked at the clock when he pushed his call light. He did this because staff were slow to come in. Resident #266 explained he had a stroke in 2010 and he could not get out of bed my himself to go to the bathroom, therefore he had to wait on staff for help. He stated, I don't like to lay here in my urine and feces, it makes me feel violated. He revealed he initially called for assistance approximately 2 hours ago. Sometime after his initial call Nurse #4 came in his room and said she would send in the nurse aide, but no one had come in yet.
At 10:40 AM Resident #266 was observed to activate his call light. At 10:50 AM Nurse Aide (NA) #4 entered the room. While observing incontinence care Resident #266 was noted to have a large bowel movement that was difficult for NA #4 to remove from his skin. The nurse aide had to leave the room because she needed a 2nd pack of wipes to complete the incontinence care. NA #4 completed the incontinence care and applied a clean brief. She then assisted Resident #266 to his wheelchair.
An interview was conducted on 12/12/22 at 11:00 AM where Nurse #4 stated Resident #266 told her he needed to be changed, but she was unsure of how long it had been since he asked. She revealed she told NA #4 that Resident #266 needed incontinence care. She further revealed that NA #4 was working in another resident's room.
During an interview on 12/12/22 at 11: 10 AM NA #4 revealed she was not aware that Resident #266 had been waiting 2 hours for care. She explained she had 2 residents that she had gotten ready for appointments this morning. Both residents needed baths and dressed before their appointments, and she had spent a lot of time in those resident's rooms that morning. When she exited the last resident's room, she saw Resident #266 call light on and went in and provided care. NA #4 stated this was the first time she had seen Resident #266 on that day, no one told her Resident #266 needed to be changed. She indicated the reason he did not get care sooner was she was working with the other 2 residents, and she did not know he was soiled.
During an interview on 12/15/22 at 5:26 PM the DON revealed all staff were to answer call lights and the call lights should be answered as soon as possible. She further revealed if a resident needed incontinence care it should be provided as soon as possible. If the NA was unavailable the nurse should provide care or delegate to someone else that could.
An interview was conducted on 12/15/22 at 7:00 PM the Administrator revealed call lights should be answered and incontinence care should be provided in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, staff, and Care Coordinator for Podiatry interviews, the facility failed to ensure toenails were trimmed and to refer residents to podiatry services for 2 of 2 diabetic residents reviewed for foot care. (Resident #30 and Resident #50)
The findings included:
1. Resident #30 was admitted to the facility on [DATE] with diagnoses that included diabetes and dementia.
The most recent quarterly Minimum Data Set for Resident #30 dated 10/26/22 revealed he was cognitively intact. He required extensive assistance with personal hygiene.
Review of Resident #30's care plan revised on 12/12/22 revealed the following:
Resident #30 had an ADL self-performance deficit. The interventions included check the resident's nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. The resident required 1 staff for personal hygiene and oral care.
Physician orders for Resident #30 included:
May initiate evaluation and treatment by Podiatry/Dental/Ophthalmology/Optometry/Audiology consult care per regulation 9/30/22
An observation of Resident #30 on 12/12/22 at 11:26 AM revealed he was resting in bed with a gown on. Resident #30's toenails were long, thick, and extended approximately ½ inch past the tips of his toes.
An observation was made of Resident #30 on 12/13/22 at 8:49 AM he was in his bed being fed by a nurse aide. His toenails were long, thick, and extended approximately ½ inch past the tips of his toes.
During an interview on 12/13/22 at 3:07 PM Nurse Aide (NA) #4 revealed she was new to day shift, she had only been working this shift for about 1 week and she had not trimmed any nails. NA #4 stated she had not noticed Resident #30's toenails being long.
An interview was conducted on 12/13/22 at 3:11 PM where the Director of Nursing (DON revealed the NA's could trim fingernails but not toenails, they should report concerns to the nurse or Unit Manager (UM). The UM assessed the resident's nails. She further revealed podiatry came to the facility to trim toenails. She was unsure of how often podiatry came to the facility. The DON revealed she and the former Social Worker use to make the list of residents to be seen be podiatry, but she had recently taken over this responsibility.
During an interview on 12/13/22 at 3:20 PM the Unit Manager (UM) revealed she completed ADL audits daily and she assessed nails during those audits. She audited 3 random residents per day. If nails needed to be trimmed, she let the NA know. If the resident was a diabetic, the UM trimmed their nails.
Review of the list of Residents that were seen during the most recent podiatry visit on 10/25/22 revealed Resident #30 was not on that list.
An observation of Resident #30 on 12/15/22 at 9:51 AM revealed his toenails were long, thick, and extended approximately ½ inch past the tips of his toes.
On 12/15/22 at 12:25 PM an observation and interview were conducted with the UM. The UM stated she could not remember how Resident #30's toenails looked. Upon observation the UM stated the resident's toenails were long and thick. She further stated his toenails needed to be trimmed by podiatry. She was not sure why Resident #30 was not seen on 10/25/22 when podiatry was in the facility.
During an interview on 12/15/22 at 3:09 PM the care coordinator for podiatry services revealed residents at the facility could receive podiatry services every 62 days but they typically saw residents every 90 days. All residents needed to be referred to podiatry. Residents were referred by the facility, when podiatry received the referral, they faxed an order form to the facility to be signed and returned to podiatry. The Care Coordinator stated they had they ability to view the facility census from their office. They periodically reviewed the census and sent order forms for residents that had not been referred and have certain diagnoses. Those diagnoses included diabetes. The facility needed to return the signed order; residents could only receive services if they had a signed order by the physician. She further stated the facility could request an extra visit for any concerns that needed to be addressed before the next scheduled visit, using the same referral process. The Care Coordinator revealed Resident #30 had not been seen by podiatry. She stated that meant he either had not been referred or his signed order had not been returned.
An interview with the DON on 12/15/22 at 5:26 PM revealed she was unsure why Resident #30's toenails were not trimmed on 10/25/22 when podiatry services were in the building. She stated the former social worker oversaw podiatry appointments at that time. She indicated Resident #30 should have received a podiatry referral and services. She stated she was currently gathering resident names to refer to podiatry.
During an interview with the Administrator on 12/15/22 at 7:00 PM revealed if a resident required podiatry services, she expected them to be referred so they could be provided those services.
2. Resident #50 was admitted to the facility on [DATE] with diagnosis which included diabetes.
Resident #50's quarterly MDS dated [DATE] revealed he was cognitively intact and required limited assistance of 2 staff with personal hygiene and extensive assistance of 1 staff with bathing.
Review of the resident's care plan dated 10/2/22 revealed a focus area for the resident having diabetes mellitus type II. The interventions included refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails.
Observation and interview on 12/12/22 at 3:07 PM revealed Resident #50 sitting in his wheelchair in his room with his feet bare. Observation of both feet revealed his nails on both big toes were ½ to ¾ inch beyond the end of both toes. There were other toes on both feet that were ¼ to ½ inches beyond the end of his toes. The resident stated he had asked staff (could not remember names) about seeing the podiatrist when he was there last (on 10/25/22) but had not been seen by him.
Interview on 12/13/22 at 3:03 PM with Nurse Aide (NA) #4 revealed she was assigned to care for Resident #50 on the day shift. NA #4 stated she had not clipped Resident #50's nails and stated nails were usually done by the nurses if they were diabetic and their toenails by the podiatrist. NA #4 further stated she had not noticed his toenails or that they needed to be trimmed and had not reported to the nurse they needed to be trimmed.
Interview on 12/13/22 at 3:30 PM with the Unit Manager (UM) revealed she or one of the nurses were responsible for auditing residents' nails and when they needed to be trimmed it was done by the Unit Manager or a designated nurse. The UM further stated she had not noticed Resident #50's toenails and was not aware they needed to be trimmed.
Interview on 12/15/22 at 3:35 PM with Nurse #5 who was assigned to care for Resident #50 from 7:00 AM to 7:00 PM revealed she had not noticed the resident's toenails needing trimmed. She stated he was diabetic and should have been seen by the podiatrist on his last visit to the facility on [DATE].
Interview on 12/15/22 at 5:42 PM with the Director of Nursing (DON) revealed in the absence of a social worker she had asked the Unit Manager and Assistant Director of Nursing to compile a list of residents that needed to be seen by the podiatrist the week of December 5th. The DON stated they were unable to find the list of residents referred for podiatry services in the social worker office, so they had compiled a list themselves last week. The DON further stated Resident #50 was on the list to be seen at the next scheduled podiatry visit but couldn't remember who had told her to add him to the list. She indicated they emailed a list to the podiatry office of residents that needed to be seen and then the podiatry office confirms insurance approval and diagnosis for them to be seen. The DON further indicated she did not know why Resident #50 was not seen on the last podiatry visit on 10/25/22.
Interview on 12/15/22 at 6:55 PM with the Administrator revealed she was not sure why the resident had not been seen on 10/25/22 when the podiatrist had last been at the facility but said she expected all residents in need of services to be referred to the podiatrist for foot dare.

Based on observations and staff interview, the facility failed to label, date and seal open food items stored for use in 1 of 1 walk- in refrigerator and 1 of 1 reach in cooler. This practice had the potential to affect the food served to residents.
The findings included:
An initial tour of the kitchen was made on 12/12/22 at 9:58 AM with the Dietary Manager (DM).
The following problems were observed with the walk-in refrigerator:
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1 unsealed container labeled turkey sausage with a date of 12/11/22.
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1 unsealed, undated container of brown substance.
The following problems were observed with the reach in cooler:
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1 pack of hotdogs in an unmarked open clear plastic bag. No expiration date or best buy date was observed on the packaging.
An interview with the DM on 12/12/22 at 10:05 AM revealed the brown substance in the walk in refrigerator was beef gravy. The DM stated the items identified were supposed to be covered and dated when placed in the refrigerator or cooler.
A follow-up interview conducted with the DM on 12/13/22 at 3:00 PM revealed the turkey sausage was served the day prior and should have been covered that night before dietary staff left the facility. He stated he did not know when the beef gravy had last been served. The interview revealed the dietary staff often would place food items uncovered in the refrigerator to cool down and the staff had just forgotten to recover the items.
An interview conducted with the Administrator on 12/14/22 at 11:23 AM revealed it was the facility policy to ensure all food items were stored properly and she expected the dietary staff to follow those guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, and staff interviews the facility failed to provide care in a manner that maintained the resident's dignity by not providing incontinence care when needed. This is evidenced by Resident #266 feeling violated. This occurred for 1 of 4 residents reviewed for dignity. (Resident #266)
The findings included:
Resident #266 was readmitted to the facility on [DATE] with diagnoses that included stroke, muscle weakness, lack of coordination and major depressive disorder.
Resident #266's most recent Minimum Data Set, dated [DATE] revealed he was cognitively intact with no refusals of care. He required extensive assistance with bed mobility, toileting, and personal hygiene. He had functional limitations on one side for the upper and lower extremities. Resident #266 was frequently incontinent of bladder and always incontinent of bowel.
While touring the 200 hall on 12/12/22 at 10:15 AM there was a noticeable odor of feces when passing Resident #266's room. An observation was made from the hall and the resident's privacy curtains were pulled closed.
During an observation and interview with Resident #266 on 12/12/22 at 10:37 AM there was still a strong odor of feces in his room. Resident #266 revealed he was not having a good day because he had been waiting for 2 hours to be changed. He explained this occurs frequently, and he had waited up to 5 hours in the past. He further explained that staff would come in and turn off the call light and say they would be right back but would take a long time to return. He had reported this to the Director of Nursing (DON) in the past, but nothing had changed. Resident #266 stated he knew he had been waiting 2 hours because he always looked at the clock when he pushed his call light. He did this because staff were slow to come in. Resident #266 explained he had a stroke in 2010 and he could not get out of bed my himself to go to the bathroom, therefore he had to wait on staff for help. He stated, I don ' t like to lay here in my urine and feces, it makes me feel violated. He revealed he initially called for assistance approximately 2 hours ago. Sometime after his initial call Nurse #4 came in his room and said she would send in the nurse aide, but no one had come in yet. At 10:40 AM Resident #266 activated his call light. At 10:50 AM Nurse Aide (NA) #4 entered the room.
An interview was conducted on 12/12/22 at 11:00 AM where Nurse #4 stated Resident #266 told her he needed to be changed, but she was unsure of how long it had been since he asked. She revealed she told NA #4 that Resident #266 needed incontinence care.
During an interview on 12/12/22 at 11: 10 AM NA #4 revealed she was not aware that Resident #266 had been waiting 2 hours for care. She explained she had 2 residents that she had gotten ready for appointments this morning. Both residents needed baths and dressed before their appointments, and she had spent a lot of time in those resident's rooms that morning. When she exited the last resident's room, she saw Resident #266 call light on and went in and provided care. NA #4 stated no one told her Resident #266 needed to be changed. She indicated the reason he did not get care sooner was she was working with the other 2 residents, and she did not know he was soiled.
During an interview on 12/15/22 at 5:26 PM the DON revealed all staff were to answer call lights and the call lights should be answered as soon as possible. She further revealed if a resident needed incontinence care it should be provided as soon as possible. If the NA was unavailable the nurse should provide care or delegate to someone else that could.
An interview was conducted on 12/15/22 at 7:00 PM the Administrator revealed call lights should be answered and incontinence care should be provided in a timely manner. She indicated residents should be treated in a dignified manner.