WOOLDRIDGE PLACE NURSING CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report an alleged violation of abuse for (1 of 4 residents) in a timely manner.The facility failed to report to the state of Texas within 24 hours indicating Resident #1 hit her head, in a timely manner. R#1 hit her head during transport on March 7, 2005, the facility reported the incident 3 months later.This failure could place residents at risk for abuse and neglect. Findings included:Record review of Resident #1's face sheet dated June 30, 2025, revealed she was an [AGE] year-old female, admitted on [DATE], Resident #1 had a medical dx of Dementia (a group of thinking and social symptoms that interferes with daily function), Alzheimer's (a progressive disease that destroys memory and other important functions), Hypothyroidism ( condition in which the thyroid gland doesn't produce enough thyroid hormone), Muscle Weakness, Abnormal Gait (abnormal way of walking), and Lack of Coordination.An MDS assessment dated [DATE], revealed Resident #1 had a BIMS (brief interview of mental status) score of 15 (indicating resident is cognitively intact) and needed help with transferring and toileting. The MDS also indicated Resident #1 used a walker to assist with ambulation. Resident #1 was mostly independent in activities of daily living other than shower and toileting with minimal assistance. Record review of Resident #1's care plan, undated, revealed The resident has impaired cognitive ability /impaired thought processes related to Dementia. Interventions included: Allowing extra time for resident to respond to questions and instructions and to speak clearly when talking with the resident. During an interview on June 30, 2025, at 3:30 p.m., Resident #1 stated she was with one of the CNAs and the van driver going to an eye appointment, or coming back, and when she was walking into the van, she hit her head on the ceiling of the van. Resident #1 stated she could not remember the date it happened. Resident #1 stated it didn't hurt and she was okay. Resident #1 stated hitting her head surprised her. Resident #1 stated the van driver looked at her head, but it was fine. Resident #1 stated that is all she can recall from hitting her head; everything else went okay. During an interview on June 30, 2025, at 11:15 a.m., the facility Van Driver stated Resident #1 informed him she hit her head on the van ceiling when getting into the van. The Van Driver stated, CNA A and myself were telling her to duck down when walking into the van, but he did not see her hit her head. The Van Driver stated it happened just as hewas walking around the van. The van driver stated when she told me, he looked at her head and he didn't see any redness, bruising, or bump, and the resident said she was okay. The Van Driver stated he did not report the incident because the resident said she was okay. The Van Driver stated he was trained on abuse, neglect and exploitation and should have reported it to the nursing staff and to the Administrator. During an interview on June 30, 2025, at 11:45 a.m., CNA A stated while escorting Resident #1 to an eye appointment on March 7th, 2025, the resident claimed she hit her head on the ceiling of the van when walking with a walker to get into the van. CNA A stated she did not see it happen, but the resident said she was okay and there was no bump, bruise or abrasion on the resident's head and there were not any issues later. CNA A stated we told Resident #1 to duck down and to watch out for the low part of the ceiling. CNA A stated she did not report it to my manager or the Administrator because she just didn't. CNA A stated she should have reported it and she knew she should have but she didn't report it. CNA A stated she was trained on abuse, neglect, and exploitation. During an interview on 7/11/25 at 1:35 p.m., with the Administrator, he stated he found out Resident #1 hit her head while being transported to her eye doctor 3 months after the incident happened. The Administrator stated his expectations were to be to be informed of any resident hitting their head, or any occurrence immediately. The Administrator also stated staff did not connect that even though they didn't see anything (redness, abrasion and /or bruising) they did need to report this incident occurred. The Administrator stated the staff (Van driver and CNA A ) rationalized that because they did not see any injury and the resident stated she was fine, they did not need to report it. They should have reported it because there was still a possibility that she was injured. The Administrator stated Resident #1 was assessed and no head injuries noted. The Administrator stated it was and is my responsibility to complete the investigation of abuse or neglect and our findings were unfounded for the allegation of neglect or abuse, however we still did a thorough investigation including reviewing the resident's full chart. We (myself and the DON) interviewed all residents that traveled with both staff members during the time this occurred in March up until then. There were 7 residents, and all residents reported feeling safe around the staff, and no one has hit their head on the ceiling of the van. The Administrator also stated both staff members were suspended during this investigation and both staff members received corrective action because of not reporting this incident. The Administrator stated, It is my expectation that staff will follow the Abuse and Neglect Policy and report accordingly. During an interview on July 17, 2025, at 2:40 p.m., the DON stated I was made aware Resident #1 bumping her head on the ceiling in the van on June 30, 2025, but the incident occurred back in March. The DON stated this incident should have been reported to me or/and the Administrator as soon as it happened. The DON stated she assisted in the investigation for abuse and neglect by reviewing the residents record, interviewing the resident, and performing a head-to-toe assessment on the resident. The DON stated Resident #1 could not remember details of the situation, and even said she may have dreamed it happened. The DON also stated the head-to-toe assessment revealed no bruises, redness or abrasions and nothing beyond the resident's baseline of forgetfulness. The DON stated we expect our staff to follow the proper policy and protocol regarding abuse and neglect. Record review of the facility's policy titled, Protecting the Residents: Reducing the threat of Abuse and Neglect, revised 8/10/2021 revealed Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. The policy verbiage also stated, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: <BR/>1. The facility failed to ensure personal items were not stored in the refrigerator.<BR/>2. The facility failed to ensure spice containers were properly closed and sealed.<BR/>3. The facility failed to ensure utensils were in safe working order.<BR/>4. The facility failed to ensure the deep fryer was vented into the vent hood properly.<BR/>5. The facility failed to ensure the steam table wells was cleaned.<BR/>6. The facility failed to ensure the shelf above the steam table was cleaned.<BR/>7. The facility failed to ensure the thermometer was calibrated for food service.<BR/>8. The facility failed to ensure the cleaning schedule was being followed.<BR/>These failures could place residents at risk of acquiring foodborne illnesses.<BR/>The findings included: <BR/>Observation during the initial tour of the kitchen on 08/08/23 at 9:15 am revealed a personal bag with a gallon of milk inside the refrigerator, seventeen, 16 oz. containers of spices were open to the air, four plastic soup bowls on the clean rack had a white residue in them, 4 large, and 1 small rubber spatula was cracked and had small pieces breaking off. The edge of the vent hood directly above the deep fryer was heavily soiled with a dark brown substance and where the vent hood met the wall, the wall was discolored with a yellowish-brown substance. The walls and bottoms of the steam table wells were heavily corroded. <BR/>Follow-up observations of the kitchen on 08/10/23 at 11:21 am revealed the COOK did not calibrate the thermometer prior to temping the lunch service food. There was a half-full 16 oz. soda in the refrigerator that was unlabeled and undated.<BR/>Interviews with the DS and DA A on 08/08/23 beginning at 9:15 am revealed the personal items in the refrigerator belonged to DA A. DA A stated the bag belonged to her and she would keep it in the refrigerator until she went home. DA A stated she had kept personal items in the refrigerator before. The DS moved the bag from the back of the refrigerator to the front of the refrigerator but did not remove it. The DS stated there was no refrigerator for the kitchen staff to place their personal items, but there was a refrigerator for the regular staff in the break room. The DS stated the spatulas should be replaced when they started cracking, and she had new ones in her office. The DS stated the staff did not let her know about the spatulas and she had not had time to check the utensil drawer for items needing replacement. The DS stated the kitchen staff knew when items needed replacement and they should have told her. The DS placed the spatulas back in the drawer. The DS stated the steam table was cleaned two times a week and it needed to be chemically de-limed. The DS stated the staff did not sign off items on the cleaning schedule as they were cleaned like they were supposed to. The DS stated their process to remove the grease from the deep fryer was they funneled it into the original plastic container the grease came in, put the lid on the container, then threw the full container of used grease into the dumpster. The DS stated they did not use the facility grease trap and did not know why.<BR/>An interview with the MS on 08/09/23 at 8:15 am revealed the grease trap was used for facility water, not for directly emptying grease into it. The MS stated the deep fryer was attached to the ground and was supposed to vent directly into the vent hood, but the ventilation from the deep fryer was directly hitting the edge of the vent hood and was also on the wall below the edge of the vent hood. The MS stated the heat was hitting the vent hood and the thick brown substance was grease. The MS stated if the grease got too hot, it could catch fire. The MS stated the kitchen staff could not get to it easily to clean, so they did not clean it. <BR/>In interviews with the COOK, DA B, and the DS on 08/10/23 at 11:23 am the COOK stated the DS calibrated the thermometers. The DS stated she had not calibrated the thermometer the cook used in about two weeks. The COOK stated he believed the thermometer should be calibrated before every food service. When asked why it was important to calibrate the thermometer, the COOK stated, I have to get back to my cheese sauce. The DS stated it was important to calibrate the thermometer to get accurate temperatures, to make sure the residents did not get sick. The DS stated she calibrated new thermometers every 4 months. The DS said nothing when asked what other times a thermometer should be calibrated. The DS stated she calibrated the thermometer the COOK used 2 days ago because one of the kitchen staff told her it was acting up-not staying on. When asked how she ensured the thermometer was still in working order, the DS stated she did not know. The DS stated, I am not going to tell you I calibrate the thermometer before every service because I don't. The DS stated the bottle of soda in the refrigerator belonged to one of the staff. DA B stated he did not know who the soda belonged to, but it was not his. The DS stated it was ok for staff to have personal drinks in the kitchen refrigerator if they had a lid on it. The DS stated, Kitchen staff did not have a refrigerator for themselves, and she did not see a reason why they had to walk all the way to the breakroom when there was a refrigerator right there (in the kitchen). <BR/>An interview and observation with the RD on 08/10/23 at 4:10 pm revealed she thought thermometer calibration was bi-weekly or when it (the thermometer) may be not working. The RD stated no personal items should be kept in the kitchen refrigerator because the chance of cross-contamination could occur, or it could get mixed up with the other things in the refrigerator that was meant for the residents. The RD stated it sounded like the staff needed an in-service. Policies for Thermometer calibration and Personal Items in the kitchen refrigerator and in-services for the last three months were requested.<BR/>Record review of the cleaning schedule for 08/06/23-08/08/23 revealed 2 of 66 opportunities to clean equipment on the cleaning schedule were checked off.<BR/>Record review of the DS Certification documented Food Safety Manager Certification dated 05/15/23.<BR/>Record review of the facility policy, Food from Outside Sources Policy revised 07/27/22 documented under #12. Associate and resident food items should not be stored together in the same refrigerator.<BR/>In-services and thermometer calibration guidelines were not provided.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) observed for infection control practices during personal care, in that: <BR/>Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) and one staff (LVN A) observed for infection control practices during personal care, in that: <BR/>-LVN A did not: <BR/>-perform hand hygiene before and/or after assisting R#1 with personal care <BR/>-perform hand hygiene between glove changes <BR/>This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.<BR/>The Findings:<BR/>Observation of Peg tube care on 4/3/2023 at 11:36AM. LVN A knocked and entered R#1's room, performed hand hygiene by using ABHR (alcohol-based hand rub). LVN A continued by applying clean gloves, took sanitation wipes and cleansed bedside table. Hand hygiene performed after sanitation of bedside table for 1 minute. LVN A proceeded by applying new gloves, retrieved clean gauze saturated with normal saline and performed cleaning of the insertion gastric tube area. LVN A discarded dirty gloves, no hand hygiene performed after removal of dirty gloves and application of new gloves was applied. LVN A opened additional gauze package on clean surface, took another gauze applied normal saline and cleaned R#1's peg tube from proximal to distal (top to bottom). LVN A removed dirty gloves, applied new gloves, and then applied split gauze sponge and tape on top of R#1's peg tube area with current date. LVN A connected R#1's peg tube feeding and made R#1 comfortable. <BR/>Interview on 04/03/2023 at 12:03PM LVN A, stated he or she should have performed hand hygiene washed/hands or used antibacterial hand rub, after taking dirty gloves off prior to applying new clean gloves. LVN A continued by stating that this would aid in minimizing cross contamination and in-serviced on hand hygiene on a computer-based training program upon start date and then annually. <BR/>Interview on 04/03/2023 at 1:38PM. DON, stated the expectation of the facility is to perform hand hygiene before, during, and after resident care. DON stated antibacterial hand rub as well as soap and water are sufficient forms of hand hygiene. DON stated hand hygiene is promoted and expected while performing resident care as a preventative measure to minimize infection spread. Staff are in serviced as needed and annually.<BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023 states:<BR/>The facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. <BR/>The facility has systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable diseases. <BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023<BR/>Hand Hygiene Policy dated Revised on 7/15/2022 states, to decrease the risk of transmission of infection by appropriate hand hygiene.<BR/>The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to;<BR/>Before and after all resident contact.<BR/>Before applying gloves.<BR/>After removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, for one (Resident #3) of five reviewed for dignity issues.<BR/>Resident #3's foley catheter drainage bag did not have a privacy bag, leaving the urine in the bag visually exposed to visitors, staff, and other residents. <BR/>This failure could place residents at risk of feeling uncomfortable and disrespected which could decrease residents' self-esteem and/or quality of life.<BR/> Findings were:<BR/>Record review of Resident #3's Face Sheet dated 10/12/2024 revealed Resident #3 was an [AGE] year-old male who was admitted on [DATE] with diagnoses of sepsis (infection), bacteremia (blood infection), and personal history of malignant neoplasm (cancer) of rectum (buttock). <BR/>Record review of Resident #3's Care Plan date initiated 09/09/2024 revealed the resident has an Indwelling Catheter. Goal: Will have no complications related to indwelling catheter use. Interventions: Catheter care every shift.<BR/>Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 14 and coded for an indwelling catheter. The MDS also revealed Resident #3 was dependent of staff for toileting hygiene, and partially dependent of staff for other activities of daily living. <BR/>During an observation on 10/12/2024 at 2:04PM and 2:28PM, Resident #3's room door was open and upon immediate observation there was visible urine in his urinary catheter. Upon further inspection there was a visibly full chamber of yellow urine with no privacy veil. Additionally, staff members, residents, and resident family members were observed to be walking pass Resident #3's room. <BR/>During an interview on 10/12/2024 at 2:32PM Resident #3 was asked the reasoning for his foley catheter and was additionally asked if he knew the foley urinary bag was visible from the hallway to which Resident #3 responded with incoherent sentences. Multiple attempts were made to interview Resident #3 with no success. <BR/>During an interview on 10/12/2024 at 2:35PM CNA B stated Resident #3 was not cognitively aware and had frequent moments of confusion. CNA B stated Resident #3 can feed himself independently but does need substantial assistance with majority of all other activities of daily living including toileting. CNA B stated Resident #3 frequently forgets the topic of his conversations. CNA B stated Resident #3 has a foley. CNA B stated she has worked at the facility since May 2024 and was still learning the facility's policy and procedures. CNA B stated Resident #3 has moments of agitation and confusion but was redirectable. CNA B stated she was unaware that Resident #3 was missing a privacy bag on his foley catheter, and continued by stating she does not regularly work on Resident #3's hallway CNA B stated she was aware that privacy bags for foley catheters were required and could not definitively state why Resident #3's foley urinary catheter did not have a privacy bag. When asked how Resident #3's psychosocial well-being could be impacted, CNA B did not verbalize a response. CNA B stated she was under the understanding that privacy bags were implemented by the nurses, and continued by stating privacy bags were used to maintain a resident's right to privacy. CNA B stated she could not recall attending any recent in-service regarding urinary catheter privacy bags. <BR/>During an interview on 10/12/2024 at 2:47PM RN A stated Resident #3 had a foley catheter placed during his previous hospitalization date unknown. RN A stated the foley catheter was placed due to urinary complications of urinary retention. RN A stated Resident #3 was very forgetful and was alert to self. RN A stated the CNAs will empty Resident #3's catheter of urine and report the numerical value to him while also documenting it in the resident's electronic health record. RN A stated while directly looking into Resident #3's room that he would place a privacy bag over Resident #3's foley catheter to maintain Resident#3's right to privacy. RN A stated Resident #3's foley catheter needed a privacy bags, and stated privacy bags were utilized to maintain a resident's right to privacy. RN A stated he tried to maintain privacy for all his patients. RN A stated by not utilizing a catheter privacy bag, Resident #3 could have potentially been affected negatively. RN A stated privacy bags were kept in their supply closet and it was the responsibility of the nurse to put them on the resident. RN A stated he will get the privacy bag and apply it right away. RN A stated he attended an educational in-service regarding catheter care, privacy bags within the past 2-3months and stated these in-services were done frequently. <BR/>During an interview on 10/14/2024 at 5:44PM the DON and the Administrator stated all resident foley catheters must have a privacy bag. Both stated Resident #3 has been in the facility for over a month. Both stated Resident #3 was sent out initially to the hospital for urinary complications date unknown and returned to the facility a month ago. The DON stated upon Resident #3's return, the clinical staff should have placed a privacy bag over Resident #3's urinary foley catheter. Both stated by the clinical staff failing to implement a privacy cover on Resident #3's foley urinary catheter, Resident #3's dignity may have been compromised, could have affected him negatively, and could have compromised his psychosocial well-being. Both stated they will conduct an impromptu privacy bag in-service to the nurses.<BR/>Record review of the facility's Resident Rights policy and procedure, within the Resident admission Agreement, review dated 2002, 2016, 2018, 2022, 2024 documented [NAME] of Rights 1. The resident has a right to a dignified existence .<BR/>43. The resident has a right to personal privacy and confidentiality of their personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. <BR/>The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke.<BR/>On 3/25/2024, during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status.<BR/>An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.<BR/>This failure could place residents at risk of choking or death.<BR/>Findings included:<BR/>Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR.<BR/>Record review of Resident #2's face sheet dated 3/26/24, revealed he was a [AGE] year-old male, admitted on [DATE]. Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning).<BR/>Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, <BR/>Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. <BR/>Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24.<BR/>Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression.<BR/>Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident.<BR/>During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m.<BR/>During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall.<BR/>During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. CNA A stated she is unsure how much time passed because it happened so quickly.<BR/>During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. LVN B stated she is unsure how much time passed because it all happened so quickly. <BR/>During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. Resident #2 did expire with the Hospice nurse in the room and the Hospice nurse pronounced time of expiration.<BR/>During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. <BR/>During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes.<BR/>During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911.<BR/>During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair.<BR/>Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m.<BR/>The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice.<BR/>Identification of other residents having the potential to be affected:<BR/>o Audit completed of all residents' diets and NPO status.<BR/>o The facility has a binder at the nurse's station that identifies residents that have an NPO status.<BR/>o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm.<BR/>Measures/Systemic Changes to ensure the deficient practice does not recur:<BR/>All licensed staff will be re-educated on responding timely to emergent situations by DON and/or IP nurse. <BR/>DON was reeducated by the Regional Director of Clinical Services on 3/26/2024.<BR/>In-servicing by administrative nursing staff on Heimlich Maneuver per policy to be done facility wide.<BR/>NPO book will be reviewed and updated as needed by DON and /or IP nurse Monday - Friday.<BR/>In-servicing by administrative nursing staff (DON and/or IP nurse) on resident assessment and response to emergencies in a timely manner.<BR/>Ongoing Monitoring:<BR/>Daily rounding during mealtimes by administrative staff to ensure dining room supervision until compliance is achieved.<BR/>All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved.<BR/>The Medical Director was notified and agrees with the plan of correction.<BR/>The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, or designee are responsible for the corrections and continued monitoring. Completion date: 3-29-24<BR/>Verification of the facility's Plan of Removal Included: <BR/>Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. <BR/>Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted.<BR/>Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted.<BR/>Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted.<BR/>Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted.<BR/>During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. <BR/>During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern.<BR/>During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. <BR/>During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. <BR/>During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important.<BR/>During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. <BR/>During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2 had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. <BR/>During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. <BR/>During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. <BR/>During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. <BR/>During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS) full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024.<BR/>During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. <BR/>During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-serviced on the multiple topics yesterday, 03/29/2024. <BR/>During an interview on 03/30/2024 at 4:21PM, (10PM-7A night shift) CNA M stated she was educated/in-serviced about if there was an incident, she must notify the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents receive adequate supervision to prevent accidents for 1 of 3 residents reviewed for NPO status. <BR/>The facility failed to ensure Resident #1 was adequately supervised while eating lunch. <BR/>On 3/25/2024, during lunch service about 12:00 p.m., CNA D did not ensure adequate supervision of Resident #1 while eating. Resident #2 obtained access to Resident #1's food, choked and died. Resident #2 had a g-tube and was on NPO status.<BR/>An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. <BR/>This failure could place residents at risk of choking or death.<BR/>Findings included:<BR/>Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR.<BR/>Record review of Resident #2 face sheet revealed he was a [AGE] year-old male, admitted on [DATE], Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning).<BR/>Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, <BR/>Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. <BR/>Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24.<BR/>Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression.<BR/>Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident.<BR/>During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m.<BR/>During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall.<BR/>During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room.<BR/>During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room.<BR/>During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. LVN E stated she did see the suctioning process produce some residual particles of something. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. <BR/>During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. <BR/>During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes.<BR/>During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911.<BR/>During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair.<BR/>Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status.<BR/>Record review of facility dining, and meal service policy titled, Meal Service and Resident Dining Services dated 8/24/2023 and 4/26/2023 does not indicate monitoring or supervision of residents during mealtimes.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m.<BR/>The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice.<BR/>Identification of other residents having the potential to be affected:<BR/>o <BR/>DON updates NPO book in morning meeting which is shared with all staff.<BR/>o <BR/>This will be reviewed Monday - Friday and updates as needed.<BR/>o <BR/>Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm.<BR/>Measures/Systemic Changes to ensure the deficient practice does not recur:<BR/>Daily rounding during mealtimes by administrative staff to ensure adequate dining room supervision. Supervision will be done by nursing staff with direct over-sight while feeding assistants assist with feeding patients that will need it.<BR/>In-services and education for all staff will be completed by 3-29-24 by Admin Nursing Staff to include, DON, , Infection Prevention, , , Regional Director of Clinical Services, , RN. In-service topics will include the following:<BR/>Specialized Diets/NPO Binder<BR/>Abuse and Neglect<BR/>DON/ADON re-in serviced nursing staff of supervisory schedule of one dining room for all three meals on 3-28-24.<BR/>Meal assignments <BR/>Ongoing Monitoring:<BR/>Department heads making dining room rounds ensuring supervision in dining area.<BR/>All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved.<BR/>The Medical Director was notified and agrees with the plan of correction.<BR/>The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, , LNFA, are responsible for the corrections and continue monitoring. Completion date: 3-29-24<BR/>Verification of the facility's Plan of Removal Included: <BR/>Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. <BR/>Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted.<BR/>Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted.<BR/>Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted.<BR/>Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted.<BR/>During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. <BR/>During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern.<BR/>During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. <BR/>During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. <BR/>During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important.<BR/>During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. <BR/>During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. <BR/>During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. <BR/>During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. <BR/>During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. <BR/>During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS)full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024.<BR/>During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. <BR/>During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-se[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 7 (Resident #2, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, and Resident #10) of 7 residents reviewed for clinical records.<BR/>1a. The facility failed to ensure that RN A documented Resident #2's blood pressure on the MAR (medication administration record) or in the vital signs when Resident #2 was given medication that would decrease her blood pressure in 5 of 16 opportunities reviewed for medication administration.<BR/>1b. The facility failed to ensure that LVN E documented Resident #2's blood pressure on the MAR when Resident #2's medication that would decrease her blood pressure was not given due to her vital signs being outside of parameters for blood pressure medication administration in 4 of 38 opportunities reviewed for medication administration.<BR/>1c. The facility failed to ensure that RN J documented Resident #2's blood pressure on the MAR or in the vital signs when Resident #2 was given medication that would decrease her blood pressure in 1 of 1 opportunity reviewed for medication administration.<BR/>2a. The facility failed to ensure that RN A documented Resident #4's blood pressure and/or pulse on the MAR or in the vital signs when Resident #4 was given medication that would decrease her blood pressure and/or pulse in 44 of 61 opportunities reviewed for medication administration.<BR/>2b. The facility failed to ensure that LVN E documented Resident #4's blood pressure and/or pulse on the MAR or in the vital signs when Resident #4 was given medication that would decrease her blood pressure and/or pulse in 81 of 132 opportunities reviewed for medication administration.<BR/>2c. The facility failed to ensure that RN J documented Resident #4's blood pressure and/or pulse on the MAR or in the vital signs when Resident #4 was given medication that would decrease her blood pressure and/or pulse in 2 of 2 opportunities reviewed for medication administration.<BR/>3a. The facility failed to ensure that RN A documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 14 of 17 opportunities reviewed for medication administration.<BR/>3b. The facility failed to ensure that LVN E documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 1 of 35 opportunities reviewed for medication administration.<BR/>3c. The facility failed to ensure that RN J documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration.<BR/>3d. The facility failed to ensure that LVN C documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration.<BR/>4a. The facility failed to ensure that RN A documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 22 of 35 opportunities reviewed for medication administration. <BR/>4b. The facility failed to ensure that LVN F documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 12 of 12 opportunities reviewed for medication administration.<BR/>4c. The facility failed to ensure that LVN E documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 2 of 69 opportunities reviewed for medication administration.<BR/>4d. The facility failed to ensure that LVN E documented Resident #7's blood pressure in the vital signs when Resident #7's medication that would decrease her blood pressure was not given due to her vital signs being outside of parameters for blood pressure medication administration.<BR/>4e. The facility failed to ensure that LVN L documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 1 of 1 opportunity reviewed for medication administration.<BR/>5. The facility failed to ensure that RN A documented Resident #8's blood pressure and pulse on the MAR or in the vital signs when Resident #8 was given medication that would decrease her blood pressure and pulse in 6 of 16 opportunities reviewed for medication administration.<BR/>6a. The facility failed to ensure that RN A documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 14 of 15 opportunities reviewed for medication administration.<BR/>6b. The facility The facility failed to ensure that LVN E documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 4 of 38 opportunities reviewed for medication administration.<BR/>6c. The facility The facility failed to ensure that LVN C documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration.<BR/>6d. The facility The facility failed to ensure that RN J documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration.<BR/>7a. The facility failed to ensure that RN A documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 14 of 16 opportunities reviewed for medication administration.<BR/>7b. The facility failed to ensure that LVN E documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 1 of 37 opportunities reviewed for medication administration.<BR/>7c. The facility failed to ensure that LVN C documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 1 of 1 opportunity reviewed for medication administration.<BR/>7d. The facility failed to ensure that RN J documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 1 of 1 opportunity reviewed for medication administration.<BR/>This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.<BR/>The findings included:<BR/>1. Record review of Resident #2's admission record reflected at [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included non-traumatic brain hemorrhage (brain bleed not caused by a head injury), left hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (brain bleed), essential (primary) hypertension (high blood pressure), unspecified dementia, and cognitive communication deficit.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 had a BIMS score of 15 which indicated she was cognitively intact. <BR/>Record review of Resident #2's provider order summary report reflected the following orders for medications that would decrease blood pressure:<BR/>Amlodipine Besylate tablet 10mg. Give 1 tablet PO (by mouth) one time a day for HTN (high blood pressure). Hold for BP (blood pressure) &lt; (under)120/60. (No space to document blood pressure on the MAR)<BR/>Lisinopril tablet 20mg. Give 1 tablet PO one time a day for HTN. Hold for BP &lt;120/60. (There was a space to document blood pressure on the MAR)<BR/>Record review of Resident #2's vital signs in the September 2024 and October 2024 MARs reflected the following:<BR/>RN A documented NA in the space where Resident #2's blood pressure was supposed to be documented when Lisinopril was administered on 9/4/24, 9/22/24, 10/10/24, and 10/16/24.<BR/>LVN E documented an x in the space where Resident #2's blood pressure was supposed to be documented when Lisinopril was not administered due to her vital signs being outside of parameters for blood pressure medication administration on 9/24/24, 10/2/24, 10/7/24 and 10/20/24.<BR/>RN J documented NA in the space where Resident #2's blood pressure was supposed to be documented when Lisinopril was administered on 9/10/24. <BR/>Record review of Resident #2's September 2024 and October 2024 vital signs in the EHR reflected the following: <BR/>RN A did not document Resident #2's blood pressures on 9/4/24, 9/22/24, 10/10/24 and 10/16/24. <BR/>LVN E documented Resident #2's blood pressures on 9/24/24, 10/2/24, 10/7/24 and 10/20/24.<BR/>RN J did not document Resident #2's blood pressure on 9/10/24.<BR/>2. Record Review of Resident #4's admission record reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure (the heart does not pump blood effectively and causes fluid build up in the lungs), atrial fibrillation (the upper chambers of the heart beat out of coordination with the lower chambers and causes poor blood flow), unspecified dementia, and essential (primary) hypertension (high blood pressure).<BR/>Record review of Resident #4's quarterly MDS dated [DATE] reflected Resident #4 had a BIMS score of 13 which indicated she was cognitively intact.<BR/>Record review of Resident #4's provider order summary report reflected the following orders for medications that would decrease blood pressure and/or pulse:<BR/>Amiodarone Hcl tablet 100mg. Give 1 tablet PO one time a day for arrhythmia (irregular heartbeat). Hold for HR &lt;60. (No space to document HR on the MAR)<BR/>Carvedilol tablet 3.125mg. Give 1 tablet PO BID (2 times a day) for HTN. Hold for BP &lt;120/60, HR &lt;50. (No space to document BP or HR on the MAR)<BR/>Digoxin tablet 125mcg. Give 1 tablet PO in the morning every other day for CHF. Check pulse and hold for HR &lt;60. (No space to document HR on the MAR)<BR/>Losartan Potassium tablet 100mg. Give 1 tablet PO HS (at bedtime) for HTN. Hold for BP &lt;120/60, HR &lt;50. (There was space to document the BP and HR on the MAR).<BR/>Record review of Resident #4's vital signs in the September 2024 and October 2024 MARs reflected the following:<BR/>RN A documented NA in the space where Resident #4's blood pressure and pulse were supposed to be documented when Losartan was administered on 9/11/24, 9/29/24, 10/4/24, 10/9/24, and 10/16/24. (1 medication = 5 of 12 opportunities)<BR/>Record review of Resident #4's vital signs in the EHR for September 2024 and October 2024 reflected the following:<BR/>RN A did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/3/24, 10/4/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, and 10/22/24. (1 medication = 14 of 15 opportunities)<BR/>RN A did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, and 10/22/24. (3 medications = 18 of 18 opportunities)<BR/>RN A did not document Resident #4's blood pressure with the bedtime administration of blood pressure decreasing medications on 9/11/24, 9/29/24, 10/4/24, 10/9/24, and 10/16/24. (2 medications = 6 of 16 opportunities)<BR/>LVN E did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/1/24, 9/2/24, 9/3/24, 9/7/24, 9/8/24, 9/9/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24,9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/30/24/24, 10/1/24, 10/2/24, 10/3/24, 10/6/24, 10/7/24, 10/9/24, 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/18/24, and 10/24/24. (1 medication = 34 of 37 opportunities)<BR/>LVN E did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/1/24, 9/2/24, 9/3/24, 9/7/24, 9/8/24, 9/9/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/24/24, 9/25/24,9/26/24, 9/27/24, 9/30/24, 10/2/24, 10/3/24, 10/6/24, 10/7/24, 10/9/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/18/24, 10/19/24, 10/22/24, and 10/24/24. (3 medications = 105 of 108 opportunities)<BR/>LVN E did not document Resident #4's heart rate when heart rate decreasing medications were not administered in the morning due to her vital signs being outside of parameters for heart rate decreasing medication administration on 9/27/24, 10/1/24 and 10/11/24. (1 medication = 3 of 7 opportunities)<BR/>LVN F did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/6/24. (1 medication = 1 of 1 opportunity)<BR/>LVN F did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/6/24. (2 medications = 2 of 2 opportunities)<BR/>RN J did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/10/24. (1 medication = 1 of 1 opportunity)<BR/>RN J did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/10/24. (2 medications = 2 of 2 opportunities)<BR/>LVN K did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/19/24. (1 medication = 1 of 1 opportunity)<BR/>LVN K did not document Resident #4's heart rate with morning administration of heart rate decreasing medications on 9/19/24. (3 medications = 3 of 3 opportunities)<BR/>3. Record review of Resident #5's admission record reflected a [AGE] year-old male that was originally admitted to the facility on [DATE] an re-admitted on [DATE]. Resident #5's diagnoses included atrial fibrillation, essential (primary) hypertension, and dementia.<BR/>Record review of Resident #5's quarterly MDS dated 10.4.24 reflected Resident #5 had a BIMS score of 11 which indicated moderate cognitive impairment. <BR/>Record review of Resident #5's provider order summary report reflected the following order for a medication that would decrease blood pressure:<BR/>Metoprolol Tartrate tablet 25mg. Give 1 tablet PO one time a day for HTN. Hold for BP&lt;120/60.<BR/>Record review of Resident #5's vital signs in the EHR for September 2024 and October 2024 reflected:<BR/>RN A did not document Resident #5's blood pressure with the morning administration of a blood pressure decreasing medication on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24 and 10/23/24. (1 medication = 14 of 17 opportunities)<BR/>LVN E did not document Resident #5's blood pressure with the morning administration of a blood pressure decreasing medication on 9/1/24. (1 medication = 1 of 35 opportunities)<BR/>RN J did not document Resident #5's blood pressure with the administration of a blood pressure decreasing medication on 9/10/24. (1 medication = 1 of 1 opportunity)<BR/>LVN C did not document Resident #5's blood pressure with the morning administration of a blood pressure decreasing medication on 10/22/24. (1 medication = 1 of 1 opportunity)<BR/>4. Record review of Resident #7's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7's diagnoses included persistent atrial fibrillation and chronic kidney disease stage 4.<BR/>Record review of Resident #7's admission MDS reflected Resident #7 had a BIMS score of 15 which indicated she was cognitively intact.<BR/>Record review of Resident #7's provider order summary report reflected the following orders for medications that would decrease blood pressure and pulse:<BR/>Isosorbide Mononitrate Extended Release 24 hour tablet 30mg. Give 1 tablet PO one time a day for HTN. (No hold parameters indicated. No place to document BP or HR on the MAR. Discontinued 9/28/24)<BR/>Metoprolol Tartrate tablet. Give 12.5mg PO BID for HTN. (No hold parameters indicated. No place to document BP or HR on the MAR.)<BR/>Record review of Resident #7's September 2024 and October 2024 vital signs in the EHR reflected:<BR/>RN A did not document Resident #7's blood pressure and heart rate with the morning administration of blood pressure and heart rate decreasing medications on 9/22/24, 9/23/24, 10/4/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, 10/22/24, and 10/23/24. (2 medications = 11 of 19 opportunities)<BR/>RN A did not document Resident #7's blood pressure and heart rate with the evening administration of a blood pressure and heart rate decreasing medication on 9/8/24, 9/10/24, 9/11/24, 9/20/24, 9/23/24, and 10/4/24, 10/5/24(BP), 10/6/24(HR), 10/11/24, 10/16/24, 10/17/24, 10/19/24, 10/22/24, and 10/24/24. (1 medication = 14 of 18 opportunities)<BR/>LVN E did not document Resident #7's blood pressure and heart rate with the evening administration of a blood pressure and heart rate decreasing medication on 10/1/24 and 10/23/24. (1 medication = 2 of 10 opportunities)<BR/>LVN E did not document Resident #7's blood pressure and heart rate in the evening when a heart rate and blood pressure decreasing medication was documented as not given due to her vital signs being outside of parameters for blood pressure and heart rate decreasing medication administration on 10/12/24 and 10/23/24. (1 medication = 2 of 8 opportunities)<BR/>LVN F did not document Resident #7's blood pressure and heart rate with the evening administration of a blood pressure and heart rate decreasing medication on 9/14/24, 9/15/24, 9/17/24, 9/26/24, 9/27/24, 10/2/24, 10/3/24, 10/8/24, 10/14/24, 10/15/24, 10/20/24, and 10/21/24. (1 medication = 12 of 12 opportunities)<BR/>5. Record review of Resident #8's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8's diagnoses included essential (primary) hypertension, occlusion (blockage) and stenosis (hardening) of unspecified carotid artery (artery in the neck that helps supply the brain with blood) and unspecified heart failure.<BR/>Record review of Resident #8's annual MDS dated [DATE] reflected that Resident #8 had a BIMS score of 5 which indicated she had severe cognitive impairment.<BR/>Record review of Resident #8's provider order summary report reflected the following orders for blood pressure and heart rate decreasing medications:<BR/>Digoxin tablet 125mcg. Give 1 tablet PO one time a day for heart failure. Hold for HR &lt;60. (No place to document HR on the MAR)<BR/>Metoprolol Tartrate tablet 50mg. Give 1 tablet PO one time a day for HTN. Hold for BP &lt;120/60 or HR &lt;60. (There are places to document the BP and HR on the MAR)<BR/>Lisinopril tablet 20mg. Give 1 tablet PO one time a day for HTN. Hold for BP &lt;120/60. (No place to document BP on the MAR)<BR/>Record review of Resident #8's September 2024 and October 2024 MARs reflected the following:<BR/>RN A documented NA in the space for BP and NA in the space for HR on the MARs with the morning administration of a blood pressure and heart rate decreasing medication on 9/4/24, 9/22/24, 9/29/24, 10/10/24, and 10/26/24. (1 medication = 5 of 15 opportunities)<BR/>RN J documented NA in the space for BP and NA in the space for HR on the MARs with the morning administration of a blood pressure and heart rate decreasing medication on 10/10/24. (1 medication = 1 of 1 opportunity)<BR/>Record review of Resident #8's September 2024 and October 2024 vital signs in the EHR reflected:<BR/>RN A did not document Resident #8's blood pressure and heart rate with the morning administration of blood pressure and heart rate decreasing medications on 9/4/24, 9/22/24, 9/29/24, 10/10/24, and 10/16/24. (3 medications = 15 of 45 opportunities)<BR/>RN J did not document Resident #8's blood pressure and heart rate with the morning administration of blood pressure and heart rate decreasing medications on 9/10/24. (3 medications = 3 of 3 opportunities)<BR/>6. Record review of Resident #9's admission record reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #9's diagnoses included essential (primary) hypertension, dementia, and chronic kidney disease. <BR/>Record review of Resident #9's quarterly MDS dated [DATE] reflected Resident #9 had a BIMS score of 13 which indicated he was cognitively intact.<BR/>Record review of Resident #9's provider order summary report reflected an order for the following blood pressure decreasing medication:<BR/>Lisinopril oral tablet 20mg. Give 20mg PO one time a day for HTN. Hold for BP &lt;110/50. (No place to document BP on the MAR)<BR/>Record review of Resident #9's September 2024 and October 2024 vital signs in the EHR and September 2024 and October 2024 MARs reflected the following:<BR/>RN A did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, and 10/23/24. (1 medication = 15 of 16 opportunities)<BR/>LVN E did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 9/25/24 and 10/14/24, 10/21/24, and 10/25/24. (1 medication = 4 of 38 opportunities)<BR/>RN J did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 9/10/24. (1 medication = 1 of 1 opportunity)<BR/>LVN C did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 10/22/24. (1 medication = 1 of 1 opportunity)<BR/>7. Record review of Resident #10's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10's diagnoses included chronic systolic (congestive) heart failure, essential (primary) hypertension, and dementia.<BR/>Record review of Resident #10's quarterly MDS reflected Resident #10 had a BIMS score of 6 which indicated she had severe cognitive impairment.<BR/>Record review of Resident #10's provider order summary report reflected an order for the following blood pressure and heart rate decreasing medication:<BR/>Metoprolol Tartrate tablet 25mg. Give 1 tablet PO one time a day for HTN. Hold for BP &lt;120/60, HR &lt;50. (There were no places to document the BP or HR on the MAR)<BR/>Record review of Resident #10's September 2024 and October 2024 vital signs in the EHR and September 2024 and October 2024 MARs reflected the following:<BR/>RN A did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, 10/19/24(HR), and 10/23/24. (1 medication = 15 of 16 opportunities)<BR/>LVN E did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 10/24/24. (1 medication = 1 of 37 opportunities)<BR/>RN J did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 9/10/24. (1 medication = 1 of 1 opportunity)<BR/>LVN C did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 10/22/24. (1 medication = 1 of 1 opportunity)<BR/>In an interview on 10/18/24 at 1:26pm LVN I stated vital signs were done by whoever was passing the medications and they were usually in the morning from 7am to 9am. LVN I stated, On the long-term residents sometimes you get all the blood pressures first, document, and then give the medications. Medications are documented as they are given. LVN I stated if the BP was not checked before giving a BP medication and the resident's BP was low, it could cause the resident to have hypotension (low blood pressure), which could lead to distress or hospitalization. LVN I stated it was important to document accurately and timely so that they would know what information to give the provider if something happened to the resident. LVN I stated if things were not documented accurately, it could lead to inaccurate information being passed along.<BR/>In an interview on 10/18/24 at 2:43pm RN A stated he checked vital signs before he gave medications to make sure they were within the parameters to be given. RN A stated he would check vital signs as he went along, document them (the vital signs) as soon as they were done, give the med, then document the med right after it was given. RN A stated if a BP was not checked before a BP med was given, it could drop the pressure too low and the resident could have an adverse reaction such as syncope (fainting), falls, or dizziness. RN A stated if he found a resident with a BP too low, he would assess the resident and notify the provider. RN A stated if vital signs or medications were not documented correctly, another nurse might medicate the resident again. RN A stated, On 10/10 and 10/16 I know I took a bp before I gave the meds. I don't know if I clicked something that made it show NA and not record the bp, but I know that I took them because otherwise I wouldn't know if it was ok to give the BP meds. I will make sure from now on that it is documented correctly. RN A stated occasionally if the resident was not in the room (out to an appt or something) then the vital signs and the medication administration might get documented later on when the resident returned. <BR/>In an interview on 10/18/24 at 3:35pm LVN E stated blood pressures were checked right before he gave the medications, and the blood pressure was usually documented when he put it in the computer after he gave the medication. LVN E stated he could not think of any reason why the BP and meds would be documented at a later time. LVN E stated if a medication had 8:00am, it could be given between 7am and 9am. LVN E stated if he did not check a blood pressure before giving a blood pressure med, it could cause the resident to become hypotensive which could lead to dizziness, falls, hospitalization or even death if the blood pressure got too low. LVN E stated it was important to document accurately and timely so that something was not forgotten and so that another nurse did not medicate a resident again because it appeared they had not been medicated. LVN E stated, I don't dispute the documented times on 10/11-10/15 for Resident #2's blood pressures. I documented the blood pressures once I got all the meds passed and had a chance to sit down and put the information in the computer. LVN E further stated, I have about 60 (or more) residents to medicate in a 2 hour time span. I start medicating at 6:15am and usually finish around 11:00am and that's just medicating- that's not documenting. I don't document the actual times I checked BPs, I just put them in when I get the chance to document. I've told administration that there's no way to get that many residents medicated in that amount of time. <BR/>In an interview on 10/17/24 at 4:13pm, the DON stated the person giving the medication checked the BP and pulse and was supposed to document the BP and pulse at the same time the medication was given and documented.<BR/>In a follow up interview on 10/25/24 at 12:42pm, the DON stated there were 2 primary people who did medication pass- RN A and LVN E and that only 1 medication aide was scheduled at a time. The DON stated the medication aide passed medications to all of the residents except the ones with G tubes because the floor nurses did those. The DON stated on average the medication aide passed medications to 58 residents. RN A and LVN E usually worked 6am to 10pm. LVN F usually worked evening shift, 2pm to 10pm, as a medication aide or 3p to 11p as a nurse. When asked about the medication aide having to pass medications to approximately 58 residents in a 2 hour time span the DON stated, I think that it CAN be done. It looks like what they are doing is signing off after medications were done. The DON further stated, I talked to my corporate nurse and we are looking at ways to change 2 of the halls to a 9am medication pass so the medication aides have a little better time frame to pass medications. The DON stated it was very important to check and document blood pressures and pulses when giving certain cardiac medications because if the med aide or nurse did not check blood pressures and/or pulses prior to medication administration, it could lower the resident's BP or HR to a dangerous level. The DON further stated when blood pressures and heart rates were checked, they should have been documented in the vitals and on the MAR. The DON stated if the vital signs were not documented where they were supposed to be, the next nurse would not know what the most recent vital signs were. The DON stated, The 3 primary medication aides were probably last in[T

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) observed for infection control practices during personal care, in that: <BR/>Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) and one staff (LVN A) observed for infection control practices during personal care, in that: <BR/>-LVN A did not: <BR/>-perform hand hygiene before and/or after assisting R#1 with personal care <BR/>-perform hand hygiene between glove changes <BR/>This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.<BR/>The Findings:<BR/>Observation of Peg tube care on 4/3/2023 at 11:36AM. LVN A knocked and entered R#1's room, performed hand hygiene by using ABHR (alcohol-based hand rub). LVN A continued by applying clean gloves, took sanitation wipes and cleansed bedside table. Hand hygiene performed after sanitation of bedside table for 1 minute. LVN A proceeded by applying new gloves, retrieved clean gauze saturated with normal saline and performed cleaning of the insertion gastric tube area. LVN A discarded dirty gloves, no hand hygiene performed after removal of dirty gloves and application of new gloves was applied. LVN A opened additional gauze package on clean surface, took another gauze applied normal saline and cleaned R#1's peg tube from proximal to distal (top to bottom). LVN A removed dirty gloves, applied new gloves, and then applied split gauze sponge and tape on top of R#1's peg tube area with current date. LVN A connected R#1's peg tube feeding and made R#1 comfortable. <BR/>Interview on 04/03/2023 at 12:03PM LVN A, stated he or she should have performed hand hygiene washed/hands or used antibacterial hand rub, after taking dirty gloves off prior to applying new clean gloves. LVN A continued by stating that this would aid in minimizing cross contamination and in-serviced on hand hygiene on a computer-based training program upon start date and then annually. <BR/>Interview on 04/03/2023 at 1:38PM. DON, stated the expectation of the facility is to perform hand hygiene before, during, and after resident care. DON stated antibacterial hand rub as well as soap and water are sufficient forms of hand hygiene. DON stated hand hygiene is promoted and expected while performing resident care as a preventative measure to minimize infection spread. Staff are in serviced as needed and annually.<BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023 states:<BR/>The facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. <BR/>The facility has systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable diseases. <BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023<BR/>Hand Hygiene Policy dated Revised on 7/15/2022 states, to decrease the risk of transmission of infection by appropriate hand hygiene.<BR/>The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to;<BR/>Before and after all resident contact.<BR/>Before applying gloves.<BR/>After removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one of one central supply rooms reviewed for environment in that: <BR/>The central supply room door on the 200 hall was propped open with a large roll of plastic, allowing easy access to potentially harmful supplies such as razors and lancets. <BR/>There were 9 full boxes of disposable razors on the shelves within reach and easily accessible. <BR/>There was a full case of deodorant that expired on [DATE]. <BR/>There were 33 cases of lancets (a sharp, spring-loaded pointed tool used to check blood sugars (finger sticks) accessible. <BR/>These failures could place residents, staff, and visitors at risk of receiving incorrect care and cause health complications with subsequent illnesses, and injury. <BR/> Findings were: <BR/>Observation of the facility ' s central supply room on [DATE] at 9:15 am revealed the door was propped open with a large roll of plastic, allowing easy access to potentially harmful supplies such as razors and lancets. Expired deodorant was also found. The boxes of lancets and razors on the shelves were within reach and easily accessible. The full case of deodorant expired on [DATE]. <BR/>In an interview with the DON on [DATE] at 9:15 am, she stated the door of the central supply room should not have been propped open. She said there were hazardous supplies on the shelves that residents could have gotten into. She said the razors and lancets were sharp objects and they could harm anyone with misuse, such as a resident who did not know how to handle them properly. She said she was unaware the deodorant had expiration dates. She said the CS was responsible for maintaining the central supply room including ordering supplies and making sure there was nothing expired. <BR/>In an interview with the CS on [DATE] at 3:02 pm, she said she was responsible for the central supply room and its contents. She said her responsibility included ordering supplies, not storing anything on the ground, nothing could be expired, and she had to keep it stocked. She said the door was supposed to be closed and locked at all times. She said she has had the issue of the door being propped open with a large roll of plastic. She said she was getting rid of the roll of plastic. She said she did not know who or when someone was going in and out of the door enough to prop it open. She said she assumed the CNAs probably propped the door open when they were re-stocking their areas. She said they only had one cart to assist with taking bulky items such as briefs out of central supply. She said she thought she should order another cart to prevent staff from having to prop the door open. She said her other job in the facility was staffing and she spent 90% of her time on that and she could not check the central supply door very often. She said she did not delegate to anyone to check the door for her. She said there were hazardous materials in the central supply room such as razors, lancets, nail clippers, and syringes. She said the residents would have easy access to those items and staff would probably not know they were in there because the central supply room was at the end of the 200 hall. She said she kept her main stock in the medication room. She said she highlighted expiration dates so she could keep up with items that were about to expire. She said she was unaware of the expired deodorant. <BR/>In an interview with the DON and ADON on [DATE] at 3:10 pm, they said the facility did not have a specific policy on general supplies. They both said the only policy they could find was Storage of Chemicals and they would look for something more appropriate for storage of supplies. They said the policies they had were from corporate. <BR/>In an interview with the DON on [DATE] at 3:35 pm, she presented another facility policy titled, Licensure and Compliance with Federal, State, Local Laws, and Professional Standards. She stated she did not understand the difference between a facility policy and Federal Regulations. <BR/>In an interview with the RCNS on [DATE]/ at 3:50 pm, she stated, The facility did not have their own policies, that under the definition of the policy on what they had, implied what the facility was compliant with regulations. The RCNS then provided an eleven-page document from Lippincott procedures titled, Indwelling urinary catheter (Foley) insertion, assigned male at birth. She stated, We just don ' t have policies. <BR/>Record review of the facility policy titled; Storage of Chemicals reviewed [DATE] revealed it quoted Federal regulations F689 483.25 (d) Accidents. The facility must ensure that- 483.25(d)(1) The resident environment remains as free of accident hazards as is possible. F584 483.10(i) Safe Environment .the physical layout of the facility does not pose a safety risk. Under Policy, the facility will store chemicals in accordance with manufacturer guidelines while maintaining supervision while in use. <BR/>Record review of the facility policy titled; Licensure and compliance with Federal, State, Local Laws, and Professional Standards reviewed [DATE] revealed it quoted Federal regulations F836 483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. Under Policy, the facility will provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to any professional providing services in the facility, whether temporary or permanent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. <BR/>The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke.<BR/>On 3/25/2024, during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status.<BR/>An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.<BR/>This failure could place residents at risk of choking or death.<BR/>Findings included:<BR/>Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR.<BR/>Record review of Resident #2's face sheet dated 3/26/24, revealed he was a [AGE] year-old male, admitted on [DATE]. Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning).<BR/>Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, <BR/>Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. <BR/>Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24.<BR/>Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression.<BR/>Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident.<BR/>During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m.<BR/>During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall.<BR/>During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. CNA A stated she is unsure how much time passed because it happened so quickly.<BR/>During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. LVN B stated she is unsure how much time passed because it all happened so quickly. <BR/>During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. Resident #2 did expire with the Hospice nurse in the room and the Hospice nurse pronounced time of expiration.<BR/>During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. <BR/>During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes.<BR/>During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911.<BR/>During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair.<BR/>Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m.<BR/>The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice.<BR/>Identification of other residents having the potential to be affected:<BR/>o Audit completed of all residents' diets and NPO status.<BR/>o The facility has a binder at the nurse's station that identifies residents that have an NPO status.<BR/>o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm.<BR/>Measures/Systemic Changes to ensure the deficient practice does not recur:<BR/>All licensed staff will be re-educated on responding timely to emergent situations by DON and/or IP nurse. <BR/>DON was reeducated by the Regional Director of Clinical Services on 3/26/2024.<BR/>In-servicing by administrative nursing staff on Heimlich Maneuver per policy to be done facility wide.<BR/>NPO book will be reviewed and updated as needed by DON and /or IP nurse Monday - Friday.<BR/>In-servicing by administrative nursing staff (DON and/or IP nurse) on resident assessment and response to emergencies in a timely manner.<BR/>Ongoing Monitoring:<BR/>Daily rounding during mealtimes by administrative staff to ensure dining room supervision until compliance is achieved.<BR/>All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved.<BR/>The Medical Director was notified and agrees with the plan of correction.<BR/>The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, or designee are responsible for the corrections and continued monitoring. Completion date: 3-29-24<BR/>Verification of the facility's Plan of Removal Included: <BR/>Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. <BR/>Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted.<BR/>Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted.<BR/>Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted.<BR/>Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted.<BR/>During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. <BR/>During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern.<BR/>During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. <BR/>During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. <BR/>During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important.<BR/>During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. <BR/>During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2 had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. <BR/>During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. <BR/>During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. <BR/>During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. <BR/>During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS) full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024.<BR/>During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. <BR/>During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-serviced on the multiple topics yesterday, 03/29/2024. <BR/>During an interview on 03/30/2024 at 4:21PM, (10PM-7A night shift) CNA M stated she was educated/in-serviced about if there was an incident, she must notify the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents receive adequate supervision to prevent accidents for 1 of 3 residents reviewed for NPO status. <BR/>The facility failed to ensure Resident #1 was adequately supervised while eating lunch. <BR/>On 3/25/2024, during lunch service about 12:00 p.m., CNA D did not ensure adequate supervision of Resident #1 while eating. Resident #2 obtained access to Resident #1's food, choked and died. Resident #2 had a g-tube and was on NPO status.<BR/>An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. <BR/>This failure could place residents at risk of choking or death.<BR/>Findings included:<BR/>Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR.<BR/>Record review of Resident #2 face sheet revealed he was a [AGE] year-old male, admitted on [DATE], Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning).<BR/>Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, <BR/>Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. <BR/>Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24.<BR/>Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression.<BR/>Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident.<BR/>During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m.<BR/>During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall.<BR/>During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room.<BR/>During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room.<BR/>During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. LVN E stated she did see the suctioning process produce some residual particles of something. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. <BR/>During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. <BR/>During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes.<BR/>During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911.<BR/>During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair.<BR/>Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status.<BR/>Record review of facility dining, and meal service policy titled, Meal Service and Resident Dining Services dated 8/24/2023 and 4/26/2023 does not indicate monitoring or supervision of residents during mealtimes.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m.<BR/>The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice.<BR/>Identification of other residents having the potential to be affected:<BR/>o <BR/>DON updates NPO book in morning meeting which is shared with all staff.<BR/>o <BR/>This will be reviewed Monday - Friday and updates as needed.<BR/>o <BR/>Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm.<BR/>Measures/Systemic Changes to ensure the deficient practice does not recur:<BR/>Daily rounding during mealtimes by administrative staff to ensure adequate dining room supervision. Supervision will be done by nursing staff with direct over-sight while feeding assistants assist with feeding patients that will need it.<BR/>In-services and education for all staff will be completed by 3-29-24 by Admin Nursing Staff to include, DON, , Infection Prevention, , , Regional Director of Clinical Services, , RN. In-service topics will include the following:<BR/>Specialized Diets/NPO Binder<BR/>Abuse and Neglect<BR/>DON/ADON re-in serviced nursing staff of supervisory schedule of one dining room for all three meals on 3-28-24.<BR/>Meal assignments <BR/>Ongoing Monitoring:<BR/>Department heads making dining room rounds ensuring supervision in dining area.<BR/>All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved.<BR/>The Medical Director was notified and agrees with the plan of correction.<BR/>The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, , LNFA, are responsible for the corrections and continue monitoring. Completion date: 3-29-24<BR/>Verification of the facility's Plan of Removal Included: <BR/>Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. <BR/>Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted.<BR/>Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted.<BR/>Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted.<BR/>Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted.<BR/>During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. <BR/>During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern.<BR/>During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. <BR/>During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. <BR/>During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important.<BR/>During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. <BR/>During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. <BR/>During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. <BR/>During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. <BR/>During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. <BR/>During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS)full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024.<BR/>During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. <BR/>During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-se[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. <BR/>The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke.<BR/>On 3/25/2024, during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status.<BR/>An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.<BR/>This failure could place residents at risk of choking or death.<BR/>Findings included:<BR/>Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR.<BR/>Record review of Resident #2's face sheet dated 3/26/24, revealed he was a [AGE] year-old male, admitted on [DATE]. Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning).<BR/>Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, <BR/>Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. <BR/>Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24.<BR/>Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression.<BR/>Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident.<BR/>During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m.<BR/>During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall.<BR/>During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. CNA A stated she is unsure how much time passed because it happened so quickly.<BR/>During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. LVN B stated she is unsure how much time passed because it all happened so quickly. <BR/>During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. Resident #2 did expire with the Hospice nurse in the room and the Hospice nurse pronounced time of expiration.<BR/>During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. <BR/>During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes.<BR/>During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911.<BR/>During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair.<BR/>Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m.<BR/>The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice.<BR/>Identification of other residents having the potential to be affected:<BR/>o Audit completed of all residents' diets and NPO status.<BR/>o The facility has a binder at the nurse's station that identifies residents that have an NPO status.<BR/>o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm.<BR/>Measures/Systemic Changes to ensure the deficient practice does not recur:<BR/>All licensed staff will be re-educated on responding timely to emergent situations by DON and/or IP nurse. <BR/>DON was reeducated by the Regional Director of Clinical Services on 3/26/2024.<BR/>In-servicing by administrative nursing staff on Heimlich Maneuver per policy to be done facility wide.<BR/>NPO book will be reviewed and updated as needed by DON and /or IP nurse Monday - Friday.<BR/>In-servicing by administrative nursing staff (DON and/or IP nurse) on resident assessment and response to emergencies in a timely manner.<BR/>Ongoing Monitoring:<BR/>Daily rounding during mealtimes by administrative staff to ensure dining room supervision until compliance is achieved.<BR/>All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved.<BR/>The Medical Director was notified and agrees with the plan of correction.<BR/>The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, or designee are responsible for the corrections and continued monitoring. Completion date: 3-29-24<BR/>Verification of the facility's Plan of Removal Included: <BR/>Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. <BR/>Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted.<BR/>Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted.<BR/>Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted.<BR/>Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted.<BR/>During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. <BR/>During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern.<BR/>During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. <BR/>During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. <BR/>During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important.<BR/>During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. <BR/>During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2 had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. <BR/>During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. <BR/>During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. <BR/>During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. <BR/>During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS) full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024.<BR/>During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. <BR/>During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-serviced on the multiple topics yesterday, 03/29/2024. <BR/>During an interview on 03/30/2024 at 4:21PM, (10PM-7A night shift) CNA M stated she was educated/in-serviced about if there was an incident, she must notify the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to have physician orders for the resident's immediate care at the time the resident was admitted for 2 of 5 (Resident #41 and Resident #116) residents whose records were reviewed for physician orders in that: <BR/>The facility failed to ensure there was an active order for PICC Line dressing changes for Resident #41.<BR/>The facility failed to clarify physician orders for Heparin Flushes for Resident #41.<BR/>The facility failed to clarify physician orders for Resident #116. <BR/>These failures could place residents at risk of inadequate monitoring of medical conditions and not receiving the care and services to meet their needs.<BR/>Findings included:<BR/>Record review of Resident #41's face sheet, dated and admitted on [DATE] reflected a [AGE] year-old female with diagnoses that included orthopedic aftercare following surgical amputation of toes, diabetes, high blood pressure, and malnutrition. <BR/>A record review of Resident #41's MDS dated [DATE] documented a BIMS of 15, which indicated no cognitive impairment.<BR/>Record review of Resident #41's care plan, dated 07/24/23, documented on page 6, a focus of the resident was on IV medication initiated and revised on 07/25/23, and interventions of IV dressing, PICC Line, observe dressing, change dressing and record observations of site-initiated and revised 07/25/23. <BR/>Observation of Resident #41's PICC Line dressing and interview on 08/08/23 at 11:44 AM revealed a date of 08/05/23. Resident #41 stated PICC Line dressing was changed every Friday.<BR/>Observation of Resident #41's MAR and interview with RN A on 08/09/23 at 2:39 PM revealed there were no orders documented for the PICC Line dressing changes. RN A stated there should be an order for the PICC Line dressing changes at least weekly and she had changed the dressing on the 5th of August 2023. RN A stated she did not have any documentation about the PICC Line dressing change or observations of the PICC Line site in the skilled assessments. RN A stated it was important to have orders for dressing changes and assessments so they would not be missed and possibly create an infection if the dressing was never changed and if there were no assessments of the site, there would be no way to track if the site was getting infected. <BR/>In an interview with the DON on 08/09/23 at 2:42 PM revealed she could not find the order for dressing changes on the PICC Line for Resident #41 and stated there should be an order for dressing changes for every PICC line every Sunday. The DON stated staff should know about the dressing changes and should have gotten an order. The DON stated no one reviewed the orders except the person who ordered them. <BR/> In an interview with the DON on 08/09/23 at 3:46 PM, she stated the staff followed whatever order was on the MAR, and there was no order on the MAR for PICC Line dressing changes. The DON stated the negative outcome could be placing residents at risk for infection if there was no order for dressing changes. The DON stated there had to be an order for a dressing change. The DON stated dressing changes should be documented. The DON stated the nurses should have gotten an order for the dressing changes because, without an order, the electronic charting system would not trigger to document, and the staff would not document-they could put something in the progress notes, but there would still be no order for the dressing change. <BR/>A record review of Resident #41's physician orders, dated 07/24/23-08/09/23, revealed no orders to change the dressing for the PICC Line. <BR/>A record review of the facility policy, Central Vascular Access Device Dressing Change, revised 06/01/21, documented under Considerations: 2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Under Guidance: 1. Perform sterile dressing changes 1., 1.2 At least weekly. Under Procedures: 24. Documentation in the medical record includes but is not limited to Date and time, site assessment, length of the external catheter, arm circumference, the reason for dressing change, patient response to the procedure, and patient/other teaching.<BR/>Record review of Resident #41's care plan, dated 07/24/23, documented on page 4, a focus of the resident was on anticoagulant therapy, initiated 07/25/23. The goal was: INR (International Normalized Ratio) and/or Protime (prothrombin time) within specified limits through the next review initiated on 07/25/23. Interventions included: Labs, as ordered, initiated on 07/25/23. (These lab values are used when a patient is on anticoagulant therapy to determine if their blood is clotting too fast or too slow. Depending on the value, the physician will order the anticoagulant dose to increase, decrease, or stay the same to maintain a therapeutic level) <BR/>Record review of Resident #41's physician orders, dated 07/24/23, reflected: <BR/>-Heparin Lock Flush Solution 10 Unit/ml Use 5 cc intravenously every shift (every 8 hours) Flush PICC line after post-medication Normal Saline flush.<BR/>- On hand heparin flush 10 unit/ml disposable syringe flush 5ml (10 units) each lumen every 12 hours.<BR/>Observation of Heparin Flush to Resident #41's PICC Line, on 08/09/23 at 02:39 PM, with RN A revealed- 10ml Normal Saline expiration date 08/31/23 and Heparin 10U /ml, 3ml with expiration date of 10/31/23. <BR/>Gathered supplies, washed hands &gt;30 seconds, Donned gloves, disconnected IV tubing (Vancomycin), doffed gloves, placed a paper barrier beneath RUE, used ABHR, donned gloves, primed NS saline, used alcohol swipe, and flushed line. Used another alcohol swipe, flushed with Heparin, and placed an antiseptic cap on the PICC Line. RN A doffed gloves removed the IV tubing and bag and disposed of them. Washed hands for 20 seconds, then again for 30 seconds.<BR/>Observation of the MAR and interviews with the DON and RN A on 08/09/23 at 2:42 PM reflected the order documented 5cc of Heparin every 12 hours. The DON stated that according to the order, we should give 5cc, but the facility did not have any 5cc heparin syringes. RN A stated the MAR documented heparin was administered 4 times on 08/08/23 and 3 times on the rest of the dates in August. The DON stated Heparin was given 5cc at least every 8 hours.<BR/>Observation of the 200/400 medication cart and interview with LPN B on 08/10/23 at 9:12 AM revealed there were prefilled 5cc heparin syringes. LPN B stated they always had the 5cc prefilled heparin syringes. LPN B stated she did not know about the 3cc pre-filled heparin syringes; she only knew what was in her cart. <BR/>Interview with LPN A on 08/09/23 at 2:45 PM, LPN A stated according to the order, it (the MAR) documented 5cc every 12 hours but was given every 8 hours. LPN A stated the MAR was confusing, as it documented 2 different orders, and the order documented 5cc of heparin, but they only had 3cc syringes of heparin. She stated it looked like 2 different orders for the heparin and the saline flushes. She stated the orders definitely needed to be clarified. LPN A stated staff only followed the orders on the MAR. LPN A stated the orders were not customized and therefore were not complete. LPN A stated the nurses should have changed the heparin order to 3cc or used 2 syringes to get the 5cc-the orders should have been clarified. <BR/>An interview with RN A on 08/09/23 at 2:48 PM revealed she would need to find out from the doctor what the order should be because the discrepancy was that heparin was ordered 5cc and heparin should be 3cc-the facility gave the 3cc and they were not following the doctor's orders. RN A stated she should have called the doctor as soon as she discovered the discrepancy but did not.<BR/>Interview with the DON on 08/09/23 at 3:46 PM, the DON stated the negative outcome could be a medication error, and the staff followed whatever order was on the MAR. The DON did not know what the correct order should have been. <BR/>Record review of Resident #41's Central Venous Catheter- Physician/Licensed Independent Practitioner Order Sheet, dated 07/26/23, under Treatment Orders: Change Administration set was checked through, and no box was checked to indicate the timing. Under Flushing Orders, Intermittent Meds were checked, but the amount, type, and frequency of fluid to flush were not checked. <BR/>A record review of Resident #116's face sheet, dated and admitted on [DATE] reflected a [AGE] year-old female with diagnoses that included encounter for surgical aftercare following surgery on the circulatory system, pneumonia, COPD, high blood pressure, nicotine dependence, lack of coordination, reflux, heart failure, and A-Fib . <BR/>A record review of Resident #116's MDS, dated [DATE], reflected a BIMS of 13, which indicated no cognitive impairment.<BR/>Record review of Resident #116's care plan, dated 07/28/23, documented on page 18 with a focus on the resident having oxygen therapy related to respiratory illness initiated and revised on 07/28/23. Interventions included Oxygen settings: O2 via nasal prongs at 3 L (liters) continuous. Humidified as ordered.<BR/>Observation of Resident #116's oxygen on 08/08/23 at 1:48 PM revealed O2 continuous 5L/NC. There was a humidifier bottle near the O2 concentrator, but it was not connected to anything.<BR/>Interview and record review with LPN/MDS on 08/10/23 at 1:55 PM, the LPN/MDS stated there was no way to know what the original order was for Resident #116's oxygen because it could not be found in Resident # 116's chart. There were no discharge orders from the hospital found in the chart as well. The LPN/MDS showed the State Surveyor a physician's note dated 07/26/23 (prior to admission) that documented 3L NC but there was no definitive order. The LPN/MDS stated the discrepancy between the care plan and the physician's order was human error but could not say if the physician's order was correct or if what was documented on the care plan was correct. The LPN/MDS stated whoever the nurse was who admitted any resident, that nurse would input in the orders. LPN/MDS stated that the ADON checked all the orders for clarification the next day. <BR/>In an interview with the DON on 08/10/23 at 2:22 PM, the DON stated the admission orders were in the computer but could not say where those orders came from. The DON stated the nurse reconciled medications with either the MD or the NP but still could not explain or produce the original admission orders. The DON stated medication orders came from the hospital, but no oxygen orders were on them. The DON stated the admitting nurse should call the MD or NP for oxygen orders. The DON explained verbal orders or phone orders could be placed directly into the EHR, and there was nowhere medication reconciliation for admission or discharge orders was visible in the EHR. <BR/>Record review of physician orders dated 07/27/23-08/10/23, documented Oxygen at 3 liters/minute continuously per nasal cannula. Document every shift, dated 07/28/23.<BR/>A record review of Resident #116's discharge Medication Report from the local hospital, dated 07/27/23, did not have oxygen orders listed. <BR/>Record review of admission Progress notes, dated 07/27/23 documented Resident #116 arrived at the facility with O2 at 3 lpm (liters per minute) via nasal cannula .medications were verified with the NP (nurse practitioner) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of three residents (Resident #1) reviewed for pressure ulcer care and prevention.<BR/>The facility failed follow physician orders and did not apply the hydrafera blue dressing to Resident #1's stage 4 right lateral ankle pressure ulcer. <BR/>This failure could place residents at risk of improper wound management, the development of new pressure ulcers, deterioration in existing pressure ulcers, infection, sepsis, and pain.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 08/09/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture), stage 4 pressure ulcer of right ankle, stage 4 pressure ulcer of sacral region, schizoaffective disorder (mental health disorder ), and depression . <BR/>Record review of Resident #1's Physician's Order, dated 05/23/2023, stated cleanse right lateral ankle with Vashe, pat dry with gauze, apply hydrafera blue, ready use cut to size and cover with foam dressing, every dayshift, every Monday, Wednesday, Friday for Stage 4. <BR/>Record review of Resident #1's Wound Observation Tool, dated 05/23/2023, the woundcare nurse documented right lateral ankle pressure ulcer stage 4. Granulation tissue present, and 40% slough tissue present. Wound measurements: length (cm ): 4.5; width (cm): 3.0; depth (cm): 0.3. <BR/>Record review of Resident #1's Wound Observation Tool, dated 08/04/2023, the woundcare nurse documented right lateral ankle pressure ulcer stage 4. Granulation tissue present and 40% slough tissue present. Wound measurements: length (cm):1.0; width (cm):1.2; depth (cm): 0.2.<BR/>Record review of Resident #1's Minimum Data Set, dated [DATE], revealed Resident#1 had a BIMS score of 12/15 which indicated the resident was cognitively intact. Resident #1 had two stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers that were present upon admission/entry. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfer, dressing, and personal hygiene, and was at risk for pressure ulcer development. <BR/>Record review of Resident #1's comprehensive care plan, dated 05/23/2023, documented Has break in skin integrity . open wounds to sacrum and right ankle. Interventions: Educate resident and/or family regarding skin problem and treatment. Pressure reducing mattress. Treatment as ordered. Use of low Air Loss Mattress, setting 3. <BR/>An observation and interview on 08/10/2023 at 10:36 AM, upon entering Resident #1's room, revealed Resident#1's right ankle area was open to the air, with visible red with yellow color in the middle of the wound opening with no dressing on right lateral ankle wound. Interview with Resident #1 stated she recalled receiving wound care yesterday (08/09/2023) but was not sure if dressing was applied to her wound. Resident #1 stated she did notify the Wound Care Nurse that there was no dressing on right ankle wound but was told the Wound Care Nurse had to pick up her kids and did not come back to apply dressing on right ankle. <BR/>During an interview on 08/10/2023 at 11:30 AM, the Wound Care Nurse stated she arrived to work early in morning at 6AM on 08/09/2023 and performed wound care to Resident #1's sacrum and right lateral ankle. The Wound Care Nurse stated it took about an hour to perform wound care to Resident #1. The Wound Care Nurse stated on 08/09/2023 she left around 7:00-7:30AM to drop her kids off to school and returned to the facility around 9AM. The Wound Care Nurse stated she did apply a wound care dressing to the right lateral ankle and when questioned about why Resident #1 did not have a dressing on the right lateral ankle, the wound care nurse stated she could not recall being notified on 08/09 about the residents concern for not having a wound dressing, nor did she provide an answer as to why Resident #1 had no dressing on her right ankle. The Wound Care Nurse stated she applied a wound dressing to the right lateral ankle on 08/10/2023 at 11:25 AM. The Wound Care Nurse stated she could not perform any wound care without a physician order, and stated it was imperative to follow and specifically execute care as directed by the physician's order. The Wound Care Nurse stated by not complying with physician orders, could jeopardize the healing process for any resident. The Wound Care Nurse stated she attended monthly wound care meetings that specifically went over physician orders. The Wound Care Nurse stated she was in the process of finishing her wound care certification training and would prioritize completion. <BR/>During an interview on 08/10/2023 at 11:12AM, CNA A stated she did not remember the last time she saw Resident's #1 ankle dressing, but knew to notify the nurse of any observed skin abnormalities. <BR/>During an interview on 08/10/2023 at 1:16 PM, the DON stated it was the expectation of the facility for the clinical nursing staff which included the Wound Care Nurse to follow physician orders. The DON stated by not following orders, errors could occur and lead to small or large detrimental issues for Resident #1 which included Resident #1's wound getting bigger or increased tissue damage. The DON stated the Wound Care Nurse did attend monthly meetings with a Regional Wound Care Consultant and maintained current knowledge-based courses.<BR/>Record review of the facility's Treatment Orders, revised 04/19/2022 and reviewed 03/31/2023, stated 3. The physician order is followed as are the manufacturer's instruction for use for each product ordered.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: <BR/>1. The facility failed to ensure personal items were not stored in the refrigerator.<BR/>2. The facility failed to ensure spice containers were properly closed and sealed.<BR/>3. The facility failed to ensure utensils were in safe working order.<BR/>4. The facility failed to ensure the deep fryer was vented into the vent hood properly.<BR/>5. The facility failed to ensure the steam table wells was cleaned.<BR/>6. The facility failed to ensure the shelf above the steam table was cleaned.<BR/>7. The facility failed to ensure the thermometer was calibrated for food service.<BR/>8. The facility failed to ensure the cleaning schedule was being followed.<BR/>These failures could place residents at risk of acquiring foodborne illnesses.<BR/>The findings included: <BR/>Observation during the initial tour of the kitchen on 08/08/23 at 9:15 am revealed a personal bag with a gallon of milk inside the refrigerator, seventeen, 16 oz. containers of spices were open to the air, four plastic soup bowls on the clean rack had a white residue in them, 4 large, and 1 small rubber spatula was cracked and had small pieces breaking off. The edge of the vent hood directly above the deep fryer was heavily soiled with a dark brown substance and where the vent hood met the wall, the wall was discolored with a yellowish-brown substance. The walls and bottoms of the steam table wells were heavily corroded. <BR/>Follow-up observations of the kitchen on 08/10/23 at 11:21 am revealed the COOK did not calibrate the thermometer prior to temping the lunch service food. There was a half-full 16 oz. soda in the refrigerator that was unlabeled and undated.<BR/>Interviews with the DS and DA A on 08/08/23 beginning at 9:15 am revealed the personal items in the refrigerator belonged to DA A. DA A stated the bag belonged to her and she would keep it in the refrigerator until she went home. DA A stated she had kept personal items in the refrigerator before. The DS moved the bag from the back of the refrigerator to the front of the refrigerator but did not remove it. The DS stated there was no refrigerator for the kitchen staff to place their personal items, but there was a refrigerator for the regular staff in the break room. The DS stated the spatulas should be replaced when they started cracking, and she had new ones in her office. The DS stated the staff did not let her know about the spatulas and she had not had time to check the utensil drawer for items needing replacement. The DS stated the kitchen staff knew when items needed replacement and they should have told her. The DS placed the spatulas back in the drawer. The DS stated the steam table was cleaned two times a week and it needed to be chemically de-limed. The DS stated the staff did not sign off items on the cleaning schedule as they were cleaned like they were supposed to. The DS stated their process to remove the grease from the deep fryer was they funneled it into the original plastic container the grease came in, put the lid on the container, then threw the full container of used grease into the dumpster. The DS stated they did not use the facility grease trap and did not know why.<BR/>An interview with the MS on 08/09/23 at 8:15 am revealed the grease trap was used for facility water, not for directly emptying grease into it. The MS stated the deep fryer was attached to the ground and was supposed to vent directly into the vent hood, but the ventilation from the deep fryer was directly hitting the edge of the vent hood and was also on the wall below the edge of the vent hood. The MS stated the heat was hitting the vent hood and the thick brown substance was grease. The MS stated if the grease got too hot, it could catch fire. The MS stated the kitchen staff could not get to it easily to clean, so they did not clean it. <BR/>In interviews with the COOK, DA B, and the DS on 08/10/23 at 11:23 am the COOK stated the DS calibrated the thermometers. The DS stated she had not calibrated the thermometer the cook used in about two weeks. The COOK stated he believed the thermometer should be calibrated before every food service. When asked why it was important to calibrate the thermometer, the COOK stated, I have to get back to my cheese sauce. The DS stated it was important to calibrate the thermometer to get accurate temperatures, to make sure the residents did not get sick. The DS stated she calibrated new thermometers every 4 months. The DS said nothing when asked what other times a thermometer should be calibrated. The DS stated she calibrated the thermometer the COOK used 2 days ago because one of the kitchen staff told her it was acting up-not staying on. When asked how she ensured the thermometer was still in working order, the DS stated she did not know. The DS stated, I am not going to tell you I calibrate the thermometer before every service because I don't. The DS stated the bottle of soda in the refrigerator belonged to one of the staff. DA B stated he did not know who the soda belonged to, but it was not his. The DS stated it was ok for staff to have personal drinks in the kitchen refrigerator if they had a lid on it. The DS stated, Kitchen staff did not have a refrigerator for themselves, and she did not see a reason why they had to walk all the way to the breakroom when there was a refrigerator right there (in the kitchen). <BR/>An interview and observation with the RD on 08/10/23 at 4:10 pm revealed she thought thermometer calibration was bi-weekly or when it (the thermometer) may be not working. The RD stated no personal items should be kept in the kitchen refrigerator because the chance of cross-contamination could occur, or it could get mixed up with the other things in the refrigerator that was meant for the residents. The RD stated it sounded like the staff needed an in-service. Policies for Thermometer calibration and Personal Items in the kitchen refrigerator and in-services for the last three months were requested.<BR/>Record review of the cleaning schedule for 08/06/23-08/08/23 revealed 2 of 66 opportunities to clean equipment on the cleaning schedule were checked off.<BR/>Record review of the DS Certification documented Food Safety Manager Certification dated 05/15/23.<BR/>Record review of the facility policy, Food from Outside Sources Policy revised 07/27/22 documented under #12. Associate and resident food items should not be stored together in the same refrigerator.<BR/>In-services and thermometer calibration guidelines were not provided.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) observed for infection control practices during personal care, in that: <BR/>Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) and one staff (LVN A) observed for infection control practices during personal care, in that: <BR/>-LVN A did not: <BR/>-perform hand hygiene before and/or after assisting R#1 with personal care <BR/>-perform hand hygiene between glove changes <BR/>This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.<BR/>The Findings:<BR/>Observation of Peg tube care on 4/3/2023 at 11:36AM. LVN A knocked and entered R#1's room, performed hand hygiene by using ABHR (alcohol-based hand rub). LVN A continued by applying clean gloves, took sanitation wipes and cleansed bedside table. Hand hygiene performed after sanitation of bedside table for 1 minute. LVN A proceeded by applying new gloves, retrieved clean gauze saturated with normal saline and performed cleaning of the insertion gastric tube area. LVN A discarded dirty gloves, no hand hygiene performed after removal of dirty gloves and application of new gloves was applied. LVN A opened additional gauze package on clean surface, took another gauze applied normal saline and cleaned R#1's peg tube from proximal to distal (top to bottom). LVN A removed dirty gloves, applied new gloves, and then applied split gauze sponge and tape on top of R#1's peg tube area with current date. LVN A connected R#1's peg tube feeding and made R#1 comfortable. <BR/>Interview on 04/03/2023 at 12:03PM LVN A, stated he or she should have performed hand hygiene washed/hands or used antibacterial hand rub, after taking dirty gloves off prior to applying new clean gloves. LVN A continued by stating that this would aid in minimizing cross contamination and in-serviced on hand hygiene on a computer-based training program upon start date and then annually. <BR/>Interview on 04/03/2023 at 1:38PM. DON, stated the expectation of the facility is to perform hand hygiene before, during, and after resident care. DON stated antibacterial hand rub as well as soap and water are sufficient forms of hand hygiene. DON stated hand hygiene is promoted and expected while performing resident care as a preventative measure to minimize infection spread. Staff are in serviced as needed and annually.<BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023 states:<BR/>The facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. <BR/>The facility has systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable diseases. <BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023<BR/>Hand Hygiene Policy dated Revised on 7/15/2022 states, to decrease the risk of transmission of infection by appropriate hand hygiene.<BR/>The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to;<BR/>Before and after all resident contact.<BR/>Before applying gloves.<BR/>After removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1), reviewed for care plans in that:<BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #1(R#1) in that:<BR/>-Care Plan states R#1 had decline in cognitive abilities that impacts a person's ability to do everyday activities<BR/>This deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. <BR/>The Findings include:<BR/>1)Record review of the admission record dated 07/12/23 for R#1 revealed R#1 was admitted to the facility initially on 03/21/2022, was a [AGE] year-old male. R#1's diagnosis included Type 2 Diabetes (insufficient production of insulin), Atherosclerosis (thickening, hardening, and loss of elasticity of the walls of the arteries), Hypertension (high blood sugar), Heart failure, and Chronic Kidney Disease (gradual loss of kidney function).<BR/>Record review of Resident #1's care plan dated 07/05/23 indicated R#1 The resident is resistive to care related to Dementia. (There is no active diagnosis of Dementia)<BR/>Record review of Resident # 1's quarterly MDS assessment dated [DATE] indicated R#1 has a BIMS score of 14 (Cognition Intact), required limited assistance with bed mobility, transfers, personal hygiene, toilet use, and dressing. Supervision with eating.<BR/>Interview on 7/13/2023 at 3:31pm stated, dementia diagnosis on R#1's care plan is a mistake and an error on her part. ADON stated, R#1 has not been diagnosed with Dementia and assumed R#1 had dementia because of behaviors and resistance to some care. ADON stated, all the behaviors on resident's (R#1's) care plan is correct however, and the only thing wrong with the care plan is the diagnosis of dementia and since the behaviors displayed by resident (R#1) are correct, there is not much in the care plan that would harm resident (R#1) or interfere with care. The purpose of the care plan is to make sure that each resident's individualized care is being implemented. <BR/>Interview with DON on 7/15/23 at 2:41pm stated, resident (R#1) does not have Dementia and believes it was an error. Under diagnosis, there is no record of dementia noted for R#1. DON confirmed resident does not have dementia and ADON did the care plan for R#1. DON stated the diagnosis of dementia should not be on R#1's care plan and will be updated immediately. DON stated it is important for care plans to be updated and correct so residents can receive the individualized care that is to be implemented for each resident. <BR/>Record review of Care Planning-Baseline, Comprehensive, and Routine Updates dated 12/5/2022 states:<BR/>The Comprehensive Care Plan cannot be completed until the MDS, the Care Area Triggers are addressed through the Care Area Assessment Process.<BR/>The Comprehensive Care Plan must include a problem/focus statement, measurable goals, and interventions.<BR/>Identifying goals and objectives of care<BR/>-Identify causes of, and factors contributing to, the individual's current dysfunctions, disabilities, impairments, and risks<BR/>-Identify pertinent evaluation and diagnostic tests<BR/>-Identify how existing symptoms, signs, diagnosis, test results, dysfunctions, impairments, disabilities, and other findings relate to one another<BR/>-Identify how addressing those causes is likely to affect consequences<BR/>Selecting interventions/planning care<BR/>Identify and implement interventions and treatments to address the individual's physical functional, and psychosocial needs, concerns, problems, and risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with an indwelling urinary catheter received appropriate treatment and services for one (R #3) of three residents reviewed for urinary catheters, in that:<BR/>CNA A did not ensure R#3's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in R#3's care plan. R#3's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning. Back-flow of urine was observed during the catheter cleaning as well as when CNA A held indwelling catheter, in midair, above shoulder length, for an undetermined amount of time. <BR/>This deficient practice affected one of three residents who had indwelling urinary catheters and placed them at risk for infection.<BR/>The findings include:<BR/>Record review of R#3's Face Sheet dated 07/13/2023, documented a [AGE] year-old male admitted [DATE], with the diagnoses of: chronic obstructive pulmonary disease (chronic obstructed airway), hypertension (high blood pressure), anxiety, depression, retention of urine, and generalized muscle weakness.<BR/>Record review of R#3's Minimum Data Set, dated [DATE], revealed R#3 had a BIMS score of 8 -moderately impaired cognitive skills for decision making. Resident #3 maintained need for encouragement/cueing with one-person physical assist for bed mobility, transfers, and personal hygiene. R#3 was coded for having an indwelling catheter and incontinence of bowel.<BR/>Record review of R#3's Physician Orders dated July 14,2023 stated, Catheter care every shift with soap and water. Leg<BR/>strap in place at all times to secure tubing. Every shift, for catheter care, keep catheter bag placed below the level of the bladder.<BR/>R #3's Comprehensive Care Plan dated 06/03/2023 documented:<BR/>Focus: The resident has an Indwelling Catheter. Goal: Will have no complications related to indwelling catheter use, the resident will be/remain free from catheter-related trauma through review date, and the resident will show no signs/symptoms of urinary infection through review date. Interventions: catheter care every shift, the resident has # 16 FR 10 ml indwelling catheter, position catheter bag and tubing below the level of the bladder, check tubing for kinks every shift and as needed, educate resident and/or family regarding indwelling catheter and care, intake and output as per facility policy, and observe for and document for pain/discomfort due to catheter.<BR/>During an observation on 07/13/2023 at 09:52 AM, CNA A gained consent from R#3 to perform foley catheter care. CNA A knocked and entered R#3's room then proceeded to wash her hands for 26 seconds. CNA A applied clean gloves, removed R#3's blanket, foley leg anchor and while attempting to remove R#3's shorts proceeded to lift the foley drainage bag that had 350ml of yellow urine, above shoulder length, in midair, for undetermined amount of time. During this time visible backflow of urine was observed. CNA A continued by placing the foley catheter drainage bag on bed, and again urine backflow of urine was visualized. The foley catheter drainage bag remained on resident's bed throughout the care procedure. <BR/>During an interview on 07/13/2023 at 10:10 AM, CNA A stated she was nervous and did not verbalize a definitive answer for her reason for removing the leg anchor, nor did she give a definitive answer for positioning the catheter drainage bag on top of the bed, resulting in the drainage bag being positioned above the bladder. CNA A stated she did not realize she held the bag in midair, nor could definitively state what contraindication could potentially occur regarding backflow of urine. CNA A stated R#3's leg anchor was specifically used to ensure catheter dislodgement would not occur. CNA A stated she does attend mandatory in-services, does not recall any education or competencies given upon hire but does recall an in-service regarding perineal/foley catheter care in June 2023. <BR/>During an interview on 07/13/2023 at 01:57 PM, with both ADON and DON stated that foley catheters must be positioned below the bladder to prevent urine from reentering bladder, which could potentially be detrimental to a resident's safety. The DON stated that re-entry of urine could lead to potential infection of excreted microorganisms. The DON stated the drainage bag should definitively not be positioned in midair nor on bed and must remain below the level of bladder to minimize chance of potential infection. The DON stated the ADON conducted an in-service on perineal catheter care procedures on 06/06/2023. The DON stated the ADON conducts skill check-offs, and competencies regarding perineal catheter to all care staff upon hire, monthly, annually, and as needed. <BR/>Record review of facility's Indwelling Urinary Catheter (Foley) Management issued 04/01/2022 and reviewed 08/22/2022 stated, Maintaining Unobstructed Urine Flow: The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. <BR/>Record review of facility's Perineal and Catheter in-service was conducted on June 6, 2023, for all care staff, CNA A was in attendance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain management to one resident (R#2), of five residents reviewed for pain management, that was consistent with professional standards of practice, her comprehensive person-centered care plan, and her goals and preferences.<BR/>The facility did not administer R#2's PRN (as needed) pain medication from time of pain complaint on 03/26/2023 at 6:54 PM, to the following morning on 03/27/2023 at 12:29AM to adequately control R#2's pain.<BR/>This failure could affect residents who were on a pain management program.<BR/>The findings were:<BR/>Review of R#2's Face Sheet dated 07/13/2023, revealed an [AGE] year-old-female, who was originally admitted to the facility on [DATE] and readmitted on [DATE]. R#2's diagnoses included surgical aftercare following surgery on the nervous system, asthma, dementia, heart disease, and hypertension (high blood pressure).<BR/>Record review of R#2's Care Plan dated 03/28/2023, revealed focus: resident expresses pain/discomfort related to lumbar fracture (a break in the bones of the spine, collectively known as vertebrae, which protect the spinal cord), goal: the resident will express pain relief through the review date, and interventions: evaluate the effectiveness of pain interventions, and pain medications as ordered.<BR/>Review of R#2's MDS dated [DATE], revealed R#2 was admitted to the facility with documented receival of scheduled pain medication as well as PRN pain medication. The MDS revealed R#2 had a BIMS score of 11 out of 15 signifying a moderately impaired cognitive function. The MDS also coded R#2 with no swallowing disorder but needed extensive assistance with ADLs.<BR/>Record review of R#2's Physician Order dated 3/26/2023 at 14:45 (2:45 PM) start time, revealed an order for Acetaminophen 325mg two tablets PO (by mouth) PRN (as needed) every six hours for pain or fever<BR/>Record review of R#2's Physician Order dated 3/26/2023 at 15:00 (3:00 PM) start time, revealed an order for Tramadol 50 mg one tablet PO PRN every six hours for pain. <BR/>Record review of R#2's Physician Orders dated 3/26/2023 at 17:15 (5:15 PM) start time, revealed an order for Norco 10-325mg one tablet PO PRN every six hours for pain. <BR/>Record review of R#2's Admission/readmission Assessment was started at 15:30 (3:30 PM) on 03/26/2023, and on the Pain Assessment Section documented at 18:54 (6:54 PM), R#2's pain numerical level was 4/10. Pain medication was documented as the specific source of pain relief. Also documented on the admission Assessment, was that R#2 was alert and oriented as well as could communicate her needs and understood others.<BR/>Record review of R#2's Medication admission Record (MAR) dated March 2023, revealed R#2 was administered Norco 10-325mg tablet PO on 03/27/2023 at 00:29 (12:29 AM). There was no documentation of pain medication being administered between 03/26/2023 at 6:54PM through 03/27/2023 12:29AM on the MAR.<BR/>Unable to observe R#2 due to resident being transported to another Nursing Facility upon familial request. <BR/>During an interview on 07/13/2023 at 3:11PM the DON stated all nursing staff are educated during orientation and annually on the necessary steps to acquire pain medication for residents. The DON stated it was the expectation of the facility, for every resident's admission/ readmission, for the admitting nurse to inquire about any pain medications administered prior to discharge from hospital. The DON stated Norco (Hydrocodone) medications are readily available at the facility's electronic medication dispensary. The DON stated the way medication orders are implemented are that the discharging hospital's physician will electronically send the prescription to the facility's pharmacy on file. The DON stated once the prescription is received by the facility's pharmacy, and the resident is admitted into the facility, the pharmacy will check for medicinal allergic contraindications. The DON stated the process to check for medication allergies does not take long. The DON stated once the pharmacy has completed a resident's medication allergy check, the medication will be available to pull from the electronic medication dispensary located on the premises. The DON stated when a nurse has difficulty pulling medications from the electronic medication dispensary, the nurse will contact the facility's pharmacy who would then provide a numerical code to open the electronic medication dispensary. The DON stated from reading the documentation, on 03/26/2023 at 6:54PM R#2 complained about pain during the admission assessment and was not administered any pain medication until 12:29AM on 03/27/2023 the following morning. The DON stated this was not an acceptable practice for any resident at the facility and pain should be dealt with immediately. The DON stated, she minimally would have administered the Tramadol and Acetaminophen as active measures to aide R#2's pain management, but as she read R#2's MAR for March 2023 out loud, she verbalized no pain medication was administered from 6:54 PM on 03/26/2023 through 12:29 AM on 03/27/2023. The DON stated, R#2's pain was not managed, and the lack of pain management could have potentially led to multiple negative outcomes. The DON stated the expectation of the facility was to manage all pain to a resident's tolerable pain level. The DON stated pain assessments are expected to be assessed every shift for every resident in the facility. The DON stated that for any resident that either does not have pain medication, or pain is not manageable by physician medication orders, nurses are expected to call and notify the physician and attain physician recommendations or orders. The DON stated, she does not know why LPN A, the admitting nurse, did not medicate R#2 for pain management given that there were active orders for Tramadol, Acetaminophen, and Norco. The DON stated LPN A, should have actively sought to advocate for R#2's pain management, by not only calling the pharmacy to check the status of pain medications, but also notifying the physician of R#2's pain concern. The DON stated, upon reviewing R#2's MAR, R#2's pain went without any pain medication management. <BR/>During an interview on 07/13/2023 at 4:06PM LPN A stated she could not recall receiving an admission regarding R#2. LPN A stated during the month of March 2023, she did not have access to the electronic medication dispensary, and when questioned about calling the facility's pharmacy for access, LPN A gave no definitive answer. LPN A stated she knew to call the facility's pharmacy to inquire about electronic prescriptions but did not definitively answer if she called R#2's physician, to advocate for pain medication ensue of documenting R#2's pain level 4 out of 10 upon admission. LPN A stated she began employment during February 2023 and stated the reason she did not document any attempts to contact the physician was that she was not familiar with the computer software system. LPN A stated that the facility she previously worked for was solely paper documentation. LPN A stated she could not recall any in-services or education regarding the electronic medication dispensary. LPN A stated waiting for over five hours for medication was a long time, as well as stated resident's pain could get worse if not managed immediately. LPN A stated she did not know why she did not administer Acetaminophen due to the medication being easily available to administer. LPN A stated she may have administered Acetaminophen pain medication to R#2 but may not have documented in R#2's MAR.<BR/>During an interview on 07/14/2023 at 9:40AM, the facility's pharmacy customer service representative stated an electronic script was received from R#2's discharging hospital on [DATE] 4:17 PM ET. The customer service representative stated once a resident is admitted into the nursing facility, the pharmacy will check for allergic reactions which does not take long. The representative stated if a medication needs to be withdrawn from the electronic medication dispensary, the staff member would call the pharmacy, and the pharmacy would give an authorization code to retrieve medication. The representative stated pain medication was available to pull on 3/26/2023. <BR/>Record review of the facility's Pain Assessment and Management policy, revised 09/08/2022 stated, <BR/>Purpose: To help residents attain or maintain their highest practicable level of well-being by proactively identifying, care planning, monitoring and managing the resident's pain indicators. <BR/>Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) observed for infection control practices during personal care, in that: <BR/>Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) and one staff (LVN A) observed for infection control practices during personal care, in that: <BR/>-LVN A did not: <BR/>-perform hand hygiene before and/or after assisting R#1 with personal care <BR/>-perform hand hygiene between glove changes <BR/>This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.<BR/>The Findings:<BR/>Observation of Peg tube care on 4/3/2023 at 11:36AM. LVN A knocked and entered R#1's room, performed hand hygiene by using ABHR (alcohol-based hand rub). LVN A continued by applying clean gloves, took sanitation wipes and cleansed bedside table. Hand hygiene performed after sanitation of bedside table for 1 minute. LVN A proceeded by applying new gloves, retrieved clean gauze saturated with normal saline and performed cleaning of the insertion gastric tube area. LVN A discarded dirty gloves, no hand hygiene performed after removal of dirty gloves and application of new gloves was applied. LVN A opened additional gauze package on clean surface, took another gauze applied normal saline and cleaned R#1's peg tube from proximal to distal (top to bottom). LVN A removed dirty gloves, applied new gloves, and then applied split gauze sponge and tape on top of R#1's peg tube area with current date. LVN A connected R#1's peg tube feeding and made R#1 comfortable. <BR/>Interview on 04/03/2023 at 12:03PM LVN A, stated he or she should have performed hand hygiene washed/hands or used antibacterial hand rub, after taking dirty gloves off prior to applying new clean gloves. LVN A continued by stating that this would aid in minimizing cross contamination and in-serviced on hand hygiene on a computer-based training program upon start date and then annually. <BR/>Interview on 04/03/2023 at 1:38PM. DON, stated the expectation of the facility is to perform hand hygiene before, during, and after resident care. DON stated antibacterial hand rub as well as soap and water are sufficient forms of hand hygiene. DON stated hand hygiene is promoted and expected while performing resident care as a preventative measure to minimize infection spread. Staff are in serviced as needed and annually.<BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023 states:<BR/>The facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. <BR/>The facility has systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable diseases. <BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023<BR/>Hand Hygiene Policy dated Revised on 7/15/2022 states, to decrease the risk of transmission of infection by appropriate hand hygiene.<BR/>The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to;<BR/>Before and after all resident contact.<BR/>Before applying gloves.<BR/>After removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility nursing staff failed to demonstrate competencies and skills sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (Resident #1) of the two residents observed with feeding tubes.<BR/>LPN A administered Resident #1's enteral feeding through Resident #1's Percutaneous Endoscopic Gastrostomy tube (PEG) without any assessments done prior to commencement of the feeding, contradicting the facility's policy and procedure. <BR/>This failure could place residents with feeding tubes at risk for aspiration by placing fluids into the lungs that can cause potentially fatal complications.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 04/04/23 documented a [AGE] year-old female admitted [DATE] and readmitted [DATE] with the following diagnosis: aphasia (loss of ability to understand or express speech), schizoaffective disorder (mental health problem that experience psychosis as well as mood symptoms), gastrostomy (artificial external opening into the stomach for nutritional support), dysphagia (swallowing difficulties), and diabetes mellitus (insulin resistance). <BR/>Record review of Resident #1's Minimum Data Set, dated [DATE] revealed the following:<BR/>- Brief Interview of Mental Status score of 9/15, which indicated moderately impaired cognition<BR/>-required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene<BR/>-always incontinent and <BR/>-feeding tube. <BR/>Record review of Resident #1's comprehensive care plan dated 03/08/2022 documented:<BR/>&middot;[Resident #1] requires tube feeding related to dysphagia. <BR/>&middot; The resident needs the HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed.<BR/>&middot; Enteral feeding as ordered.<BR/>&middot; Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications.<BR/>&middot; Observe and report PRN any s/sx [signs or symptoms] of: Aspiration- fever, SOB, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration.<BR/>&middot; Lab/diagnostic work as ordered. Report results to MD and follow up as indicated.<BR/>Record review of Resident #1's April 2023 Order Summary Report documented: On 03/01/2023 start date, Physician ordered Enteral Feed Order which stated, every shift check residual at beginning of shift and record amount. Notify MD if residual is greater than 60ml or if resident has nausea, abdominal distension, or bleeding. Perform PEG tube site care every day shift and as needed. Every shift administers at least 15 ml free water flush before and after medication administration Glucerna 1.2, 50 milliliters per hour for 22 hours. 150mL water every 4 hours every shift for Enteral feed, turn OFF at 8am, turn on at 12pm, daily.<BR/>During an observation on 04/03/2023 at 11:57AM, LPN A was asked to complete all steps for setting up enteral feeding as well as the necessary steps taken prior to commencement of the enteral feeding. LPN A began by applying new clean gloves without performing hand hygiene. LPN A continued by retrieving connection tubing from the feeding pump system and attached to the PEG tube on Resident #1. LPN A activated the feeding system and started enteral feeding. Throughout the enteral feeding procedure, no gastric residual volume was check nor were any assessment performed prior to commencement of enteral feeding.<BR/>During an interview on 04/03/2023 at 12:03PM LPN A stated, Resident #1's gastric tube placement was not assessed prior to or during this observation. LPN A stated the next intervention would be an assessment check for gastric residual volume and auscultation to ensure Resident #1's fluid and digestion safety. LPN A stated, due to LPN A knowing Resident #1 for a while, LPN A stated they were confident Resident #1 had no digestive issues nor any fluid abnormality. LPN A was then asked about the safety of bypassing an assessment prior to commencement of enteral feeding, to which LPN A reiterated they were confident in Resident #1's fluid and digestive safety. LPN A proceeded to state the facility administered computer-based trainings, periodically, annually, and upon hire. <BR/>During an interview on 04/03/2023 at 1:41PM The DON stated all care staff, according to job title, are mandated to go their specific job requirement skill check offs prior to admittance onto floor. DON continued by stating that general in services are done periodically, and on an as needed base. DON was then asked about competencies regarding enteral feeding, to which DON responded competencies are performed upon hire by DON, as needed, and annually. DON was then asked about what steps are to be done prior to commencement of enteral feeding, to which DON replied, nursing staff need to check for placement by performing an assessment via auscultation and a check of gastric residual volume. DON was then asked when a nurse should perform those two assessments, to which DON replied every time a nurse will be administering any medication or feeding via gastric tube, to eliminate chances of fluid abnormalities which could be fatal to a resident's safety.<BR/>Record review of the facility's Gastric Enteral Tube Feedings Procedures via Lippincott procedures, undated stated: Verify enteral tube placement by using at least two methods. <BR/>Record review of facility's Enteral Nutritional Therapy (Tube Feeding) Policy dated 08/25/22 stated, A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. <BR/>There was no competency documentation provided prior to exit conference.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) observed for infection control practices during personal care, in that: <BR/>Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (R #1) and one staff (LVN A) observed for infection control practices during personal care, in that: <BR/>-LVN A did not: <BR/>-perform hand hygiene before and/or after assisting R#1 with personal care <BR/>-perform hand hygiene between glove changes <BR/>This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.<BR/>The Findings:<BR/>Observation of Peg tube care on 4/3/2023 at 11:36AM. LVN A knocked and entered R#1's room, performed hand hygiene by using ABHR (alcohol-based hand rub). LVN A continued by applying clean gloves, took sanitation wipes and cleansed bedside table. Hand hygiene performed after sanitation of bedside table for 1 minute. LVN A proceeded by applying new gloves, retrieved clean gauze saturated with normal saline and performed cleaning of the insertion gastric tube area. LVN A discarded dirty gloves, no hand hygiene performed after removal of dirty gloves and application of new gloves was applied. LVN A opened additional gauze package on clean surface, took another gauze applied normal saline and cleaned R#1's peg tube from proximal to distal (top to bottom). LVN A removed dirty gloves, applied new gloves, and then applied split gauze sponge and tape on top of R#1's peg tube area with current date. LVN A connected R#1's peg tube feeding and made R#1 comfortable. <BR/>Interview on 04/03/2023 at 12:03PM LVN A, stated he or she should have performed hand hygiene washed/hands or used antibacterial hand rub, after taking dirty gloves off prior to applying new clean gloves. LVN A continued by stating that this would aid in minimizing cross contamination and in-serviced on hand hygiene on a computer-based training program upon start date and then annually. <BR/>Interview on 04/03/2023 at 1:38PM. DON, stated the expectation of the facility is to perform hand hygiene before, during, and after resident care. DON stated antibacterial hand rub as well as soap and water are sufficient forms of hand hygiene. DON stated hand hygiene is promoted and expected while performing resident care as a preventative measure to minimize infection spread. Staff are in serviced as needed and annually.<BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023 states:<BR/>The facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. <BR/>The facility has systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable diseases. <BR/>Infection Prevention and Control Program and Plan dated 5/31/2022 and revised on 1/25/2023<BR/>Hand Hygiene Policy dated Revised on 7/15/2022 states, to decrease the risk of transmission of infection by appropriate hand hygiene.<BR/>The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to;<BR/>Before and after all resident contact.<BR/>Before applying gloves.<BR/>After removal of gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding, for one (Resident #1) of the two residents observed with feeding tubes.<BR/>LPN A administered Resident #1's enteral feeding through Resident #1's Percutaneous Endoscopic Gastrostomy tube (PEG) without any assessments done prior to commencement of the feeding, contradicting the facility's policy and procedure. <BR/>This failure could place residents with feeding tubes at risk for aspiration by placing fluids into the lungs that can cause potentially fatal complications.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 04/04/23 documented a [AGE] year-old female admitted [DATE] and readmitted [DATE] with the following diagnosis: aphasia (loss of ability to understand or express speech), schizoaffective disorder (mental health problem that experience psychosis as well as mood symptoms), gastrostomy (artificial external opening into the stomach for nutritional support), dysphagia (swallowing difficulties), and diabetes mellitus (insulin resistance). <BR/>Record review of Resident #1's Minimum Data Set, dated 03/09/ 2023 revealed the following:<BR/>- Brief Interview of Mental Status score of 9/15, which indicated moderately impaired cognition<BR/>-required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene<BR/>-always incontinent and <BR/>-feeding tube. <BR/>Record review of Resident #1's comprehensive care plan dated 03/08/2022 documented:<BR/>&middot;[Resident #1] requires tube feeding related to dysphagia. <BR/>&middot; The resident needs the HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed.<BR/>&middot; Enteral feeding as ordered.<BR/>&middot; Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications.<BR/>&middot; Observe and report PRN any s/sx [signs or symptoms] of: Aspiration- fever, SOB, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration.<BR/>&middot; Lab/diagnostic work as ordered. Report results to MD and follow up as indicated.<BR/>Record review of Resident #1's April 2023 Order Summary Report documented: On 03/01/2023 start date, Physician ordered Enteral Feed Order which stated, every shift check residual at beginning of shift and record amount. Notify MD if residual is greater than 60ml or if resident has nausea, abdominal distension, or bleeding. Perform PEG tube site care every day shift and as needed. Every shift administers at least 15 ml free water flush before and after medication administration .Glucerna 1.2, 50 milliliters per hour for 22 hours. 150mL water every 4hours every shift for Enteral feed, turn OFF at 8am, turn on at 12pm, daily.<BR/>During an observation on 04/03/2023 at 11:57AM, LPN A was asked to complete all steps for setting up enteral feeding as well as the necessary steps taken prior to commencement of the enteral feeding. LPN A began by applying new clean gloves without performing hand hygiene. LPN A continued by retrieving connection tubing from the feeding pump system and attached to the PEG tube on Resident #1. LPN A activated the feeding system and started enteral feeding. Throughout the enteral feeding procedure, no gastric residual volume was check nor were any assessment performed prior to commencement of enteral feeding.<BR/>During an interview on 04/03/2023 at 12:03PM LPN A stated, Resident #1's gastric tube placement was not assessed prior to or during this observation. LPN A stated the next intervention would be an assessment check for gastric residual volume and auscultation to ensure Resident #1's fluid and digestion safety. LPN A stated, due to LPN A knowing Resident #1 for a while, LPN A stated they were confident Resident #1 had no digestive issues nor any fluid abnormality. LPN A was then asked about the safety of bypassing an assessment prior to commencement of enteral feeding, to which LPN A reiterated they were confident in Resident #1's fluid and digestive safety. LPN A proceeded to state the facility administered computer-based trainings, periodically, annually, and upon hire. <BR/>During an interview on 04/03/2023 at 1:41PM The DON stated all care staff, according to job title, are mandated to go their specific job requirement skill check offs prior to admittance onto floor. DON continued by stating that general in services are done periodically, and on an as needed base. DON was then asked about competencies regarding enteral feeding, to which DON responded competencies are performed upon hire by DON, as needed, and annually. DON was then asked about what steps are to be done prior to commencement of enteral feeding, to which DON replied, nursing staff need to check for placement by performing an assessment via auscultation and a check of gastric residual volume. DON was then asked when a nurse should perform those two assessments, to which DON replied every time a nurse will be administering any medication or feeding via gastric tube, to eliminate chances of fluid abnormalities which could be fatal to a resident's safety.<BR/>Record review of the facility's Gastric Enteral Tube Feedings Procedures via Lippincott procedures, undated stated: Verify enteral tube placement by using at least two methods. <BR/>Record review of facility's Enteral Nutritional Therapy (Tube Feeding) Policy dated 08/25/22 stated, A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. <BR/>There was no competency documentation provided prior to exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding, for one (Resident #1) of the two residents observed with feeding tubes.<BR/>LPN A administered Resident #1's enteral feeding through Resident #1's Percutaneous Endoscopic Gastrostomy tube (PEG) without any assessments done prior to commencement of the feeding, contradicting the facility's policy and procedure. <BR/>This failure could place residents with feeding tubes at risk for aspiration by placing fluids into the lungs that can cause potentially fatal complications.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 04/04/23 documented a [AGE] year-old female admitted [DATE] and readmitted [DATE] with the following diagnosis: aphasia (loss of ability to understand or express speech), schizoaffective disorder (mental health problem that experience psychosis as well as mood symptoms), gastrostomy (artificial external opening into the stomach for nutritional support), dysphagia (swallowing difficulties), and diabetes mellitus (insulin resistance). <BR/>Record review of Resident #1's Minimum Data Set, dated 03/09/ 2023 revealed the following:<BR/>- Brief Interview of Mental Status score of 9/15, which indicated moderately impaired cognition<BR/>-required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene<BR/>-always incontinent and <BR/>-feeding tube. <BR/>Record review of Resident #1's comprehensive care plan dated 03/08/2022 documented:<BR/>&middot;[Resident #1] requires tube feeding related to dysphagia. <BR/>&middot; The resident needs the HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed.<BR/>&middot; Enteral feeding as ordered.<BR/>&middot; Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications.<BR/>&middot; Observe and report PRN any s/sx [signs or symptoms] of: Aspiration- fever, SOB, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration.<BR/>&middot; Lab/diagnostic work as ordered. Report results to MD and follow up as indicated.<BR/>Record review of Resident #1's April 2023 Order Summary Report documented: On 03/01/2023 start date, Physician ordered Enteral Feed Order which stated, every shift check residual at beginning of shift and record amount. Notify MD if residual is greater than 60ml or if resident has nausea, abdominal distension, or bleeding. Perform PEG tube site care every day shift and as needed. Every shift administers at least 15 ml free water flush before and after medication administration .Glucerna 1.2, 50 milliliters per hour for 22 hours. 150mL water every 4hours every shift for Enteral feed, turn OFF at 8am, turn on at 12pm, daily.<BR/>During an observation on 04/03/2023 at 11:57AM, LPN A was asked to complete all steps for setting up enteral feeding as well as the necessary steps taken prior to commencement of the enteral feeding. LPN A began by applying new clean gloves without performing hand hygiene. LPN A continued by retrieving connection tubing from the feeding pump system and attached to the PEG tube on Resident #1. LPN A activated the feeding system and started enteral feeding. Throughout the enteral feeding procedure, no gastric residual volume was check nor were any assessment performed prior to commencement of enteral feeding.<BR/>During an interview on 04/03/2023 at 12:03PM LPN A stated, Resident #1's gastric tube placement was not assessed prior to or during this observation. LPN A stated the next intervention would be an assessment check for gastric residual volume and auscultation to ensure Resident #1's fluid and digestion safety. LPN A stated, due to LPN A knowing Resident #1 for a while, LPN A stated they were confident Resident #1 had no digestive issues nor any fluid abnormality. LPN A was then asked about the safety of bypassing an assessment prior to commencement of enteral feeding, to which LPN A reiterated they were confident in Resident #1's fluid and digestive safety. LPN A proceeded to state the facility administered computer-based trainings, periodically, annually, and upon hire. <BR/>During an interview on 04/03/2023 at 1:41PM The DON stated all care staff, according to job title, are mandated to go their specific job requirement skill check offs prior to admittance onto floor. DON continued by stating that general in services are done periodically, and on an as needed base. DON was then asked about competencies regarding enteral feeding, to which DON responded competencies are performed upon hire by DON, as needed, and annually. DON was then asked about what steps are to be done prior to commencement of enteral feeding, to which DON replied, nursing staff need to check for placement by performing an assessment via auscultation and a check of gastric residual volume. DON was then asked when a nurse should perform those two assessments, to which DON replied every time a nurse will be administering any medication or feeding via gastric tube, to eliminate chances of fluid abnormalities which could be fatal to a resident's safety.<BR/>Record review of the facility's Gastric Enteral Tube Feedings Procedures via Lippincott procedures, undated stated: Verify enteral tube placement by using at least two methods. <BR/>Record review of facility's Enteral Nutritional Therapy (Tube Feeding) Policy dated 08/25/22 stated, A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. <BR/>There was no competency documentation provided prior to exit conference.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 2 of 4 medication carts (Hall 300 Medication Cart and wound care cart) reviewed for storage, in that:<BR/>300 hall medication cart and Wound Care cart was left unlocked on 6/14/22. <BR/>This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. <BR/>The findings included:<BR/>During an observation on 6/14/22 at 9:43 AM, 300 hall medication cart was noted unlocked at the nurse's station and was unattended. The medication cart contained vitamins in the top drawer. <BR/>During an interview with LVN A on 6/14/22 at 9:45 AM revealed, the medication cart was for hall 300 and it was no longer used because the hall was closed. She stated, she doesn't know who opened the cart and she doesn't know why there was vitamins in the cart, but all carts should be locked when unattended. <BR/>During an observation on 6/14/22 at 10:10 AM, it was noted the Wound Care Nurse left her wound care cart on hall 100, unlocked and unattended. Observation revealed one resident passed by the cart on a scooter. The wound care cart was noted with wound care supplies and ointments such as Medihoney, Santyl, and Lidocaine Hydrochloride. <BR/>During an interview with Wound Care Nurse on 6/14/22 at 10:23 AM, she said she thought she had locked the cart. She stated the cart should be locked, and she stated it should be locked because it had medications in it. She stated it was important to keep medications locked properly because anyone can get them or take them. <BR/>During an interview with DON on 6/16/22 at 10:39AM revealed, that medication carts should be locked at all times while the nurse was away from the cart. She stated it was important to keep them locked when unattended to keep residents from getting into the carts and taking medications. She stated they had not educated the nurses on the keeping carts locked because that was something nurses should already know. All nurses should know to lock their carts when they are unattended. <BR/>Record review of the facility's pharmacy services and procedures manual for Storage and expiration of medication, biologicals, syringes, and needles dated 12/01/07 documented Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on interviews and observation, the facility failed to dispose of garbage and refuse properly for 1 of 1 deep fryer reviewed for dispose of garbage and refuse properly.<BR/>The facility failed to dispose of grease properly.<BR/>This deficient practice could place residents at risk of the attraction of vermin and rodents and affect residents by exposing them to germs and diseases carried by vermin and rodents.<BR/>The findings were:<BR/>Observation of the underground grease trap on 08/08/23 at 9:15 am with the MS revealed a large covered vat (large container to hold liquid) that was near full. There was no seepage on the ground.<BR/>Interview with the DS on 08/08/23 at 9:15 am revealed the process to remove the grease from the deep fryer was to funnel it into the original plastic container the grease came in, put the lid on the container, then threw the full container of used grease into the dumpster. The DS stated they did not use the facility grease trap and did not know why. <BR/>An interview with the MS on 08/09/23 at 8:15 am revealed the grease trap was used for facility water, not for directly emptying grease into.