Every finding on record at Abbey Rehabilitation and Nursing Center

Based on observations, interviews, and record review, the facility failed to report an elopement (an unauthorized exit from a secure unit) in accordance with State law through established procedures for one resident (#1) out of three residents sampled.Findings Included:During a phone interview on 06/25/2026 at 11:43 a.m., the Resident Representative (RR) for Resident #1 stated, I received a call from the facility letting me know [Resident #1] had escaped from the secure unit. I spoke to the police who told me they found Resident #1 quite a ways away from the facility. The facility told me he left during a fire drill. [Resident #1] was placed at the facility on the secure unit because of the history of exit seeking and attempting to leave from another facility.Review of Resident #1's admission record revealed Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 01/21/2026. Resident #1 was admitted to the facility with diagnoses to include; lack of coordination, unspecified dementia, unspecified severity, with agitation, unspecified mood [affective] disorder, muscle wasting and atrophy, not elsewhere classified, multiple sites, other specified disorders of muscle.Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 01, indicating severe cognitive impairment.Review of Resident #1's nurse progress note for 01/14/2026 at 17:45 revealed, Narrative: Resident observed leaving the facility for a walk at approximately 3:51 p.m. Resident #1 returned to the facility. Upon return, Resident #1 remained at baseline. Vital signs obtained and within normal limits. A Skin assessment/pain was completed. No signs or symptoms of injury. Skin intact. Gait steady and unchanged from baseline. Resident #1 denies pain, dizziness, shortness of breath, or discomfort. Resident #1 returned safely to room/unit and resting comfortably on 1:1. Safety measures in place. There are no signs of distress.Review of the facility's reportable adverse and grievance log revealed no entries for elopement for the month of January 2026.During an interview on 06/25/2026 at 1:00 p.m., Staff A, Registered Nurse (RN) stated, A certified nursing assistant (CNA) came up to me and told me they were doing their rounds and the head count was off. We started searching for Resident #1 on the secure unit. I then called the code, so the rest of the facility would be aware and could start looking for Resident #1. Me calling the code alerted the Nursing Home Administrator (NHA), who called the police. I believe he was missing for 15 minutes, I'm not sure how long he had been missing. Staff A stated, the facility was doing back-to-back drills and this caused her to have to leave the unit during one of the drills. Staff A stated the police are the ones who located Resident #1 and brought him back to the facility. Staff A stated Resident #1 was able to leave the building because when the fire alarms go off it disables the locked doors. Staff A stated, I did not know this happened, until after this incident.During an interview on 06/25/2026 at 1:45 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated they report resident and family concerns about not being changed, and any allegation of abuse, misappropriation, or neglect. They stated they would report an unauthorized exit if it rises to that level, it depends on the circumstances. If the resident was unharmed and we did not deem the resident to be at risk we would not report it. They stated they were not sure if an elopement would be considered an adverse event and they would have to do an investigation first to determine if the elopement would be adverse or if it needed to reported. They stated, during a fire drill on January 14th, the Maintenance Director responded to the door in the second building on [local street] going off, he opened the door, looked left and right, did not see anything, turned the alarm off, and alerted the front desk, and we started doing a head count of all residents in the building. They stated after the head count they could not locate Resident #1, so the police and the family were notified. They stated the police found Resident #1 and brought him back to the facility. They stated Resident #1 left at 3:41 p.m. and was returned to the facility at 5:45 p.m. They stated they did not report it because Resident #1 was safe, and Resident #1 was able to demonstrate safety awareness with traffic and he was able to cross the road. They stated the path he took was not dangerous and he was dressed appropriately for the time of day. Review of the facility policy titled Abuse Prevention Program, dated September 2025, revealed the following:,.procedure, the facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. The administrator is responsible for designating an abuse coordinator. The designated shift supervisor is identified as the responsible for immediate initiation of the reporting process. The administrator, DON, and or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. The administrator, DON and or designated individual are also utliaetly responsible for the following: implementation, ongoing monitoring, investigation, reporting, and tracking and trending.Identification.Event reports and resident concern/grievance reports are reviewred, tracked, and trended for indicatgors suspicious for abuse, neglect, mistreatment, exploitation and or misappropriation.Reporting, the facility will identifyi person(s) responsible for the reporting and investigating, the facilty will follow federal regulations and stated specific reporting requirements. DCF will be notified promptly, the administrator of the facility and or designee will be notified immediately, an immediate report will be filed with AHCA for alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries or unknown source that is suspicious of abuse or neglect and misappropriation of resident property: not later than two hours after the allegations is made if the events that cause the allegation involve abuse or result n serious bodyily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not resulting in serious bodily injury.The facility reports alleged violations and substantiated incidents to the state agency and to other agencies, as required and takes necessary corrective actions depending on the results of the investigation.

Based on observations, staff interview and record review, the facility failed to 1. Ensure planned meals were held at and below required temperatures and were ready to serve to residents for consumption during one of three meal service observations, (on 4/1/2026). It was found several of the planned cold food times were held over 41 degrees F.; 2. The facility kitchen staff failed to conduct and promote good hand hygiene practices when handling food. Findings included:1.On 4/1/2026 at 10:00 a.m. the meal menu board posted in the main 100 hallway outside the kitchen revealed the following menu food items to be served: (1. Turkey Croissant, 2. Macaroni Salad, 3. Relish Salad, Pudding, and with an alternate menu item of Beef Stew).It was determined the primary meal to be served for lunch meal service were cold items and with beef stew to be the hot item as an alternate. The menu further revealed residents could order choice items to include grilled cheese, hot turkey sandwiches, etc.On 4/1/2026 at 11:00 a.m. the kitchen was entered and met with the Dietary Manager (DM). The DM stated the food items to be served for the lunch meal were prepared and ready for service and for resident consumption. He confirmed the primary food items for lunch were to be served cold and to be below 41 degrees F. He further confirmed they did have an alternate menu item to be served as hot food, which included beef stew. The DM stated the lunch meal for the day was already pre planned as cold food.The DM stated that the kitchen was ready for food temperature test/demonstration and that he would have Staff A, [NAME] conduct the food items temperatures. Staff A stated she conducts food item temperatures prior to meal service before setting up meal trays for both the breakfast and lunch meal service. Staff A stated another cook will do the same thing for the dinner meal service. Staff A confirmed all cooks had been trained and in serviced on how and when the kitchen staff take food item temperatures. Staff A stated she takes food item temperatures with a digital thermometer and will calibrate that thermometer three times a day by using a ice and water bath until the thermometer reads 32 degrees F. Staff A and the DM both confirmed that the thermometer had been calibrated and was ready to use.Prior to taking food item temperatures Staff A revealed the following about food holding temperatures. She stated if the food item is a hot item, then the holding temperature must reach at least 135 degrees F. or higher. She stated if the food item is a cold item and to be served cold, the holding temperature of that item should be below 41 degrees F. and not below 32 degrees F.Staff A confirmed all their lunch items were to be cold food items and the temperatures should be at least below 41 degrees F. Staff A and the DM again confirmed the thermometer was calibrated correctly and that all the food items were on the tray line and ready to be served to residents at that time. At 11:05 a.m. Staff A began to provide a food item temperature demonstration for all the food items on the holding table. The following was observed; Turkey Croissant with cheese slice only reached 47.9 degrees F. The thermometer never read below this temperature. At 11:07 a.m. another temperature demonstration was conducted and the food item only reached 46.9 degrees F. Macaroni Salad reached 40 degrees F. It was found this item met temperature requirement.Sandwich mechanical soft reached 40 degrees F. It was found this item met temperature requirement. Puree consistency turkey reached 44.4 degrees F. The thermometer never read below this temperature. It was found the Croissant sandwich and the puree turkey both did not reach safe serving and consumption temperatures.Since two of the food items did not reach the minimum food holding requirement, the Dietary Manager stated they would go ahead and take all the food items from the service table and bring them to the walk in freezer to have chill in there a bit longer. The Dietary Manager stated the normal process for preparing and serving cold food items is; staff will prepare the food items then place them in the walk in refrigerator for about an hour prior to meal service. He confirmed this process was completed today, but it appeared some of the items did not get to below 41 degrees F. The Dietary Manager continued to state when the items are removed from the walk in refrigerator, they are placed in a container with ice, to help keep the items at the required temperature and below. The Dietary Manager further stated his staff will conduct the temperatures with a thermometer and document the temperature on the food temperature log. He reviews the logs daily to ensure his staff are in keeping with temperature requirements. The kitchen was left at 11:10 a.m. and returned to at 11:41 a.m. for another food item temperature demonstration. Both Saff A and the DM revealed they were now ready and that again, they felt all the food items were at appropriate holding temperatures and were all ready to be served for resident consumption. At 11:42 a.m. the following was observed: Turkey Croissant with cheese slice 40.6. This food item barely met requirement of below 41 degrees F. Puree consistency turkey reached 44.6 degrees F. The thermometer never read below this temperature. At this point the food temperature demonstration was ended. The Dietary Manager confirmed he and his staff did not get the puree turkey to meet food holding requirement and stated he was not going to serve the food items that were temped over 40 degrees F. He revealed he would still need to place those items in the walk in freezer for a bit longer, until meeting requirement. He confirmed the lunch meals would be served a little late due to having to place the food items.2.On 4/1/2026 at 11:00 a.m. an observation was made with Staff A, [NAME] conducting food temperature demonstration at the food holding table. Staff A had one plastic glove on her left hand and no glove on her right hand. During the entire food temperature demonstration, which lasted approximately eight minutes, Staff A was observed to touch exposed food items and the side of her chin with her right hand. After making self contact, she did not wash her hands. She did not remove the plastic glove on her left hand during any point of the demonstration. It was not observed she had washed either of her hands prior to the food temperature demonstration. The Dietary Manager and Staff A both confirmed all the meal items were prepared and ready to be served to residents for consumption.On 4/2/2026 at 10:58 a.m. the kitchen was observed and Staff C, [NAME] walked to the steam table, where all the food items were held. Staff C was not observed to wash her hands prior to the temperature demonstration. Staff C and the Dietary Manager both confirmed all the meal items were prepared and ready to be served to residents for consumption. At 11:00 a.m. Staff C was noted touching food items with her right hand while taking temperatures with the digital thermometer. She was also observed using her right hand and touching the side of her pants and then her left hand and arm. She was not observed washing her hands at any point of the demonstration, which lasted approximately nine to ten minutes. During an interview with Staff C, she did not remember she touched herself, but remembered she did touch food items with her bare hands and did not wash her hands after. On 4/2/2026 at 2:56 p.m. the Dietary Manager confirmed all his staff have been trained and in serviced on hand hygiene and should be washing hands after touching self, other food items or other areas that may be potentially contaminated. The Dietary Manager could not remember if Staff A or C were promoting good hand hygiene during observations on 4/1/2026 and 4/2/2026. He did say Staff A was wearing a glove on her left hand due to having a previous cut injury. Continued interview with the Dietary Manager revealed best practices for handwashing is anytime hands are soiled or touching of surfaces, it is expected staff wash their hands.On 4/2/2026 at 4:00 p.m. the Dietary Manager and the Nursing Home Administrator provided the Food Holding policy and procedure, with effective date June 2025 for review. The policy stated;Policy - To ensure the quality and safety of foods that are being held hot or cold. Cold foods:Use cold-holding equipment that can keep foods at 41 degrees F. or lower. Cold holding equipment includes refrigerators, freezers, and coolers. The policy also stated to utilize food temperature logs. On 4/2/2206 at 4:00 p.m. the Dietary Manager and Nursing Home Administrator provided the Hand washing and glove use policy and procedure with an effective date June 2024 for review. The policy stated;Policy - Hand washing is a vital role in infection control, reducing the surface microorganisms on our hands. Gloves are used to provide a barrier between potential microorganisms and ready-to-eat food items being prepared and/or portioned by staff. Procedure:Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food sources, following contact with unsanitary surfaces, and before wearing gloves. 5 . Gloves should be changed frequently, single use task. 6 . Hands must be washed between changing gloves.

Based on observations, record review and interviews, the facility failed to promote and maintain dignity for residents during activities, during meal services, and while in their rooms for six residents (#87, #8, #34, #101, #52, and #51) out of sixty-one sampled residents.Findings included: 1. On 3/30/2026 at 10:39 a.m. Resident #87 was observed lying in bed with the call light cord/button was on the floor, out from her reach. Resident was noted with what appeared to be a dark color saliva from her mouth. Resident #87 was attempted interview, but she did not want to answer. The resident was lying on brown colored saliva with brown matter all over her upper buttock area, the surface of the mattress, the side of the mattress, the bed frame, and trash can on the side of the bed. On 3/30/2026 at 12:04 p.m. just before the lunch meal service, Resident #87 was still observed in her room and lying in bed in the same position with heavy saliva coming from her mouth to a white with brown stained towel, and all over her bed. During an interview on 3/31/2026 at 2:00 p.m. Resident #87 confirmed she receives her tobacco to chew from her family who come to visit. She said she at times she spits it out and sometimes it does not get on the towel or trash can. The resident stated she had been lying on the tobacco spit from the day before. She said she wanted to get staff to come in and clean it up, but her call light was out from her reach. Review of Resident #87's medical record revealed she was admitted to the facility on [DATE] with diagnoses to include encephalopathy, dysphagia, dementia, lack of coordination, depression, schizoaffective disorder, mood, and anxiety. Review of Resident #87's most current quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed under cognition, the resident had a Brief Interview for Mental Status BIMS) score of 15 out of 15, which meant the resident was cognitively intact. On 4/2/2026 at 4:00 p.m. an interview with the Director of Nursing (DON) revealed she was aware of Resident #87 and knew she at times has chewing tobacco in her room and that family continually bring it in. She confirmed the resident was care planned for this behavior and if staff find her using it, they are to take it away and store it for her, so she can use during smoking times in the smoking patio. The DON acknowledged being aware Resident #87 has saliva coming from her mouth after chewing tobacco and said they give her a clean towel daily to catch it. The DON reviewed the photographic evidence from 3/30/2026 where the saliva was all over the resident's bed and surrounding surfaces. She confirmed staff should have cleaned that up and said Resident #87 should not be lying in that for long periods of time. (Photographic Evidence Obtained). 2. During an observation on 03/30/2026 at 10:13 a.m., Resident #8 was observed standing in the hallway of the secured unit. Resident #8 was heard speaking in another language to several other residents and staff. Staff J, Licensed Practical Nurse (LPN) repeatedly redirected the resident from speaking a language of their choice. Staff J stated to Resident #8, Speak English Resident #8, speak English. Review of Resident #8's quarterly MDS dated [DATE] revealed in section C- cognitive Patterns, the resident had a BIMS score of 02 out of 15 meaning severe cognitive impairment. 3. During an observation on 03/30/2026 at 11:43 a.m., Resident #34 was observed standing in between dining tables and chairs in the dining room. Staff J, LPN, was observed briefly tapping Resident #34 on the buttocks while standing beside him. Staff J was not immediately available for an interview. Review of Resident #34's entry MDS dated [DATE] revealed in section C- cognitive patterns, a BIMS score of 02 out of 15 showing severe cognitive impairment. 4. During an observation on 03/30/2026 at 11:43 a.m., Resident #101 was observed seated alone in a chair in the dining room, she was positioned away from other residents near a sink. There was no table in front of Resident #101. Resident #101 remained waiting for her meal while other residents in the dining room were served and assisted with their meals. Resident #101 was the last resident to be served and assisted. During an observation on 04/01/2026 at 12:15 p.m., lunch trays were observed being delivered to the secured unit (300 unit). The residents were observed being served and assisted with their meals. Resident #101 was observed in her room in bed during this time period. Resident #101 was assisted out of bed for lunch at 12:45 p.m., after the other residents had been served and consumed their meals. During an observation on 04/02/2026 at 11:34 a.m., Resident #101 was observed sitting at a table in the dining room. Staff Q, Certified Nursing Assistant, CNA, told Resident #101 she could not sit at that table and was assisted to the back of the dining room to a chair without a table. At 12:00 p.m., after the residents in the dining room were served their meals, Resident #101 was assisted with her meal. Staff Q, CNA was observed sitting in front of Resident #101, with a Styrofoam container on her lap containing Resident #101's lunch. Review of Resident #101's entry MDS dated [DATE] revealed in section C - cognitive Patterns a BIMS score of 02 out of 15 meaning severe cognitive impairment. 5. During an observation on 04/01/2026 at 12:15 p.m., Staff Z, CNA was observed standing next to Resident #52 assisting him with his meal.During an observation on 04/02/2026 at 11:53 a.m. Staff Q, CNA was observed standing next to Resident #52 while assisting him with his meal. 6. During an observation on 04/02/2026 at 11:51 a.m., Staff V, CNA was overheard talking to Staff Q, saying, Resident #51 is a feeder, you have to help him eat. Review of Resident #51's quarterly MDS dated [DATE] revealed in section C - cognitive patterns, a BIMS score of 00 out of 15 meaning severe cognitive impairment. During an interview on 03/30/2026 at 3:01 p.m., Staff R, CNA, stated residents who need assistance with meals have to wait until last, because there are only two aides and a nurse on the floor to assist with feeding the residents. During an interview on 04/02/2026 at 12:15 p.m., Staff Q, CNA stated dignity is making sure residents are dressed appropriately and are clean. Staff Q said they assisted residents with their meals if they need the help. Staff Q said, We should sit down next to the residents when assisting them with their meal. During an interview on 04/02/2026 at 12:32 p.m., Staff V, CNA stated dignity was making sure residents are kept clean and assisting them with their meals. She stated they also make sure the curtain stays closed when providing them with care. During an interview on 04/02/2026 at 4:30 p.m., the Nursing Home Administrator (NHA) stated dignity should always be held. The NHA said, staff should be knocking on doors, covering residents and announcing themselves. The NHA said the residents should be addressed by their preferred names. Review of the facility policy titled Resident Rights, dated August 2025, revealed under Policy - The facility strives to ensure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident the facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility and exercising his or her rights and to be supported by the facility and the exercise of his or her rights.

Based on observations interviews and review of the facility policy, the facility failed to provide a homelike environment in15 resident rooms (#1 through #15) out of 15 rooms located on the secured unit (300 Hall).Findings Included: During multiple facility tours of the secured unit (300 Hall) conducted from 03/30/3026 through 04/02/2026, observations revealed a plain halls layout with minimal decor, and no personal touches or affects throughout the physical environment. The resident rooms were observed to be bare with no personal effects and the overall atmosphere lacking warmth, comfort and familiar features. The Common areas appeared sparce, with little decoration and non-inviting seating which failed to promote a comfortable living environment for the residents. Attempts to interview the residents of the secured unit were unsuccessful due to noted severe cognitive impairments.During an interview on 03/31/2026 at 11:50 a.m., a family representative stated, This place could use some personal touches. It is not very home like.During an interview on 04/01/2026 at 4:45 p.m., the Nursing Home Administrator (NHA) confirmed the secured unit could use some more items to make it feel more homelike. The NHA said the walls were bare.During an interview on 04/01/2026 at 4:51 p.m., the Director of Nursing (DON) stated they were working on getting things to add to the unit for the residents that are more interactive and things the residents cannot remove from the walls. The DON said, But, we have to wait for them to approve it in the budget.Review of the facility policy titled, Physical Environment, with an effective date of August 2024, revealed a policy: A safe, clean, comfortable, and home life environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment and dining, health services, recreation, in program areas are provided to enable staff to provide residents with needed services.(Photographic Evidence Obtained)

Based on observations, record review and interview the facility failed to ensure adequate staffing related to 1.) administering medications within their scheduled time frames or two residents (#100 and #94) out of two residents reviewed; 2.) answering call lights in a timely manner as reported by all residents in the Resident council meeting.Findings included: 1. On 3/30/2026 at 9:26 a.m., an interview was conducted with Resident #100 in his room. The resident stated over the weekend the nursing staff were low. The resident stated normally there are three nurses each with a cart on his hallway (100) but stated yesterday there were two nurses on the evening shift. The resident stated yesterday, the nurse [Staff Y] was running around and trying his best during his medication administration but the resident was not sure if he got his mediation on time. Resident #100 stated Staff Y, Licensed Practical Nurse (LPN) stated he had close to 40 residents to give all their medications to. Resident #100 stated he seemed very rushed. A record review of Resident #100 admission Record showed an admit date of 02/23/2026 with diagnoses to include but not limited to Major depressive disorder recurrent moderate, primary insomnia, opioid dependence uncomplicated, chronic pain syndrome, chronic systolic (congestive) heart failure and essential primary hypertension. A record review of Resident #100's Minimum Data Set (MDS) dated [DATE], Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) of 15, indicating he was cognitively intact. A record review of physician orders for Resident #100 showed an order for the following: Pregabalin oral capsule 100 mg (milligram), give 100 mg by mouth three times a day for pain. Medication scheduled for 09:00 a.m., 13:00 (1:00 p.m., and 17:00 (5:00 p.m.). Oxycodone HCL (hydrochloride) oral tablet 10 mg, give 10 mg by mouth every 4 hours for Pain. Medication scheduled for 01:00 a.m., 05:00 a.m., 09:00 a.m., 13:00 (1:00 p.m.), 17:00 (5:00 p.m.), and 21:00 (9:00 p.m.) A record review of the Medication Admin Audit Report for Resident #100 showed on 3/29/2026, the resident received his scheduled 17:00 (5:00 p.m.)Pregabalin 100 mg and Oxycodone 10 mg at 19:06 (7:06 p.m.) Upon further review, Resident received his next dose of Oxycodone at 20:30 (8:30 p.m.) 2. On 3/30/2026 at 9:38 a.m., an interview was conducted with Resident #94. Resident #94 stated her medications were late yesterday during the evening shift. Resident #94 stated the nurse assigned to her hallway had 40 residents to administer medications to. Resident #94 stated the residents suffer when the staff are limited in providing quality of care. A record review of Resident #94 admission Record showed an admit date of 4/29/2025 with a readmission date of 01/30/2026 with diagnoses to include but not limited to chronic obstructive pulmonary disease with (acute) exacerbation, essential hypertension, major depressive disorder recurrent moderate, generalized anxiety disorder, and dislocation of internal left hip prosthesis subsequent encounter A record review of Resident #94's Minimum Data Set (MDS) dated [DATE], Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) of 15, indicating she was cognitively intact. A record review of physician orders for Resident #94 showed an order for the following: Baclofen oral tablet 10 mg, give one tablet by mouth two times a day for pain. Medication scheduled for 09:00 a.m. and 17:00 (5:00 p.m.) Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml (milliliters), one vial orally via nebulizer four times a day related to sepsis, unspecified organism . Medication scheduled for 09:00 a.m., 13:00 (1:00 p.m.), 17:00 (5:00 p.m.) and 21:00 (9:00 p.m.) Buspirone HCL oral tablet 10 mg, give one tablet by mouth three times a day for anxiety. Medication scheduled for 09:00 a.m., 12:00 (1:00 p.m.) and 17:00 (5:00 p.m.) Oxycodone-Acetaminophen oral tablet 10-325 mg, give one tablet by mouth every 4 hours for chronic pain. Medication scheduled for 01:00 a.m., 05:00 a.m., 13:00 (1:00 p.m.), 17:00 (5:00 p.m.) and 21:00 (9:00 p.m.). A record review of the Medication Admin Audit Report for Resident #94 showed on 3/29/2026, the resident received her scheduled 17:00 (5:00 p.m.) Baclofen, Ipratropium-Albuterol, Buspirone HCL and Oxycodone-Acetaminophen at 19:40 (7:40 p.m.). Upon further review, Resident received her next dose of Oxycodone at 20:38 (8:38 p.m.) On 3/31/2026 at 5:40 p.m., an interview was conducted with Staff Y, Licensed Practical Nurse (LPN) assigned to the 100 low hallway. Staff Y, LPN stated it was him and another nurse for the entire 100 hallway. Staff Y, LPN stated on Friday ( 3/27/26), he was so busy trying to pass medications for the residents he was assigned to that he did not get a bathroom break or a break in general. Staff Y, LPN stated sharing a cart with another nurse is challenging. Staff Y, LPN stated his legs were so sore by the end of his shift. Staff Y, LPN stated on Sunday the same scenario presented itself where he was sharing a cart with one other nurse when normally it is three nurses on the 100 hallways. Current census for the 100 hallways was 71 residents. Staff Y, LPN stated he knew the residents were unhappy with their care. He stated he is new to the facility and has been told it will get better. Staff Y, LPN stated, I don't know what good nurse can realistically get their work done. On 4/01/2026 at 8:16 a.m., an observation was made of Staff O, LPN in the nurses' station for the 200 hallways. Staff O, LPN was observed taking report from the off going shift nurse. Staff O, LPN was observed starting her medication administration at 8:23 a.m. On 4/01/2026 at 8:55 a.m., an interview was conducted with Staff O, LPN during medication administration of a resident with a gastrostomy tube (g tube). Staff O, LPN stated she had 18 residents of which 4 residents had tracheostomies, 6 residents with gastrostomy tubes and three wound dressings to do today. Staff O, LPN stated she had a late start because the night shift nurse giving report was still providing care and overwhelmed by the workload. Staff O, LPN stated currently there is not a unit manager to assist with any additional job duties; therefore, the workload is challenging. On 4/01/2026 at 9:14 a.m., an interview was conducted with the DON. The DON stated Staff O, LPN should have started her medication pass when she arrived at the facility. The DON stated a quick medication cart exchange/narcotic count could have been done prior to off coming nurse finishing her documentation. The DON stated the 100 hallways could be managed with two nurses and added it is a matter of better time management. The DON stated she as well as the ADON have assisted numerous times with any assistance. On 4/01/2026 at 5:30 p.m., an observation was made of Staff O, LPN in the nurses' station documenting for her shift. Staff O, LPN stated a few concerns developed where she had to stay and document. Staff O, LPN stated they had an extra nurse come in for the evening shift so he is assisting with labs and calling for orders that she could not get to. 3. During an interview 03/31/2026 at 2:30 p.m., Residents of the resident council stated the 7 a.m.-3 p.m., and midnight shift needs extra help. They can take an hour to two hours to answer call lights. Two residents stated they have been left in the bathroom waiting for assistance for up to two hours. The lights don't make different noises, so they don't know that you are in the bathroom. This has happened a few times. Other residents stated they have had to wait for up two hours for incontinence care. It always happens on these shifts. During an interview on 04/02/2026 at 2:43 p.m., the staffing coordinator stated I am new to this position, I just started last week. I have experience with scheduling, but nothing with nursing. We use our hours per patient day (PPD), we total all of our CNA's hours to make sure there are enough on each shift and base it on the census. I have a chart in my office that I use to give me the guidelines and tells me how many CNAs and nurses I need for based off of the census. The 100 unit get the most the CNAs, because that is where our census the is highest compared to the other floors. We do get call outs. When I get a call out, I will try to reach out and see if I can have someone fill the position. I have had it happen to where I was not able to fill a position after a call out. Right now, it is hard, it seems like nobody wants to work. If we have enough people, then they don't have to wait. No, I have not used the facility assessment, to staff the building, I am not sure what that is. We need more staff. Review of the facility policy titled Staffing dated August 2024 revealed, Policy: The administrator and director of nursing are responsible to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by federal law and sufficient staff to meet applicable state law requirements the projected staffing plans are reevaluated on an ongoing basis in response to changes in the facility, resident population, or other circumstances. Staffing is monitored on an ongoing basis through reviews conducted by the facility. The facility administrator and director of nursing should evaluate staffing on a daily basis.

Based on observations, interviews and record review the facility failed to follow standards of care for infection control related to; 1. offering hand hygiene to residents before meals for three of three meal observations; 2. Failed to follow hand hygiene practices during meal services; 3. Failed to use personal protection equipment (PPE) in one room (room [ROOM NUMBER]) of 3 rooms with transmission-based precautions.Findings included: 1. During an observation on 03/30/2026 at 11:44 a.m., multiple residents on the secure unit (300 hall) were observed sitting in the dining room at tables. Staff began passing meal trays without offering hand hygiene to residents. During an observation on 03/30/2026 at 1:18 p.m. of multiple rooms on the 300 unit revealed no paper towel holders in multiple resident rooms. During an observation on 04/01/2026 at 12:04 p.m., multiple residents on the secure unit (300 hall) were observed sitting in the dining room at tables. Staff began passing meal trays without offering hand hygiene to residents. During an observation on 04/02/2026 at 11:30 a.m., multiple residents on the secure unit (300 hall) were observed sitting in the dining room at tables. Staff began passing meal trays without offering hand hygiene to residents. During an observation on 04/02/2026 at 11:50 a.m., Staff I, Registered Nurse (RN) moved glasses from the top of her head to her face, began lifting lids off of food in the meal cart and passed meal trays to residents. No hand hygiene was performed. During an observation on 04/02/2026 at 11:52 a.m., Staff Q, Certified Nursing Assistant (CNA), passed meal trays to multiple residents with no hand hygiene in-between. While assisting a resident with the meal, Staff Q grabbed a food item with bare hands and began cutting the item up. During an interview on 03/31/2026 at 1:12 p.m., Staff R, CNA, stated It is hard to do hand hygiene when providing care to the residents on the 300 hall because they removed the paper towel dispensers. How do I do hand hygiene if there are no paper towels? We should use hand hygiene in-between residents when passing food trays. We have hand sanitizer to offer residents hand hygiene. During an interview on 04/02/2026 at 12:34 p.m., Staff H, CNA stated Hand hygiene sucks. I hate having to walk out of a residents room shaking my hands so they will dry. There are no paper towels in the rooms for me to dry when I am trying to provide care to residents on 300 units. During an interview on 04/02/2026 at 5:15 p.m., the Assistant Director of Nursing (ADON) stated there is hand sanitizer for staff to use and for residents to use before meals. Residents should be offered hand hygiene before their meals. Staff should do hand hygiene in-between residents, and no staff should not touch food with their bare hands. 2. On 04/01/206 at 1:00 p.m., an observation was made outside of room [ROOM NUMBER] of Staff L, CNA. A contact precautions sign was posted on the door of room [ROOM NUMBER]. Staff L was observed exiting room [ROOM NUMBER] with gloves, Staff L removed and disposed gloves at the nurse's station. Staff L was not observed performing hand hygiene upon exiting room [ROOM NUMBER]. Staff L was then observed inside of room [ROOM NUMBER] not wearing a gown. Staff L was observed inside of room [ROOM NUMBER] wearing a glove, reaching outside of the room to obtain a gown. An interview was conducted with Staff L, CNA on 04/01/2026 at 1:11 p.m. Staff L said there are three residents in the 200 unit that are under contact precautions. room [ROOM NUMBER] is under contact precautions. Staff L said that hand hygiene is to be performed before and after providing care, in addition to putting on a gown and gloves before entering a room with a resident under contact precautions. An interview was conducted with Staff O, LPN on 04/01/2026 at 1:28 p.m. Staff O said she will enter a room with contact based precautions with gloves, gown, and mask. Staff O said to perform hand hygiene before entering a room with contact precautions and upon exit. Staff O said room [ROOM NUMBER] is on contact precautions. A review of Isolation Precautions-Categories of Transmission-Based Infections effective October 2021 revealed standard precautions shall be used when caring for residents regardless of the or suspected or confirmed infection status. Contact Precautions for resident known or suspected to infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). Remove gloves before leaving the room and wash hands with an antimicrobial agent or antiseptic agent. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's environment. Review of the facility policy dated June 2024, titled Hand Washing and Glove use, revealed, Policy: Hand washing is a vital role in infection control, reducing the surface microorganisms on our hands. 1. Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food sources, following contact with unsanitary services, and before wearing gloves. 2. Follow proper washing procedures: .h. dry hands using disposable paper towels.

Based on observation, interviews and review of the facility policy, the facility failed to ensure implementation of their abuse policy related to an allegation of physical abuse and failure to immediately remove the resident from the alleged perpetrator, for one resident (#80) out of one resident sampled. Findings included: On 3/30/26 at 9:46 a.m., an observation of the closed door of the shower room in the 300 (secured) unit revealed elevated voices, the sound of a loud smack, and a male voice stated, Ow, he slapped me. The Activities Director (AD) was observed walking to the closed shower room door; she asked who was in there and Staff F, Certified Nursing Assistant (CNA) opened the door. Staff F, CNA was behind Resident #80 who was observed in a wheelchair with a pink substance covering the front of his dark colored shirt and the top of his dark colored pants. Resident #80 said Staff F, CNA slapped him. Staff F, CNA said he did not slap the resident, but that Resident #80 slapped himself. Staff F stated the resident was care planned for accusing staff of hitting him. The Activities Director was observed asking Resident #80 if he wanted Staff J, Licensed Practical Nurse (LPN) to assist, to which he responded, Yes. Staff J, LPN walked over with the Activities Director and said he had a care plan for vomiting on himself. The Activities Director walked away after Staff J, LPN came to the door of the shower room. Resident #80 was observed saying he wanted the Activities Director to stay with him, but Staff J, LPN responded she could not. Staff J, LPN was observed turning Resident #80 in his wheelchair around, then escorted him into the shower room and left him with Staff F, CNA. The resident was not assessed by the nurse for markings or skin changes that may indicate a slap or hit following the resident's allegation. The shower room door closed with Staff F, CNA and Resident #80 inside and no other staff with them. Staff J, LPN was observed walking away. Resident #80 said loudly, from the shower room, You hit me, and continued to yell unidentifiable words. On 3/31/26 at 2:34 p.m., an interview was conducted with the Activities Director. She stated Resident #80 would accuse residents and say, Hey, you hit me. She said she had witnessed him accuse other residents of hitting or kicking him, but never towards staff. She said Resident #80 had never accused her of hitting him. She said she sometimes worked on the secured unit as a CNA and has observed Resident #80 say, She just kicked me or he hit me. She said she would ask Resident #80 who hit him and he would say, The resident over there, but there would be no one there. She said the resident would then shift to a different conversation and say he liked her outfit or requested to listen to a song. The Activities Director said on 3/30/26 she was walking up the stairs to the 300 unit. When she got to the unit she saw the shower room door was closed and heard Resident #80 yelling, He hit me, it hurts. She said she heard Staff F, CNA yelling as well. She said she went to the shower room to see what was going on. The Activities Director said she observed Resident #80 being pushed in a rough manner and aggressively by Staff F, CNA. She described Staff F, CNA as being, Very elevated, while Resident #80 was telling her the CNA hit and slapped him. The Activities Director said Staff F, CNA's tone of voice was inappropriate and felt he should not have been speaking in that manner. She stated she told Staff F, CNA, I need you to calm down. The Activities Director said she knelt down to talk to Resident #80 and told him, I see you have thrown up on you. She said she tried to get Resident #80 out of the shower room and away from Staff F, CNA as she felt it was hostile. She said Resident #80 told her, I don't want him, in reference to Staff F, CNA. She said she explained what happened to Staff J, Licensed Practical Nurse (LPN) and went back to the shower room with the nurse. She said Resident #80 told Staff J, LPN she wanted the activities director to come with him. She said Staff J, LPN responded that the activities director was in a different department and could not. She said she thought Staff J, LPN went in the shower room with Resident #80 and felt the resident was taken out of the situation. She said she had never observed that type of interaction before with Resident #80 and a staff member. She said she reported the allegation to the Nursing Home Administrator (NHA)/Risk Manager.On 3/31/26 at 4:09 p.m., a telephone interview was conducted with Staff F, CNA. He said right after breakfast, on 3/30/26, he was notified by the activities staff member that Resident #80 vomited, All over the place. He said he went to the dining area to clean the vomit. He stated Resident #80 had, Throw up all over his clothes from head to toe. He cleaned the resident and assisted him out of the dining room. Staff F, CNA said he told Resident #80 he needed to take a shower as he had a red substance all over him. He said he went to get towels and linens, as well as the residents' clothes. He said he approached the resident who told him, No, no I don't want a shower. Staff F, CNA stated he was leading Resident #80 to the shower room, and described the resident as, Already being dramatic. Being his normal self, and saying he did not want to take a shower. He said he pushed the resident in his wheelchair into the shower room, closed the door, then transferred the resident to the shower chair, and went to turn on the shower. Staff F, CNA said Resident #80 clapped his hands and stated, Ow you hit me, you hit me. Staff F, CNA said he told the resident, [Resident #80] you know I did not hit you. He said the activities director knocked on the door and he told her, [Resident #80] just being [Resident #80] saying I hit him and I didn't. Staff F, CNA said the activities director went to get Staff J, LPN. He said when Staff J, LPN came over Resident #80 was in his wheelchair saying, No, I don't want a shower. He said Staff J, LPN helped him transfer the resident to the shower chair and remove his shirt. He confirmed he provided a shower to the resident and Staff J, CNA was not present. He said Resident #80 told him, Thank you for cleaning me. Staff F, CNA said he assisted with dressing him and the resident asked where his wheelchair was. Staff F, CNA stated, This is what he does every day. He said the residents' behavior was normal for the staff and they were used to it. He confirmed Resident #80 had previously accused him and other staff of hitting him. He said he always notified the nurse when Resident #80 had behaviors. He said most of the staff who worked on the secured unit knew how the resident acted, there was nothing they could do about his behaviors, and they needed to continue to complete their jobs. He said in this situation, he and Resident #80 were not separated because the staff knew how the resident was. He said they would separate the Resident #80 and a staff member the resident accused of hitting him if it was new staff who did not typically work on the unit. On 3/31/26 at 4:35 p.m., a telephone interview was conducted with Staff J, LPN. She stated Resident #80 yells a lot and, Says someone is hitting me. She said he will accuse staff and residents of doing something, such as hitting him, or taking his items. Staff J, LPN stated when he makes the accusations, Most of the time there's no one around him. She said this was his behavior at a previous facility as well. She stated, If he didn't say it, I would think something is wrong with him, as he said it multiple times a day. She confirmed the resident has previously accused her of hitting him. Staff J, LPN said when Resident #80 makes the accusations she checked to make sure, but typically there was no one there. She said on 3/30/26 the resident has finished his meal, and he wheeled himself out of the dining room. She said she did not see any interaction between Staff, F, CNA and Resident #80. When asked if she was present in the shower room after the resident alleged that Staff F, CNA hit him, she said may have taken a step in but did not stay there. She said she observed Staff F, CNA put Resident #80 in the shower chair and she left. She said she was in the shower room for a few seconds. Staff J, LPN said they did not separate the resident and the CNA because that was Resident #80's normal behavior and he had a care plan that included him accusing staff.On 3/31/26 at 3:09 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She said the activities director reported the allegation of abuse to her. She said she observed video footage of Staff F, CNA pushing Resident #80 wheelchair into the shower room. She said she did not like Staff F, CNA's motions or gestures and how the CNA pushed the resident's wheelchair.On 4/2/26 at 12:34 p.m., an interview was conducted with Staff S, central supply/activities. She stated Resident #80, Always yells when I'm up here, but normally he is good. Staff S said on 3/30/26 Resident #80 was agitated and did not want to take a shower after he vomited. She said he was in the dining yelling that he wanted to go to his room and was agitated, but not towards the staff. Staff S said at approximately 9:30 a.m. to 10:00 a.m., Staff F, CNA came to the dining room to assist with cleaning Resident #80. She said the resident was not aggressive or combative toward Staff F, CNA and stated, He was wanting to go to his room and not get cleaned up.On 4/2/26 at 2:02 p.m., an interview was conducted with the NHA and the Director of Nursing (DON). They both confirmed they were not aware that Resident #80 had a behavior of making accusations towards staff and resident until after interviews about the incident on 3/30/26. The NHA said the expectation when staff responded to an allegation of abuse is making sure the resident was safe, intervening, and not let the action continue. She said for an allegation of abuse between a staff member and a resident, the expectation was for staff to separate themselves from the situation. The NHA and DON confirmed Resident #80 should not have gone back into the shower room with Staff F, CNA. They both said they were not aware Staff F, CNA went back into the shower room with the resident. The NHA said the CNA needed to be removed and staff should have sure the resident was safe.A review of Resident #80's admission record revealed an admission date of 7/17/25. Further review of the admission record revealed diagnoses to include personal history of traumatic brain injury, other recurrent depressive disorders, major depressive disorder, recurrent, mild, other schizophrenia, other specified persistent mood disorders, psychotic disorder with delusions due to known physiological condition, generalized anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and cerebral infarction, unspecified.A review of Resident #80's physician orders active as of 4/2/2026 revealed the following:- Side effects monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth, tongue, trunk or extremities, n&v [nausea and vomiting], pacing, seizure activity, stiffness of neck, sore throat, tremors, rashes every shift do not use if any side effects are present or resident appears to be lethargic, drowsy, or sedated. report change to practitioner if needed., with an order date of 7/17/25.- Clonazepam Oral Tablet 0.5 mg [milligrams] (Clonazepam) Give 1 tablet by mouth every 8 hours for anxiety hold for sedation, with an order date of 7/18/25.- Seroquel Oral Tablet 200 MG (Quetiapine Fumarate) Give 1 tablet by mouth three times a day for delusions, paranoia related to Schizophrenia, unspecified (f20.9), with an order date of 9/2/25.- Trazodone HCl [hydrochloric acid] Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Depression, with an order date of 10/10/25.- Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule by mouth every morning and at bedtime for mood disorder, with an order date of 1/27/26.A review of Resident #80's quarterly minimum data set (MDS), dated [DATE], revealed the following: Under section C - cognitive patterns, the brief interview for mental status (BIMS) score was 8 out of 15, indicating Resident #80 was moderately impaired. Section E - behavior, showed, Behavior not exhibited, was marked under physical, verbal and other behavioral symptoms.A review of Resident #80's change in condition assessments dated 8/20/25 revealed, .increased audio and verbal hallucinations . continues to yell out . Recommendation of Primary Clinician(s) IM [intramuscular] Haldol injection . A review of Resident #80's assessments from 1/2026 to 3/2026 revealed the following:A review of the nursing quarterly assessment, dated 1/20/26, showed there no documentation under behaviors.a review of the psychosocial history and assessment, dated 2/27/26, showed the following: .a. mental health a. psychiatric diagnosis . a 2.if yes, what medication do you take? Depakote, trazadone, Seroquel, clonazepam . e. list mental health issue depression, schizophrenia, mood disorder, psychotic disorder, anxiety . f. document how resident and/or family are coping with current illness/placement coping well .memory/cognition 1a. long term a. yes . 1c. fluctuates a. yes . 2. cognitive skills/daily decision making 3.change in cognitive status in the last 6 months 1. no change . c. mood/behavior 1l. pleasant . change in mood or behavior in last 6 months? 1. no change. A review of Resident #80's progress notes from 1/2026 to 3/2026 revealed the following:On 1/1/26, CNA reported resident vomitted [sic] by bed. Noted moderate amount of undigested food. Medicated as ordered.On 1/5/26, . He is seen today for routine psychiatric follow-up, with the last psychiatric evaluation on 11/11/2025. Since the last visit, the presentation has remained stable without acute concerns. Staff observations during this interval are consistent with an unchanged clinical course, and the current plan is to continue the current medication regimen. Behavior remains cooperative without agitation, sleep problems are not reported, and appetite is noted as normal. Cognition appears consistent with baseline, with orientation to person and place and moderate attention and concentration. **Largely unknown--lot of anxiety and impulse control issues. Schizophrenia, MDD [major depressive disorder], GAD [generalized anxiety disorder], unspecified Mood affective d/o [disorder], other recurrent Depressive d/o, unspecified Psychosis, Seizures, TBI [traumatic brain injury], CI [cerebral infarction] . Attention and concentration are moderate, with deficient fund of knowledge and intact language and associations. Insight and judgment are poor. Behavior : Cooperative . Insight : Poor Judgment : Poor Attention and Concentration : Moderate .On 1/13/26, Labs received and reviewed results with NP [nurse practitioner]; resident does not exhibit behaviors at this time. No new orders given. All RPs [responsible parties] were notified.On 1/18/26, Resident gives CNA a lot of push back when attempting to deliver care. Yelling out and creating untoward behaviors without warrant. Resident assessed and there are no issues which lead to this behavior.On 2/4/26, Date of Service: 2026-02-03 . Today, he presents with loud speech and impulsive verbalizations . Summary: He is alert and oriented to person and place. Memory and attention were limited, with deficient fund of knowledge and moderate attention and concentration. Speech was loud, language was intact, and engagement was cooperative with a congruent affect. On 2/16/26, Date of Service: 2026-02-13 . The patient is being seen by a psychiatric nurse practitioner in a long-term care setting. Since the last visit, he presents for assessment of Gradual Dose Reduction (GDR) and has remained stable and cooperative with care without agitation . Mood appears stable, and there have been no behavioral concerns.-On 3/3/26, Emesis noted in hall in front of resident on floor. Med [medication] given as ordered.-On 3/12/26, Emesis reported and noted of undigested food. Med given as ordered.On 3/22/26, Date of Service: 2026-03-13 . According to staff, the patient has been stable and cooperative with care, displaying no signs of agitation. The patient has good medication compliance and no reported side effects. Plan: Given the patient's stability and minimally effective dosages of psychotropic medications, a GDR was deemed contraindicated as it could potentially lead to an exacerbation of the patient's psychiatric symptoms and instability. Therefore, all current psych [psychiatric] medications were continued without any changes.On 3/23/26, The resident is currently on a secure unit with two locked exit doors in place. Resident has short term memory impairment and is unable to recall exit door codes. No recent exit seeking behaviors were observed. No attempts of elopement were noted during recent assessment. IDT [interdisciplinary] met and discussed resident's safety status. Resident will continue to be monitored for exit seeking behaviors. Staff instructed to report any changes in behavior and/ or exit seeking behaviors. MD [medical doctor] notified.On 3/26/26 psych note, Date of Service: 03/25/2026 . The patient was observed seated in the dining room of the memory care unit and appeared confused but in no acute distress. Due to his cognitive status, history is significantly limited. He is noted to be fidgety during today's examination. The patient is typically observed in his wheelchair wandering the unit hallways. Neurological: Alert and pleasantly confused . A review of the behavior task for Resident #80 from the last 30 days showed daily documentation of, No behaviors observed.A review of Resident #80's care plan revealed the following: BEHAVIORAL: The resident is noted with the following behaviors: Difficulty communicating thoughts or needs: Territorial of personal space, picks at and eats scabs from sore or wound. Accuses others of hitting him .when there is no one around. Date Initiated: 08/20/2025, Revision on: 03/30/2026, with interventions to include, .Document episodes of behavior & [and] review to determine the effectiveness of intervention Date Initiated: 03/30/2026.A review of the facility's incident and accident log showed an alleged abuse incident for Resident #80 occurred on 3/30/26 at 11:00 a.m. A review of the facility's Abuse Prevention Program, dated November 2024, revealed the following, Policy- The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Further review of the policy revealed the following, Verbal Abuse - Oral, written, or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident with in their hearing distance, regardless of their age &/or ability to comprehend or disability. Physical Abuse - Includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. Under Training, the policy revealed the following, . How to provide protection for residents. Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may not be limited to, recognizing signs of burnout, frustration and stress, stress management and relaxation techniques. Under Protection, the policy revealed the following, Upon identification of actual, suspected, or alleged abuse, neglect, mistreatment, exploitation, and/or misappropriation, systems are in place to provide for the protection of the resident. These systems may include but may not be limited to: . Moving another resident to another room or unit if indicated. Initiation of behavioral interventions per Behavior Management Program as indicated.

Based on record review and staff interviews, the facility failed to complete the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for three residents (#10, #34, #62) of seven residents sampled.Findings included: 1. A review of Resident #10's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses to include; schizoaffective disorder, bipolar type, depressive disorder, Epilepsy, mood disorder, psychoactive substance abuse, antisocial personality disorder, generalized anxiety disorder, and alcohol use, Review of Resident #10's records revealed the resident did not have a level one PASARR completed prior to admission. The review further showed a level II PASARR was not submitted for consideration following qualifying diagnoses. 2.Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified sequelae of cerebral infarction, cognitive communication deficit, mixed receptive-expressive language disorder, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, mood disorder due to known physiological condition with mixed features; other psychotic disorder not due to a substance or known physiological condition; major depressive disorder, recurrent, mild; generalized anxiety disorder; anxiety disorder, unspecified; primary insomnia; alcohol abuse, uncomplicated. Review of Level I PASARR for Resident #34 dated 1/30/26 revealed the following mental illnesses: anxiety disorder, depressive disorder, psychotic disorder, substance abuse, mood disorder due to known physiological condition with mixed features, and other related conditions of unspecified sequelae of cerebral infarction. Review of Section I, part B, revealed no items marked for intellectual disability or suspected intellectual disability. Review of Section II revealed yes responses to questions 1 and 2B. Review of Section III revealed no provisional admission or hospital discharge exemption. Review of Section IV showed serious mental illness and intellectual disability. Review of Resident #34's medical record revealed a request for Level II PASARR evaluation was not submitted for consideration following the qualifying diagnoses. 3. Review of Resident #62's medical record revealed the resident was admitted on [DATE]. Review of diagnoses revealed the following to include but not limited to: unspecified dementia, unspecified severity, with anxiety; mood disorder due to known physiological condition, unspecified; major depressive disorder, recurrent, mild; other specified persistent mood disorders; primary insomnia; pseudobulbar affect; major depressive disorder, single episode, unspecified; insomnia, unspecified; cannabis use, unspecified, uncomplicated; bipolar disorder, unspecified; anxiety disorder, unspecified; unspecified dementia, unspecified severity, with agitation. Review of a level I PASARR for Resident #62 dated 1/30/26, revealed mental illness to include: anxiety disorder; bipolar disorder; depressive disorder; mood disorder due to known physiological condition, unspecified; other specified persistent mood disorders; pseudobulbar affect; and cannabis use, uncomplicated. Review of Section II revealed yes responses to questions 1 and 2B. Review of Section III revealed no provisional admission or hospital discharge exemption. Review of Section IV revealed serious mental illness. The review of Resident #62's medical record revealed a request for Level II PASARR evaluation was not submitted for consideration following the qualifying diagnoses. On 4/1/2026 at 1:02 p.m. an interview with the Social Services Director (SSD) revealed they stated an audit in the 100 hallway, and it was identified that the majority of the Level I PASARRs were incorrect. The stated SSD she completed all Level I PASARR screens for the 100, 200, and 300 halls. The SSD reported that once all Level 1 PASARRs were completed, she would work on Level II PASARRs. The SSD said, I had to wait to submit for Level II because we needed psychiatry notes. The SSD stated keeping a weekly audit log for tracking. A follow -up interview on 4/1/2026 at 1:52 p.m. with the SSD revealed the SSD cannot submit Level II evaluations without the assistance of the Director of Nursing (DON). The SSD confirmed a Level II is requested when there are, any related conditions. The SSD confirmed the expectation was for a Level II to be requested as soon as possible once they are triggered by the Level I screen. The facility did not provide a policy for PASARR evaluations.

Based on observations, interviews and record review, the facility failed to implement care plan interventions related to 1. Positioning of adaptive eating equipment and 2.Ensuring call light bell/cords are within reach for two residents (#87 and #114) of sixty-one sampled residents, during four days (3/30/2026, 3/31/2026, 4/1/2026, and 4/2/2026) of four days observed. Findings included: 1. On 3/30/2026 at 12:29 p.m. the main dining room was observed for the lunch meal service. There were nine residents including Resident #114 seated at various tables and being served and assisted by staff with their meals. Resident #114 had already received his plate of food, observed with adaptive eating assistive equipment including a high scoop plate. Resident #114 was noted with his left hand and arm positioned on his lap while he used his right hand to grip the eating utensil. Resident #114 used the eating utensil and began to scoop food inward towards him as the high side of the scoop plate was positioned outwards and away from him. Due to the improper positioning of the scoop plate, Resident #114 at times was scraping some food items off the plate, to the table and some to his lap. The staff observed in the room did not adjust the plate to accommodate his scooping need. Review of the meal ticket placed on the table read; use of scoop plate. It did not mention how the scoop plate needed to be positioned. Resident #114 was not able to answer questions related to his medical care and services. On 3/31/2026 at 12:20 p.m. Resident #114 was observed seated in the main dining room at a table by himself. He was served his lunch meal and set up done by staff. Resident #114 received a scoop plate, adaptive eating equipment with the high side of the scoop plate facing away from him. Resident #114 continued to use his eating utensil and was scooping food inwards on the short side of the plate. He was found to scrape food items onto the table from not having the high side of the scoop plate nearest to him. Staff in the room did not readjust the plate as he was scooping some food items on the table. On 4/2/2026 at 12:23 p.m. an interview was conducted with with Staff T, Registered Nurse (RN)supervisor, who was in the main dining room and supervising the lunch meal service. She stated she and the staff in the dining room are to review the meal tickets for diet orders, diet consistency, food allergies, likes and dislikes, and use of adaptive eating equipment. She confirmed Resident #114 had the use of adaptive eating equipment to include a scoop plate. She reviewed the meal ticket, and it did not indicate how the scoop plate needed to be positioned. Staff T confirmed the scoop plate has a high side and a low side, and the high side should be positioned in a manner where the resident can scoop the food comfortably and properly. Staff T stated that based on how the resident uses and scoops his eating utensil, staff should place the high side towards him. She stated she was not aware the scoop plate was in the wrong position during the lunch meal of 3/30/2026 and 3/31/2026. Review of Resident #114's medical record revealed he was admitted on [DATE] with diagnoses to include but not limited to cerebral infarction, seizures, dementia, dysphagia, anxiety, mood, lack of coordination, muscle wasting and atrophy, cognitive communication deficit, and stiffness of joint. Review of the current quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed - Cognition/Brief Interview Mental Status (BIMS) score - not scored but revealed Short Term/Long Term memory problem and with severely impaired decision-making skills.). Under ADL (activities of daily living) Resident #114 was impaired on one side, upper extremity, and impaired one side, lower extremity. For eating the resident requires set up and clean up assistance. Review of the current care plans with a next review date 5/17/2026 revealed a focus- CVA stroke with L (left) side neglect hemiparesis, with interventions in place to include but not limited to: use of adaptive equipment. Focus - Nutrition has a potential nutritional problem r/t (related to) cerebral infarct, dementia, HTN (hypertension), dysphagia, dx. (diagnosis), BMI (Body Mass Index) low, hx. (history) sig (significant ) wt. (weight) changes, need for mech. (mechanical) altered diet, with interventions to include: Diet as ordered, Adaptive device: Scoop plate.On 4/1/2026 at 10:20 a.m. an interview with the Director of Rehabilitation (DOR) confirmed Resident #114 had been screened and provided with care and services from Speech Therapy. The DOR confirmed Resident #114 utilizes a scoop plate when eating meals and the scoop plate should always be positioned in a manner where the resident can easily scoop food items with an eating utensil. She confirmed it would not be beneficial for the scoop plate high side to be away from the resident when he scoops inward. She stated that the high side should be close and towards the resident when scooping inward. 2. On 3/30/2026 at 10:39 a.m. Resident #87 was observed lying in bed with the call light cord/button was on the floor, out from her reach. Resident was noted with what appeared to be a dark color saliva from her mouth. Resident #87 was attempted interview, but she did not want to answer. The resident was lying on brown colored saliva with brown matter all over her upper buttock area, the surface of the mattress, the side of the mattress, the bed frame, and trash can on the side of the bed. Resident could not reach her call light.On 3/31/2026 at 9:40 a.m. Resident #87 was observed in bed. Her call light button/cord was clipped on the rear right side of the pillow. Her head was positioned on the very low side of the pillow, and she would not have been able to reach it. An interview was obtained with Resident #87 who confirmed she would not be able to reach the call light cord as staff routinely clip it to the top of her pillow. She stated, This happens all the time.On 4/1/2026 at 10:30 a.m. Resident #87 the resident was observed in her room with her call light attached to the back end of the right side of the pillow, out from her reach. Resident #87 stated she needed to speak to a nurse during the time of the visit but was not able to call due to her call light cord being out of reach. On 4/2/2026 at 9:41 a.m. Resident #87 was observed in her room and lying flat in bed and her call light cord on the floor behind her head of bed. The resident confirmed she would not be able to reach the cord if she needed to get help from staff. On 4/2/2026 at 9:43 a.m. the Assistant Director of Nursing (ADON) went into the Resident #87's room and confirmed the call light cord was on the floor. The ADON was observed to talk with the resident as she picked up the call light cord and clipped it to the right side of the bed linen, near the resident's hand. The resident reacted well to the ADON placing the call light within her reach and thanked her. The ADON confirmed the call light should be placed within Resident #87's reach while in bed and it did not matter if they could use it or not. The ADON confirmed the resident utilizes the call light but did not know if she had any behaviors of dropping it on the floor. She was not sure why staff would clip it to the back of the pillow. Review of Resident #87's medical record revealed she was admitted to the facility on [DATE] with diagnoses to include encephalopathy, dysphagia, dementia, lack of coordination, depression, schizoaffective disorder, mood, and anxiety. Review of Resident #87's most current quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed under cognition, the resident had a Brief Interview for Mental Status BIMS) score of 15 out of 15, which meant the resident was cognitively intact. The assessment revealed the resident had no behaviors and required set up/clean up assistance for personal hygiene, toileting and toilet transfer. Review of the current care plans with a next review date 5/4/2026 revealed Resident #87 has an ADL self-care performance deficit as evidenced by: Cannot complete ADL tasks independently and requires individualized interventions to maintain hygiene, with interventions in place to include: Call Bell within reach while in room/bathroom, shower room and remind to use. A second focus revealed Resident #87 is at risk for falls or fall related injuries with interventions in place to include, provide environment adaptations: Call light within reach. On 4/2/2026 at 4:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). They both confirmed all residents whether they can use the call lights or not are to have the call light cord placed within their reach while in bed or while in the shower room/bathroom. The DON confirmed the call light cord is to be securely placed in an area that is beneficial for the resident to use. A review of the facility's policy Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024, revealed the following, The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions.

Based on observation, record review, and interviews, the facility failed to ensure a care plan was revised in a timely manner related to behaviors for one resident (#80) out of seven residents reviewed. Findings included: On 3/30/26 at 9:46 a.m., an observation of the closed door of the shower room in the 300 (secured) unit revealed elevated voices, the sound of a loud smack, and a male voice stated, Ow, he slapped me. The Activities Director (AD) was observed walking to the closed shower room door; she asked who was in there and Staff F, Certified Nursing Assistant (CNA) opened the door. Staff F, CNA was behind Resident #80 who was observed in a wheelchair with a pink substance covering the front of his dark colored shirt and the top of his dark colored pants. Resident #80 said Staff F, CNA slapped him. Staff F, CNA said he did not slap the resident, but that Resident #80 slapped himself. Staff F stated the resident was care planned for accusing staff of hitting him. The Activities Director was observed asking Resident #80 if he wanted Staff J, Licensed Practical Nurse (LPN) to assist, to which he responded, Yes. Staff J, LPN walked over with the Activities Director and said he had a care plan for vomiting on himself. The Activities Director walked away after Staff J, LPN came to the door of the shower room. Resident #80 was observed saying he wanted the Activities Director to stay with him, but Staff J, LPN responded she could not. Staff J, LPN was observed turning Resident #80 in his wheelchair around, then escorted him into the shower room and left him with Staff F, CNA. The resident was not assessed by the nurse for markings or skin changes that may indicate a slap or hit following the resident's allegation. The shower room door closed with Staff F, CNA and Resident #80 inside and no other staff with them. Staff J, LPN was observed walking away. Resident #80 said loudly, from the shower room, You hit me, and continued to yell unidentifiable words.A review of Resident #80's admission record revealed an admission date of 7/17/25. Further review of the admission record revealed diagnoses to include personal history of traumatic brain injury, other recurrent depressive disorders, major depressive disorder, recurrent, mild, other schizophrenia, other specified persistent mood disorders, psychotic disorder with delusions due to known physiological condition, generalized anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and cerebral infarction, unspecified.A review of Resident #80's physician orders active as of 4/2/2026 revealed the following:- Side effects monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth, tongue, trunk or extremities, n&v [nausea and vomiting], pacing, seizure activity, stiffness of neck, sore throat, tremors, rashes every shift do not use if any side effects are present or resident appears to be lethargic, drowsy, or sedated. report change to practitioner if needed., with an order date of 7/17/25.- Clonazepam Oral Tablet 0.5 mg [milligrams] (Clonazepam) Give 1 tablet by mouth every 8 hours for anxiety hold for sedation, with an order date of 7/18/25.- Seroquel Oral Tablet 200 MG (Quetiapine Fumarate) Give 1 tablet by mouth three times a day for delusions, paranoia related to Schizophrenia, unspecified (f20.9), with an order date of 9/2/25.- Trazodone HCl [hydrochloric acid] Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Depression, with an order date of 10/10/25.- Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule by mouth every morning and at bedtime for mood disorder, with an order date of 1/27/26.A review of Resident #80's quarterly minimum data set (MDS), dated [DATE], revealed the following: Under section C - cognitive patterns, the brief interview for mental status (BIMS) score was 8 out of 15, indicating Resident #80 was moderately impaired. Section E - behavior, showed, Behavior not exhibited, was marked under physical, verbal and other behavioral symptoms.A review of Resident #80's change in condition assessments dated 8/20/25 revealed, .increased audio and verbal hallucinations . continues to yell out . Recommendation of Primary Clinician(s) IM [intramuscular] Haldol injection . On 3/30/26 at 11:30 a.m., an interview was conducted with Staff F, CNA. He said Resident #80 bites and scratches himself. Staff F, CNA confirmed he has observed the resident biting himself.On 3/30/26 at 11:32 a.m., an interview was conducted with Staff G, Registered Nurse (RN). She said Resident #80 is verbally aggressive with residents sometimes, such as cursing. She said during medication administration if he did not get his medication right away, he would start touching the medication cart and would attempt to get the medications. She said he would stand up from the wheelchair and get agitated. Staff G, RN stated, If you don't get what he wants right away, he will get agitated.On 3/31/26 at 1:53 p.m., an interview was conducted with Staff H, CNA. She stated, [Resident #80] is pretty loud. She confirmed he would yell and accuse staff of taking his personal items. Staff H, CNA said he had accused her previously saying, That lady, that lady, she took all my money. She confirmed Resident #80 had accused her of hitting him as well. When asked about the scabs (hardened protective crust that forms over broken skin) on the resident's arms she stated, He picks and eats his scabs. She said she did not know how he got the scabs on the front of his hand but confirmed she had seen Resident #80 bite his own hand.On 3/31/26 at 1:56 p.m., an interview was conducted with Staff I, RN. She said Resident #80 would sometimes yell. She stated, He'll claim things that didn't happen. He'll say a person has fallen and nobody has fallen. He makes up things. She said he picks and eats his scabs. She said she was not aware how he obtained the scabs on his right hand and was not sure if he could bite himself. Staff I, RN was observed asking Staff H, CNA if Resident #80 was able to bite himself and Staff H, CNA stated, Yes. On 3/31/26 at 2:34 p.m., an interview was conducted with the Activities Director. She stated Resident #80 would accuse residents and say, Hey, you hit me. She said she had witnessed him accuse other residents of hitting or kicking him, but never towards staff. The Activities Director confirmed he picks at his skin and scabs. She said she sometimes worked on the secured unit as a CNA and had observed Resident #80 say, She just kicked me or he hit me. She said she would ask Resident #80 who hit him and he would say, The resident over there, but there would be no one there. The Activities Director said regarding documentation of the behaviors, she would tell the nurse about his behaviors and document in the Kardex (documentation system with the resident's plan of care). She said in the Kardex there was a specific task for behaviors. She said if the behaviors occurred in an activities setting, she would notify the nurse and document in the activities progress note and care plan.On 3/31/26 at 4:09 p.m., a follow up interview was conducted by telephone with Staff F, CNA. He said right after breakfast, on 3/30/26, he was notified by the activities staff that Resident #80 vomited on himself. Staff F, CNA said he informed Resident #80 he had to take a shower and the resident replied, No, no I don't want a shower. He said himself and other staff members informed the resident he needed to take a shower. He said Resident #80 continued to say, I don't want to do it. Staff F, CNA said he pushed the resident in his wheelchair to the shower room and closed the door; then Resident #80 clapped his hands and stated, Ow you hit me, you hit me. Staff F, CNA stated, [Resident #80] will accuse they [staff] hit him, take his stuff, everyone knows so it's not a red flag. He said he told the Activities Director who knocked on the door that, [Resident #80] just being [Resident #80] saying I hit him and I didn't. Staff F, CNA stated, This is what he does every day, and it was normal for the staff, so they were used to it. He confirmed Resident #80 had previously accused him and other staff of hitting him. He said the resident was loud in group settings such as in the dining room. He stated, He likes to get really loud and rowdy. Staff F, CNA confirmed Resident #80 bites himself, hits things, and scrapes his hands against the wheelchair.On 3/31/26 at 4:35 p.m., a telephone interview was conducted with Staff J, LPN. She stated Resident #80 yells a lot and says, Someone is hitting me. She said he will accuse staff and residents of doing something, such as hitting him, or taking his items. Staff J, LPN stated when he makes the accusations, Most of the time there's no one around him. She stated, If he didn't say it, I would think something is wrong with him, as he said it multiple times a day. Staff J, LPN said when he first came to the secured unit, she went to the MDS staff to care plan his behavior of accusing staff and residents of hitting him. She confirmed they had not initiated a care plan for his behaviors until yesterday. Staff J, LPN said typically when a resident had behaviors, she communicated with the MDS staff. She said she was not sure where the scabs on his arms came from, but they wrap his arms and Resident #80 removes them. She confirmed he picks at his scabs.On 4/2/26 at 11:18 a.m., an interview was conducted with Staff K, LPN/Clinical Reimbursement Specialist (CRS) and the Clinical Reimbursement Director (CRD)/RN. Staff K, LPN/CRS said they received communication through the nursing staff to make changes to a resident's care plan. She said for new residents they reviewed orders, the history and physical, past history, various provider notes, medications, and side effects of medications. Staff K, LPN/CRS said they reviewed the 24-hour report to include if a resident had a change in condition or update. She said they reviewed the order listing reports and new physician orders to update the care plan accordingly. Staff K, LPN/CRS said in the interdisciplinary meeting held every morning and at stand down meetings at the end of the day, they discussed new residents and changes in conditions. The CRD/RN said it was the same process if a resident had behaviors, they expected the nursing staff to communicate that information. Staff K, LPN/CRS said they also reviewed progress notes to identify if a resident was having behaviors and required an update to the care plan. She said staff would communicate directly or document the behaviors and she would update the care plan. Staff K, LPN/CRS confirmed a recent update to Resident #80's care plan that occurred on 3/30/26. She said the nurse informed her Resident #80 was accusing others of hitting him when no one was around. She stated she did not know about the resident's behavior of accusing staff but knew, He has fluctuating behaviors. The CRD/RN confirmed she was not aware of the behaviors prior to 3/30/26.On 4/2/26 at 2:31 p.m., an interview was conducted with the Director of Nursing (DON). She said the nursing staff should have documented in a note that Resident #80 had a behavior of accusing staff and residents when no one was around and there was no physical contact. She stated, That's when the care plan needed to be updated. She confirmed if Resident #80 had behaviors previously, the care plan should have been updated.A review of the facility's policy Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024, revealed the following, The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. Further review of the policy revealed the following, .The overall care plan should be oriented towards: . 2. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. b. Assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs. c. Involving the direct care staff with the care planning process relating to the resident's expected outcomes. d. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. Further review of the policy under procedure, revealed the following, .8. Care Plan Meeting . 6. Nursing . i. Review current diagnosis, tests, or procedures, treatments (wounds, rashes, etc.), discuss current interventions and risk of further breakdown, if applicable, recent, or pending referrals, Physician consults, Restorative, medications, pain management plan, behavioral management plan, special needs, risk of falls and current interventions, and recent falls or other issues (informed consents, isolation, etc.) ii. Clinical representative will be UM or charge nurse familiar with the care of the resident. Assigned CNA also attends or provides input to IDT regarding care provided and resident response. Absence of UM or charge nurse should be by exception.

Based on observation, interviews and record review the facility failed to provided assistance with meals for two residents ( #34 and #61) out of two residents reviewed for activities of daily living (ADL).Findings Included:1.During an observation on 03/30/2026 at 11:56 a.m., Resident #34 was observed sitting at a table in the dining room of the secure unit (300 unit). Resident #34 was observed attempting to scoop food off of his plate and dropping it onto the table.During an observation on 04/02/2026 at 11:46 a.m., Resident #34 was observed sitting at a table in the dining room of the secure unit (300 unit), scooping food off of his plate, and feeding himself.Review of Resident #34's admission record revealed an admission date of 02/24/2026. Resident #34 was admitted to the facility with diagnosis to include unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified protein-calorie malnutrition, other lack of coordination, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness (generalized) , anxiety disorder, mood disorder due to known physiological condition with mixed features, generalized anxiety disorder and other psychotic disorder not due to a substance or known physiological condition.Review of Resident #34's Entry MDS dated [DATE] revealed, Section C. Cognitive Patterns, a BIMS of 02 out of 15 showing severe cognitive impairment.Review of Resident #34's care plan dated 10/27/2025 revealed:Focus:NUTRITIONAL: The resident has a potential nutritional problem related to history of dysphagia, protein calorie malnutrition, anemia, dementia and significant weight loss. Mechanically altered diet.Interventions:Assisted Dining . Observe/ document as indicated: meal Consumption, amount assistance needed with meal, tolerance to diet/fluids.2. During an observation on 03/30/2026 at 11:53 a.m. Resident #61 was observed sitting a table in the dining room of the secure unit (300 Hall). Resident #61 was observed feeding herself with no assistance.Review of Resident #61's admission record revealed an admission date of 03/18/2025. Resident #61 was admitted to the facility with diagnosis to include metabolic encephalopathy, dementia and other diseases classified elsewhere major depressive disorder altered mental status in unspecified convulsions.Review of Resident #61's Quarterly MDS dated [DATE] revealed Section C. Cognitive Patterns, a BIMS of 0 out of 15 showing severe cognitive impairment. Section GG. Functional Abilities revealed eating, Resident #61 was dependent meaning helper does all of the effort. Resident does none of the effort to complete the Activity. Or the assistance of two or more helpers is required for the resident to complete the activity.Review of Resident #61's care plan dated 03/18/2025 revealed:Focus:ADL: resident 61 has an ADL self-care performance deficit/cognitive deficit, may wander from task, poor focus on tasks assist for thoroughness, weakness, may require more assistance than allowing staff to render, self performance level need fluctuate throughout the course of the day.Intervention:. eating dependent assist of 1 .During an interview on 04/02/2026 at 12:15 p.m., Staff Q, Certified Nursing Assistant (CNA) stated we will assist resident with meals if we see they need assistance. Resident #34 needs assistance with meals on his bad days when he is in bed.During an interview on 04/02/2026 at 12:23 p.m., Staff H, CNA, stated yes Resident #61 needs assistance with her meals. I helped her with her meal today.During an interview on 04/02/2026 at 4:30 p.m. the Director of Nursing stated staff should be helping all residents who need assistance with their meals.The facility was asked to provide a policy related to this citation. The facility stated they did not have a policy related to ADL's.

Based on record review and interviews, the facility failed to ensure a notification of change was completed for one resident (#129) out of one resident reviewed who was severely cognitively impaired.Findings included: A review of Resident #129's admission record revealed an initial admission date of 3/5/26, and a re-entry date of 3/26/26 with diagnoses to include unspecified intracranial injury with loss of consciousness of unspecified, duration, subsequent encounter, unspecified sequelae of unspecified cerebrovascular disease, acute and chronic respiratory failure with hypoxia, encephalopathy, unspecified, and tracheostomy status. The admission record, under contacts, revealed Resident #129 was documented as the responsible party and two family members were listed as emergency contacts #1 and #3.A review of Resident #129's minimum data set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0.0. indicating severe cognitive impact. A BIMS evaluation dated 3/30/26 showed severe cognitive impact and a score of 0.0.Review of a change in condition evaluation dated 3/11/26 revealed, . Representative Notification 1.Name of family/resident representative notified: SELF 2. Date and time of family/resident representative notification: 3/11/2026 1722 [5:22 p.m.] . Review of a transfer form dated 3/11/26 showed, . Section E. Key Contacts . 1. Resident Representative . a. Name: [Resident #129] b. Contact Type: Agent . Personal 2. Notified of Transfer? 1. Yes 3. Aware of clinical situation? 1. Yes . 3. Contact Person at SNF/NF [skilled nursing facility/nursing facility] for Further Information 1. Name and Designation: SELF . Review of a change in condition evaluation dated 3/28/26 showed, .Representative Notification 1.Name of family/resident representative notified: Resident own RP [responsible party] 2.Date and time of family/ resident representative notification: 3/28/2026 0000 .A review of Resident #129's progress notes revealed the following: On 3/9/26, ETA [estimated time of arrival] notification via [by] fax 645 p.m.-845 p.m. This is an estimated time based on current scheduling and may change depending on volume and resource availability.MD [medical doctor] and RP aware. On 3/29/26, Spoke with ARNP [advanced practice nurse practitioner] regarding labs. No new orders at this time. Resident own RP.On 3/29/26, Vancomycin trough (on 3/28/26- 11.1) Antibiotic kinetic dosing orders received from pharmacy. Continue current dose Vanco [vancomycin] 1000 mg [milligrams] IV [intravenous] every 12 hrs. [hours] no further labs required.MD aware Resident own RP.On 4/1/26 at 11:05 a.m., an interview was conducted with the Social Services Director (SSD). She confirmed Resident #29 had a BIMS score of zero. She said the nursing home administrator (NHA) and the Director of Nursing (DON) have communicated with two different family members. She said based on hospital documentation, there are two family members who have been communicated with in the past. The SSD said the resident returned on 3/26/26 from the hospital and she planned to work on his letter of incapacity and designating his family member as a healthcare surrogate.On 4/1/26 at 3:06 p.m., an interview was conducted with Staff O, Licensed Practical Nurse (LPN). She said for changes in condition she always communicated with the doctor and family member regardless of their BIMS. Staff O, LPN said for changes in medication, hospitalizations, and changes in condition, she would contact the residents' family. She said for Resident #129, his family lives out of the country. She said she thought the DON or SSD tried to communicate with the family member. She confirmed the resident is listed as the responsible party. Staff O, LPN said she had not communicated with the family as their phone numbers are from outside of the country.On 4/1/26 at 11:32 a.m., an interview was conducted with the DON. She confirmed Resident #129 had a BIMS of zero. She said the resident had a family member in a different country. The DON said she communicated with the care managers at the hospital who were asking for the family member's telephone number and how to dial the out of country number. The DON said she explained to the family member he was transferred to the hospital due to bleeding and told her she was going to receive a phone call from the hospital. She stated, [Family member name] is very involved. She said there was communication with the family member about Resident #129's change in condition and medication changes. Regarding documentation about Resident #129 being his own responsible party, The DON stated, The documentation was probably fast, and they wrote it like that. She said for lab results, changes in condition, and updates, the expectation would be to call the family member. She said the family member is his next of kin. The DON confirmed Resident #129 cannot make decisions for himself due to his cognition.A review of the facility's policy titled Notification of Resident Change in Condition, effective February 2026, revealed the following, Nurses will notify the resident/resident representative, if there is a crucial/significant change in the resident condition. If the change in the resident's condition is not crucial or significant, the resident's Physician, resident representative or legal representative will be notified at the earliest convenient time during regular business hours. Further review of the policy under Procedure, revealed the following, 1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day.

Based on observation, record review, and interview, the facility did not ensure ongoing monitoring for changes in condition related to catheter use for one resident (#126) out of two resident sampled.Findings included: An observation on 03/20/2026 at 2:23 PM revealed Resident #126 had a catheter bag that contained dark red and cloudy urine. An observation was made on 04/01/2026 at 1:28 PM with Staff O, Licensed Practical Nurse, (LPN) of Resident #126 having red and amber urine in the catheter bags. Staff O stated the physician should be notified if changes are observed in the residents output or color.Review of Resident #126's admission record revealed Resident #126 was admitted to the facility on [DATE] with diagnoses to include anoxic brain damage and obstructive and reflux uropathy.Review of physician orders active as of 04/02/2026 revealed: Nephrostomy catheter, drain nephrostomy catheter bag every shift and PRN (as needed) every shift.Review of the care plan report for Resident #126 revealed a focus of catheter/nephrostomy: the resident uses a urinary catheter with risk for infection and/or complications, initiated on 03/13/2026 and revised on 03/16/2026. The goal showed - will minimize the risk of complications associated with catheter usage, will not develop signs or symptoms of UTI. The interventions/tasks related to this focus included to observe/document/report to MD (medical doctor) for signs and symptoms of UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urine frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns, initiated 03/13/2026. Review of the electronic medical record (EMR) revealed there was no documentation or follow up with the physician regarding the signs and symptoms as documented in the interventions.An interview conducted with Staff P, Certified Nursing Assistant (CNA), on 04/02/2026 at 12:56 PM revealed she provided morning care for Resident #126, which consisted of a bed bath and draining the urine from Resident #126's nephrostomy bag. Staff P said red urine was observed when providing morning care this morning but did not report the observations. Staff P confirmed having previously provided care to Resident #126, and there was red urine observed. Staff P did not notify the nurse because, It was believed to be normal.An interview and observation was conducted with Staff O, LPN on 04/01/2026 at 1:28 PM. The interview revealed Staff O was not aware Resident #126 was observed to have red urine in the catheter bag. Staff O said if red urine were to be reported, it would require a change in condition to be documented. Staff O said they frequently provided care for Resident #126 during morning medicine pass and during tracheostomy care. Staff O, LPN stated she did not notice red urine, nor was it reported to the physician. Staff O observed the red and amber urine at that time and immediately said a change in condition would be documented in addition to notifying Resident #126's primary care physician and family member.An interview with the facility's Assistant Director of Nursing (ADON) was conducted on 04/02/2026 at 3:05 PM. The interview revealed an expectation for the nephrostomy care provided by the CNA. The ADON said it should include draining the catheter bag at least every shift and monitoring for abnormal urine output every shift. The ADON stated the amount and color of the urine output should be documented every shift. The ADON said urine output would be considered abnormal if there was a change in color. The ADON said if abnormal urine output is observed, the CNA should notify the resident's nurse. The nurse should do an assessment, notify the resident's physician and their family. The ADON did not provide documentation of abnormal urine output for Resident #126.The facility did not provide a policy for catheter care.

Based on observation record review and interview, the facility did not ensure oxygen therapy was provided per physician orders for one resident (#126) out of one resident sampled.Findings included: On 03/30/2026 at 2:21 PM, an observation revealed Resident #126's oxygen concentrator was set to 9 liters per minute (LMP).Review of physician orders for Resident #126 active as of 04/02/2026 revealed: Humidified oxygen per trach continuously, 7 liters every shift for shortness of breath, effective 03/26/2026.Review of Resident #126's admission record revealed Resident #126 was admitted to the facility on [DATE] with diagnoses to include anoxic brain damage, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. Review of the care plan report for Resident #126 revealed a focus initiated on 03/13/2026, Revised 3/27/2026, Oxygen - Resident #126 has oxygen therapy related to O2 (oxygen) via tracheostomy, O2 dependent. The goals revealed; Will experience minimal to no shortness of breath (SOB), will have no untreated s/s (Signs and symptoms) of SOB through the next review. Interventions included special equipment oxygen, and administer oxygen as ordered by the physician. Monitor/document side effects and effectiveness.An interview with Staff O, Licensed Practical Nurse, (LPN) on 04/01/2026 at 1:28 PM revealed tracheostomy care was provided to Resident #126 by Staff O on 04/01/2026. Staff O stated the nurse is responsible for setting and maintaining the resident's oxygen concentrator according to their orders. Staff O said on 03/31/2026, a respiratory care therapist visited the residents and reported a resident's oxygen concentrator was excessively high but she did not recall which resident this report was specific to.An interview with the Assistant Director of Nursing (ADON) was conducted on 04/02/2026 at 3:05 PM. The interview revealed respiratory therapists visits the facility once per month and/or when a resident is admitted requiring the care of a respiratory therapist. The ADON said respiratory therapists evaluate the resident, determine the appropriate oxygen settings, and input the orders into the electronic medical records system. The ADON said if a resident was admitted into the facility from a hospital, the facility may follow the hospital orders, or the respiratory therapy may perform a separate evaluation to determine the resident's oxygen needs. The ADON said the residents' nurses should follow the orders in the electronic medical record system, and if a nurse notices the oxygen is not set in accordance with the orders, the nurse should change the oxygen concentrator. The ADON said the nurses should check the oxygen concentrator settings every time they provide care or pass medications. The ADON acknowledged the photographic evidence obtained of Resident #126's oxygen concentrator setting of 9 LMP on 03/30/2026. The ADON was unsure how or why the concentrator was not set to 7 LMP as ordered by the physician.A review of the policy and procedure titled, Oxygen Therapy effective August 2025, revealed oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. Procedure: 1. Verify physician order; 7. Apply device to the resident with appropriate liter flow.(Photographic Evidence Obtained)

Based on observation, record review and interviews, the facility failed to ensure nursing staff were competent, related to residents with behavioral health needs, as evidenced by the following: 1) accurately documenting behavior monitoring for three residents (#8, #62, and #80) out of three residents reviewed for behaviors; 2) supervising residents on the 300 (secured) unit for two residents (#61, and #34) out of two residents observed during dining; and 3) sufficient staffing to meet the needs of residents on the secured unit. Findings included: 1. On 3/30/2026 at 9:46 a.m., an observation of the closed door of the shower room in the 300 (secured) unit revealed elevated voices, the sound of a loud smack, and a male voice stated, Ow, he slapped me. The Activities Director was observed walking to the closed shower room door; she asked who was in there and Staff F, Certified Nursing Assistant (CNA) opened the door. Staff F, CNA was behind Resident #80 who was observed in a wheelchair with a pink substance covering the front of his dark colored shirt and the top of his dark colored pants. Resident #80 said Staff F, CNA slapped him. Staff F, CNA said he did not slap the resident, Resident #80 slapped himself, and he was care planned for accusing staff of hitting him. The Activities Director was observed asking Resident #80 if he wanted Staff J, Licensed Practical Nurse (LPN) to assist, to which he responded, Yes. Staff J, LPN walked over with the Activities Director and said he had a care plan for vomiting on himself. The Activities Director walked away after Staff J, LPN came to the door of the shower room. Resident #80 was observed saying he wanted the Activities Director to stay with him, but Staff J, LPN responded she could not. Staff J, LPN was observed turning Resident #80 and the wheelchair around, then into the shower room with Staff F, CNA. The resident was not assessed by the nurse for markings or skin changes that may indicate a slap or hit. The shower room door closed with Staff F, CNA and Resident #80 inside and no other staff with them. Staff J, LPN was observed walking away. Resident #80 said loudly, from the shower room, You hit me, and continued to yell unidentifiable words. A review of Resident #80's admission record revealed an admission date of 7/17/25. Further review of the admission record revealed diagnoses to include personal history of traumatic brain injury, other recurrent depressive disorders, major depressive disorder, recurrent, mild, other schizophrenia, other specified persistent mood disorders, psychotic disorder with delusions due to known physiological condition, generalized anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and cerebral infarction, unspecified. A review of Resident #80's physician orders revealed the following: -Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V [nausea and vomiting], Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes every shift Do not use if any side effects are present or resident appears to be lethargic, drowsy, or sedated. Report change to practitioner if needed., with an order date of 7/17/25. A review of Resident #80's quarterly minimum data set (MDS), dated [DATE], revealed the following: - Under section C – cognitive patterns, the brief interview for mental status (BIMS) score was eight, indicating he is moderately impaired. - Under section E – behavior, Behavior not exhibited, was marked under physical, verbal and other behavioral symptoms. A review of Resident #80's change in condition assessments revealed the following: - 8/20/25, .increased audio and verbal hallucinations . continues to yell out . Recommendation of Primary Clinician(s) IM [intramuscular] Haldol injection . A review of change in condition assessments dated 8/2/25, 10/4/25, 12/24/25, and 1/20/26, were not related to behavioral symptom changes or concerns. A review of Resident #80's assessments from 1/2026 to 3/2026 revealed the following: - A review of the nursing quarterly assessment, dated 1/20/26, showed no documentation under behaviors. - A review of the psychosocial history and assessment, dated 2/27/26, showed the following. Change in Mood or Behavior in last 6 months? 1. No Change. A review of Resident #80's progress notes from 1/2026 to 3/2026 revealed the following: - 1/1/26, CNA reported resident vomitted [sic] by bed. Noted moderate amount of undigested food. Medicated as ordered. - 1/5/26, . He is seen today for routine psychiatric follow-up, with the last psychiatric evaluation on 11/11/2025. Since the last visit, the presentation has remained stable without acute concerns. Staff observations during this interval are consistent with an unchanged clinical course, and the current plan is to continue the current medication regimen. Behavior remains cooperative without agitation, sleep problems are not reported, and appetite is noted as normal. Cognition appears consistent with baseline, with orientation to person and place and moderate attention and concentration. **Largely unknown--lot of anxiety and impulse control issues. Schizophrenia, MDD [major depressive disorder], GAD [generalized anxiety disorder], unspecified Mood affective d/o [disorder], other recurrent Depressive d/o, unspecified Psychosis, Seizures, TBI [tramautic brain injury], CI [cerebral infarction] . Attention and concentration are moderate, with deficient fund of knowledge and intact language and associations. Insight and judgment are poor. Behavior : Cooperative . Insight : Poor Judgment : Poor Attention and Concentration : Moderate . - 1/13/26, Labs received and reviewed results with NP [nurse practitioner]; resident does not exhibit behaviors at this time. No new orders given. All RPs [responsible parties] were notified. -1/18/26, Resident gives CNA a lot of push back when attempting to deliver care. Yelling out and creating untoward behaviors without warrant. Resident assessed and there are no issues which lead to this behavior. - 2/4/26, Date of Service: 2026-02-03 . Today, he presents with loud speech and impulsive verbalizations . Summary: He is alert and oriented to person and place. Memory and attention were limited, with deficient fund of knowledge and moderate attention and concentration. Speech was loud, language was intact, and engagement was cooperative with a congruent affect. - 2/16/26, Date of Service: 2026-02-13 . The patient is being seen by a psychiatric nurse practitioner in a long-term care setting. Since the last visit, he presents for assessment of Gradual Dose Reduction (GDR) and has remained stable and cooperative with care without agitation . Mood appears stable, and there have been no behavioral concerns. - 3/3/26, Emesis noted in hall in front of resident on floor. Med [medication] given as ordered. - 3/12/26, Emesis reported and noted of undigested food. Med given as ordered. - 3/22/26, Date of Service: 2026-03-13 . According to staff, the patient has been stable and cooperative with care, displaying no signs of agitation. The patient has good medication compliance and no reported side effects. Plan: Given the patient's stability and minimal effective dosages of psychotropic medications, a GDR was deemed contraindicated as it could potentially lead to an exacerbation of the patient's psychiatric symptoms and instability. Therefore, all current psych [psychiatric] medications were continued without any changes. - 3/23/26, The resident is currently on a secure unit with two locked exit doors in place. Resident has short term memory impairment and is unable to recall exit door codes. No recent exit seeking behaviors were observed. No attempts of elopement were noted during recent assessment. IDT [interdisciplinary] met and discussed resident's safety status. Resident will continue to be monitored for exit seeking behaviors. Staff instructed to report any changes in behavior and/ or exit seeking behaviors. MD [medical doctor] notified. - 3/26/26 psych note, Date of Service: 03/25/2026 . The patient was observed seated in the dining room of the memory care unit and appeared confused but in no acute distress. Due to his cognitive status, history is significantly limited. He is noted to be fidgety during today's examination. The patient is typically observed in his wheelchair wandering the unit hallways. Neurological: Alert and pleasantly confused . A review of Resident #80's care plan revealed the following -BEHAVIORAL: The resident is noted with the following behaviors: Difficulty communicating thoughts or needs: Territorial of Personal Space, Picks at and eats scabs from sore or wound. Accuses others of hitting him .when there is no one around. Date Initiated: 08/20/2025 Revision on: 03/30/2026, with interventions to include, .Document episodes of behavior & [and] review to determine the effectiveness of intervention Date Initiated: 03/30/2026. A review of the behavior task over the last 30 days, for Resident #80, showed daily documentation of, No behaviors observed. On 3/30/2026 at 11:30 a.m., an interview was conducted with Staff F, CNA. He said Resident #80 bites and scratches himself. Staff F, CNA confirmed he has observed the resident biting himself. On 3/30/2026 at 11:32 a.m., an interview was conducted with Staff G, Registered Nurse (RN). She said Resident #80 is verbally aggressive with residents sometimes, such as cursing. She said during medication administration if he did not get his medication right away, he would start touching the medication cart and attempted to get the medications. She said he would stand up from the wheelchair and get agitated. Staff G, RN stated, If you don't get what he wants right away, he will get agitated. On 3/31/2026 at 1:53 p.m., an interview was conducted with Staff H, CNA. She stated, [Resident #80] is pretty loud. She confirmed he would yell and accuse staff of taking his personal items. Staff H, CNA said he had accused her previously saying, That lady, that lady she took all my money. She confirmed Resident #80 had accused her of hitting him as well. When asked about the scabs on the resident's arms she stated, He picks and eats his scabs. She said she did not know how he got the scabs on the front of his hand but confirmed she had seen Resident #80 bite his own hand. On 3/31/2026 at 1:56 p.m., an interview was conducted with Staff I, RN. She said Resident #80 would sometimes yell. She stated, He'll claim things that didn't happen. He'll say a person has fallen and nobody has fallen. He makes up things. When asked about the scabs on his arm and hand, she said he picks and eats his scabs. She said she was not aware how he obtained the scabs on his right hand and was not sure if he could bite himself. Staff I, RN was observed asking Staff H, CNA if Resident #80 was able to bite himself and Staff H, CNA stated, Yes. On 3/31/2026 at 2:34 p.m., an interview was conducted with the Activities Director. She stated Resident #80 would accuse residents and say, Hey, you hit me. She said she had witnessed him accuse other residents of hitting or kicking him, but never towards staff. She said Resident #80 had never accused her of hitting him. She said she sometimes worked on the secured unit as a CNA and has observed Resident #80 say, She just kicked me or he hit me. She said she would ask Resident #80 who hit him and he would say, The resident over there, but there would be no one there. She said the resident would then shift to a different conversation and say he liked her outfit or requested to listen to a song. The Activities Director said on 3/30/26 she was walking up the stairs to the 300 unit. When she got to the unit she saw the shower room door was closed and heard Resident #80 yelling, He hit me, it hurts. She said she heard Staff F, CNA yelling as well. She said she went to the shower room to see what was going on. The Activities Director said she observed Resident #80 being pushed in a rough manner and aggressively by Staff F, CNA. She described Staff F, CNA as being, Very elevated, while Resident #80 was telling her the CNA hit and slapped him. The Activities Director said Staff F, CNA's tone of voice was inappropriate and felt he should not have been speaking in that manner. She stated she told Staff F, CNA, I need you to calm down. The Activities Director said she knelt down to talk to Resident #80 and told him, I see you have throw up on you. She said she tried to get Resident #80 out of the shower room and away from Staff F, CNA as she felt it was a hostile situation. She said Resident #80 told her, I don't want him, in reference to Staff F, CNA. She said she explained what happened to Staff J, Licensed Practical Nurse (LPN) and went back to the shower room with the nurse. She said Resident #80 told Staff J, LPN she wanted the activities director to come with him. She said Staff J, LPN responded that the activities director was in a different department and could not. She said she thought Staff J, LPN went in the shower room with Resident #80 and felt the resident was taken out of the situation. She said she had never observed that type of interaction before with Resident #80 and a staff member. When asked about documentation of behaviors, the Activities Director said she would tell the nurse about his behaviors and document in the Kardex (documentation system with the resident's plan of care). She said in the Kardex there was a specific task for behaviors. She said if the behaviors occurred in an activities setting, she would notify the nurse and document in the activities progress note and care plan. On 3/31/2026 at 4:09 p.m., a telephone interview was conducted with Staff F, CNA. He said right after breakfast, on 3/30/2026, he was notified by the activities staff member that Resident #80 vomited, All over the place. He said he went to the dining area to clean the vomit. He stated Resident #80 had, Throw up all over his clothes from head to toe. He cleaned the resident and assisted him out of the dining room. Staff F, CNA said he told Resident #80 he needed to take a shower as he had a red substance all over him. He said he went to get towels and linens, as well as the residents' clothes. He said he approached the resident who told him, No, no I don't want a shower. Staff F, CNA stated he was leading Resident #80 to the shower room, and described the resident as, Already being dramatic. Being his normal self, and saying he did not want to take a shower. He said he pushed the resident in his wheelchair into the shower room, closed the door, then transferred the resident to the shower chair, and went to turn on the shower. Staff F, CNA said Resident #80 clapped his hands and stated, Ow you hit me, you hit me. Staff F, CNA said he told the resident, [Resident #80] you know I did not hit you. He said the activities director knocked on the door and he told her, [Resident #80] just being [Resident #80] saying I hit him and I didn't. Staff F, CNA said the activities director went to get Staff J, LPN. He said when Staff J, LPN came over Resident #80 was in his wheelchair saying, No, I don't want a shower. He said Staff J, LPN helped him transfer the resident to the shower chair and remove his shirt. He confirmed he provided a shower to the resident and Staff J, CNA was not present. He said Resident #80 told him, Thank you for cleaning me. Staff F, CNA said he assisted with dressing him and the resident asked where his wheelchair was. Staff F, CNA stated, This is what he does every day. He said the residents' behavior was normal for the staff and they were used to it. He confirmed Resident #80 had previously accused him and other staff of hitting him. He said he always notified the nurse when Resident #80 had behaviors. He said most of the staff who worked on the secured unit knew how the resident acted, there was nothing they could do about his behaviors, and they needed to continue to complete their jobs. He said in this situation, he and Resident #80 were not separated because the staff knew how the resident was. He said they would separate the Resident #80 and a staff member the resident accused of hitting him if it was new staff who did not typically work on the unit. He said the resident was loud in group settings such as in the dining room. He stated, He likes to get really loud and rowdy. Staff F, CNA confirmed Resident #80 bites himself, hits things, and scrapes his hands against the wheelchair. On 3/31/2026 at 4:35 p.m., a telephone interview was conducted with Staff J, LPN. She stated Resident #80 yells a lot and, Says someone is hitting me. She said he will accuse staff and residents of doing something, such as hitting him, or taking his items. Staff J, LPN stated when he makes the accusations, Most of the time there's no one around him. She said this was his behavior at a previous facility as well. She stated, If he didn't say it, I would think something is wrong with him, as he said it multiple times a day. She confirmed the resident has previously accused her of hitting him. Staff J, LPN said when Resident #80 makes the accusations she checked to make sure, but typically there was no one there. She said on 3/30/26 the resident has finished his meal, and he wheeled himself out of the dining room. She said she did not see any interaction between Staff, F, CNA and Resident #80. When asked if she was present in the shower room after the resident alleged that Staff F, CNA hit him, she said may have taken a step in but did not stay there. She said she observed Staff F, CNA put Resident #80 in the shower chair and she left. She said she was in the shower room for a few seconds. Staff J, LPN said they did not separate the resident and the CNA because that was Resident #80's normal behavior. Staff J, LPN said when he first came to the secured unit, she went to the MDS staff to care plan his behavior of accusing staff and residents of hitting him. She confirmed they had not initiated a care plan for his behaviors until yesterday. Staff J, LPN said typically when a resident had behaviors, she communicated with the MDS staff. She said she was not sure where the scabs on his arms came from, but they wrap his arms and Resident #80 removes them. She confirmed he picks at his scabs. On 4/2/2026 at 10:49 a.m., a telephone interview was conducted with Staff U, Psychiatry (Psych) Advanced Practice Registered Nurse (APRN). She said Resident #80 had been seen on a monthly basis and at times more than monthly, about two times a month, by psych services. She said she took over for another psych provider about three to four weeks ago. She said she saw Resident #80 briefly on the secured unit. Staff U, Psych APRN had a history of confusion, anxiety, and impulse control issues. She said she had not heard of any behaviors since she has taken over and there have been no concerns about his behaviors communicated to her. She said she was on the secured unit on 3/31/2026 and the nurses did not have any concerns about Resident #80 that past week. She said even if she was not there to see Resident #80, she rounds and asked the nursing staff about the residents. Staff U, Psych APRN said she relied on staff, especially if the resident was confused, as they have direct contact and know about acute changes. She said it was her expectation that staff communicated with her about residents' behaviors. Staff U, Psych APRN stated she reviewed past documentation, from August 2025, for Resident #80 and, Did not see anything standing out. She said she should have been made aware of Resident #80 eating/ picking his scabs and accusing staff and residents of hitting him. She said she encouraged nursing staff to document when a resident had behaviors, especially if they are completing medication changes, and preferred documentation in real time. She said all behaviors should be documented, including new behaviors, as it could be a medical and/or psychiatric concern. She said when she is told something verbally, she will look at the chart but sometimes did not see the documentation. She stated, I like for it to be documented so it correlates with what I see. On 4/2/2026 at 11:18 a.m., an interview was conducted with Staff K, LPN/Clinical Reimbursement Specialist (CRS) and the Clinical Reimbursement Director (CRD)/RN. Staff K, LPN/CRS said through the nursing staff was how they received communication to make changes to a resident's care plan. The CRD/RN said if a resident had behaviors, they expected the nursing staff to communicate that information. Staff K, LPN/CRS said they reviewed progress notes to identify if a resident was having behaviors and required an update to the care plan. She said staff would communicate directly or document the behaviors and she would update the care plan. Staff K, LPN/CRS confirmed a recent update to Resident #80's care plan that occurred on 3/30/2026. She said the nurse informed her Resident #80 was accusing others of hitting him when no one was around. She stated she did not know about the resident's behavior of accusing staff but knew, He has fluctuating behaviors. The CRD/RN confirmed she was not aware of the behaviors prior to 3/30/26. On 4/2/2026 at 2:02 p.m., an interview was conducted with the NHA and the Director of Nursing (DON). They both confirmed they were not aware that Resident #80 had a behavior of making accusations towards staff and resident until after interviews about the incident on 3/30/2026. The NHA said the expectation when staff responded to an allegation of abuse is making sure the resident was safe, intervening, and not let the action continue. She said for an allegation of abuse between a staff member and a resident, the expectation was for staff to separate themselves from the situation. The NHA and DON confirmed Resident #80 should not have gone back into the shower room with Staff F, CNA. They both said they were not aware Staff F, CNA went back into the shower room with the resident. The NHA said the CNA needed to be removed and staff should have sure the resident was safe. The DON said the nursing staff should have documented in a note that Resident #80 had a behavior of accusing staff and residents when no one was around and there was no physical contact. She stated, That's when the care plan needed to be updated. She confirmed if Resident #80 had behaviors previously, the care plan should have been updated. The DON said any behaviors, such agitation, hitting, kicking, or biting, can be documented as a free text in the behavior monitoring on the medication administration record. She said nursing staff have their own behavioral task, or they could write a behavioral progress note. She stated, That's when they catch the data and update the care plan. The DON said I was important to document the residents' behavior because it was helpful for psychiatry staff to know when they are evaluating medications and side effects. 2. During multiple observations on 03/30/2026 thru 04/02/2026 residents located on the secure unit (300 Unit) residents remained confined to the secure unit and were not observed accessing outdoor activities or opportunities for time outside. During an observation on 03/30/2026 at 9:45, Resident #62 was observed in a room of three male residents with the door closed. Resident #62 moved around the room slowly, appearing confused but calm, Resident #62 opens drawers and looks through personal belongings on the bedside tables and dressers. During an observation on 03/30/2026 at 9:53 a.m., Staff were observed in the dining room with residents and sitting at the nurse's station. During an observation on 04/01/2026 at 9:43 a.m., Resident #62 was observed in a room of three male residents. Resident #62 was observed opening nightstand drawers and looking through personal belongings on the bedside tables and dressers. During an observation on 04/01/2026 at 9:54 a.m., Staff were observed in the dining room with residents and sitting at the nurse's station. Review of Resident #62's admission record revealed an admission date of 02/06/2023. Resident #62 was admitted to the facility with diagnosis to include unspecified dementia, unspecified severity, with anxiety, primary insomnia, mood disorder due to known physiological condition, major depressive disorder, recurrent, mild, other specified persistent mood disorders, pseudobulbar affect, anxiety disorder, and bipolar disorder. Review of Resident #62's Minimum Data Set (MDS) dated [DATE] revealed, Section C. Cognitive Patterns, Brief interview mental status of 01 out of 15 indicating severe cognitive impairment. Review of Resident #62's Care Plan dated 02/06/2023 revealed: Behavioral: The Resident is noted with the following Behaviors: Combative with staff at times, will yell and screams out. Diagnosis of dementia with behaviors. Resident wanders at times. Has the potential to hit others, yells and curses at others, enter others personal space and can be exit seeking at times. Sexually inappropriate at times. Can be destructive with furniture/surroundings. Making repetitive motions, rummages through stuff, and can appear sad or tearful. Physically aggressive towards others, expresses frustration/anger, threatens others and becomes easily agitated. Interventions: Observe/document for side effects and effectiveness. Document episodes of behavior and review to determine the effectiveness of intervention. Observe for changes and behavior and report to physician ie; insomnia, nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Focus: Elopement Risk: Resident is at risk for elopement. Resident #62 has cognitive impairment and is independently mobile. Interventions: . If the residents wondering, offer frequent rest and snacks if indicated . Review of task Behavior Monitoring and interventions dated 03/20/2026 thru 04/02/2026 revealed no behaviors were marked. 3. During an observation on 03/31/2026 at 10:00 a.m., Resident #8 was observed carrying a yellow gift bag, yelling at Staff J, RN, stating I know you have it. Just give me my money. Staff J stated She does this, she always wants me to give her money. Review of Resident #8's admission record revealed an admission date of 11/24/2025. Resident #8 was admitted to the facility with diagnosis to include major depressive disorder, recurrent, moderate, generalized anxiety disorder, and unspecified dementia, unspecified severity, with agitation. Review of Resident #8's Quarterly MDS dated [DATE] revealed, Section C. Cognitive Patterns, a BIMS of 02 out of 15 showing severe cognitive impairment. Review of Resident #8's care plan dated 06/24/2026 revealed: Focus: Behavioral: The resident is noted with the following behaviors: Agitation . sits on floor at times. Interventions: . observe/document for side effects and effectiveness. document episodes of behavior and review to determine the effectiveness of intervention Focus: Mood: The resident has a mood problem related to crying, tearfulness Interventions: . observe/document for side effects and effectiveness Review of Resident #8's task for Behavior monitoring and interventions for 14 days revealed no behaviors was marked. 4. During an observation on 03/30/2026 at 11:56 a.m., Resident #34 was observed sitting at a table in the dining room of the secure unit (300 unit). Resident #34 was observed attempting to scoop food off of his plate and dropping it onto the table. During an observation on 04/02/2026 at 11:46 a.m., Resident #34 was observed sitting at a table in the dining room of the secure unit (300 unit), scooping food off of his plate, and feeding himself. Review of Resident #34's admission record revealed an admission date of 02/24/2026. Resident #34 was admitted to the facility with diagnosis to include unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified protein-calorie malnutrition, other lack of coordination, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness (generalized) , anxiety disorder, mood disorder due to known physiological condition with mixed features, generalized anxiety disorder and other psychotic disorder not due to a substance or known physiological condition. Review of Resident #34's Entry MDS dated [DATE] revealed, Section C. Cognitive Patterns, a BIMS of 02 out of 15 showing severe cognitive impairment. Review of Resident #34's care plan dated 10/27/2025 revealed: Focus: NUTRITIONAL: The resident has a potential nutritional problem related to history of dysphagia, protein calorie malnutrition, anemia, dementia and significant weight loss. Mechanically altered diet. Interventions: Assisted Dining . Observe/ document as indicated: meal Consumption, amount assistance needed with meal, tolerance to diet/fluids . 5. During an observation on 03/30/2026 at 11:53 a.m. Resident #61 was observed sitting a table in the dining room of the secure unit (300 Hall). Resident #61 was observed feeding herself with no assistance. Review of Resident #61's admission record revealed an admission date of 03/18/2025. Resident #61 was admitted to the facility with diagnosis to include metabolic encephalopathy, dementia and other diseases classified elsewhere major depressive disorder altered mental status in unspecified convulsions. Review of Resident #61's Quarterly MDS dated [DATE] revealed Section C. Cognitive Patterns, a BIMS of 0 out of 15 showing severe cognitive impairment. Section GG. Functional Abilities revealed eating, Resident #61 was dependent meaning helper does all of the effort. Resident does none of the effort to complete the Activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident #61's care plan dated 03/18/2025 revealed: Focus: ADL: resident 61 has an ADL self-care performance deficit/cognitive deficit, may wander from task, poor focus on tasks assist for thoroughness, weakness, may require more assistance than allowing staff to render, self performance level need fluctuate throughout the course of the day. Intervention: . eating dependent assist of 1 . During an interview on 03/30/2026 at 3:01 p.m, Staff R, CNA, stated there is normally three aides and one nurse. Today there is only two aides and a nurse because one of the aides got sent home. It can be challenging during lunch time. We have 20 residents assigned to us and our residents are very much hands on. You saw how lunch went, we have to pass lunch trays and the residents who need assistance with meals must wait to be eat because we can't help them until we have [NAME] all the lunch trays. During an interview on 04/01/2026 at 12:00 p.m., Staff J, LPN stated we only document behaviors like resident to resident or sexual behaviors. We don't document behaviors if they are behaviors the residents always have. We have one resident who always yel

Based on interviews and record review, the facility did not ensure pharmacy recommendations related to labs were completed for one resident (#13) out of five residents reviewed. Findings include:A record review of Resident #13's Medication Regimen Review (MMR) from 01/01/2026 - 01/08/2026 showed the following recommendation for the Nursing staff: The resident is no longer receiving drug therapy requiring lab monitoring. Please consider discontinuing the following lab orders: RECOMMEND DC [discontinue] LITHIUM LEVELS (MED DC'D) [medication discontinued] dated 01/08/2026. A further review of the documentation showed a column to the right labeled Follow-Through. The recommendation showed a hand-written note Done. A record review of Resident #13's MMR (Nursing Recommendations) dated 3/01/2026-3/05/2026 showed the following recommendation for the nursing staff: This resident is no longer receiving drug therapy requiring lab monitoring. Please consider discontinuing the following lab orders: RECOMMED TO DC LITHIUM LEVELS (MED DC'D) dated 3/05/2026.A record review of Resident #13's lab results showed the following lab results for Lithium: 10/13/2025 L <0.1010/28/2025 L<0.1012/29/2025 L<0.10 01/28/2026 L <0.1003/27/2026 L <0.10A record review of Resident #13's physician orders showed an order for Lithium Carbonate oral capsule 300 mg (milligrams) to give one capsule by mouth one time a day for MOOD DISORDER, ordered on 6/14/2025 and discontinued on 12/12/2025.A record review of Resident #13's admission Record showed an admit date of 02/26/2016 with a readmission date of 8/29/2022 with medical diagnoses to include but not limited to: other persistent mood disorders, undifferentiated schizophrenia, generalized anxiety disorder, unspecified psychosis not due to a substance or known physiological condition.A record review of the progress notes for psychiatric services dated 12/12/2025 under the section labeled Assessment/Plan showed the following: -Other Specified Persistent Mood Disorders- continue lithium 300 mg PO (oral) daily, Last lithium level was very low and patient has been stable. Will consider restarting if patient mood destabilizes.A record review of the progress notes for psychiatric services dated 3/13/2026 under section labeled Interval History showed the following: The patient's current psychotropic medications were reviewed and assessed for the need for any changes or adjustments. According to the staff, the patient has been stable and cooperative with care. There has been no reports of behavioral disturbances, anxiety, or agitation. The patient's behavior has been stable and uneventful. Medication compliance is good and no side effects have been reported or evidenced.On 4/02/2026 at 5:03 p.m., a telephone interview was conducted with the consulting pharmacist. The consulting pharmacist stated her recommendations were based on her record review of Resident #13. The consulting pharmacist stated the resident was getting lithium level labs every month but did not see an order for the medication. She stated it was an unnecessary lab order. The consulting pharmacist stated she wrote her first recommendation on 01/08/2026, saw the lab continued the next month during her recommendations prompting a second recommendation in February. The consulting pharmacist stated she rewrote her recommendation on March 5th to discontinue the lithium lab based on the fact the medication was discontinued and/or not reordered. On 4/02/2026 at 5:15 p.m., an interview was conducted with the Director of Nursing (DON). The DON acknowledged the consulting pharmacist recommendations. The DON stated there may have been some confusion over the lab orders because there were two orders, one for monthly lithium labs and the other was for every three months lithium lab order. The DON stated both orders have now been discontinued. A review of the facility's policy titled, Medication Monitoring Medication Regimen Review and Reporting, 2007, showed the following policy statement: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities. The MRR also includes collaborating with other members of the IDT, including the resident, their family, and or resident representative.2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescribers orders, progress notes, nurses notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care.6. Resident specific MRR recommendations and findings are documented and acted upon by the nursing care center and or physician.8. The nursing care center follows up on their recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols.

Based on interviews, observations and record review, the facility did not ensure outside physician appointments were arranged/scheduled in a timely manner for one resident (#5) out of two residents reviewed.Findings included:On 3/31/2026 at 9:30 a.m., an interview was conducted with Resident #5 in his room. Resident #5 stated he had missed an outpatient appointment for an ophthalmologist. Resident #5 pointed to his right eye and stated he needs to be seen by his eye doctor for his vision. An observation was made of the resident's appointment card scheduled for 01/16/2026 at 12:10 p.m. for an ophthalmologist appointment. Resident #5 stated he also missed his monthly urologist appointment for the month of March. Resident #5 stated he had a suprapubic catheter in which he sees the urologist monthly.On 3/31/2026 at 2:39 p.m., an interview was conducted with Staff T, Registered Nurse/Unit Manager (RN/UM)for the 100 hallways. Staff T, RN/UM stated she is new to the role of unit manager and was not familiar with the process of arranging appointments and deferred to her Assistant Director of Nursing (ADON). Staff T, RN/UM stated there is a transportation binder for outpatient appointments. An observation was made for the month of March without an entry for Resident #5 for any appointments. On 3/31/2026 at 2:42 p.m., an interview was conducted with the ADON. The ADON stated the nursing staff will arrange the follow-up appointments or referrals, and the medical records staff will arrange the transportation. The ADON stated if the medical record staff member is out, arrangements for transportation will default to the nurses.On 4/01/2026 at 8:20 a.m., the transportation log was reviewed for the months of January and February. There were no entries observed for Resident #5. A record review of Resident #5's progress notes showed the following:-01/12/2026- The resident has returned from his urology appointment with a follow up appointment scheduled for February 2, 2026, at 13:45 (1:45 p.m.), no new orders. The resident is his own responsible party and is aware.-01/16/2026- The resident declined to attend his scheduled ophthalmology appointment. The resident was educated on the risk vs. benefits associated with such appointments and confirmed their comprehension; however, they maintained their refusal. A new appointment has been arranged for February 2nd at 11:00 a.m. The MD (Medical Doctor) has been notified; the resident is his own responsible party.A review of Resident #5's progress notes dated 3/30/2026 from his nurse practitioner showed the following:-Missed recent urology appointment due to transport issues.-Recommend rescheduling urology [NAME]-up appointment as neededMonitor for recurrent infection given history of recurrent UTIs.On 4/01/2026 at 2:13 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated when outside appointments or referrals are made, the unit manager will make the appointment, contact the medical record staff responsible for arranging transport, and notify the resident and/or resident responsible party. The DON stated the request for the appointment will be transposed into the Medication Administration Record (MAR) for the nursing staff to view. The DON stated, on the night prior to the appointment, the nurse will print the appropriate documents for the resident's appointment, verify transportation and notify resident of the following day's appointment(s). The DON acknowledged the process did not get the outcome expected for Resident #5 and would be rectified.A review of the facilities policy titled, Resident Rights, effective August 2025, showed the following policy statement: the facility strives to ensure that each resident has a dignified existence, self- determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility and exercising his or her rights and to be supported by the facility in the exercise of his or her rights.

Based on observations, interviews, and record review, the facility failed to keep residents free from neglect related to 1.) failing to inform the attending physician of critical lab values in a timely manner and infusing three doses of Vancomycin after receiving those critical labs for one resident (Resident #1) of three sampled residents, requiring Resident #1 to be admitted to the Intensive Care Unit and receive renal dialysis and 2.) failing to provide a safe, secure environment, and adequate supervision for one resident (Resident #3) of three sampled residents, who had a history of alcohol abuse, methamphetamine abuse, homelessness, and leaving medical facilities against medical advice (AMA). The facility also failed to properly assess Resident #3 for Leave of Absence, who had an Intravenous site at the time. Findings included: 1. During an observation on 12/11/2024 at 11:10 a.m. Resident #1 was lying in bed on an air mattress. An interview was conducted with Resident #1. He stated he had a big a decubitus ulcer on his bottom from being in another facility. The resident had a urinary catheter and an IV (intravenous) access in his left upper arm. He stated he was getting antibiotics. It was noted on the door he was on contact isolation precautions. He stated the staff mostly used gowns and gloves when they come in the room. Resident #1 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to pressure ulcer of sacral region, stage IV, necrotizing fasciitis, chronic kidney disease, neuromuscular dysfunction of bladder, extended spectrum lactamase (ESBL) resistance, diabetes, hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and adult failure to thrive. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] showed the following: - Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). - Section I - Active Diagnoses showed wound infection, renal insufficiency or renal failure, and pressure ulcer of sacral region stage IV. - Section M - Skin Conditions showed one stage IV pressure ulcer. - Section N - Medications showed the resident was on antibiotics. - Section O - Special Treatments, Procedures, and Programs showed he was receiving Intravenous (IV) antibiotics. Review of Resident #1's Order Summary Report, for the date range 10/28/2024 to 11/30/2024, showed the following: - Pharmacy to dose Vancomycin (Vanco) as of 11/1/2024. - Transmission Based Precautions, Contact Precautions-ESBL, wound as of 10/30/2024. - Vancomycin HCL (hydrochloride) in NaCL (sodium chloride) Intravenous Solution 750-0.9 mg (milligrams)/250 ml (milliliters) % use 750 ml intravenously two times a day for ESBL in wound as of 10/29/2024. - Vanco trough, one time only for monitoring and fax results to pharmacy, ordered on 11/13/2024 and revised on 11/14/2024. - Vanco trough only, NO VANCO PEAK and fax results to pharmacy ordered on 11/13/2024 and revised on 11/14/2024. - CBC (Complete Blood Count) with differential, CMP (Comprehensive Metabolic Panel) STAT (right now) ordered on 11/13/2024 and revised on 11/14/2024. - Appointment on 11/14/2024 with the Infectious Disease physician at 10:00 a.m. Review of Resident #1's November 2024 Medication Administration Record (MAR) showed the following: - Vancomycin HCL in NaCL Intravenous Solution 750-0.9 mg /250 ml.% use 750 ml intravenously two times a day for ESBL in wound as of 10/29/2024 was administered on 11/13/2024 at 5:20 a.m. by Staff J, Licensed Practical Nurse (LPN), 11/13/2024 at 6:02 p.m. by Staff H, LPN, and 11/14/2024 at 5:52 a.m. by Staff I, Registered Nurse (RN). Review of Resident #1's November 2024 Treatment Administration Record showed the following: - CBC, CMP, sed rate and Vanco trough scheduled for 11/13/2024 - Vanco trough, one time only for monitoring and fax results to pharmacy, performed on 11/13/2024 at 6:32 a.m. - Vanco trough only, NO VANCO PEAK and fax results to pharmacy was performed on 11/14/2024 at 7:38 a.m. - CBC with differential, CMP, STAT performed on 11/14/2024 at 8:25 a.m. Review of Resident #1's lab values showed the following: - On 11/13/2024 Vancomycin Peak was drawn at 7:00 a.m.: Vancomycin Peak was 78.3 (20.0 -40.0). On 11/13/2024 at 9:29 a.m. the critical results were read back and acknowledged. - On 11/13/2024 a CBC, CMP was drawn STAT at 8:30 p.m. with the following results: Sodium 122 (L) (136-145), Potassium critical value 8.1 (HH) (3/5-5.1), Creatinine 4.45 (H) (0.70-1.30), eGFR (estimated glomerular filtration rate) 13 or below, 15 may mean kidney failure. On 11/13/2024 at 10:41 p.m. the following critical results were read back and acknowledged by Staff I, RN: a Potassium level of 8.1, high critical. - On 11/14/2024 a Vancomycin Trough was drawn at 3:45 a.m. The Vancomycin Trough was 74.1 (10.0-20.0). On 11/14/2024 at 6:16 a.m. the critical results were read back and acknowledged by Staff I, RN. A review of Resident #1's Progress Notes showed the following: - On 11/13/2024, 3:37 p.m. a Summary for Providers note, written by Staff F, LPN, revealed Resident #1 had a change in condition, documented under the section titled Situation: Other change in condition. The section titled Primary Care Provider Feedback documented: perform stat labs and urine. - On 11/13/2024 at 3:43 p.m. a CNA (Certified Nursing Assistant) reported Resident #1 had a small amount of urine in the Foley bag, which was reported to the M.D. (Medical Doctor). Received an order to irrigate and change Foley catheter. Blood work on electronic chart and urine sample in the soiled utility room fridge. Passed to the next shift. Written by Staff F, LPN. - On 11/14/2024 at 7:59 a.m., a Post Event Every Shift Nursing Note Assessment Initiated showed MD notified and treatment initiated. Written by Staff G, RN, Unit Manager (UM). - On 11/14/2024 at 8:46 p.m. an eMAR (electronic medication administration record) Note showed Resident #1 was at the hospital. Written by Staff H, LPN. Review of Resident #1's Hospital records showed the following: - A Nephrology consult dated 11/14/2024 showed: (Resident #1) presented due to abnormal labs that were drawn the evening before. Labs at 2030 (8:30 p.m.) yesterday evening showed a potassium of 8.1, sodium 122, chloride 91, CO2 (carbon dioxide) of 20, BUN (Blood Urea Nitrogen) 78, creatinine of 4.45. Patient has been treated for hyperkalemic protocol. He is apparently on Vancomycin and Vancomycin peak was 78.3 and trough of 74.1. Assessment: Acute kidney injury secondary to bladder outlet obstruction in combination with Vanco toxicity hyperkalemia, hyponatremia, metabolic acidosis, Vanco toxicity, large sacral decubitus, BPH [benign prostatic hyperplasia] with urinary retention. Plan: daily dialysis for Vanco toxicity, stat Vanco level 81.9, daily Vanco levels, do not resume Vanco at this time. - An Infectious Disease Service Consult on 11/14/2024 showed Vanco level was found to be 74 and Vanco was discontinued. Assessment: necrotizing fasciitis sacral area, suspected osteomyelitis of sacral area, bilateral pneumonia with possible aspiration with Haemophilus influezae, suspected UTI (urinary tract infection) with E. (Escherichia) coli, vancomycin related nephrotoxicity with hyperkalemia, diabetes, and respiratory failure. Plan: will continue to monitor once Vanco level falls below 15 then will start patient on daptomycin. - An Internal Medicine note dated 11/17/24 showed Acute renal failure, suspected Vanco toxicity, hyperkalemia, hyponatremia, d/c (discontinue) Vanco due to acute renal failure. Review of Resident #1's care plan showed the resident had a sacral/coccyx stage 4 wound, complications related to wound healing related to infection, diabetes, and PVD. Interventions included but not limited to Enhanced Barrier Contact Precautions, obtain and review lab/diagnostic work as ordered, and report results to MD and follow up as indicated, as of 11/21/2024. Resident #1's care plan also revealed the resident is on antibiotic therapy related to having MRSA (Methicillin-resistant Staphylococcus aureus) in sacral/coccyx wound. Interventions included but not limited to administer medication as ordered and report pertinent lab results to MD. During interview on 12/12/2024 at 10:02 a.m. Staff G, RN, UM, stated Resident #1 was a long-term care resident with a wound on his buttocks. The resident was receiving Vanco and another antibiotic IV for his wound. Staff G RN, UM stated the resident required total care, including a mechanical lift, and he rarely got out of bed because he did not want to get out of bed. Staff G RN, UM stated Resident #1 had a Stage III pressure ulcer and got labs drawn one to two times a week, to manage the Vanco levels. Staff G RN, UM also stated they sent the results (lab) to the ID (Infectious Disease) doctor. Staff G RN, UM stated the day Resident #1 was going to the ID doctor, they physically put the lab results in an envelope instead of faxing the labs to the doctor, which was done by the nurse. Staff G RN, UM also stated she printed the labs, but did not look at them and did not review the labs. Staff G RN, UM stated she logged into the lab website, clicked and printed the labs, and the nurse picked the labs up off the printer. The nurse involved was Staff F, LPN on 11/13/2024. Staff G RN, UM stated she does not remember when the labs came in and she was not notified of any abnormal labs when she came in that morning on 11/13/2024. Staff G, RN, UM stated now, she checks the labs herself to see all the labs. Staff G RN, UM also stated the nurses notify her sometimes now, but not all of the nurses notify her. Staff G RN, UM stated she works Monday through Friday, 7 a.m. to 3 p.m. and the weekend supervisor or the nurses working on the weekend should check the labs on evenings and weekends. Staff G RN, UM stated they (the nurses) were all trained and went through the process to make sure they were following up with the labs, calling the doctor and the family. Staff G RN, UM also stated she started at the facility on 11/12/2024 and started that process with the DON (Director of Nursing) to make sure they were following up with the labs, calling the doctor and the family. Staff G, RN, UM stated they all received the log-in documentation to get labs and call the doctor and they are to document in the progress notes that they talked to the doctor. The lab results are kept in the patient's hard/paper chart. Staff G RN, UM stated on Monday she goes to the portal and checks the labs, checks the patient chart and MAR to make sure all labs are completed, and the DON double checks the labs. Staff G RN, UM also stated the nurses are responsible to review the labs, call the doctor and write orders. Staff G RN, UM stated they normally do Vanco troughs here for every patient, the labs are sent to the pharmacy, and based on pharmacy recommendations the dosing and follow-up labs are followed. Staff G RN, UM stated Staff F, LPN was the day nurse on 11/13/2024, and just took the labs off the printer and put them in the envelope for the transport. Staff G RN, UM stated Staff I, RN was the night nurse who had received the call the night before about the lab results. Staff G, RN, UM stated her expectation was for any critical labs to be called to the doctor, no matter what time. During an interview on 12/12/2024 at 10:48 a.m. Staff F, LPN stated she had worked with Resident #1 a couple of times at the facility. Staff F, LPN stated, I was having to log in for labs, but I did not have access at that time [on 11/13/2024]. That day they hired a UM, and she was the one who brings the labs. Staff F, LPN stated, I did not look at the labs. The UM printed everything and put it in an envelope and the face sheet. I was passing meds and asking for help. The laptops do not print, and I asked for help from the UM to print the forms and went back to passing meds. Staff F, LPN also stated, They only told me, I don't remember what was abnormal (labs) but not the Vanco level. Staff F stated, The labs were done the night before. [Staff I, RN] reported to me something was abnormal but not the Vanco. Staff F, LPN also stated, I don't have any way to see [the labs]. Staff F, LPN stated she went to the DON when she started working at the facility and asked her for the lab access, but she was a traveling DON and did not know how to get access. Staff F, LPN also stated she did not ask the UM for labs. Staff F stated, The way [Staff I, RN] reported, [the doctor] had the [lab] report, they did these labs, and [Resident #1's] was okay. Staff F, LPN also stated, [Staff I, RN] said she called the doctor and to keep an eye on when the doctor calls. Staff F, LPN stated she wrote a statement about the incident and, [the facility] knew what was going on over there, the UM started that day. They did not tell me about the appointment. I knew I needed a face sheet, labs, meds. Everything was a rush. So, the UM handed me the face sheet, med list, and labs. I put them into the envelope and rushed off. During an interview on 12/12/2024 at 11:44 a.m. with the Nursing Home Administrator (NHA) and the DON, the NHA stated on 11/14/2024 she was observing on the 100 main nursing station and overheard Staff F, LPN talking to the Infectious Disease clinic and asking questions in reference to the labs sent with Resident #1. The NHA stated Staff F, LPN was speaking with them (ID) and the ID clinic was transferring Resident #1 to the hospital. Staff F, LPN told the NHA, Resident #1 had a critical lab. The NHA stated she started the investigation and spoke with Staff E, Traveling DON and Staff G, RN, UM in the conference room. The NHA stated she told Staff E, Traveling DON and Staff G, RN, UM the ID clinic was sending Resident #1 to the hospital. The NHA stated Staff F, LPN initially told her she was not aware of the lab results when she gave the labs to transportation, she put the results in the envelope and handed them over. The NHA also stated once they started to investigate and looked back, they looked at the orders and lab results. The NHA stated Staff G, RN, UM told her she was not aware of the lab results; she just printed them. The NHA verified Staff I, RN's first statement which showed resident had abnormal blood work results. RN was passing meds. I intended to call MD in a.m. where I thought I would get a response. There was an admission I had to work on my shift. The resident had no [signs and symptoms] of the abnormal labs in my shift. Signed 11/14/24. The NHA verified the second statement by Staff I, RN showed, on 11/20/24, on the night in question, I had many things to tend to. I believe that a Vanco trough level was drawn sometime that evening or early night shift. I believe that if I knew I should have placed a phone call out to the MD. I do know I hung the 0500 Vanco and passed the results of the trough off to the day nurses with another lab result. And explained to her that I hadn't called the MD in the night. Both statements were provided by the NHA. The NHA stated, I called [Staff I, RN] and spoke to her first, she came in and wrote a statement. I explained that there was critical lab/Vanco level. She said she tended to the admission and did not call the doctor. [Staff I, RN] did admit that she knew the Vanco was critical. I asked her why she did not follow the protocol, call the DON and the MD. She instead handled the admission. The NHA stated they brought Staff I, RN back in after doing the investigation. The NHA stated, [Staff I, RN] admitted hanging the Vanco after getting the critical Vanco lab. She acknowledged she should have followed a different protocol, of calling the MD, calling the DON, and not hanging the Vanco. She stated she mentioned to [Staff F, LPN] about the abnormal labs, but it was just word of mouth at this time. The NHA stated Staff F, LPN was getting ready to send Resident #1 out to the appointment around 8 a.m., and she just grabbed the paperwork and sent it off. The NHA verified the statement from Staff F, LPN dated on 11/14/2024 showed, During report nurse-to-nurse today, my co-worker report [to] me only results from Vanco levels. No more labs was reported to pass to me. The NHA verified a second statement from Staff F, LPN on 11/15/2024, showed, that morning night shift only report me Vanco trough levels. I start passing meds, but I stop for print face sheet and med list from the patient. I went to the nurse station and log me in from the print the papers if request to the UM to print the recent labs. She found an envelope and pass the envelope to me. I put the face sheet and med list papers inside and give it to transport. Labs all ready was in the envelope. The NHA stated during the investigation, they got the information about the 11/14/2024 incident and found the 11/13/2024 critical Vanco peak. The NHA stated, I asked [Staff F, LPN] if she called a doctor about the 11/13/2024 [Vanco peak] and she stated to me I called him for several things, and I thought for sure I told him about the labs. She was not confident enough to say she had or not. The NHA stated she called the doctor herself just to ask him (MD) if Staff F, LPN called him about the critical labs. He (the doctor) stated he did not recall, and he had spoken with Staff F, LPN several times and knows his orders would be standard to send the resident out. The NHA stated when she interviewed Staff F, LPN, She stated to me, when she got the envelope, she put the labs in the envelope and gave it to the transportation. The NHA verified two nurses had knowledge of Resident #1's critical labs on two different days, and no one called a doctor or the DON, and the protocol was to call both. The NHA verified the statement from Staff J, LPN which showed, labs were drawn at 2:30 a.m. on 11/13/24 for trough and peak. Peak was drawn by mistake. Call labs back and reordered trough at 8:30 a.m. peak was mistakenly ordered by the nurse. The NHA stated after they obtained the statements, they continued their investigation. During an interview on 12/12/2024 at 1:06 p.m. Staff I, RN stated she was working the night shift on 11/12 through 11/13/2024, and she checked on Resident #1 many times. Staff I, RN also stated, I received the lab results and was going to call the doctor the next morning .The results came in late in the night. It was an elevated abnormal potassium. I make a little mistake once in a while and not call a doctor. All I remember is [the lab] calling about the potassium. I know they drew the Vanco. I was busy putting in orders and room changes. The potassium level was 74. That was the potassium level. There is just so much to do there. I had 28-30 patients to work with. I was going to call [the doctor] at 7 a.m., I forgot to call. I left all the things on the desk and told the day nurse. I expected the day nurse to call the doctor. I have called the doctors many times at night, and they do not call back. I had a lot to do that night. I have not been involved in Vanco levels, hanging the antibiotics. It is a difficult place to work. During an interview on 12/12/24 at 2:03 p.m. Staff E, Traveling DON, stated she was notified by the NHA, and the UM, Resident #1 had gone to an appointment and had critical labs and was sent to the hospital on 11/14/2024. Staff E, Traveling DON also stated, I was told he had a critical Vanco trough level. The NHA said she called the Risk Manager regarding, and they said to report it, and an investigation was started. I with the NHA spoke with [Staff I, RN], the night nurse. I did ask why she did not use her nursing judgment and call the doctor, and her response was [the doctors] don't answer on night shift. I asked [Staff I, RN] about using her nursing judgement to send him to the hospital. Staff E, Traveling DON stated Staff I, RN responded, I guess you're right. Staff E, Traveling DON stated Staff I, RN had to come in and write a statement. Staff E, Traveling DON also stated she was not informed of Resident #1's abnormal potassium levels and was only aware of the abnormal Vanco levels initially. Staff E stated, Once I looked at the labs and saw the critical potassium. I could not understand [Staff I, RN's] thinking. I am not sure if [the labs] were called at the same time. Staff E, Traveling DON verified the dates and times of the critical labs and stated, They were not acted upon, I see that. Staff E, Traveling DON verified two extra doses of Vanco was given even though there were critical labs and stated, My expectation was nursing 101, critical labs call the doctor. Immediately send him out and call the doctor. Nurse to call the DON. Pharmacy gets a copy to dose. If pharmacy had received, they would have given us orders to hold or next process. The nurse was responsible to fax [the labs] to the pharmacy. She did not talk to the doctor. Staff E, Traveling DON stated the only part of the investigation she was part of was to speak with Staff I, RN. Staff E, Traveling DON also stated, I did the education on lab logins, how to use labs, input the labs into the computer, process of to call the doctor, write a progress note if orders or change orders. I did not include sending to the pharmacy. Lab results are filed in the hard chart. They are to get a report-to-report. Staff E, Traveling DON stated the labs are in the lab book of who had labs that day and there was a printout of who had labs for the day. The critical labs are brought to the morning meeting, if the nurse documents in the clinical dashboard. During a second interview 12/12/2024 at 2:30 p.m. with the NHA and the DON, they stated they found the elevated potassium level after the fact when they went deeper into the investigation. During an interview on 12/12/2024 at 3:05 p.m. with Resident #1's attending physician, the attending physician stated, I just started coming here. If [the labs] had been reported to us, we would have sent [Resident #1] to the hospital. I have a lot of patients and don't remember them all. My expectation was for the nurse to call me and call pharmacy with critical labs. Call right away and not wait. With elevated potassium of 8.1, sodium of 122, creatine of 4.45; the Vanco peak of 78.3 and Vanco trough of 74.1 the Vanco was frying his kidneys. He needed to be in the ICU. The attending physician also stated, Yes, we have someone on 24/7, they should have called as soon as they got the critical results. During an interview on 12/12/2024 at 3:29 p.m. with the Consulting Pharmacy providing the Vanco to Resident #1, the Pharmacist stated their expectation was to receive labs for the dosing of the Vanco. He would expect to get a fax of the lab results. If they had any questions they would call the facility. If the labs are critical, they would prefer a call so they can be discussed. Review of the facility policy titled Laboratory Services, dated August 2024, showed under Policy, the facility will provide or obtain laboratory services to meet the needs of its residents. The facility will be responsible for the quality and timeliness of services whether provided by the facility or an outside agency. The policy also showed the following under Procedure: 1. Assure laboratory test or completed and results provided to the facility within time frames normal for appropriate interventions. 2. Provide or obtain laboratory services only when ordered by a physician. 3. Assure nursing notifies the physician promptly of the findings . 5. Assure the laboratory reports submitted by the laboratory and filed in the resident / patient's clinical record contain at least the following: a. date B. Resident name C. Name and address of the testing laboratory 6. Monitor services, timeliness, and quality through the Quality Assurance Committee. Review of the facility policy titled Care Plan-Interdisciplinary Plan of Care form Interim to Meeting, dated February 2024, showed under Policy, the facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address each issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives, and time frames and describes the services that are to be furnished to or attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence. Managing risk factors to the extent possible or indicating the limits of each of such interventions. Review of the facility's policy titled Medication Administration, September 2018, showed under Policy, medications are administered as prescribed in accordance with the manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. 50434 2. Review of Resident #3's Hospital record revealed Resident #3 was hospitalized from 8/1/2024 to 8/15/2024. The History of Present Illness (HPI) section revealed the following: Patient (Resident #3) is a [AGE] year old male with a past medical history of hypertension, alcohol use, tobacco use, and history of open reduction internal fixation, who presents to the ER (emergency room ) with complaints of worsening right wrist pain. He was recently admitted on [DATE], due to a right wrist abscess, which was MRSA positive osteomyelitis for which he underwent irrigation/debridement. He required 6 weeks of IV Vancomycin as per ID recommendations for which he received a total of 10 days of antibiotics before leaving AMA on July 26th. Today (8/1/2024), the patient arrived at ER due to progressive worsening pain and swelling of the right wrist. Review of Resident #3's Admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including primary osteoarthritis right wrist, arthritis due to bacteria, great wrist, alcohol abuse, housing instability, housed, homelessness and past 12 months, other psychoactive substance abuse, tobacco use, and patient's other noncompliance with medication regimen for other reasons. Review of Resident #3's medical record revealed two elopement risk assessments, both completed on 8/16/2024, which did not indicate Resident #3 was an elopement risk. Review of Resident #3's Order Summary Report for December 2024 revealed the following orders: - 8/19/2024: LOA Independent - 8/16/2024: IV: Change Injection cap every 7 days as well as PRN (as needed). Injection cap to be changed after each blood draw. Every day shift every 7 day(s) for iv therapy. - 8/16/2024: IV: Change IV dressing every 7 days as well as PRN for soiling and or dislodgement. Every evening shift every 7 days. - 8/16/2024: IV: Measure external catheter length every 7 days and as needed with dressing change. Every day shift every 7 days for maintain iv access IV. - 8/16/2024: Vancomycin HCI in NaCI intravenous Solution 750-0.9 MG/250 mL-% (Vancomycin HCI-Sodium Chloride) Use 1 dose intravenously every 12 hours for osteomyelitis until 9/12/2024 13:01 (1:01 p.m.). Review of Resident #3's Progress Notes revealed: - A note dated 8/16/2024 at 1:15 p.m. documenting a skin check was completed for Resident #3. Resident has a PICC (peripherally inserted central catheter) line in the left upper arm, for IV therapy post incision 7.5 cm (centimeters) right wrist, all other skin completely intact; will continue to monitor. - An Admission note dated 8/16/2024 at 1:50 p.m.: Admitting Diagnosis: Right wrist osteomyelitis, observation of resident speech: clear .The resident stated reason for admission: IV therapy .The resident or resident representative stated discharge goal: other discharge location arrangements (i.e. group home or hotel) .No, the resident does not use alcohol. No, the resident does not use illegal drugs .The resident has NOT had any of the following: current psychotropic medication use, balance issue with sitting, standing or walking, wandering use of restraint .Yes, Is resident currently receiving antibiotics Route: IV .The resident is Independent for Eating. The resident is Independent for setting up supplies and/or brushing their teeth or Dentures. The resident is Independent for toileting. The resident is Independent for bathing . - A note dated 8/16/2024 at 3:02 p.m. documenting Resident #3 was admitted for IV therapy and would like to go LOA to the store. A call was placed to physician for instructions. - A Shift Level Administration note dated 8/17/2024 at 7:35 a.m.: Spoke to the pharmacist regarding the order of Vancomycin HCl IV not be delivered yet. The pharmacist requested new order for serum creatinine level to be drawn. Laboratory order placed and creatinine was drawn. Waiting for results. Day shift made aware. - A Medication Administration note dated 8/17/2024 at 11:38 a.m. documenting Resident #3's Vancomycin HCl IV would be delivered that evening. - A Medication Administration note dated 8/17/2024 at 1:48 p.m. documenting the facility was awaiting lab results for Resident #3. - A Medication Administration note dated 8/17/2024 at 11:20 p.m. documenting Resident #3 was absent from the facility. - A note dated 8/18/2024 at 4:21 p.m.: Resident [#3] is alert and oriented, with independent LOA Order. On 8/17/2024, he left the facility in stable condition to go to [a local] hospital. On 8/18, the admissions department was notified by .Hospital this resident was admitted for Osteomyelitis. Signed by the DON. - A Social Services note dated 8/19/2024 at 6:59 p.m. documenting a wellness check was conducted for Resident #3 while Resident #3 was in the hospital. During an interview on 12/11/2024 at 2:50 PM the NHA stated Resident #3 was alert and oriented and he was able to mobilize independently. She stated on 8/17/2024, she received a call from nursing staff stating Resident #3 was missing from the facility. The NHA started the investigation by asking staff when the last time they saw Resident #3. She stated the nurse assigned to Resident #3 stated she went to administer the IV antibiotics and noticed he was gone. The NHA interviewed the smoking-aide, who stated she had not seen the resident at the last smoking session. At this point, she started a full investigation, called the police, Department of Children and Families (DCF), and reported to the State Agency. She called all of the staff from that day to check on the resident's demeanor. When she contacted the emergency contact for Resident #3, he provided information related to where the resident would normally hang out. The NHA stated she started to call hospitals and found the hospital where Resident #3 was. She was able to speak with Resident #3, who told her he snuck out of a window. He told her he was able to twist the screws from the window and popped the window open. He then used a bench that was in front of the fence and jumped over the fence into the neighbor's yard. The NHA stated they also found a note on Resident #3's bedside table explaining he left the building. During an interview on 12/12/2024 at 11:16 a.m. with Staff C, CNA, she stated Resident #3 kept asking the nurse for his IV antibiotics, and they were scheduled at certain times. Resident #3 kept reminding the nurse throughout the day and the nurse would just brush him off. Staff C, CNA stated around 2 or 2:30 p.m. on 8/17/2024, she reassured Resident #3 he would get his medication. Staff C, CNA also stated before she left her shift around 3:00 p.m., she saw Resident #3 out on the patio smoking. She stated as she was returning to

Based on observations, interviews, and record review, the facility failed to implement an effective Infection Control and Prevention program by 1.) failing to ensure staff donned appropriate personal protective equipment (PPE) while caring for a resident under Enhanced Barrier Precautions for one resident (Resident #5) of two residents sampled for Infection Control precautions, and 2.) failing to ensure staff donned appropriate PPE while in the room of a resident under Transmission Based Precautions for one resident (Resident #4) of two residents sampled for Infection Control precautions. Findings included: A review of Resident #5's Admission Record showed Resident #5 was admitted on [DATE] and was readmitted on [DATE]. Review of the Admission Record also showed diagnoses including but not limited to cachexia, obstructive and reflux uropathy, gastrostomy status, neuropathic bladder. Review of Resident #5's Order Summary Report, active as of 12/12/2024, showed an order dated 6/24/2024 for Enhanced Barrier Precautions while providing direct care for G-tube (gastrostomy tube) and wound. Review of Resident #5's care plan showed the resident required Enhanced Barrier Precautions related to gastrostomy tube and IV (intravenous line) as of 11/18/2024. Interventions included but not limited to Enhanced Barrier Precautions/gloves and gowns to be worn when providing high touch resident care as of 05/13/2024. A review of Resident #4's Admission Record showed Resident #4 was admitted on [DATE]. Review of the Admission Record also showed diagnoses included but not limited to cellulitis of right and left lower limbs, cutaneous abscess of limb, sepsis, and MRSA (Methicillin-resistant Staphylococcus aureus). Review of Resident #4's Order Summary Report, active as of 12/12/2024, showed an order dated 12/7/2024 for Transmission Based Precautions/Contact Precautions - ESBL (extended-spectrum beta-lactamase)/MRSA. Review of Resident #4's care plan showed the resident has an infection, MRSA/ESBL. Interventions included but not limited to Contact Precautions as of 12/9/2024. During an observation on 12/11/2024 at 10:06 a.m., Resident #5 was lying in bed. Resident #5 asked to have her brief to be changed. Resident #5 turned on her call light at 10:06 a.m. Observed Resident #5 had a feeding tube in place. On the door, Contact Precautions, everyone must: clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. (Photographic Evidence Obtained) An employee walking down the hallway went in the room and came out of the room and was overheard telling Resident #5 she would get her aide. Staff K, Certified Nursing Assistant (CNA) came down the hallway, performed hand hygiene, and entered the room at 10:09 a.m. and stated she would be back. Staff K, CNA exited the room without hand sanitizing. While going down the hallway, Staff K, CNA touched another resident on the shoulder. Staff K, CNA went to the closet in the hallway and gathered a bag of towels. Staff K, CNA returned to the room at 10:12 a.m. and entered without a gown or gloves on and shut the door. At 10:20 a.m. Staff K, CNA was observed providing care without a gown on, only gloves. Staff K, CNA exited the room at 10:33 a.m. and walked down hallway to another closet for more items. Staff K, CNA returned to the room and an interview was conducted. Staff K, CNA stated she washed her hands only and the sign on the door was for contact precautions. Staff K, CNA also stated she did not see the sign and she should have put on a gown and gloves, but she only put on gloves. Staff K, CNA stated she did not know which residents were on the contact isolation precautions and she did not know which one was on Enhanced Barrier Precautions (EBP) and there was not an EBP sign on the door. Staff K, CNA stated residents with a catheter should be on EBP and she was not sure if a resident with a g-tube should be on EBP or not. Staff K, CNA also stated, they usually tell us, but I did not get report. Staff K, CNA stated she did not see the PPE container outside of the door nor the posted signage. Staff K, CNA was observed to have long, artificial fingernails. Staff K, CNA was not able to state any concerns related to infection control and having long fingernails. During an interview on 12/12/2024 at 10:02 a.m. Staff G, Registered Nurse/Unit Manager (RN/UM) stated Resident #5 was a long-term care resident and was receiving Vancomycin (Vanco) for osteomyelitis. Staff G, RN/UM also stated Resident #5 had a gastrostomy tube and no wounds and the resident was on Enhanced Barrier Precautions due to the g-tube, not due to having an IV. Staff G, RN/UM stated Resident #4 was on Contact Precautions due to having MRSA in a right hip wound and ESBL in the urine. Resident #4 was also receiving Vanco via IV. Staff G, RN/UM stated Resident #4 had a #6 sign above her bed, meaning she was on Contact Precautions. Staff G, RN/UM also stated there should be an Enhanced Barrier sign on the door also because Resident #5 is on EBP. Staff G, RN/UM stated the staff should know the type of precautions the residents are on, which should be communicated during report for each resident. Staff G, RN/UM stated due to Resident #5 being on Contact Precautions, the staff should put on a gown and gloves for incontinence care and if a possibility of spilling, they need goggles as well. Staff G, RN/UM also stated the aide should have worn a gown, gloves, and if possible splashing, she needed a face shield while performing incontinence care for Resident #5. During an interview on 12/12/2024 at 2:48 p.m. the Infection Control Preventionist/Assistant DON (ICP/ADON) and DON stated the PPE for contact isolation was the use of gloves and gowns and, depending on what they are doing, a mask. The ICP/ADON stated for EBP, staff should use gloves and gowns for incontinence care. The ICP/ADON also stated the staff should be aware of what type of PPE to be used and precautions based on the door signage posted and the information received in report. If contact isolation signage is on the door, there should be a blue #6 over the bed which correlates with EBP. The ICP/ADON stated Resident #4 was on contact precautions due to ESBL in the wound, a surgical site with a lot of drainage. The ICP/ADON also stated Resident #5 was EBP only, due to having a g-tube and IV. The ICP/ADON stated the floor staff should not have long artificial nails due to infection control issues and they should be trimmed neatly. Review of the facility policy titled Isolation Precautions - Categories of Transmission - Based Infections dated October 2021 showed under Policy, standard precautions shall be used when caring for residents regardless of their suspected or confirmed infection status. Transmission based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. 1. Transmission-Based precautions will be used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. In addition to standard precautions, implement contact precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident - care items in the residence environment. Examples of infections requiring Contact Precautions include but are not limited to gastrointestinal, respiratory, skin, or wound infections or colonization with multi drug resistant organisms. Review of the facility policy titled Progressive Discipline Policy dated April 2019, showed under Personal Hygiene, fingernails should be kept neat, clean, and of conservative length. Employees providing patient care must keep nails short so not to create safety or infection control issues. No artificial nails, appliques or studs on nails may be worn by any clinical staff who provide patient care.

Based on interviews, record review, and policy review the facility failed to protect residents' right to be free from neglect related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not performing laboratory tests and not following up on critical lab results for two residents (#11 and #13) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. These failures created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death to Residents #1, #11, and #13 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously deceased when they arrived. An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over care. EMS notified. Resident pronounced deceased at 3:10 p.m. Review of Admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Review of an Order Summary Report for Resident #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:,d+[DATE]:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths before EMS got there. Staff L, Nurse said they were still following through with compressions when EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like can someone else do this, does anyone know how to do this. I did not think much of it. An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the suction and Staff K, Nurse suctioned the resident only one time. A follow-up interview was conducted on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who was doing CPR. An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Not performing laboratory tests: Review of the Admission Records showed Resident #13 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease and epilepsy. Review of medical records showed Resident #13 had a care plan in place for Seizure Disorder, dated [DATE]. Interventions to include Obtain and Monitor lab/diagnostic work as ordered. Report results to doctor and follow up as indicated. Review of Resident #13's physician orders showed the following active orders: -Levetiracetam (Keppra) oral solution 100 milligram (mg) per milliliter (ml) Give 12 ml in the evening for seizure, dated [DATE] -Levetiracetam 100mg/ml Give 14 ml one time a day for seizures, dated [DATE], -Keppra level every 6 months starting on the 5th for 1 day, dated [DATE]. Review of Resident #13's [DATE] Treatment Administration Record (TAR) showed the Keppra level lab was due on [DATE]. It was signed off on the TAR as completed. Review of the Facility Lab book that is kept at the nurses' station contained a Lab Monitoring Sheet, dated [DATE], showing Resident #13's Keppra level was to be drawn that day. The lab was not signed off by the phlebotomist as being drawn. There was no documentation on the Lab Monitoring Sheet or progress notes to indicate the resident refused the lab draw. Review of Resident #13's Quarterly Minimum Data Set (MDS,) dated [DATE], Section C, Cognitive Patters, showed he had a Brief Interview for Mental Status (BIMS) score of 3, indicating a severely impaired cognition. He was unable to be interviewed. An interview was conducted on [DATE] at 1:05 p.m. with Staff H, Nurse. Staff H reviewed the Lab Monitoring Sheet for [DATE] out of the lab book. She then logged into the laboratory company's website and confirmed the last lab for Resident #13 was drawn in [DATE]. Staff H reviewed Resident #13's physician orders and confirmed it should have been drawn on [DATE] and it was not completed and there was no documentation as to why. Staff H said this lab was scheduled to be drawn on a Saturday and the missed lab should have been caught when it was reviewed by management on Monday morning. 3. Not following up on critical lab results and not ensuring treatment and care for immune deficiency syndrome: Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was readmitted on [DATE], after a hospitalization for a gastrointestinal bleed. Review of medical records showed a Social Services note, dated [DATE] that said Resident #11 is alert and oriented and can make her needs known. The resident reported to Social Services she lived in shelters, and she would like to improve her health. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. It also noted the resident was cooperative, pleasant, and motivated. According to a National Heart, Lung, and Blood Institute article titled, Thrombocytopenia, dated [DATE], Thrombocytopenia is a condition that occurs when the platelet count in your blood is too low. The article stated this can be life-threatening, especially if the patient had serious bleeding or bleeding in the brain, but early treatment could help avoid serious complications. The article explains bleeding causes the main symptoms of thrombocytopenia with signs including bleeding that last a long time, even from small injuries, petechia (small, flat red spots under the skin from blood leaking out of blood vessels), purpura (bleeding in your skin that can cause red, purple, or brownish-yellow spots) nosebleeds or bleeding from gums, or blood in urine or stool. (Accessed on [DATE] at https://www.nhlbi.nih.gov/health/thrombocytopenia) According to an (IMMUNE DEFICIENCY SYNDROME).gov article titled Guidelines for the Use of Antir[TRUNCATED]

Based on interviews, record review, and policy review the facility failed to ensure an allegations of neglect were reported related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not following up on critical lab results for one resident (#11) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. This failure created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: On [DATE] at 2:14 p.m. after multiple requests for the facility to provide a list of incidents that had been reported in [DATE], the DON confirmed the facility had no reportable events in [DATE]. An interview was conducted on [DATE] at 2:46 p.m. with the DON. The DON said she did not hear there were any problems with the code for Resident #1 on [DATE]. She said no one reported anything to her. The DON said the fire supervisor came to visit her on [DATE] regarding concerns during the code blue for Resident #1 and he asked about the CNAs and their participation during the code, and she told him they are not certified in CPR and are only there to assist. The DON said he wanted to talk about two staff members not assisting in CPR and he said they were CNAs. When the DON was asked why the fire supervisor would take the time to make a trip to the facility to discuss two CNAs who did not participate in CPR, if there were no concerns with the CPR or care the resident was receiving. The DON said she thought it was odd but didn't think much of it. The DON said she did not ask him if the two staff members could have been nurses. She said, I did not think to ask. I did not think that nurses stopped CPR. No one told me. I guess I could have asked more questions. The DON said she did not interview nurses about not doing CPR. She said she did not think it was a neglect issue and she focused on the CNAs. The DON said she did not document the visit or what was said, and she did not know who the person was that visited their facility or what his title was. The DON said after he left, she did not get staff involved in Resident #1's code blue to write statements. The DON said she did not know how many staff went into Resident #1's room, she did not ask. A phone interview was conducted on [DATE] at 12:08 p.m. with the Nursing Home Administration (NHA) regarding the code blue for Resident #1. The NHA said if there were concerns after a code blue, sometimes an investigation occurs when it is over. The process is to get statements to see if everything went well during a code. The NHA said after every code staff should make sure everything is documented, all staff that were present are interviewed and their role was documented. The NHA said, we do this with every code. The NHA said she was not aware there was a visit from an outsider, she thought it was a phone call. The NHA said the DON told her he called to talk about two CNAs that were standing around during CPR and he asked what their role was. The DON said she clarified the CNAs role to him and he was okay with that. The NHA said she worked on [DATE] but did not know there was a concern. She said she did not think they needed to investigate or report anything. 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously deceased when they arrived. An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over care. EMS notified. Resident pronounced deceased at 3:10 p.m. Review of Admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Review of an Order Summary Report for Resident #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:,d+[DATE]:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths before EMS got there. Staff L, Nurse said they were still following through with compressions when EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like can someone else do this, does anyone know how to do this. I did not think much of it. An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the suction and Staff K, Nurse suctioned the resident only one time. A follow-up interview was conducted on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who was doing CPR. An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Not following up on critical lab results and not ensuring treatment and care for immune deficiency syndrome: Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was readmitted on [DATE], after a hospitalization for a gastrointestinal bleed. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. It also noted the resident was cooperative, pleasant, and motivated. According to an (IMMUNE DEFICIENCY SYNDROME).gov article titled Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with [IMMUNE DEFICIENCY SYNDROME], dated [DATE], ART is now recommended for all patients with immune deficiency syndrome. In patients who remain untreated for whatever reason, CD4 counts should be monitored every ,d+[DATE] months to assess the urgency of ART initiation . (Accessed on [DATE] at https://clinicalinfo.immune deficiency syndrome.gov/en/guidelines/immune deficiency syndrome-clinical-guidelines-adult-and-adolescent-arv/plasma-[immune deficiency syndrome]-1-rna-cd4-monitoring#:~:text=In%20patients%20who%20remain%20untreated,of%20immune%20reconstitution%20(AIII).) Review of medical records for Resident #11 [TRUNCATED]

Based on interview and record review facility failed to ensure an allegations of neglect were investigated related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not following up on critical lab results for one resident (#11) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. This failure created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: An interview was conducted on [DATE] at 2:46 p.m. with the DON. The DON said she did not hear there were any problems with the code for Resident #1 on [DATE]. She said no one reported anything to her. The DON said the fire supervisor came to visit her on [DATE] regarding concerns during the code blue for Resident #1 and he asked about the CNAs and their participation during the code, and she told him they are not certified in CPR and are only there to assist. The DON said he wanted to talk about two staff members not assisting in CPR and he said they were CNAs. When the DON was asked why the fire supervisor would take the time to make a trip to the facility to discuss two CNAs who did not participate in CPR, if there were no concerns with the CPR or care the resident was receiving. The DON said she thought it was odd but didn't think much of it. The DON said she did not ask him if the two staff members could have been nurses. She said, I did not think to ask. I did not think that nurses stopped CPR. No one told me. I guess I could have asked more questions. The DON said she did not interview nurses about not doing CPR. She said she did not think it was a neglect issue and she focused on the CNAs. The DON said she did not document the visit or what was said, and she did not know who the person was that visited their facility or what his title was. The DON said after he left, she did not get staff involved in Resident #1's code blue to write statements. The DON said she did not know how many staff went into Resident #1's room, she did not ask. A phone interview was conducted on [DATE] at 12:08 p.m. with the Nursing Home Administration (NHA) regarding the code blue for Resident #1. The NHA said if there were concerns after a code blue, sometimes an investigation occurs when it is over. The process is to get statements to see if everything went well during a code. The NHA said after every code staff should make sure everything is documented, all staff that were present are interviewed and their roll was documented. The NHA said, we do this with every code. The NHA said she was not aware there was a visit from an outsider, she thought it was a phone call. The NHA said the DON told her he called to talk about two CNAs that were standing around during CPR and he asked what their roll was. The DON said she clarified the CNAs roll to him and he was okay with that. The NHA said she came in to the facility on [DATE] but did not know there was a concern. She said she did not think they needed to investigate or report anything. 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously deceased when they arrived. An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over care. EMS notified. Resident pronounced deceased at 3:10 p.m. Review of Admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Review of an Order Summary Report for Resident #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:,d+[DATE]:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths before EMS got there. Staff L, Nurse said they were still following through with compressions when EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like can someone else do this, does anyone know how to do this. I did not think much of it. An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the suction and Staff K, Nurse suctioned the resident only one time. A follow-up interview was conducted on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who was doing CPR. An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Not following up on critical lab results and not ensuring treatment and care for immune deficiency syndrome: Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was readmitted on [DATE], after a hospitalization for a gastrointestinal bleed. Review of medical records showed a Social Services note, dated [DATE] that said Resident #11 is alert and oriented and can make her needs known. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. Review of medical records for Resident #11 showed a progress note, dated [DATE], saying the resident reported to the nurse she was vomiting on the floor inside her room. When nurse arrived in resident's room, she noticed a huge amount of coffee brown and red blood on the floor. The resident denied any pain, discomfort, or shortness of breath. This nurse immediately called the doctor and received orders to send the resident to the hospital for evaluation and treatment. Review of Resident #11's hospital History and Physical, dated [DATE], noted resident had a significant history for an immune deficiency syndrome and noncompliance with medications. It was also noted the resident was homeless, took no medications and did not see a physician on a regular basis. No lab results related to an immune deficiency syndrome or immune function were found in the hospital medical records. Review of the

Based on observation, record review and interviews, facility failed to ensure Cardiopulmonary Resuscitation (CPR) was performed according to professional standards on one resident (#1) out of three reviewed for CPR, the facility failed to ensure three out of five emergency carts were stocked correctly and ready to be utilized in a code blue, and failed to ensure six out of thirty-two nurses had hands-on and in person skills assessment training with their CPR certification. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 during the code on [DATE]. Staff M, Nurse called this surveyor at 3:52 p.m. on [DATE] and said, my conscious got to me. She said she was downstairs and heard the code called. She said she walked fast to get to the 300 unit. She said it was about 5 minutes after the code was called, she got to the unit, and no one was doing compressions on the resident. She said EMS had not yet arrived at the time she got to the room. She said the primary nurse usually starts compressions and other nurses come up and help. Staff M said the resident was lying on the floor with her head towards the foot of the bed and her legs were underneath her. She said it looked like she had been standing and collapsed with her legs under her. She said in that position it would have been difficult to do compressions. Staff M said, I was in shock no one started compressions. She said she didn't know if they were looking for a Do Not Resuscitate (DNR) order or what. Staff M said there were a lot of people in the room, and no one was doing CPR. She said they were just like staring. She said prior to her leaving the room, Staff K, Nurse was getting oxygen for the resident, but she didn't know what that was going to do when she wasn't breathing. She asked the nurses if they needed help and they said no, so she left the room. Technically, there's no formal definition for a code, but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. https://www.webmd.com/a-to-z-guides/code-blue-code-black-what-does-code-mean An interview was conducted on [DATE] at 2:27 p.m. with the Emergency Services Paramedic. She said their unit arrived at the facility first after receiving a 911 call for cardiac arrest. When they arrived at the resident's room, there were two male staff members sitting on the bed, while the patient was lying on the floor. One female staff member was by the crash cart and one by the doorway. The Paramedic said, They were basically watching the resident lying on the floor. She said CPR was not being performed on the resident. The Paramedic said one nurse was messing with the suction on the cart, but nothing was open from that cart. The Paramedic said no one identified themselves as a nurse or a CNA. The Paramedic said no one was doing compressions, suctioning the resident, or providing oxygen to the resident. The Paramedic said, I was mind blown. The Paramedic said she asked staff to do compression while they (emergency services team) set up their equipment and got medications out because there were only two responders on the first unit to arrive. The Paramedic said she had to ask multiple times for staff to help and for someone to do compressions. She said one male started doing compressions and he put his hands in completely wrong placement, hit her chest three times and stood up and looked at them. She told the male she needed him to keep going so he did three more compressions. She said the male was in a hoodie, but she did see him in the nurses' station prior to leaving the facility so she assumed he was staff. The male did three more compressions the Paramedic said she spoke up and asked someone else to do compressions because the male was doing it incorrectly. She said a female said, I ain't doing it, and walked out of the room. She said the second male, a tall white gentleman, had been fumbling with the suction machine. He had the suction tubing but no suction attachment on the end, such as a flexible tubing or yankauer (rigid oral suctioning tool.) The Paramedic said the male was attempting to suction the resident, but it wasn't doing anything since he did not have an attachment on the tubing. The Paramedic said after the female staff member said she wasn't doing compressions, the second EMS (Emergency Medical Services) unit arrived, and they took over. The Paramedic said staff didn't know if the resident had been down a while or not, no one could say. She said EMS responders do compressions and work on the resident until cardiac pads are on and heart rhythm can be verified. The Paramedic said the resident was not obviously deceased when they arrived. An interview was conducted on [DATE] at 12:31 p.m. with an Emergency Medical Technician (EMT). The EMT confirmed she came to the facility on the call for Resident #1 on [DATE]. The EMT said when she walked in the room two male staff were sitting on the bed bending over trying to figure out the suction. She said there was a cart with suction and oxygen and staff were trying to figure that out. The EMT said no one was doing compressions. She said the Paramedic on scene had to ask multiple times for someone to get on the chest. The EMT said one male staff member started compressions, but he wasn't doing it correctly. She said there were only two responders at the time, and they needed the staff to assist while they set up. She said the Paramedic was good at dealing with the staff and wasn't rude, but she was frustrated because she was having to ask multiple times for them to do their job. The EMT said she was trying to get the monitor set up and on the patient. She said when the 911 call was made it came in as CPR in progress and all the staff should know how to do CPR. The EMT said after the male had been asked to do compressions the Paramedic asked for someone to take over, then the second crew arrived, and they took over CPR from staff. An interview was conducted on [DATE] at 5:26 p.m. with an EMS Field Supervisor. He said he received a report from his Paramedic on Monday, [DATE], about the call they received to the facility. He said the Paramedic wrote an incident report regarding arriving at the facility and CPR not being performed on the resident when they arrived. He said he wanted to go talk to management at the facility to see what happened. He said the visit was more of a fact-finding mission. The EMS Field Supervisor said he spoke with the DON on [DATE] and she said she wasn't even aware Resident #1 had a cardiac arrest. He said he told her what happened and what the Paramedic witnessed. He said the DON told him it was probably CNAs in the room, and they are not trained to do CPR and are not allowed to do CPR in the facility. A review of Resident #1's medical record revealed a progress note, dated [DATE] at 5:29 p.m. by Staff I, Nurse, the nurse assigned to the resident. The note showed CNA [Certified Nursing Assistant] notified nurse resident was on floor in room. Nurse observed resident without respirations or pulse. Code status verified. Code blue called. CPR initiated and continued until EMS arrival whom took over care. EMS notified. Resident pronounced deceased at 3:10 p.m. Review of Admission Records showed Resident #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder, bipolar type, epilepsy, anxiety disorder, Alzheimer's disease, disease of pancreas, hypothermia, and chronic obstructive pulmonary disease (COPD). Resident #1 expired on [DATE]. Review of an Order Summary Report for Residet #1 revealed an active physician order for Full Resuscitation, order date [DATE]. An interview was conducted on [DATE] at 3:58 p.m. with Staff J, CNA. Staff J, CNA said she was just coming on her shift at about 2:45 p.m. She said she clocked in and got up to the unit just before 3:00. Staff J, CNA said she came up the back stairs and circled the unit before going to the nurses' station and when she came around the corner Staff K, Nurse and Staff I, Nurse were standing at the nurses' station directly across from Resident #1's room and both doors were open. Staff J, CNA said she and another staff member walked up at the same time and the other staff member looked in the room and said a resident had fallen. Staff J, CNA said she quickly set her things down and ran into the room. She said you could see the resident's hair on the floor from the hall. She said the resident was lying on her back and had some vomit/fluid on her face. She said she called out Resident #1's name a few times and the resident didn't respond. Staff J, CNA said she ran out the door and told Staff K, Nurse and Staff I, Nurse the resident was unresponsive and needed help. Staff J, CNA said both nurses looked at me like I was dumb and Staff I, Nurse said are you joking? She said Staff K, Nurse went in Resident #1's room and Staff I, Nurse came two minutes later. Staff J, CNA, said she went into the room to try to help but the nurses told her to leave. She said she did see Staff K, Nurse start CPR but does not know if it continued because she was told to leave. Staff J, CNA said there were 2 male nurses in the room (Staff K, Nurse and Staff L, Nurse) and 3 female Nurses (Staff I, Nurse and two nurses from downstairs.) An interview was conducted on [DATE] at 3:28 p.m. with Staff K, Nurse. He said he was coming in to work on [DATE] for the 3:00 p.m. shift. He said around 2:50 p.m. Staff J, CNA came and said Resident #1 was on her back and didn't look good. He said he went to the room and the resident was lying on her back with her head towards the bathroom door and wasn't breathing at all. He said one of the CNAs grabbed the resident's chart and Staff I, Nurse checked her code status. Staff K, Nurse said a CNA grabbed the emergency cart and he started CPR on the resident. Staff K, Nurse said Resident #1 was still warm. He said he didn't know what happened, but it looked like it just happened to me. He then said Staff I, Nurse brought the emergency cart in with her and used the AMBU bag (a bag valve mask that is used to deliver positive pressure ventilation) to give breaths to the resident and he did compressions. Staff K, Nurse said Staff L, Nurse came in to help and took over the AMBU bag from Staff I, Nurse. Staff K, Nurse said next, he and Staff L, Nurse switched places while Staff I, Nurse did paperwork. He said EMS came quick, but he was disappointed they didn't take over when they showed up. He said the female responder told him to keep doing compressions. He said two more emergency responders came into the room and they told us to continue CPR. Staff K, Nurse said EMS never did chest compressions. He said he was doing compressions when EMS walked in the door and only stopped when they told him to. He said EMS was sticking needles in her and sticking patches on and he thought it was unusual they didn't take over. He said EMS was only there about 5 minutes that's it. She was gone. He said he doesn't remember who all was in the room besides Staff I, Nurse and Staff L, Nurse but he does know the weekend supervisor (Staff N, Nurse) came up at some point. An interview was conducted on [DATE] at 10:26 a.m. with Staff N, Nurse, the weekend supervisor. She said she was not in the facility when Resident #1 coded. She said she left the facility between 11:00 a.m. and 12:00 p.m. that day. Staff N said there was no supervisor at the facility during the event and staff should have notified the ADON or DON. A follow-up interview was conducted on [DATE] 3:22 p.m. with Staff K, Nurse. Staff K said when the CNA called him to the room Resident #1 was lying on the floor unresponsive. He said he assessed the resident and went out to the nurses' station and got her chart to confirm her code status. He said the CNA stayed in the room while he went to the nurses' station, but the CNA did not do any CPR. He said Staff I, Nurse was sitting at the nurses' station and she called a code blue. Staff K then said he grabbed the emergency cart and took it in the room. He said he did a mouth sweep of the resident and that is when Staff L, Nurse got to the resident's room. He said Staff L, Nurse and himself did CPR on Resident #1. Staff K said Staff L, Nurse got there immediately and the two of them did the whole thing. No other nurse helped out. He said no one else performed compression and if anyone else told you something different that is totally incorrect. When asked who else was in Resident #1's room assisting with the code, Staff K said, I can't tell you. I didn't look around. An interview was conducted on [DATE] at 3:17 p.m. with Staff I, Nurse. Staff I said on [DATE] she worked the 7:00 a.m. to 3:00 p.m. shift. She said Resident #1 coded at shift change. She said she believed it was Staff J, CNA who let her know the resident needed help, but she doesn't remember her exact words. She said Staff K, Nurse checked on the resident while she checked the resident's code status. Staff I confirmed Resident #1 was a full code. She said Staff K, Nurse started CPR and another male nurse was in the room, but she didn't know what that nurse was doing. Staff I said she didn't know if there were any CNAs in the room. Staff I said, I believe he did CPR until EMS arrived. Staff I said she wasn't in the room; she was calling 911 and doing paperwork. She said the other nurses had the emergency cart in the room. Staff I said she did go in the room at some point but doesn't remember when. She said she was doing paperwork and calling 911. She said when EMS arrived, I handed off the paperwork and stepped out. Staff I said EMS did not ask her to assist with CPR. She said they came in and took over. Staff I said the resident was assigned to her that day. She said she saw her just before lunch and the aides said she was in the dining room and lunch ended around 2:,d+[DATE]:15 p.m. A follow-up interview was conducted on [DATE] at 3:49 p.m. with Staff I, Nurse. She said she confirmed the resident was a full code. She said when she went in the room Staff K, Nurse was doing compressions and Staff L, Nurse was giving the resident breaths, I did not pay any attention to if another nurse was on the floor. I saw [Staff K, Nurse] and [Staff L, Nurse.] Did not see another nurse hands on. When asked who was at the code cart Staff I stated, I was not paying attention to that. When ask if there were just a few people in the room or a lot of staff she said, I don't know how many people were in there. Staff I said she was not documenting and did not know who filled out the Code Blue Worksheet. She said she did not stay in the room. An interview was conducted on [DATE] at 4:29 p.m. with Staff L, Nurse. Staff L said he came in to work on [DATE] for his 3:00 p.m. shift. He said he heard the code called and went upstairs to help on the 300 unit. He said when he arrived Staff K, Nurse was assessing the resident and Staff I, Nurse was prepping the emergency cart. Staff L said he thinks there were some CNAs in the room too. He said Staff K, Nurse started CPR and I think I took the AMBU bag when Staff I, Nurse was taking it off the cart. He said, I might have taken over compressions then switched to the AMBU bag. That's probably what happened. Staff L said Staff K, Nurse was doing CPR on his own while everything was getting set up. He said a lot was going on, but they probably did 6 rounds of 15 compressions and 2 breaths before EMS got there. Staff L, Nurse said they were still following through with compressions when EMS got to the room. He said EMS wanted compressions to continue but said the nurse should stop using the AMBU bag. He said he didn't know why and maybe it was some new protocol. He said when the second EMS unit arrived, they took over compressions on Resident #1. Staff L said he does remember the female EMS responder talking about Staff K, Nurse not doing compressions correctly and could we get someone else to do it. He said, I think they were just upset about us doing the AMBU bag. Staff L said Staff I, Nurse was in the room when EMS arrived because he remembers going to stand in the corner with her. He said she was in the room pretty much the whole time. He said CPR was being done during the time I entered the room. I think it continued on until EMS took over. Staff L said they did roll the resident on her side to suction fluids in her mouth. He said he suctioned her once and Staff K, Nurse suctioned her once. Staff L said he and Staff K, Nurse were never just sitting on the bed, but he said he did sit on the bed at some point while he was using the AMBU bag on the resident. He said only he and Staff K, Nurse did compressions on the resident. He said no one else did compressions or helped position the resident. A follow-up interview was conducted on [DATE] at 10:50 a.m. with Staff L, Nurse. Staff L said when he got to Resident #1's room there were people in the room, but he did not know them because he has worked in the facility for less than a month. He said Staff K, Nurse initiated CPR, the resident was being assessed, and Staff K, Nurse was checking her pulse. He said Staff I, Nurse handed him the AMBU bag off the emergency cart. Staff L said he took over chest compressions and he and Staff K, Nurse switched between doing compressions and breaths and there was no one else assisting with CPR. He said at one point he was sitting on the bed while he was suctioning Resident #1. He said when EMS arrived, they told Staff K, Nurse to continue with compressions and Staff L, Nurse said he went and stood in the corner of the room beside Staff I, Nurse. He said one of the responders was rude to the staff and yelled about them not doing things right. He said, She was adamant and making comments like can someone else do this, does anyone know how to do this. I did not think much of it. An interview was conducted on [DATE] at 11:10 a.m. with Staff O, Nurse. She said she worked from 7:00 a.m. to 3:00 p.m. on [DATE] and responded to a code on the 300 unit. Staff O said the code was called three times over the speaker to Resident #1's room. She said when she got upstairs there were already quite a few people that had responded. Staff O, Nurse said when she got to Resident #1's room Staff K, Nurse, Staff L, Nurse, Staff P, Nurse, and Staff M, Nurse were there and Staff I, Nurse was on the phone. Staff O said the resident was lying on the floor and the emergency cart was in the room. She said Staff K, Nurse was on the lower end of the resident, Staff L, Nurse was on the top end of the resident, and Staff P, Nurse was grabbing supplies. Staff O said she grabbed the AMBU bag for Staff L, Nurse and Staff K, Nurse started compressions. She said she got on the floor and helped position the resident and tilt her head to get air. Staff O said Staff I, Nurse came back in the room and confirmed resident was a full code. She said Staff M, Nurse came in and asked if 911 had been called and asked if she could do anything to help. Staff O said at one point she took over compressions on Resident #1 from Staff K, Nurse to give him a break. She said Staff L, Nurse was doing the AMBU bag and Staff P, Nurse was grabbing supplies and paperwork. Staff O said EMS arrived and the staff continued CPR until EMS took over. She said the male responder took over compressions from Staff K, Nurse and a second EMS responder took over the AMBU bag from Staff L, Nurse. She said they were not asked to stop using the AMBU bag, they continued until EMS took it over. She said she was always taught to not stop CPR until EMS arrives and takes over. She said when EMS arrived, they could see that the staff were doing CPR. Staff O said while CPR was being done there was a little mucous/discharge that came to the resident's mouth so Staff I, Nurse grabbed the suction and Staff K, Nurse suctioned the resident only one time. A follow-up interview was conducted on [DATE] at 11:25 a.m. with Staff O, Nurse. Staff O said when she heard the code called, she ran to the room, grabbing gloves on her way. She said Staff I, Nurse was standing by the door of the nurses' station calling 911, the emergency cart was already in the room, and Staff K, Nurse, Staff L, Nurse, and Staff P, Nurse were already there. She said the resident was lying on the floor flat on her back. Staff O said Staff P, Nurse grabbed the AMBU bag off the cart and gave it to Staff L, Nurse. Staff O said she got down on the floor and held Resident #1's head in a tilt position, Staff K, Nurse was doing compressions, and Staff L, Nurse was giving breaths with the AMBU bag. Staff O said she yelled out to Staff I, Nurse and asked if EMS was coming because she was used to them responding faster. She said while Staff K, Nurse was doing compressions, she noticed there was some discharge in the resident's mouth and Staff L, Nurse said they needed to suction the resident. Staff P, Nurse was handing us supplies and Staff I, Nurse came back in the room grabbed the suction tubing, placed a yankauer catheter on the tubing and handed it to Staff L, Nurse, who quickly suctioned the resident and gave it back to Staff I, Nurse. Staff O said she switched with Staff K, Nurse and did compressions, but didn't do them for very long and she said she did not ever see Staff L, Nurse do any compressions. Staff O said they did not stop CPR and Staff K, Nurse was doing compressions when the first responders arrived. Staff O said the female medic told them to continue CPR and they didn't take over right away. She said Staff P, Nurse gave the medic the paperwork they needed, and the medic was asking their standard questions like how long the resident had been down. Staff O said a male responder arrived and took over compressions and another took over the AMBU bag. She said the female responder, who seemed to be the lead, was quite rude. Staff K, Nurse said to her, you don't have to be so [expletive] rude. She [the female responder] didn't respond. An interview was conducted on [DATE] at 12:18 p.m. with Staff P, Nurse. Staff P said the code for Resident #1 was called right at the end of her shift, around 3:00 p.m. on [DATE]. She said by the time she arrived in the room; several other nurses were there. Staff P said she asked if they needed anything and did they already do things like check code status, call 911, etc. She said they told her they did not need anything. Staff P said Staff I, Nurse, Staff, K, Nurse and Staff L, Nurse were in the room, but she did not remember if any CNAs were present. She said Staff K, Nurse was doing compressions, she doesn't remember seeing if anyone was giving breaths with the AMBU bag, and Staff I, Nurse was standing there, but Staff P doesn't know what Staff I, Nurse was doing. Staff P, Nurse said she helped get other residents from the hall to the dining room and said she did not help with any paperwork or handing off or gathering equipment. Staff P said she was not near the room when EMS arrived and was not in the room while EMS was there. A follow-up interview was conducted on [DATE] at 12:09 p.m. with Staff P, Nurse. Staff P, Nurse reiterated Staff K, Nurse was doing compressions and Staff L, Nurse and Staff I, Nurse were in Resident #1's room. She said Staff K, Nurse was the only person she knew was physically doing something. She said they all told her they didn't need anything. She confirmed she was not handing equipment or doing paperwork at any point and never went all the way into the resident's room. An interview was conducted on [DATE] at 12:36 p.m. with Staff Q, CNA. Staff Q, CNA said when the code was called on [DATE] for Resident #1 everyone went from the different units. She said CNAs do not perform CPR they just help keep other residents away from the area. She said Staff K, Nurse, Staff L, Nurse and Staff J, CNA were already there. Staff Q, CNA said she grabbed the emergency cart and she and Staff K, Nurse took it to the room. She said she didn't know if Staff K, Nurse had been in to assess the resident or not. She said Staff L, Nurse was next to arrive. Staff Q, CNA said she remembers hearing Staff K, Nurse talking about getting ready to do compressions, but didn't see who was doing CPR. An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON said she wasn't working the day Resident #1 coded. She said Staff J, CNA found the resident and told Staff I, Nurse and Staff K, Nurse to come to the room because something was wrong with the resident. The DON said the resident wasn't breathing and did not have a pulse so Staff I, Nurse called the code. She said everyone went to the room and Staff K, Nurse started CPR after the code status for Resident #1 was verified. The DON said they continued CPR until EMS arrived and then EMS took over compressions. She said the resident was declared deceased at the facility. The DON said the people involved were Staff J, CNA, Staff K, Nurse, Staff L, Nurse, Staff I, Nurse, Staff O, Nurse, Staff M, Nurse, Staff N, Nurse/weekend supervisor, and two other CNAs (Staff Q, CNA and Staff R, CNA.) The DON said Staff K, Nurse and Staff L, Nurse are the two that did CPR and the rest got items needed for them or helped get other residents out of the hall. The DON said Staff K, Nurse did CPR and Staff L, Nurse assisted, Staff I, Nurse called the code and 911, Staff P, Nurse got items they needed during the code and Staff N, Nurse/weekend supervisor was directing people what to do and who needed to do what. The DON said Staff M, Nurse was helping get people out of the room. When asked when she was informed of Resident #1's cardiac arrest, she said Staff N, Nurse /weekend supervisor called her from the facility while it was occurring or shortly after. The DON was informed Staff N, Nurse/weekend supervisor was not in the facility and she said, She didn't call me? Am I getting people confused? The DON confirmed someone from the fire department came to speak with her the day after the incident and wanted to speak with her about the code for Resident #1. She said EMS had some questions about a female staff member not assisting in the code. The DON said she asked him for a name and the circumstances around what happened, and she said he told her the females that wouldn't help were CNAs. The DON said she told him the CNAs are not trained in CPR and do not do CPR in the facility. She said he understood, and said he did not mention CPR not being done when EMS arrived. An interview was conducted on [DATE] at 3:10 p.m. with the DON. She said for a code blue she would expect there to be a nurse's note in the medical record to say what the scenario was. She said she wouldn't really expect the note to say who was involved or who did what. The DON said they have a Code Blue Worksheet that is filled out and is part of the medical record. At 3:30 p.m. the DON said she wanted to clarify that the Code Blue Worksheet is not part of the medical record. The Code Blue Worksheet for Resident #1 dated [DATE] was reviewed. The information on the sheet was incomplete and the times listed on the worksheet do not line up with the times EMS recorded as having received the 911 call and responded. The DON could not identify who filled out the Code Blue Worksheet provided. 2. Emergency Carts An observation was conducted on [DATE] at 9:44 a.m. of the 100 high hall emergency cart. The emergency cart was sitting in the hall directly across from the nurses' station. The oxygen tank meter on the cart showed the tank was only ,d+[DATE] full and the needle was pointing to where the red and yellow line met. (The yellow line indicated the oxygen tank was running low and the red indicated the tank was empty.) The cart contained an Emergency Cart Inventory Check List showing the following items should be in the cart: 1-Mobile Emergency Cart 2-Gloves 3-CPR backboard 4-AMBU bag 5-Charged Oxygen tank 6-Oxygen tubing 7-Nasal Cannula 8-Oxygen Mask simple 9-Oxygne Mask non-rebreather 10-Suction machine (set up with cannister and connection tubing ready to operate 11-Suction catheter (Yankauer) 12-Suction catheter (flexible) 13-Blood pressure cuff (large and small) 14-Stethoscope 15-Code Documentation form/Pad on clipboard 16-Pen Black ink (2) The 100 high hall emergency cart did not have a CPR backboard (#3) or a yankauer suction catheter (#11). The top of the cart was also soiled with dried liquid and debris. The Emergency Cart Inventory sheet showed the cart was signed off by a staff member daily from [DATE] to [DATE] as being verified that each item listed in the inventory was present and available for immediate use. (Photographic evidence obtained.) On [DATE] at 9:50 a.m. the cart remained with an oxygen tank only ,d+[DATE] full, with no backboard and no yankauer suction catheter. The Emergency Cart Inventory had been signed off as verified on [DATE]. (Photographic evidence obtained.) An observation was conducted on [DATE] at 9:51 a.m. of the main dining room emergency cart. The cart did not contain a small blood pressure cuff (#13), it contained two large cuffs. The Emergency Cart Inventory was signed off as verified on ,d+[DATE] to [DATE] and ,d+[DATE] to [DATE]. The cart had not been checked on [DATE] and [DATE]/24. (Photographic evidence obtained.) An observation was conducted on [DATE] at 1:35 p.m. of the 300 hall emergency cart. The cart was in the nurses' station behind a locked door, and it was being blocked by a cart with a drink cooler on it. The suction canister that was attached to the suction machine on the cart had been used and contained dried fluids. The cart did not contain a small blood pressure cuff (#13; it contained two large cuffs. Staff V, Nurse, came over and looked at the suction canister. She said it was disgusting and there is no reason for that. Staff V, Nurse, said the night shift staff checks the carts and makes sure they are stocked and clean. She said she doesn't know why this cart was signed off everyday with the used suction canister. Staff V, Nurse said she believed [DATE] was the last time the cart was used but she would have to check with the DON. (Photographic evidence obtained.) An interview was conducted on [DATE] at 1:24 p.m. with the DON. The DON confirmed the 300 hall emergency cart was last used on [DATE]. The DON confirmed on [DATE], two codes were called on the 300 hall: one around 7:00 a.m. and one around 3:00 p.m. When asked if the cart had been restocked and cleaned after the morning code she stated, I can't say that it was. The DON said the cart should be restocked with whatever was utilized during the code, ideally right after the code is completed. She said the emergency carts were checked by the night shift and they should check to make sure all items on the inventory are on the cart and available for use. When asked what level the oxygen tank should be, the DON said there is no policy to show when to change it. When asked if ,d+[DATE] of a tank of oxygen is sufficient she said, it is just supposed to be functional for use. She said if it turns on and works it is fine and if it ran out in a code someone would get another oxygen tank. Regarding the 300 hall suction canister being soiled, the DON said she doesn't know what happened with it sitting there. An interview was conducted on [DATE] at 9:47 a.m. with Staff S, Nurse, who was working on the 200 hall. She was asked where the emergency cart was located. She looked in the nurses' station and clean utility and was unable to find the cart. Staff S, Nurse asked Staff W, CNA, where the emergency cart was located and Staff W, CNA, said it was probably in the clean utility room. Staff W, CNA, checked and verified the emergency cart was not located t[TRUNCATED]

Based on record review, interview, and policy review the facility failed to perform ordered laboratory (lab) testing, failed to inform the provider of critical lab results and/or failed to carry out provider orders in response to critical lab results for two resident (#11 and #13) out of three residents reviewed for labs. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #11, and #13 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Finding included: 1. Resident #11 Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was readmitted on [DATE], after a hospitalization for a gastrointestinal bleed. According to a National Heart, Lung, and Blood Institute article titled, Thrombocytopenia, dated [DATE], Thrombocytopenia is a condition that occurs when the platelet count in your blood is too low. The article stated this can be life-threatening, especially if the patient had serious bleeding or bleeding in the brain, but early treatment could help avoid serious complications. The article explains bleeding causes the main symptoms of thrombocytopenia with signs including bleeding that last a long time, even from small injuries, petechia (small, flat red spots under the skin from blood leaking out of blood vessels), purpura (bleeding in your skin that can cause red, purple, or brownish-yellow spots) nosebleeds or bleeding from gums, or blood in urine or stool. (Accessed on [DATE] at https://www.nhlbi.nih.gov/health/thrombocytopenia) Review of medical records for Resident #11 showed a progress note, dated [DATE], saying the resident reported to the nurse she was vomiting on the floor inside her room. When nurse arrived in resident's room, she noticed a huge amount of coffee brown and red blood on the floor. The resident denied any pain, discomfort, or shortness of breath. This nurse immediately called the doctor and received orders to send the resident to the hospital for evaluation and treatment. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 3008), dated [DATE], showed Resident #11 was diagnosed with an upper gastrointestinal (GI) bleed and needed to have Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) labs drawn in ,d+[DATE] days. Discharge instructions noted the resident had a transfusion of 2 units of packed red blood cells (PRBC) on [DATE]. The plan was to follow-up with the primary care provider in ,d+[DATE] days, follow-up with a Gastroenterology physician in 2 weeks and follow-up with a cardiology physician. Review of labs drawn at the facility on [DATE] for Resident #11 had the following results. White Blood Cell (WBC) 1.1 ref range 3XXX,d+[DATE].8 Critical Low Red Blood Cell (RBC) 2.84 ref range 3XXX,d+[DATE].20 Low Hemoglobin (Hgb) 8.9 ref range 12XXX,d+[DATE].6 Low Hematocrit (Hct) 25.8 ref range 35XXX,d+[DATE].0 Low Platelets (PLT) 34 ref range ,d+[DATE] Critical Low Review of Resident #11's medical record did not show any documentation a provider was notified, or any new orders were put in place related to the critical lab results from [DATE]. The Director of Nursing (DON) provided a copy of the lab results showing they were faxed from the lab to the facility on [DATE] at 12:35 p.m. and Resident #11's primary care provider signed the results as being reviewed by him on [DATE]. At that time, he put in a stat (immediate) order to repeat the labs. Review of labs drawn on [DATE] for Resident #11 had the following results: WBC 1.1 ref range 3XXX,d+[DATE].8 Critical Low RBC 2.81 ref range 3XXX,d+[DATE].20 Low Hgb 8.8 ref range 12XXX,d+[DATE].6 Low Hct 25.5 ref range 35XXX,d+[DATE].0 Low PLT 23. ref range ,d+[DATE] Critical Low Review of medical records for Resident #11 revealed a progress note on [DATE] showing On Call MD [doctor] for [primary care provider (PCP)] notified regarding resident CBC critical lab result. Order received for Hematologist consult. Review of physician orders revealed an order dated [DATE] for a Hematologist consult for critical WBC 1.1, Platelet count 34 every day shift for Critical lab result. This order was a verbal order given by the on-call provider notified on [DATE] of critical lab values. Review of physician orders from [DATE]-[DATE] revealed no orders for the resident to follow-up with a gastroenterologist within two weeks of hospital discharge (by [DATE]) or for a cardiology consult per hospital discharge instructions. The orders did not show any antiretroviral therapy (ART) treatment in place for the resident and no lab orders to check the resident's immune deficiency syndrome status. Review of Resident #11's [DATE] Medication Administration Record (MAR) showed the order for Hematologist consult was signed off as completed by the nurse daily from [DATE] to [DATE]. However, there were no progress notes indicating a hematologist had been consulted, no appointment scheduled for the resident to see a hematologist, and no doctor notes showing a hematologist had seen the resident. Review of Resident #11's medical record did not show any interventions or orders in place to monitor the resident for signs and symptoms of bleeding related to the critically low platelet counts. Review of Resident #11's medical records showed a progress note, dated [DATE] 3:00 p.m., revealing the resident was found unresponsive without pulse or respirations in her room at approximately 2:16 p.m. on [DATE]. A code blue was called, CPR was initiated after code status was verified. Emergency Medical Services (EMS) arrived and took over care and continued with CPR. EMS pronounced the resident expired at 2:48 p.m. Review of medical records showed a Social Services note, dated [DATE] that said Resident #11 is alert and oriented and can make her needs known. The resident reported to Social Services she lived in shelters, and she would like to improve her health. Review of Resident #11's Psychosocial History and Assessment, dated [DATE], showed the resident was previously homeless, but said she was adjusting and felt safe in the facility. The resident's goals for her stay were to maintain her health and medications. The Assessment also showed the resident reported transportation had kept her from medical appointments or from getting medications. It also noted the resident was cooperative, pleasant, and motivated. An interview was conducted on [DATE] at 4:28 p.m. with the Social Services Director (SSD). The SSD stated she remembered Resident #11. She said the resident mostly kept to herself but was starting to engage a little more. She said the resident came in as a homeless person and it seemed like she had a difficult life but was happy to be here. The SSD said she knew the resident had an immune deficiency syndrome but did not discuss it with her. The SSD said, I know she wanted to get stronger. She was not resistive to care. She said she was not aware of the resident ever refusing medications, She wanted to live. She just wanted to get better. An interview was conducted on [DATE] at 12:04 p.m. with Staff G, Nurse Staff G said she completed the initial admission assessment for Resident #11. Staff G said Resident #11 would walk around like normal, she was very nice and didn't refuse medication or care. She said the resident had been homeless and was super thankful to be here. An interview was conducted on [DATE] at 5:34 p.m. with the Assistant Director of Nursing (ADON). The ADON said for critical lab results, the nurse is expected to call the resident's provider right away. She said the nurse should notify the provider of all labs, but critical labs require an immediate response. The ADON said the nurse assigned to the resident should also contact the doctor for follow-up. The ADON said she was not aware of any concerns related to Resident #11's labs. An interview was conducted on [DATE] at 10:52 a.m. with a lab technician (tech), who worked for the laboratory (lab) processing the facility's lab orders. The lab tech said when lab results are critical, the nurse caring for the resident is called and if they cannot reach the nurse caring for the resident, they ask for the Director of Nursing (DON.) If the DON is not reachable, they call the receptionist and ask for a nurse. He said if they still get no response, they fax the facility and ask for them to call the lab. He said the lab results are also faxed to the facility, even when a call is made. The lab tech reviewed Resident #11's lab work and said on [DATE] the resident had critical results and Staff F, Nurse was notified on [DATE] at 1:40 p.m. The lab tech also confirmed Resident #11 did not have any labs drawn related to her immune deficiency syndrome, she only had a CBC and CMP. An interview was conducted on [DATE] at 3:47 p.m. with Staff F, Nurse. Staff F said Resident #11 was a very pleasant, very nice lady and was very mobile and cooperative with care. She said on [DATE] she was not notified of Resident #11's critical lab results. Staff F said on [DATE] she saw critical lab results for Resident #11 and her primary care provider was in the building, so she had him review and sign the results. Staff F said I got so busy, I always put a note in. I forgot to put the note in the computer. Staff F said it is difficult because Unit Mangers follow up on labs but get put on the medication cart to work and someone else is supposed to take care of those duties. She said there needs to be a better process in place for the Unit Manger job duties for when unit managers are working on the medication cart. Regarding Resident #11 she said, We failed her. An interview was conducted on [DATE] at 1:10 p.m. with Staff E, Nurse. She stated Resident #11 was calm, compliant, and cognitively aware. She said the resident could walk around the facility independently but did like being in her room. Staff E, Nurse said when a resident had critical lab results, the lab would call the nurse and fax the results. She said the nurse then calls the provider's office immediately, even if it is after hours. Staff E, Nurse said after Resident #11 had critical lab results on [DATE] she saw a hematology consult was ordered, but she said on her screen it only showed a consult is needed, it did not show her it was related to critical lab values. Staff E, Nurse said she believed the consultation was a follow-up. Staff E, Nurse reviewed the order in the resident's electronic medical record and confirmed the order showed the consultation was for critical labs, she reiterated it does not show up like that on the nurses' screen, it only shows a consult is needed and does not provide the order details. She said she reached out to a couple of hematology offices and was waiting to hear back. She said she didn't document anything because there wasn't an appointment scheduled. Staff E, Nurse said if she had known the consultation was for critical labs, she would have made more attempts, documented, and reached out to the primary care provider to let them know there wasn't an appointment yet. Staff E, Nurse confirmed there was no monitoring in place related to signs and symptoms of bleeding for Resident #11. Staff E, Nurse said on [DATE] Resident #11 mentioned she wasn't feeling good. The facility had some residents with COVID-19, so they did a COVID test around 1:30 p.m. and it was negative. Staff E, Nurse said she called the doctor, and a chest x-ray was ordered. When the x-ray technician showed up, they found the resident unresponsive in bed. An interview was conducted on [DATE] at 10:10 a.m. with the DON. The DON reviewed Resident #11's electronic medical record regarding critical lab results. The DON said, I don't see anything written, related to the critical lab values on [DATE]. She said she thinks Staff F, Nurse talked to the provider, but she confirmed nothing was documented. The DON said for critical lab values, they receive a call and a fax from the lab. She said the fax goes directly to the nurses' station and the nurses know to check for faxes. The DON said the doctor should be notified immediately. She said management does look at results and if there are orders they follow up to ensure those were completed. The DON said I think that is why the Unit Manager, Staff F, Nurse, spoke to the nurse practitioner about the labs, I just don't see a note. Regarding the hematology consult for Resident #11, the DON said she believed one of the nurses was working on getting an appointment, but I don't see it documented. The DON confirmed the lack of action for the critical labs was a problem. The DON said with these critical lab values she would have expected monitoring for signs and symptoms of bleeding to have been in place. She reviewed the medical record and confirmed the monitoring was not in place for Resident #11. An interview was conducted on [DATE] at 2:41 p.m. with Resident #11's PCP. The PCP said he was aware of the resident, but he believed his nurse practitioner saw her. Regarding Resident #11's critical lab results on [DATE], the PCP said he was not notified of the critical lab results when they came in. He said a week or so after that (he said he didn't remember the date), he saw the results. He said when he first saw the lab results, he wanted to send Resident #11 to the hospital, but the results were so old, so he ordered repeat labs. The PCP said he didn't hear anything back and when he went to check on the resident's labs again, he was notified she died . An interview was conducted on [DATE] at 5:00 p.m. with Resident #11's PCP's Advanced Registered Nurse Practitioner (ARNP.) The ARNP said she saw Resident #11 last on [DATE] and she was not in any distress. She said the resident was cooperative with care and there had not been any non-compliance reported. The ARNP said she was not notified of Resident #11's critical lab results on [DATE]. She said if something was abnormal, she would expect to have been notified. The ARNP said she receives notifications from facilities on an application program (app) her practice uses or on her text messages. She reviewed her provider app and text messages and confirmed she had no notifications related to Resident #11's critical labs on [DATE]. She said, I rely on staff to let me know if anything needs a STAT response. They have my number. I know she was at high risk with such low numbers. That was kind of missed. It is unfortunate. The ARNP confirmed she was working on [DATE] and would have been available if staff contacted her. As for the critical lab results on [DATE] for Resident #11, she said she did not see those labs, but the response for the resident to see a hematologist should have been STAT. The ARNP said she would have personally sent the resident to the hospital with her platelet count below 40. 2.Resident #13 Review of the Admission Records showed Resident #13 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease and epilepsy. Review of medical records showed Resident #13 had a care plan in place for Seizure Disorder, dated [DATE]. Interventions to include Obtain and Monitor lab/diagnostic work as ordered. Report results to doctor and follow up as indicated. Review of Resident #13's physician orders showed the following active orders: -Levetiracetam (Keppra) oral solution 100 milligram (mg) per milliliter (ml) Give 12 ml in the evening for seizure, dated [DATE] -Levetiracetam 100mg/ml Give 14 ml one time a day for seizures, dated [DATE], -Keppra level every 6 months starting on the 5th for 1 day, dated [DATE]. Review of Resident #13's [DATE] Treatment Administration Record (TAR) showed the Keppra level lab was due on [DATE]. It was signed off on the TAR as completed. Review of the Facility Lab book that is kept at the nurses' station contained a Lab Monitoring Sheet, dated [DATE], showing Resident #13's Keppra level was to be drawn that day. The lab was not signed off by the phlebotomist as being drawn. There was no documentation on the Lab Monitoring Sheet or progress notes to indicate the resident refused the lab draw. Review of Resident #13's Quarterly Minimum Data Set (MDS,) dated [DATE], Section C, Cognitive Patters, showed he had a Brief Interview for Mental Status (BIMS) score of 3, indicating a severely impaired cognition. He was unable to be interviewed. An interview was conducted on [DATE] at 1:05 p.m. with Staff H, Nurse. Staff H reviewed the Lab Monitoring Sheet for [DATE] out of the lab book. She then logged into the laboratory company's website and confirmed the last lab for Resident #13 was drawn in [DATE]. Staff H reviewed Resident #13's physician orders and confirmed it should have been drawn on [DATE] and it was not completed and there was no documentation as to why. Staff H said this lab was scheduled to be drawn on a Saturday and the missed lab should have been caught when it was reviewed by management on Monday morning. An interview was conducted on [DATE] at 1:38 p.m. with the DON. The DON said each unit had a lab book where lab orders were listed. She said the lab tech draws the lab and signed it off in the book each day on the Lab Monitoring Sheet. The unit managers then took the daily lab monitoring sheet out of the book and made a copy of it. The original daily lab monitoring sheet was returned to the book and the unit managers used the copy to check off each section of the lab sheet (i.e. results, doctor notified, results in chart, orders received, noted in chart, and comments) as it was completed. The DON confirmed the copied daily lab monitoring sheet was not reconciled with the lab monitoring sheet in the lab book. She said the unit managers brought the copied sheet to the morning meetings where the management team reviewed labs. The completed sheets were given to the DON. She agreed a nurse would not be able to see if all the steps were completed if they checked the daily lab book. The Regional Nurse Consultant (RNC) pulled up Resident #13's medical record and confirmed his lab had not been completed as ordered. The DON said she didn't know how that happened and why it wasn't reviewed and caught. An interview was conducted on [DATE] at 3:05 p.m. with the facility's Medical Director. The Medical Director stated he would expect critical lab values to be responded to the day the facility receives them. He said the nurse should reach out to the resident's provider and if they do not get a response, they should call him. The Medical Director said for critical lab values, staff can always call him, and the resident could be sent to the emergency department for acute care. He said if staff had concerns or did not get an appropriate response from the resident's doctor, they should let me know. He said he would expect there to be documentation in a resident's record anytime a provider was contacted, or an attempt was made. The Medical Director said he would be addressing these concerns with the facility. Review of a facility policy titled Laboratory Services, effective [DATE], showed the following: Policy: The facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provided by the facility or an outside agency. The laboratory selected to perform the tests will be Medicare approved. Procedure 1. Assure laboratory tests or[sic] completed and results provided to the facility within timeframes normal for appropriate intervention. 2. Provide or obtain laboratory services only when ordered by a physician. 3. Assure Nursing notifies the physician promptly of the findings. 4. Assist the resident/patient in making transportation arrangements to and from the laboratory if specimen is unable to be obtained at the facility and if the resident/patient needs assistance. 5. Assure the laboratory reports submitted by the laboratory and filed in the resident/patient's clinical record contain at least the following: a. Date b. Resident/patient name c. Name and address of the testing laboratory 6. Monitor services, timelines, and quality through the Quality Assurance Committee. Facility immediate actions to remove the Immediate jeopardy included: 1.Regional Nurse Consultant completed education on the lab monitoring process with the facility Administrator, Director of Nursing, and Assistant Director of Nursing. 2.Director of Nursing and Assistant Director of Nursing completed education with licensed staff related to the daily lab monitoring process on [DATE]. Education included the lab monitoring process. Lab requisitions are listed on the monitoring form by the licensed nurse, the phlebotomist signs the entry when lab is drawn, the facility nurse upon receipt of the lab results notifies medical provider of any critical results. The nurse then completes the lab monitoring form which includes documentation of the notification in the medical record. The lab monitoring binder which contains the daily forms is brought to the clinical meeting and reviewed for completion by nursing leadership. 91% of Licensed Staff were educated regarding the lab monitoring process. The remaining 3 licensed nurses will receive the education prior to starting of their next shift. 3.This was completed on [DATE]. Verification of the facility's removal plan was conducted by the survey team on [DATE]. An interview was conducted on [DATE] at 3:50 p.m. with the DON, Regional [NAME] President (RVP), and Regional Nurse Consultant (RNC.) Copies of all education provided to staff were reviewed. They confirmed all nurses were educated on the process of ensuring labs were completed as ordered, reporting critical lab values, and following up on physician orders. The RNC confirmed they educated the Nursing Home Administrator and the DON. The RVP stated the facility was not correctly following the lab process. Interviews were conducted and education confirmed for 34 out of 34 nurses. Nurses signed in-service education and/or were able to state that they had been trained and were knowledgeable about the policies. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E.

Based on observation, interview and record review, the facility failed to identify and notify the physician of elevated laboratory results for one Resident #207 of the 43 sampled residents. Resident #207's physician ordered repeat labs on 12/13/19 after reviewing elevated lab results on 12/12/19. The 12/13/19 labs were received reflecting a further increase in white blood cell counts; the facility failed to follow through and notify the physician from 12/13/19 to 12/18/19. During chart review on day three of the re-certification survey, the 12/13/19 labs were identified without physician notification or follow up. The facility then obtained stat (immediate) orders for lab testing on 12/18/19. The results of the stat lab tests identified critical values resulting in Resident #207's transfer to the hospital. Findings Included: Review of Resident #207's record reflected the resident admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #207's laboratory results dated [DATE] collected at 5:30 a.m. showed: white blood cell count of 12.4 K/uL (normal 3.8 to 10.8), red blood cell count of 3.09 M/uL (normal 4.40 to 5.80), hemoglobin *verified by repeated analysis 8.5g/dL (normal 13.8 to 17.2), hematocrit 26.1% (normal 41.0 to 50.0). Written at the bottom of the lab results reflected a message for the ARNP (Advanced Registered Nurse Practitioner) left at 2:03 p.m., and also: Please do serum and urine osmolarity, urine sodium, CMP (comprehensive metabolic panel) and CBC (complete blood count) in am and send FOBT (fecal occult blood test) times 3, signed the physician on 12/12/19. Review of Resident #207's laboratory results dated [DATE] collected at 5:20 a.m. showed: white blood cell count of 14.5 K/uL (normal 3.8 to 10.8), red blood cell count of 3.26 M/uL (normal 4.40 to 5.80), hemoglobin 8.8 g/dL (normal 13.8 to 17.2), hematocrit 27.4% normal 41.0 to 50.0) an arrow next to the WBC reflected the lab was higher and out of range without a signature or new orders. Review of Resident #207's laboratory results dated [DATE], 2:00 p.m. completed stat (immediate) showed: white blood cell count of 26.4 K/uL (normal 3.8 to 10.8) Critical High * verified by microscopic examination, red blood cell count of 3.44 M/uL (normal 4.40 to 5.80), hemoglobin 9.3 g/dL (normal 13.8 to 17.2), hematocrit 28.3 % (normal 41.0 to 50.0). During an interview on 12/18/19 at 10:37 a.m., staff member A, LPN confirmed that he wrote a progress note on 12/13/19 at 2:27 p.m. after leaving a message for the nurse practitioner and stated that he would have given the oncoming nurse that report and expected them to follow up. Staff member A, LPN stated he did not work the weekend and was not aware that the labs were not followed up on. During an interview on 12/18/19 at 10:47 a.m. the Director of Nurses (DON) was notified of the abnormal lab result from 12/13/19 and stated, the nurses review the labs and notify the physician of the results. If there are no new orders the labs go in the physician box to sign, then in the resident's chart. If the nurse has new orders or does not get a response, they continue to call back and notify of the results and document in a progress note. During an interview on 12/18/19 at 11:02 a.m. with the resident's nurse practitioner, she stated she was in earlier today and did not see the labs from 12/13/19. She stated that she was told by the nurse that the resident's vitals were stable and gave orders to pull the PICC (peripherally inserted central catheter) intravenous line. The nurse practitioner stated that she saw the resident but was not aware of the 12/13/19 labs as they should have been faxed to the office and placed in the chart. The nurse practitioner stated if the labs were elevated they should have been ordered daily until they were at baseline or under 10 for the white blood cell count and she was unaware that labs were redrawn on 12/13/19. The nurse practitioner stated she saw the resident and that her notes must be at the office still. The nurse practitioner stated that she will have the office send her notes over and will contact the nurse to reorder stat labs. She stated that she was told the labs were lower and ordered the PICC line to be removed due to the information she received from the nurse. Review of the note from a physician or nurse practitioner obtained via fax from the nurse practitioner's office on 12/18/19 at 12:10 p.m. The follow-up note reflected the nurse practitioner did not document lab information received, reviewed or plan of care, documented the resident was alert and oriented times 3 with normal cranial nerves II to XII, normal sensation and strength. Heent/Neck: no neck stiffness or pain, Musculoskeletal: no limitation in motion, no muscle or joint pain, no muscle weakness, no swelling or redness in joints. Neurologic: good coordination, good memory and speech, no numbness and tingling. During an interview with Staff member A, LPN on 12/18/19 at 12:00 p.m. he stated the labs get ordered online and go in the lab book. Staff member A, LPN stated that he does not fax results to the physician's office unless they are completely normal. Staff member A, LPN stated that he never faxed the 12/13/19 results to the physicians office, just called and left a message with the ARNP and let the oncoming nurse know that a message was left. During an interview with the DON on 12/18/19 at 12:13 p.m. she stated the nurse has the ability to go online and check the labs. The DON went online and printed the labs. During an interview with with Resident #207's Physician on 12/19/19 at 2:55 p.m., he confirmed he was in the building on 12/12/19 and saw Resident #207's labs from 12/12/19 and ordered repeat labs to be done on the 13th. The physician stated he did not evaluate or review the resident's information. He confirmed the labs were all that he looked at and the nurse stated Resident #207's vitals were stable. The physician said that when the labs done on 12/13/19 were reviewed the facility should have called the on call person to let them know the results. The physician stated he comes to the facility every Thursday but did not evaluate the new resident or documents other than the labs from 12/12/19. The physician stated he could not see Resident #207 on 12/12/19 due to receiving 7 to 10 new admissions that day and was not able to see them all. The physician restated the nurse told him the vitals were stable and he would normally see all new residents but that day he had about 8 to 10 new admissions. The physician stated he was unsure of how often the ARNP comes. The physician stated he ordered labs for the next day and never heard about the resident after 12/12/19. During observation of Resident #207 on 12/16/19 at 10:30 a.m., the resident was noted in a double room without isolation precautions. Resident #207's name was not posted at the door. Resident #207's bed and feet could be observed from the doorway. After knocking and asking the roommate for permission to enter, Resident #207 was observed on an airmattress with the head of the bed elevated, a [MEDICAL CONDITION] covered in brown thick mucous with oxygen at 2.5 liters and humidity set at 35%. The urine draining from the catheter was noted a straw yellow. The tube feeding set at 75 ml per hour with 675 ml infused of fibersource HN. During the observation of Resident #207, staff member A, LPN walked in through the adjoining restroom and asked if anything was needed. Staff member A, LPN was asked about the thick brown mucous from the [MEDICAL CONDITION] and confirmed the resident needed suctioning and was unsure of the residents orders for oxygen and humidity as the resident was admitted last week. Staff member A, LPN observed hand washing and donning gloves then suctioning the thick brown mucous with a [MEDICATION NAME] suction (oral suction tool)to the [MEDICAL CONDITION] and surrounding area. Staff member A, LPN stated the resident did not need deep suctioning and the [MEDICAL CONDITION] changed weekly not daily. Staff member A, LPN completed the suctioning with the [MEDICATION NAME] then doffed gloves and washed hands. Staff member A, LPN did not listen to the residents lungs and stated that he did not like to perform deep suctioning often as he felt it was not needed. He left the room to verify the orders of the oxygen and humidity and returned stating the orders were for 2 liters of oxygen, humidity at 28% and deep suction or [MEDICATION NAME] suction as needed. Staff member A, LPN confirmed the PICC line dressing on Resident #207's left upper arm was dated 12/8/19 and confirmed the dressing was past the date it should have been changed. Staff member A, LPN stated the PICC line was not being used and would be discontinued due to improving or stable white blood cell count although the white cell count still remained elevated. During an interview on 12/16/19 at 11:31 a.m. with staff member A, LPN he confirmed new orders for a chest x-ray related to the dark colored mucous from the [MEDICAL CONDITION] and confirmed the PICC line dressing was changed. During an interview on 12/19/19 at 8:15 a.m. with staff member B, LPN she confirmed Resident #207 was sent out to the hospital for critical labs but she had not worked with him. Review of the progress notes dated 12/18/19 at 6:30 p.m. reflected the nurse documented the resident sent out to the hospital by the ARNP for critical labs and the resident's mother was in the building at the time and notified. Review of the 12/18/19 progress note at 1:26 a.m. reflected the resident was admitted to the hospital [MEDICAL CONDITION], pneumonia, UTI and abnormal labs. During an interview on 12/19/19 at 11:51 a.m. with the Director of Nursing (DON) she confirmed that the resident was sent to the hospital for elevated labs and confirmed his last labs were completed on 12/13/19. The DON stated that she had begun inservicing on [MEDICAL CONDITION] care, IV care and following up on labs. Review of in-service training completed on 7/19/19 reflected lab services/physician included Notification of the physician on any abnormal lab results, Physician should be made aware of all critical labs immediately. If unable to reach physician within two hours of stat labs or critical lab values, contact facility medical director for further orders. Review of the notification of resident/patient change in condition policy from clinical guidelines manual 5.1.1, one page dated 2/19 reflected 1) Notify the physician resident/ resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. a) If the nurse responsible for the care of the resident is remaining with the resident and us unable to place the telephone calls, another nurse will place the calls. 2) Document the Nurse's notes, the time of notification was made and the names of the person(s) to whom you spoke.

Based on review of the facility's policies and procedures for Advance Medical Directives, Code Status Orders & Response, interviews with the Resident's family member, facility staff and Resident ' s physician, review of the Resident's medical record including the Nursing Daily Skilled notes, Psychosocial History and Assessment and physician orders [REDACTED].#144) of 76 residents identified as having orders to be Fully Resuscitated according to an audit of all current resident records performed by the facility on [DATE]. Resident #144's son had participated in the admission process and relayed the information contained in the medical record that, if his mother was found with no pulse or respirations, the family's wish was that she receive CPR. The medical record contained a physician order [REDACTED]. The facility failed to follow their Policy and Procedure for Advance Medical Directives and their policy for Code Status Orders & Response. Findings of on-going Immediate Jeopardy were identified on [DATE]. Findings include: 1. Review of the facility's Policy titled Advance Medical Directives, S.S.4.2, effective [DATE], revealed; Topic Advance Medical Directive, Policy: Advance Directives and Do Not Resuscitate (DNR) Procedure; Admissions: 1. Verify that information on Advance Directives was provided to the resident/patient and/or family/legal representative at the time of admission. 2. Obtain any current Advance Directive from the resident/patient and/or family/legal representative and place in the medical record. 3. If a Do Not Resuscitate (DNR) status is elected, place the yellow DNR form in the medical record once completed. 4. Obtain physician's orders [REDACTED]. 5. Document the current Advance Directive in the medical record. 6. Record and update Advance Directive/DNR Log upon admission, quarterly or with change in condition. 7. Provide further information to the physician regarding Advance Directive when requested by the resident/patient, family and/or legal representative. 8. Update the medical record with new or revised Advance Directive as indicated. 9. Review the medical record at least quarterly and document verification of Advance Directive in place in the progress notes. Review of the facility's Policy and Procedure - Florida titled " Code Status Orders & Response ADM 11.1, no effective date, revealed the following: " Policy, The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support CPR only. No advanced life support services are offered in the facility or by facility staff. DNR order - the resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 document should not be placed in the resident's chart as the DNRO is not valid. " "Procedure for initiating CPR: Personnel First nurse on the scene Procedure 1. Confirms cardiac/or respiratory arrest. 2. Calls for help. 3. Checks airway and pulse and connect the oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. Point of Emphasis Call HELP loudly, even is no one is in sight. CODE status must be confirmed by checking the medical record. 2. Review of the medical record face sheet, dated [DATE], for Resident #144 indicated that she was [AGE] years old and the admitted was [DATE]. The responsible party listed for the Resident was herself and two sons were listed as emergency contacts. Review of the [DATE] Minimum Data Set (MDS) assessment revealed the Resident was admitted from an acute care hospital, the Resident did not participate in the assessment. The family or significant other participated. Her [DIAGNOSES REDACTED]. Her functional status was total dependence on staff with two persons assist for transfers, dressing, toileting and hygiene. 3. Review of the Resident's Advance Directives care plan, initiated on [DATE], revealed; Resident/authorized responsible party request FULL CODE wish to be honored. 4. Review of Resident #144's medical record revealed a verbal physician's orders [REDACTED]. 5. Review of Resident #144's medical record revealed a Psychosocial History and Assessment, dated [DATE], by the Social Services Director, the Advanced Directives section indicated the Resident's code status was " Full Resuscitate " ; the Resident's son was listed as her family support person. 6. Review of Resident # 144's medical record [DATE] Daily Skilled Note revealed: "Resident noted with no respirations, no blood pressure, physician and son called, new order received to release the body to the funeral home of choice. The note was signed by Employee L. There was no indication in the nurse's notes or the medical record that Cardio [MEDICAL CONDITION] Resuscitation (CPR) was performed or an attempt was made to resuscitate the resident." 7. A telephone interview with the Resident #144's son on [DATE], at 10:15 a.m. revealed that he was not aware that the facility did not perform CPR on his mother when she was found without a pulse or blood pressure. He stated he did not want his mother to be a Do Not Resuscitate (DNR) that she would open her eyes and look over when you talked to her and she was getting slightly better. He stated we (he and his brother) definitely wanted them to resuscitate her. 8. An interview was conducted with the Social Services Director on [DATE] at 8:06 a.m. She stated that Resident #144's record reflected that her status was " FULL CODE " and " FULL CODE " was also written in the care plan. She reviewed the Activities Assessment and relayed the information that the Resident was born in Kentucky, was a waitress, a home health aide and a Spiritual reader, she was divorced and had three children. She stated that she had spoken to the family on the Resident's first admission on [DATE] and that if the family had wanted a Do Not Resuscitate (DNR) status in place they would have made sure the facility knew about it. She was aware from her conversations with the Resident's two sons that they wanted their mother to receive CPR. They had told her that their mother had been very ill before and had bounced back and they were holding on to hope for her. She stated again that if they were ready for the DNR status they would have made sure she had a DNR in place 9. An Admission Minimum Data Set Assessment was completed for the Resident on [DATE]. The question " Does the Resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? " was answered NO. 10. An interview was conducted by phone on [DATE], at 11:32 a.m., with Employee O, the CNA assigned to the Resident. She stated that she had worked for the facility for 5 and ,[DATE] years and had been a CNA since 2001. She previously worked in another department. She worked full time on the ,[DATE] shift and worked all the units in the facility. She stated she was familiar with the Resident, that the Resident had a [MEDICAL CONDITION]; she opened her eyes but did not talk. She stated that she performed patient care on the Resident around 9:00 a.m. with Employee N. The Resident was breathing at that time. She stated that at approximately 11:00 a.m. she entered the resident's room to put linens in the room. The Resident was breathing at that time. She then went on her lunch break. She stated that when she returned from lunch the nurse told her that the Resident had passed away and instructed her to help the other CNA clean the body. She stated that the facility policy on a resident discovered without a pulse or respirations was that the CNA should call for help. She stated that if a resident had a DNR yellow paper in their chart they would not do CPR, if not they were to perform CPR. She stated that she was at home because she had been suspended. 11. An interview was conducted by phone on [DATE], at 11:20 a.m., with Employee N, the CNA who discovered the Resident without a pulse. She stated that she had worked for the facility for [AGE] years and had been a CNA for [AGE] years. She was regularly assigned to the Resident's unit but was not Resident #144's CNA that day. She stated that she and the Resident's assigned CNA performed care for the Resident at approximately 9:00 a.m. The Resident was breathing at that time. She checked on the Resident at 11:45 a.m. because the Resident's CNA was at lunch. She discovered the Resident was not breathing and called the nurse. She stated the nurse came and then went out to get help. She reported that she stayed with the Resident the whole time. She stated that the policy for CNAs was to call the nurse if they discovered a resident without a pulse or respirations. She stated she had been suspended since the incident. 12. An interview with Employee L, the nurse assigned to the Resident, was conducted on [DATE], at 10:02 a.m., by telephone. She stated that she had been an RN for 11 months and she had worked at the facility for [AGE] years. She worked full time usually on the day shift. She stated that she was a "floater" and worked all the units. She stated she was familiar with the Resident who had been sent out to the hospital and had been back for a week. She stated that she went into the Resident's room when the CNA (Employee N) who discovered Resident #144 without a pulse or respirations called for help. The Resident had no heart rate, no respirations and her lips and nails were blue. She stated that when she came out of the room the RN Supervisor had arrived on the unit. The RN Supervisor was holding the Resident's chart and gave the instruction to call the Resident's physician. Employee L stated that she thought the Resident had a DNR status because the RN Supervisor instructed her to call the physician. Employee L confirmed that she was aware of the facility policy to check a resident's DNR status in the chart to determine if the resident wished to have CPR or not. She stated that she had not returned to the facility since the incident because she was suspended. Review of Employee L's personnel file revealed she had been hired on [DATE] as a LPN. She had an active RN license with a renewal date of [DATE] and an active CPR certification expiring on [DATE]. There were no disciplinary actions in her file. 13. An interview was conducted by telephone on [DATE], at 10:51 a.m., with Employee M, the RN Supervisor on duty at the time of the incident. She stated she had been an RN since 1995, had worked for the facility for [AGE] years and was currently working part time on weekends only. She stated that she was in a resident's room when she was paged to Station 2. She could not recall exactly how much time it took her to get to Station 2. She stated that when she got there the nurse for the Resident, Employee L, told her the Resident had expired and that she had called the family and informed them of the death. She stated that she assessed the Resident and found her to have no pulse or respirations. She looked in the chart and did not see a yellow DNR paper or information in the progress notes about a DNR status. She stated that facility policy required staff to check a resident's chart for a yellow DNR paper and perform CPR if no DNR paper was in the chart. She stated she did not know why the Resident did not receive CPR but at that point the family had been informed of the Resident's death and was on the way to the facility. She stated that she was suspended immediately after the incident and then was asked to return the same day only for training on the Code Policy and Advanced Directives Policy. She has been away from the facility since the training due to the suspension. Review of Employee M's personnel file revealed she was hired on [DATE] as a Weekend Supervisor. She had an active CPR certification that expires February 2015. There were no disciplinary actions in her file. 14. An interview was conducted on [DATE], at 12:55 p.m. with the Advanced Registered Nurse Practitioner (ARNP), on call for the Resident's physician. She was the first provider notified of the Resident's death. She stated that a nurse called her and informed her that Resident #144 had died . She gave orders to notify the family and release the body. She stated that the facility did not tell her they had not initiated CPR. She stated that if the Resident was found without a pulse or respirations they should have automatically done CPR and called the paramedics. She stated that she was called later that day, informed that the facility did not perform CPR and was asked by the nurse to write a DNR order. She told the nurse that a DNR order is not written after the fact. 15. An interview was conducted on [DATE], at 1:05 p.m. with the Resident's physician by telephone. He stated the Resident was a lady with poorly controlled diabetes, hypertension and had been in and out of the hospital. He stated he was contacted by the facility and told she had expired. He stated that he would have expected the facility to do CPR on the Resident. He stated he was coming to the facility that afternoon or the next day to review the Resident's record. 16. An interview was conducted on [DATE], at 2:45 p.m., with the Medical Director. He stated he had been the facility's Medical Director for 4 months and had been a physician since 1995. He stated he was aware that the Resident did not have a DNR status, that she was found without a pulse or respirations and that the process of CPR was not followed. He stated that for other residents the facility had followed the proper procedure, initiated CPR and called the paramedics. He stated that he thought this was an isolated incident that the personnel involved were not focused on the protocol. He stated that he spoke to the Director of Nurses (DON) the same day, discussed their process and decided that the process in place was appropriate. They both believed it was an isolated case. 17. An interview was conducted with the DON, on [DATE], at 9:25 a.m. She stated that she had worked for the facility for approximately 3 weeks when the incident happened. She was in the facility on Saturday, [DATE], to meet the weekend staff. She learned that the Resident had expired and asked the staff if they had done CPR. She knew the Resident had an order for [REDACTED]. She obtained statements from the staff and suspended the employees involved. She stated that she and her management team reviewed the current DNR policies and determined they did not need to be changed. They started inservices for staff as they arrived for the ,[DATE] shift that day. She stated that at least one member of the management team stayed in the facility around the clock until all the staff were in-serviced to ensure CPR would be performed if necessary. She stated that the facility's policy for a resident with no pulse or respirations called for a nurse to check the resident's chart for a yellow DNR paper and a physician order. If there was no yellow DNR paper the person was to receive CPR. 18. An interview was conducted with the Risk Manager on [DATE], at 9:29 a.m., a Registered Nurse (RN), who has worked for the facility for [AGE] years, 4 years as the Risk Manager. She stated that as a result of her investigation she had determined that a Certified Nursing Assistant (CNA) had found the Resident was not breathing and called to a nurse in the hallway. The nurse assessed the Resident and called the supervisor. The supervisor arrived on the unit in less than 5 minutes. She stated that neither the nurse nor the supervisor initiated CPR. She stated that the nurse assigned to the Resident admitted that she did not look in the chart to determine if the resident was to receive CPR or not. She also stated that the Resident's resuscitation status was clear; there were no discussions in progress with family as to wanting the resident to have an advanced directive status of Do Not Resuscitate (DNR) status. 19. Review of the facility's Resident Admissions Agreement revealed; section B. Consent to Treatment: The resident and/or legal representative herby authorizes the appropriate staff at the Facility to perform such functions as are necessary to maintain the well-being of the Resident, including but not limited to assistance with bathing and hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medication and treatments, and the performance of therapies, as prescribed by the Resident's physician in the Resident's physician in the Resident's Plan of Care, or as required from time to time in the exercise of food nursing judgment, subject to any rights provided the Resident by federal and state law. 20. An interview was conducted on [DATE], at 9:29 a.m., with the Administrator. He stated that he had been working as the Administrator for this facility since [DATE] and was the interim Administrator from October to December of 2013. He outlined the facility's immediate action plan that began within 2 hours of discovery of the incident on [DATE]. He stated that the management staff conducted a conference call at 4:30 p.m. that day and carried out the following actions: suspension of the four staff members directly involved; 24 hour management supervision in the building; reeducation of staff; audit of CPR certification for all staff; review of staff education in the past year on CPR/DNR/Code response; Code Blue drills; an audit of all resident charts to verify complete and accurate DNR documentation and review of all care plans advanced directive section. He stated a long range action plan will be developed at the next QA&A meeting to be held the following week, the week of [DATE].

Based on review of the facility's Admission Agreement, policies and procedures for Advance Medical Directives, Code Status Orders & Response, interviews with the Resident's family member, facility staff and Resident's physician, and review of the Resident's medical record including the Nursing Daily Skilled notes, Psychosocial History and Assessment and physician orders, it was determined that the facility failed to implement procedures protecting the right to the receive Cardio-Pulmonary Resuscitation (CPR) for one (#144) of 76 residents identified as having orders to be Fully Resuscitated according to an audit of all current resident records performed by the facility on [DATE]. Resident #144's medical record reflected her family's wishes and her physician order [REDACTED]. The staff, upon discovering the Resident without a pulse or respirations, did not perform CPR or contact 911 Emergency Medical Services. The facility violated this Resident's rights by failing to honor the Resident/legal representative's wishes to receive the benefit of CPR and denying her the chance to have a longer life. Findings of ongoing immediate jeopardy were identified on [DATE]. Findings Include: 1. Review of the Resident Admissions Agreement provided by the facility revealed section B. Consent to Treatment: " The resident and/or legal representative hereby authorizes the appropriate staff at the Facility to perform such functions as are necessary to maintain the well-being of the Resident, including but not limited to assistance with bathing and hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medication and treatments, and the performance of therapies, as prescribed by the Resident's physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided the Resident by federal and state law. " 2. Review of Resident # 144's medical record [DATE] Daily Skilled Note revealed: "Resident noted with no respirations, no blood pressure, physician and son called, new order received to release the body to the funeral home of choice. The note was signed by Employee L. There was no indication in the nurse's notes or the medical record that Cardio [MEDICAL CONDITION] Resuscitation (CPR) was performed or an attempt was made to resuscitate the resident. " 3. Review of Resident #144's medical record revealed a verbal physician's orders [REDACTED]. 4. Review of the medical record for Resident #144 revealed a Psychosocial History and assessment dated [DATE] by the Social Services Director, the Advanced Directives section indicated the Resident's code status was "Full Resuscitate"; the Resident's son was listed as her family support person. 5. A telephone interview with the Resident #144's son on [DATE], at 10:15 a.m. revealed that he was not aware that the facility did not perform CPR on his mother when she was found without a pulse or blood pressure. He stated he did not want his mother to be a Do Not Resuscitate (DNR) that she would open her eyes and look over when you talked to her and she was getting slightly better. He stated we (he and his brother) definitely wanted them to resuscitate her. 6. An interview was conducted with the Social Services Director on [DATE] at 8:06 a.m. She stated that Resident #144's record reflected that her status was "FULL CODE" and "FULL CODE" was also written in the care plan. She reviewed the Activities Assessment and relayed the information that the Resident was born in Kentucky, was a waitress, a home health aide and a Spiritual reader, she was divorced and had three children. She stated that she had spoken to the family on the Resident's first admission on [DATE] and that if the family had wanted a Do Not Resuscitate (DNR) status in place they would have made sure the facility knew about it. She was aware from her conversations with the Resident's two sons that they wanted their mother to receive CPR. They had told her that their mother had been very ill before and had bounced back and they were holding on to hope for her. She stated again that if they were ready for the DNR status they would have made sure she had a DNR in place. 7. Review of the medical record face sheet dated [DATE] for Resident #144 indicated that she was [AGE] years old and the admitted was [DATE]. The responsible party listed for the Resident was herself and two sons were listed as emergency contacts. Review of the [DATE] Minimum Data Set (MDS) assessment revealed the Resident was admitted from an acute care hospital, the Resident did not participate in the assessment. The family or significant other participated. Her [DIAGNOSES REDACTED]. Her functional status was total dependence on staff with two persons assist for transfers, dressing, toileting and hygiene. 8. An Admission Minimum Data Set Assessment was completed for the Resident on [DATE]. The question "Does the Resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?" was answered NO. 9. An interview was conducted with the Risk Manager on [DATE], at 9:29 a.m., a Registered Nurse (RN), who has worked for the facility for [AGE] years, 4 years as the Risk Manager. She stated that as a result of her investigation she had determined that a Certified Nursing Assistant (CNA) had found the Resident was not breathing and called to a nurse in the hallway. The nurse assessed the Resident and called the supervisor. The supervisor arrived on the unit in less than 5 minutes. She stated that neither the nurse nor the supervisor initiated CPR. She stated that the nurse assigned to the Resident admitted that she did not look in the chart to determine if the resident was to receive CPR or not. She also stated that the Resident's resuscitation status was clear; there were no discussions in progress with family as to wanting the resident to have an advanced directive status of Do Not Resuscitate (DNR) status. 10. An interview was conducted by phone on [DATE], at 11:32 a.m., with Employee O, the CNA assigned to the Resident. She stated she was familiar with the Resident, that the Resident had a [MEDICAL CONDITION]; she opened her eyes but did not talk. She stated that she performed patient care on the Resident around 9:00 a.m. with Employee N. The Resident was breathing at that time. She stated that at approximately 11:00 a.m. she entered the resident's room to put linens in the room. The Resident was breathing at that time. She then went on her lunch break. She stated that when she returned from lunch the nurse told her that the Resident had passed away and instructed her to help the other CNA clean the body. She stated that the facility policy on a resident discovered without a pulse or respirations was that the CNA should call for help. She stated that if a resident had a DNR yellow paper in their chart they would not do CPR, if not they were to perform CPR. She stated that she was at home because she had been suspended. She stated that she had worked for the facility for 5 and ,[DATE] years and had been a CNA since 2001. She previously worked in another department. She worked full time on the ,[DATE] shift and worked all the units in the facility. 11. An interview was conducted by phone on [DATE], at 11:20 a.m., with Employee N, the CNA who discovered the Resident without a pulse. She was regularly assigned to the Resident's unit but was not Resident #144's CNA that day. She stated that she and the Resident's assigned CNA performed care for the Resident at approximately 9:00 a.m. The Resident was breathing at that time. She checked on the Resident at 11:45 a.m. because the Resident's CNA was at lunch. She discovered the Resident was not breathing and called the nurse. She stated the nurse came and then went out to get help. She reported that she stayed with the Resident the whole time. She stated that the policy for CNAs was to call the nurse if they discovered a resident without a pulse or respirations. She stated she had been suspended since the incident. She stated that she had worked for the facility for [AGE] years and had been a CNA for [AGE] years. 12. An interview with Employee L, the nurse assigned to the Resident, was conducted on [DATE], at 10:02 a.m., by telephone. She stated she was familiar with the Resident who had been sent out to the hospital and had been back for a week. She stated that she went into the Resident's room when the CNA (Employee N) who discovered Resident #144 without a pulse or respirations called for help. The Resident had no heart rate, no respirations and her lips and nails were blue. She stated that when she came out of the room the RN Supervisor had arrived on the unit. The RN Supervisor was holding the Resident's chart and gave the instruction to call the Resident's physician. Employee L stated that she thought the Resident had a DNR status because the RN Supervisor instructed her to call the physician. Employee L confirmed that she was aware of the facility policy to check a resident's DNR status in the chart to determine if the resident wished to have CPR or not. She stated that she had not returned to the facility since the incident because she was suspended. Review of Employee L's personnel file revealed she had been hired on [DATE] as a LPN. She had an active RN license with a renewal date of [DATE] and an active CPR certification expiring on [DATE]. There were no disciplinary actions in her file. She stated that she had been an RN for 11 months and she had worked at the facility for [AGE] years. She worked full time usually on the day shift. She stated that she was a "floater" and worked all the units. 13. An interview was conducted by telephone on [DATE], at 10:51 a.m., with Employee M, the RN Supervisor on duty at the time of the incident. She stated that she was in a resident's room when she was paged to Station 2. She could not recall exactly how much time it took her to get to Station 2. She stated that when she got there the nurse for the Resident, Employee L, told her the Resident had expired and that she had called the family and informed them of the death. She stated that she assessed the Resident and found her to have no pulse or respirations. She looked in the chart and did not see a yellow DNR paper or information in the progress notes about a DNR status. She stated that facility policy required staff to check a resident's chart for a yellow DNR paper and perform CPR if no DNR paper was in the chart. She stated she did not know why the Resident did not receive CPR but at that point the family had been informed of the Resident's death and was on the way to the facility. She stated that she was suspended immediately after the incident and then was asked to return the same day only for training on the Code Policy and Advanced Directives Policy. She stated she had been an RN since 1995, had worked for the facility for [AGE] years and was currently working part time on weekends only. She has been away from the facility since the training due to the suspension. Review of Employee M's personnel file revealed she was hired on [DATE] as a Weekend Supervisor. She had an active CPR certification that expires February 2015. There were no disciplinary actions in her file. 14. An interview was conducted on [DATE], at 12:55 p.m. with the Advanced Registered Nurse Practitioner (ARNP), on call for the Resident's physician. She was the first provider notified of the Resident's death. She stated that a nurse called her and informed her that Resident #144 had died . She gave orders to notify the family and release the body. She stated that the facility did not tell her they had not initiated CPR. She stated that if the Resident was found without a pulse or respirations they should have automatically done CPR and called the paramedics. She stated that she was called later that day, informed that the facility did not perform CPR and was asked by the nurse to write a DNR order. She told the nurse that a DNR order is not written after the fact. 15. An interview was conducted on [DATE], at 1:05 p.m. with the Resident's physician by telephone. He stated the Resident was a lady with poorly controlled diabetes, hypertension and had been in and out of the hospital. He stated he was contacted by the facility and told she had expired. He stated that he would have expected the facility to do CPR on the Resident. He stated he was coming to the facility that afternoon or the next day to review the Resident's record. 16. An interview was conducted on [DATE], at 2:45 p.m., with the Medical Director. He stated he had been the facility's Medical Director for 4 months and had been a physician since 1995. He stated he was aware that the Resident did not have a DNR status, that she was found without a pulse or respirations and that the process of CPR was not followed. He stated that for other residents the facility had followed the proper procedure, initiated CPR and called the paramedics. He stated that he thought this was an isolated incident that the personnel involved were not focused on the protocol. He stated that he spoke to the Director of Nurses (DON) the same day, discussed their process and decided that the process in place was appropriate. They both believed it was an isolated case. 17. An interview was conducted with the DON, on [DATE], at 9:25 a.m. She stated that she had worked for the facility for approximately 3 weeks when the incident happened. She was in the facility on Saturday, [DATE], to meet the weekend staff. She learned that the Resident had expired and asked the staff if they had done CPR. She knew the Resident had an order for [REDACTED]. She obtained statements from the staff and suspended the employees involved. She stated that she and her management team reviewed the current DNR policies and determined they did not need to be changed. They started inservices for staff as they arrived for the ,[DATE] shift that day. She stated that at least one member of the management team stayed in the facility around the clock until all the staff were inserviced to ensure CPR would be performed if necessary. She stated that the facility's policy for a resident with no pulse or respirations called for a nurse to check the resident's chart for a yellow DNR paper and a physician order. If there was no yellow DNR paper the person was to receive CPR. 18. Review of the facility's Policy titled Advance Medical Directives, S.S.4.2, effective [DATE], revealed; "Topic Advance Medical Directive, Policy: Advance Directives and Do Not Resuscitate (DNR) Procedure; Admissions: 1. Verify that information on Advance Directives was provided to the resident/patient and/or family/legal representative at the time of admission. 2. Obtain any current Advance Directive from the resident/patient and/or family/legal representative and place in the medical record. 3. If a Do Not Resuscitate (DNR) status is elected, place the yellow DNR form in the medical record once completed. 4. Obtain physician's orders [REDACTED]. 5. Document the current Advance Directive in the medical record. 6. Record and update Advance Directive/DNR Log upon admission, quarterly or with change in condition. 7. Provide further information to the physician regarding Advance Directive when requested by the resident/patient, family and/or legal representative. 8. Update the medical record with new or revised Advance Directive as indicated. 9. Review the medical record at least quarterly and document verification of Advance Directive in place in the progress notes." 19. Review of the facility's Policy and Procedure - Florida titled "Code Status Orders & Response ADM 11.1, no effective date, revealed the following: "Policy, The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support CPR only. No advanced life support services are offered in the facility or by facility staff. DNR order - the resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 document should not be placed in the resident's chart as the DNRO is not valid." "Procedure for initiating CPR: Personnel First nurse on the scene Procedure 1. Confirms cardiac/or respiratory arrest. 2. Calls for help. 3. Checks airway and pulse and connect the oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. Point of Emphasis Call HELP loudly, even is no one is in sight. CODE status must be confirmed by checking the medical record." 20. An interview was conducted on [DATE], at 9:29 a.m., with the Administrator. He stated that he had been working as the Administrator for this facility since [DATE] and was the interim Administrator from October to December of 2013. He outlined the facility's immediate action plan that began within 2 hours of discovery of the incident on [DATE]. He stated that the management staff conducted a conference call at 4:30 p.m. that day and carried out the following actions: suspension of the four staff members directly involved; 24 hour management supervision in the building; reeducation of staff; audit of CPR certification for all staff; review of staff education in the past year on CPR/DNR/Code response; Code Blue drills; an audit of all resident charts to verify complete and accurate DNR documentation and review of all care plans advanced directive section. He stated a long range action plan will be developed at the next QA&A meeting to be held the following week, the week of [DATE].

Based on interviews with the resident's family member and the facility staff, and review of the resident's medical record, facility policies, and facility admission agreement, it was determined that the facility failed to ensure that the necessary services to honor a resident's Advanced Directives and provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) were provided for one (#144) of 76 residents identified as having orders to be Fully Resuscitated according to an audit of all current resident records performed by the facility on [DATE]. The facility did not honor the wishes of the Resident's family or the physician's orders [REDACTED]. The facility staff failed to properly implement two of their policies and procedures related to advanced directives: 1) Code Status Orders and Response and 2) Advanced Medical Directives. The facility failed to honor their Admission Agreement Consent to Treatment that authorized the appropriate staff at the facility to perform such functions as are necessary to maintain the well-being of the Resident and prescribed by the Resident's physician. Additionally, based on observation, record review, and interviews, the facility failed to provide services to ensure the safety of 1 (#155) of five sampled residents who were residing on the secure unit of the facility, & who was identified as being an elopement risk. The facility placed residents at risk as evidenced by failure to provide services for Resident #155, for immediate and close supervision, who was agitated and exit seeking, failure to secure a hazardous area (room with broken glass) and failure to secure an exit area, a broken window. Failure of the facility staff to provide the resuscitative services of CPR when Resident #144 was found without a pulse or respirations and failure to provide services such as immediate, close supervision for an agitated and exit seeking resident; failure to secure a hazardous area (room with broken glass) and not securing an exit area (window with broken glass), led to the finding of immediate jeopardy on [DATE], which is on-going. Findings include: 1.a. Review of Resident # 144's medical record [DATE] Daily Skilled Note revealed: "Resident noted with no respirations, no blood pressure, physician and son called, new order received to release the body to the funeral home of choice." The note was signed by Employee L. There was no indication in the nurse's notes or the medical record that Cardio [MEDICAL CONDITION] Resuscitation (CPR) was performed or an attempt was made to resuscitate the resident. b. Review of Resident #144's medical record, revealed a verbal physician's orders [REDACTED]. c. Review of the medical record for Resident #144 revealed a Psychosocial History and Assessment, dated [DATE], by the Social Services Director, the Advanced Directives section indicated the Resident's code status was "Full Resuscitate"; the Resident's son was listed as her family support person. d. A telephone interview with Resident #144's son on [DATE], at 10:15 a.m. revealed that he was not aware that the facility did not perform CPR on his mother when she was found without a pulse or blood pressure. He stated he did not want his mother to be a Do Not Resuscitate (DNR), that she would open her eyes and look over when you talked to her and she was getting slightly better. He stated we (he and his brother) definitely wanted them to resuscitate her. e. An interview was conducted with the Social Services Director on [DATE] at 8:06 a.m. She stated that Resident #144's record reflected that her status was "FULL CODE" and "FULL CODE" was also written in the care plan. She reviewed the Activities Assessment and relayed the information that the Resident was born in Kentucky and had three children. She stated that she had spoken to the family on the Resident's first admission on [DATE] and that, if the family had wanted a Do Not Resuscitate (DNR) status in place, they would have made sure the facility knew about it. She was aware from her conversations with the Resident's two sons that they wanted their mother to receive CPR. They had told her that their mother had been very ill before and had bounced back and they were holding on to hope for her. She stated again that if they were ready for the DNR status they would have made sure she had a DNR in place. f. Review of the medical record face sheet, dated [DATE], for Resident #144 indicated that she was [AGE] years old and the admitted was [DATE]. The responsible party listed for the Resident was herself and two sons were listed as emergency contacts. Review of the [DATE] Minimum Data Set (MDS) assessment revealed the Resident was admitted from an acute care hospital. The Resident did not participate in the assessment. The family or significant other participated. Her [DIAGNOSES REDACTED]. Her functional status was total dependence on staff with two persons assist for transfers, dressing, toileting and hygiene. g. An Admission Minimum Data Set Assessment was completed for the Resident on [DATE]. The question, "Does the Resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?" was answered NO. h. An interview was conducted with the Risk Manager on [DATE], at 9:29 a.m., a Registered Nurse (RN), who has worked for the facility for [AGE] years, 4 years as the Risk Manager. She stated that, as a result of her investigation, she had determined that a Certified Nursing Assistant (CNA) had found the Resident was not breathing and called to a nurse in the hallway. The nurse assessed the Resident and called the supervisor. The supervisor arrived on the unit in less than 5 minutes. She stated that neither the nurse nor the supervisor initiated CPR. She stated that the nurse assigned to the Resident admitted that she did not look in the chart to determine if the resident was to receive CPR or not. She also stated that the Resident's resuscitation status was clear; there were no discussions in progress with family as to wanting the resident to have an advanced directive status of Do Not Resuscitate (DNR) status. i. An interview was conducted by phone on [DATE], at 11:32 a.m., with Employee O, the CNA assigned to the Resident. She stated that she had worked for the facility for 5 and ,[DATE] years and had been a CNA since 2001. She previously worked in another department. She worked full time on the ,[DATE] shift and worked all the units in the facility. She stated she was familiar with the Resident, that the Resident had a [MEDICAL CONDITION]; she opened her eyes but did not talk. She stated that she performed patient care on the Resident around 9:00 a.m. with Employee N. The Resident was breathing at that time. She stated that, at approximately 11:00 a.m., she entered the resident's room to put linens in the room. The resident was breathing at that time. She then went on her lunch break. She stated that, when she returned from lunch, the nurse told her that the Resident had passed away and instructed her to help the other CNA clean the body. She stated that the facility policy on a resident discovered without a pulse or respirations was that the CNA should call for help. She stated that, if a resident had a DNR yellow form in their chart, they would not do CPR, if not, they were to perform CPR. She stated that she was at home because she had been suspended. j. An interview was conducted by phone on [DATE], at 11:20 a.m., with Employee N, the CNA who discovered the Resident without a pulse. She stated that she had worked for the facility for [AGE] years and had been a CNA for [AGE] years. She was regularly assigned to the Resident's unit but was not Resident #144's CNA that day. She stated that she and the Resident's assigned CNA performed care for the Resident at approximately 9:00 a.m. The Resident was breathing at that time. She checked on the Resident at 11:45 a.m. because the Resident's CNA was at lunch. She discovered the Resident was not breathing and called the nurse. She stated the nurse came and then went out to get help. She reported that she stayed with the Resident the whole time. She stated that the policy for CNAs was to call the nurse if they discovered a resident without a pulse or respirations. She stated she had been suspended since the incident. k. An interview with Employee L, the nurse assigned to the Resident, was conducted on [DATE], at 10:02 a.m., by telephone. She stated that she had been an RN for 11 months and she had worked at the facility for [AGE] years. She worked full time usually on the day shift. She stated that she was a "floater" and worked all the units. She stated she was familiar with the Resident who had been sent out to the hospital and had been back for a week. She stated that she went into the Resident's room when the CNA (Employee N), who discovered Resident #144 without a pulse or respirations, called for help. The Resident had no heart rate, no respirations and her lips and nails were blue. She stated that when she came out of the room the RN Supervisor had arrived on the unit. The RN Supervisor was holding the Resident's chart and gave the instruction to call the Resident's physician. Employee L stated that she thought the Resident had a DNR status because the RN Supervisor instructed her to call the physician. Employee L confirmed that she was aware of the facility policy to check a resident's DNR status in the chart to determine if the resident wished to have CPR or not. She stated that she had not returned to the facility since the incident because she was suspended. Review of Employee L's personnel file revealed she had been hired on [DATE] as a LPN. She had an active RN license with a renewal date of [DATE] and an active CPR certification expiring on [DATE]. There were no disciplinary actions in her file. l. An interview was conducted by telephone on [DATE], at 10:51 a.m., with Employee M, the RN Supervisor on duty at the time of the incident. She stated she had been an RN since 1995, had worked for the facility for [AGE] years and was currently working part time on weekends only. She stated that she was in a resident's room when she was paged to Station 2. She could not recall exactly how much time it took her to get to Station 2. She stated that when she got there the nurse for the Resident, Employee L, told her the Resident had expired and that she had called the family and informed them of the death. She stated that she assessed the Resident and found her to have no pulse or respirations. She looked in the chart and did not see a yellow DNR form or information in the progress notes about a DNR status. She stated that facility policy required staff to check a resident's chart for a yellow DNR paper and perform CPR if no DNR paper was in the chart. She stated she did not know why the Resident did not receive CPR but at that point the family had been informed of the Resident's death and was on the way to the facility. She stated that she was suspended immediately after the incident and then was asked to return the same day only for training on the Code Policy and Advanced Directives Policy. She has been away from the facility since the training due to the suspension. Review of Employee M's personnel file revealed she was hired on [DATE] as a Weekend Supervisor. She had an active CPR certification that expires February 2015. There were no disciplinary actions in her file. m. An interview was conducted on [DATE], at 12:55 p.m. with the Advanced Registered Nurse Practitioner (ARNP), on call for the Resident's physician. She was the first provider notified of the Resident's death. She stated that a nurse called her and informed her that Resident #144 had died . She gave orders to notify the family and release the body. She stated that the facility did not tell her they had not initiated CPR. She stated that if the Resident was found without a pulse or respirations they should have automatically done CPR and called the paramedics. She stated that she was called later that day, informed that the facility did not perform CPR and was asked by the nurse to write a DNR order. She told the nurse that a DNR order is not written after the fact. n. An interview was conducted on [DATE], at 1:05 p.m. with the Resident's physician by telephone. He stated the Resident was a lady with poorly controlled diabetes, hypertension and had been in and out of the hospital. He stated he was contacted by the facility and told she had expired. He stated that he would have expected the facility to do CPR on the Resident. He stated he was coming to the facility that afternoon or the next day to review the Resident's record. o. An interview was conducted on [DATE], at 2:45 p.m., with the Medical Director. He stated he had been the facility's Medical Director for 4 months and had been a physician since 1995. He stated he was aware that the Resident did not have a DNR status, that she was found without a pulse or respirations and that the process of CPR was not followed. He stated that for other residents the facility had followed the proper procedure, initiated CPR and called the paramedics. He stated that he thought this was an isolated incident that the personnel involved were not focused on the protocol. He stated that he spoke to the Director of Nurses (DON) the same day, discussed their process and decided that the process in place was appropriate. They both believed it was an isolated case. p. An interview was conducted with the DON, on [DATE], at 9:25 a.m. She stated that she had worked for the facility for approximately 3 weeks when the incident happened. She was in the facility on Saturday, [DATE], to meet the weekend staff. She learned that the Resident had expired and asked the staff if they had done CPR. She knew the Resident had an order for [REDACTED]. She obtained statements from the staff and suspended the employees involved. She stated that she and her management team reviewed the current DNR policies and determined they did not need to be changed. They started inservices for staff as they arrived for the ,[DATE] shift that day. She stated that at least one member of the management team stayed in the facility around the clock until all the staff were inserviced to ensure CPR would be performed if necessary. She stated that the facility's policy for a resident with no pulse or respirations called for a nurse to check the resident's chart for a yellow DNR form and a physician order. If there was no yellow DNR form the person was to receive CPR. q. Review of the facility's Policy and Procedure - Florida titled, "Code Status Orders & Response ADM 11.1, no effective date, revealed the following: "Policy, The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support CPR only. No advanced life support services are offered in the facility or by facility staff. DNR order - the resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 document should not be placed in the resident's chart as the DNRO is not valid." "Procedure for initiating CPR: Personnel First nurse on the scene Procedure 1. Confirms cardiac/or respiratory arrest. 2. Calls for help. 3. Checks airway and pulse and connect the oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. Point of Emphasis Call HELP loudly, even is no one is in sight. CODE status must be confirmed by checking the medical record." r. Review of the Resident Admissions Agreement provided by the facility revealed section B. Consent to Treatment: "The resident and/or legal representative hereby authorizes the appropriate staff at the Facility to perform such functions as are necessary to maintain the well-being of the Resident, including but not limited to assistance with bathing and hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medication and treatments, and the performance of therapies, as prescribed by the Resident's physician in the Resident's physician in the Resident's Plan of Care, or as required from time to time in the exercise of food nursing judgment, subject to any rights provided the Resident by federal and state law." s. An interview was conducted on [DATE], at 9:29 a.m., with the Administrator. He stated that he had been working as the Administrator for this facility since [DATE] and was the interim Administrator from October to December of 2013. He outlined the facility's immediate action plan that began within 2 hours of discovery of the incident on [DATE]. He stated that the management staff conducted a conference call at 4:30 p.m. that day and carried out the following actions: suspension of the four staff members directly involved; 24 hour management supervision in the building; reeducation of staff; audit of CPR certification for all staff; review of staff education in the past year on CPR/DNR/Code response; Code Blue drills; an audit of all resident charts to verify complete and accurate DNR documentation and review of all care plans advanced directive section. He stated a long range action plan will be developed at the next QA&A meeting to be held the following week, the week of [DATE]. 2. a. A review of Resident #155's care plan, initiated on [DATE], documented a focus area of "Elopement" and that the resident was an elopement risk/wanderer. "AEB Resident presents with cognitive impairment and is independently mobile." The goal of the focus area was that the resident would not exit the facility without staff knowledge and staff would monitor whereabouts on an ongoing basis. Further review of the care plan revealed that it described interventions to be used by staff such as: "Secured unit; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs pictures and memory boxes; Identify pattern of wandering: Is wandering purposeful, aimless or escapist: Is resident looking for something: Does it indicate the need for more exercise: Intervene as appropriate; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book." b. A review of a local hospital admission History and Physical, dated [DATE], documented: "The patient is a [AGE] year old ...who presented to the hospital, brought in by EMS. He was placed on a Baker Act by the ER physician for wandering from his home and confusion. There was a concern that he was unable to care for himself. On exam today, the patient reports he is uncertain why he is here, how he got here or what the purpose of his being here is. I spoke with his (family member), who reports that she has noticed some problems with his memory over the past few years. His Neighbors were mentioning problems with his memory as far back as 3 years ago. Over the past couple of weeks he has seemed more confused. She tried taking him to another hospital a week or 2 ago, but he wandered away early in the morning. He has since been sitting at home, not eating and not caring for himself. She consulted with his primary care doctor who convinced her to bring him into the hospital by calling EMS. She does state she has noticed worsening memory problems recently. General: The patient is a [AGE] year old ...who appears reasonably healthy with good hygiene. Mental status examination: Patient is alert and oriented times 4. He is dressed in clean personal attire with good grooming ...his mood is reported to be ok with a mildly irritable affect. His thought process is organized and goal directed, but there is no ability for abstract." c. A review of Resident #155's clinical chart documented that the resident was initially admitted to the facility [DATE], a [AGE] year old male. [DIAGNOSES REDACTED]." d. A review of the facility profile revealed that the facility is a 152 bed facility. During the survey conducted on [DATE] thru [DATE], the facility provided documentation of the bed capacity of a secure unit of 32 beds which is located at the west side of the building on the second story. During the survey, it was observed that in order to access the 2nd story secure unit, a person could utilize one of 2 stair wells or an elevator. Once a person was on the 2nd floor secure area, a staff member would have to punch in a code for either the stair wells or the elevator in order to leave the secure unit. During an interview conducted on [DATE] at 3:41 p.m., the, Business Development Coordinator confirmed that the family member of Resident #155 toured the secure unit and wanted Resident #155 placed on the unit. e. Review of the [DATE] local hospital record at 7:46 p.m.: "Chief Complaint: Fall-no LOC (loss of consciousness); left ankle pain; patient hung from second story window and dropped to the ground; BA52 because they said he was trying to hurt himself; pt states he was trying to get away from the "jail" where he lives. Impression: 1. Severe Comminuted (impacted) Fracture involving the entire calcaneus (heel bone). Multiple fractured pieces are present. 2. Mildly displaced [MEDICAL CONDITION] Malleolus (lower portion of the fibula where it meets the Talus)." f. Further review of the hospital records for Resident #155, revealed an entry at 8:01 p.m., for Safety Measures comment: "Pt states he wanted to leave the place where he lived, so he opened a window, hung off window ledge, and dropped to the ground; baker acted because they say he was trying to hurt himself; swelling and pain in left ankle; small cut on right hand near wrist. Resident's cognition and speech was documented to be clear and coherent; in general, awake and oriented x2. His psychiatric was documented to be cooperative with appropriate mood and affect." g. A review of Nursing Notes, dated [DATE] at 11:11 p.m.: "ARNP visited with resident at approx. 5:30 p.m. ARNP spoke with resident who has been calm so far this shift. 1:1 was d/c ' d and other orders were written. Asked resident how he felt, says upset ...Resident did not want to eat in dr (dining room), was left sitting on his bed with meal on bedside table feeding self. At 7:00 p.m. heard noise like glass breaking. Upon entering room, found resident standing with large piece of glass in hands, coming towards nurse and cnas who also responded to the glass breaking. Asking resident to please put the glass down and to not hurt himself or anyone else. Cont ...Resident did drop the glass. As nurse backed up, resident ran out of room toward shower room. Asked CNA, Staff member K to go downstairs to let 911 in. CNA, staff member J was keeping other residents away and safe. CNA, Staff member I ran into nurses' station and states he jumped out of the window while I was cleaning up the glass. The nurse ran down stairs to assist resident, ...resident sitting on bottom with knees bent facility the street. CNA, staff member K and the police present. Resident transferred to local hospital." h. The events leading up to Resident #155's jump were memorialized in the clinical record and included the following: A review of the Neuropsychiatric consultation for Resident #155, dated [DATE], documented "Patient looks for elevator to leave. ...still thinks he can be independent." A review of the Neuropsychiatric consultation for Resident #155, dated [DATE], documented: "wish to leave. Exit seeking. Says his day ok, but doesn't like it here. Says he feels very depressed." A review of nursing progress notes documented the following: [DATE] at 7:55 p.m.: "...is pleasant, says I don't belong here. I have been here 3 weeks already ..." [DATE] at 3:30 p.m.: "Resident got on the elevator after a family member came up ...Resident angry saying he wants to leave." [DATE] at 9:38 p.m.: "Exit seeking earlier with another resident, waiting by elevator and stairwells." [DATE] at 4:14 p.m. "....up in day room all night refusing to go to bed stating he is afraid his roommate is going to hurt him. Unable to convince him that he won't hurt him stating he feels safer in the dayroom tonight." [DATE] at 9:15 a.m.: "Resident #155 noted slamming his room door, and standing by the window with a spoon trying to lift it up, this writer asked resident what are you doing, resident stated "I am lock up like a prisoner and I am trying to get out of here." This writer was able to redirect the resident by asking him to speak with his daughter first, resident handed the spoon to this writer ...Dr (_), ARNP called, new order received for 1:1 until she gets here in 15 minutes." [DATE] at 9:21 a.m.: "1:1 maintained by staff, resident remains standing by his window on 1:1 in place." [DATE] at 22:22: "Resident is alert with confusion. ...Did tell nurse he tried to leave because his daughter did not pay rent on his apt. ...but, says he is not bad off like "these guys." [DATE] at 1:20 p.m.: "...1 on 1 maintained by staff ..."I feel like I am in jail" ..." [DATE]'s entry at 11:11 p.m.:documented the resident's breaking the window and jumping out the window. i. A review of the facility Elopement Standard, effective date of ,[DATE], documented the facility elopement definition as follows: "Elopement occurs when a Resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. j. During an interview conducted on [DATE] at 12:57 p.m. with the Risk manager, she confirmed that Resident #155 was on the event log for behaviors that occurred on [DATE], that he went to the hospital for behaviors and fracture; busted a window, then went out the window, then got a fracture. k. Interviews were conducted with the 3 CNA's and the one LPN that were on duty during the [DATE] event with Resident #155. During the interviews, it was noted that the after the Resident #155 was found to have broken the glass out of his bedroom window, staff were able to have the resident exit the bedroom and staff reported that the resident was located at one point in front of the shower room (observed to be approximately 23 feet from the entry of the residents' bed room door); that somehow the resident was able to re- enter the room (seen by staff member I); but, no staff member could confirm that they had witnessed the resident going out the newly created exit area of the broken window and dropping to the parking lot, 2 stories below. During the staff interviews, no staff claimed responsibility or ownership of the resident's supervision from the point that he exited the bedroom and was located in the hall way near the shower room door; no one claimed to be responsible for his supervision after he made the verbalization that if he went down stairs, he was not coming back: CNA, K went back to the dining room; CNA I reported he went into the Resident's room to clean the glass; CNA J reported that she did not come out of the small dining room, only that she heard about the event; Nurse H, stated that she went back to the nurses station. l. Interviews were conducted with the staff present during the [DATE] event: Staff member K, CNA: An interview was conducted on [DATE] at 9:20 a.m., with Staff member K, CNA: "Around dinner time, we were serving dinner in the dining room, Staff member I, and I and we heard glass break, we proceeded to Resident #155's room and we saw that the glass was broken and Resident #155 had glass in his hand, it was approximately ? the size of the chart. He was standing at the end of the window bed; the glass in the window was not totally broke; it was the lower pane. Staff member I was in the room trying to calm the resident down, (the nurse was right there with her med cart) he started coming toward us with the glass;"Resident #155, if you calm down I will take you out for a smoke break"; he laid the glass down and he walked out of the room with me; we were in the hall way; he stated that if I took him downstairs he would not come back up. We were standing in the hall way with Resident #155. I used the dialogue with the resident to get the glass out of his hands. I went back into the dining room. Resident #155 did not come with me. I let the nurse and the other aide (Staff member I) take care of it, because I had to go and serve the (other) residents. I do not know what took place after that; I was serving the residents (in the main dining room). The nurse went and called 911 to baker act the resident; I went down to let the police officers in and when I stepped off the w/ ramp, I heard a (she clapped her hands for a sound); I ran over to him; he tried to get up and run; I saw that his ankle caused him to go down; he was immobile; I put my hands on his shoulders so he could not move to endanger himself with movement. The officers came; they took over; I went upstairs." m. An interview was conducted on [DATE] at 10:04 a.m. with Staff member I, CNA: "We were in the ending stages of the dinner and he (Resident #155) had been on a 1:1, he had been taken off. I heard a loud noise/ glass breaking; we (the nurse and I) both got to the room at the same time.. He had picked up a piece of glass and came toward the nurse. We tried to calm him down. We were able to get him to leave the room to have a cigarette; then the nurse had gone to call the police; I went in to clean up the glass; the resident had gone with the CNA (Staff member K); then as I was going out of the room with a piece of glass in my hands and, he was walking back in the room. I moved out of the way, because I had the glass in my hands, I turned, he was inside the room; I wanted to find someone to help me; I did not exit the room; I did not want to leave him by himself; he was about to walk into the glass. I did not see him jump out the window. I did not close the door after he exited the room the first time." n. An interview conducted on [DATE] at 10:18 a.m. via phone with Staff member J, CNA, she confirmed that she was present on the secure unit the date of the event, [DATE]. "I was in the dining room (small dining room), serving the residents their dinner; I did not see him go out the window; not too much I can tell you. I usually work in the secure unit; I have worked there for [AGE] years. I heard one of the CNA's (Staff member I) come to the nurse and say that the resident had gone out the window. The nurse, I am not sure where she was. We were all on the floor; Staff member K was probably in the dining room; but, I do not know. I did not hear the glass breaking. I probably saw Resident #155 before dinner, but, I was too busy in the small dining room with the (other) residents." o. An interview conducted with Staff member H, LPN, conducted on [DATE] at approximately 10:20 a.m.: "He was in his room, they were serving dinner, he did not want to eat in the main dining room, he wanted to go home, he was upset, his daughter did not pay his rent; he did not want to be with the other folks; I took his tray into his room; I sat with him for a while. I t

Based on review of the Florida Nurse Practice Act, clinical record review, staff interviews, facility policy review and job description review for a Registered Nurse (RN) [DATE] and Director of Nursing (DON), undated, it was determined that the facility did not ensure services to provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) were carried out in accordance with professional standards of quality for one (#144) of 76 residents identified as having orders to be Fully Resuscitated according to an audit of all current resident records performed by the facility on [DATE]. The Registered Nurses did not perform Cardio [MEDICAL CONDITION] Resuscitation on a resident found to have no pulse or respirations who had a physician's orders [REDACTED]. Failure of the facility to ensure the nurses met professional standards and acted in accordance with the Nurse Practice Act as defined in the Florida Statutes, Chapter 464, resulted in findings of immediate jeopardy on [DATE], which is on-going. Findings Include: 1. The Florida Nurse Practice Act includes: 464.003; 20, "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c) The supervision and teaching of other personnel in the theory and performance of any of the above acts. 464.003; 22, "Registered Nurse" means any person licensed in this state to practice professional nursing. 2. Review of the Registered Nurse (RN) job description dated [DATE] revealed this position reports to the Unit Manager (RN). The job description contained the following relevant information; Summary of position: The Registered Nurse is responsible for delivering care to resident/patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; effectively interacts with residents/patients, family members, and other health team members while maintaining the standards of professional nursing. a. Direct Care/Patient Responsibilities include; Assesses, plans, directs and evaluates total nursing care as determined by the resident/patient's age related physical, psychosocial, and cultural needs in accordance with established standards, policies, procedures and resident's/patient's care plan; Handles emergency situations in a prompt, precise and professional manner; Performs CPR as required. 3. Review of the Director of Nursing (DON) job description, undated, revealed; The DON has twenty four (24) hour responsibility for the overall delivery of nursing services and ensures the implementation of all clinical policies and procedures. The job description included the following essential duties and responsibilities: Accountable for adherence by staff to policies, procedures and standards; delivery and proper documentation of patient care. Leads and manages the General and Restorative Nursing Services on a 24 hour basis to ensure the delivery of high quality comprehensive patient care. The job description also included the following supervisory responsibilities: Supervises nursing staff whether directly or indirectly in accordance with company policies and procedures. Responsible for hiring, selection, training and coaching employees. 4. Review of Resident # 144's medical record [DATE] Daily Skilled Note revealed: Resident noted with no respirations, no blood pressure, physician and son called, new order received to release the body to the funeral home of choice. The note was signed by Employee L. There was no indication in the nurse's notes or the medical record that Cardio [MEDICAL CONDITION] Resuscitation (CPR) was performed or an attempt was made to resuscitate the resident. 5. An interview with Employee L, the Registered Nurse (RN) assigned to the Resident, was conducted on [DATE], at 10:02 a.m., by telephone. She stated she was familiar with the Resident who had been sent out to the hospital and had been back for a week. She stated that she went into the Resident's room when the CNA (Employee N) who discovered Resident #144 without a pulse or respirations called for help. The Resident had no heart rate, no respirations and her lips and nails were blue. She stated that when she came out of the room the RN Supervisor had arrived on the unit. The RN Supervisor was holding the Resident's chart and gave the instruction to call the Resident's physician. Employee L stated that she thought the Resident had a DNR status because the RN Supervisor instructed her to call the physician. Employee L confirmed that she was aware of the facility policy to check a resident's DNR status in the chart to determine if the resident wished to have CPR or not. She stated that she had been an RN for 11 months and she had worked at the facility for [AGE] years. She worked full time usually on the day shift. She stated that she was a "floater" and worked all the units. She stated that she had not returned to the facility since the incident because she was suspended. Review of Employee L's personnel file revealed she had been hired on [DATE] as a LPN. She had an active RN license with a renewal date of [DATE] and an active CPR certification expiring on [DATE]. There were no disciplinary actions in her file. 6. An interview was conducted by telephone on [DATE], at 10:51 a.m., with Employee M, the RN Supervisor on duty at the time of the incident. She stated that she was in a resident's room when she was paged to Station 2. She could not recall exactly how much time it took her to get to Station 2. She stated that when she got there the nurse for Resident #144, Employee L, told her the Resident had expired and that she had called the family and informed them of the death. She stated that she assessed the Resident and found her to have no pulse or respirations. She looked in the chart and did not see a yellow DNR paper or information in the progress notes about a DNR status. She stated that facility policy required staff to check a resident's chart for a yellow DNR paper and perform CPR if no DNR paper was in the chart. She stated she did not know why the Resident did not receive CPR but at that point the family had been informed of the Resident's death and was on the way to the facility. She stated that she was suspended immediately after the incident and then was asked to return the same day only for training on the Code Policy and Advanced Directives Policy. She has been away from the facility since the training due to the suspension. She stated she had been an RN since 1995, had worked for the facility for [AGE] years and was currently working part time on weekends only. Review of Employee M's personnel file revealed she was hired on [DATE] as a Weekend Supervisor. She had an active CPR certification that expires February 2015. There were no disciplinary actions in her file. 7. An interview was conducted on [DATE], at 1:05 p.m. with the Resident's physician by telephone. He stated the Resident was a lady with poorly controlled diabetes, hypertension and had been in and out of the hospital. He stated he was contacted by the facility and told she had expired. He stated that he would have expected the facility to do CPR on the Resident. He stated he was coming to the facility that afternoon or the next day to review the Resident's record. 8. Review of Resident #144's medical record revealed a verbal physician's orders [REDACTED]. 9. Review of the medical record for Resident #144 revealed a Psychosocial History and assessment dated [DATE] by the Social Services Director, the Advanced Directives section indicated the Resident's code status was "Full Resuscitate"; the Resident ' s son was listed as her family support person. 10. A telephone interview with the Resident #144's son on [DATE], at 10:15 a.m. revealed that he was not aware that the facility did not perform CPR on his mother when she was found without a pulse or blood pressure. He stated he did not want his mother to be a Do Not Resuscitate (DNR) that she would open her eyes and look over when you talked to her and she was getting slightly better. He stated we (he and his brother) definitely wanted them to resuscitate her. 11. An interview was conducted with the Social Services Director on [DATE] at 8:06 a.m. She stated that Resident #144's record reflected that her status was "FULL CODE" and "FULL CODE" was also written in the care plan. She reviewed the Activities Assessment and relayed the information that the Resident was born in Kentucky, was a waitress, a home health aide and a Spiritual reader; she was divorced and had three children. She stated that she had spoken to the family on the Resident's first admission on [DATE] and that if the family had wanted a Do Not Resuscitate (DNR) status in place they would have made sure the facility knew about it. She was aware from her conversations with the Resident's two sons that they wanted their mother to receive CPR. They had told her that their mother had been very ill before and had bounced back and they were holding on to hope for her. She stated again that if they were ready for the DNR status they would have made sure she had a DNR in place. 12. Review of the medical record face sheet dated [DATE] for Resident #144 indicated that she was [AGE] years old and the admitted was [DATE]. The responsible party listed for the Resident was herself and two sons were listed as emergency contacts. Review of the [DATE] Minimum Data Set (MDS) assessment revealed the Resident was admitted from an acute care hospital, the Resident did not participate in the assessment. The family or significant other participated. Her [DIAGNOSES REDACTED]. Her functional status was total dependence on staff with two persons assist for transfers, dressing, toileting and hygiene. 13. An Admission Minimum Data Set Assessment was completed for the Resident on [DATE]. The question "Does the Resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?" was answered NO. 14. An interview was conducted with the Risk Manager on [DATE], at 9:29 a.m., a Registered Nurse (RN), who has worked for the facility for [AGE] years, 4 years as the Risk Manager. She stated that as a result of her investigation she had determined that a Certified Nursing Assistant (CNA) had found the Resident was not breathing and called to a nurse in the hallway. The nurse assessed the Resident and called the supervisor. The supervisor arrived on the unit in less than 5 minutes. She stated that neither the nurse nor the supervisor initiated CPR. She stated that the nurse assigned to the Resident admitted that she did not look in the chart to determine if the resident was to receive CPR or not. She also stated that the Resident's resuscitation status was clear; there were no discussions in progress with family as to wanting the resident to have an advanced directive status of Do Not Resuscitate (DNR) status. 15. An interview was conducted on [DATE], at 12:55 p.m. with the Advanced Registered Nurse Practitioner (ARNP), on call for the Resident's physician. She was the first provider notified of the Resident's death. She stated that a nurse called her and informed her that Resident #144 had died . She gave orders to notify the family and release the body. She stated that the facility did not tell her they had not initiated CPR. She stated that if the Resident was found without a pulse or respirations they should have automatically done CPR and called the paramedics. She stated that she was called later that day, informed that the facility did not perform CPR and was asked by the nurse to write a DNR order. She told the nurse that a DNR order is not written after the fact. 16. An interview was conducted on [DATE], at 2:45 p.m., with the Medical Director. He stated he had been the facility's Medical Director for 4 months and had been a physician since 1995. He stated he was aware that the Resident did not have a DNR status, that she was found without a pulse or respirations and that the process of CPR was not followed. He stated that for other residents the facility had followed the proper procedure, initiated CPR and called the paramedics. He stated that he thought this was an isolated incident that the personnel involved were not focused on the protocol. He stated that he spoke to the Director of Nurses (DON) the same day, discussed their process and decided that the process in place was appropriate. They both believed it was an isolated case. 17. An interview was conducted with the DON, on [DATE], at 9:25 a.m. She stated that she had worked for the facility for approximately 3 weeks when the incident happened. She was in the facility on Saturday, [DATE], to meet the weekend staff. She learned that the Resident had expired and asked the staff if they had done CPR. She knew the Resident had an order for [REDACTED]. She obtained statements from the staff and suspended the employees involved. She stated that she and her management team reviewed the current DNR policies and determined they did not need to be changed. They started inservices for staff as they arrived for the ,[DATE] shift that day. She stated that at least one member of the management team stayed in the facility around the clock until all the staff were inserviced to ensure CPR would be performed if necessary. She stated that the facility's policy for a resident with no pulse or respirations called for a nurse to check the resident's chart for a yellow DNR paper and a physician order. If there was no yellow DNR paper the person was to receive CPR. 18. Review of the facility's Policy and Procedure - Florida titled "Code Status Orders & Response ADM 11.1, no effective date, revealed the following: "Policy, The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support CPR only. No advanced life support services are offered in the facility or by facility staff. DNR order - the resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 document should not be placed in the resident's chart as the DNRO is not valid." "Procedure for initiating CPR: Personnel First nurse on the scene Procedure 1. Confirms cardiac/or respiratory arrest. 2. Calls for help. 3. Checks airway and pulse and connect the oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. Point of Emphasis Call HELP loudly, even is no one is in sight. CODE status must be confirmed by checking the medical record." 19. Review of the Resident Admissions Agreement provided by the facility revealed section B. Consent to Treatment: The resident and/or legal representative hereby authorizes the appropriate staff at the Facility to perform such functions as are necessary to maintain the well-being of the Resident, including but not limited to assistance with bathing and hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medication and treatments, and the performance of therapies, as prescribed by the Resident's physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided the Resident by federal and state law. 20. An interview was conducted on [DATE], at 9:29 a.m., with the Administrator. He stated that he had been working as the Administrator for this facility since [DATE] and was the interim Administrator from October to December of 2013. He outlined the facility's immediate action plan that began within 2 hours of discovery of the incident on [DATE]. He stated that the management staff conducted a conference call at 4:30 p.m. that day and carried out the following actions: suspension of the four staff members directly involved; 24 hour management supervision in the building; reeducation of staff; audit of CPR certification for all staff; review of staff education in the past year on CPR/DNR/Code response; Code Blue drills; an audit of all resident charts to verify complete and accurate DNR documentation and review of all care plans advanced directive section. He stated a long range action plan will be developed at the next QA&A meeting to be held the following week, the week of [DATE].

Based on observation, record review and interviews, the facility failed to ensure supervision to meet the needs and provide a safe environment free of hazards for 1 (#155) of 5 sampled residents on a secure unit as evidenced by an event where the resident broke a window in his bedroom located in a "Secure Unit", the resident walked out of the bedroom and down the hall approximately 23 feet, the resident returned and re-entered the unsecured bedroom and exited the bedroom through an unsecured window exit with broken glass . The resident then dropped from the 2nd story window to the parking lot during which he broke his ankle and proceeded to attempt to leave the facility grounds unauthorized. The facility placed residents at risk due to the lack of implementation of immediate close supervision for an agitated and exit seeking resident. The facility placed residents at risk due to failing to ensure that a hazardous area (room with broken glass) was secure to prevent access by vulnerable residents. The facility placed residents at risk due to a failing to ensure that exit area, a broken window with access to the outside of the facility, was secure or quartered off to prevent residents with exit seeking behavior from choosing to leave an unsafe exit. These findings resulted in findings of immediate jeopardy, which is on-going. Findings include: 1. A review of Nursing Notes, dated 02/02/14 at 11:11 p.m.: "ARNP visited with resident at approx. 5:30 p.m. ARNP spoke with resident who has been calm so far this shift. 1:1 was d/c ' d and other orders were written. Asked resident how he felt, says upset ...Resident did not want to eat in dr (dining room), was left sitting on his bed with meal on bedside table feeding self. At 7:00 p.m. heard noise like glass breaking. Upon entering room, found resident standing with large piece of glass in hands, coming towards nurse and cnas who also responded to the glass breaking. Asking resident to please put the glass down and to not hurt himself or anyone else. Cont ...Resident did drop the glass. As nurse backed up, resident ran out of room toward shower room. Asked CNA, Staff member K to go downstairs to let 911 in. CNA, staff member J was keeping other residents away and safe. CNA, Staff member I ran into nurses station and states he jumped out of the window while I was cleaning up the glass. The nurse ran down stairs to assist resident, ...resident sitting on bottom with knees bent facility the street. CNA, staff member K and the police present. Resident transferred to local hospital." 2. A review of the 02/02/14 local hospital record at 7:46 p.m.: Chief Complaint: "Fall-no LOC ( loss of consciousness); left ankle pain; patient hung from second story window and dropped to the ground; BA52 because they said he was trying to hurt himself; pt states he was trying to get away from the "jail" where he lives. Impression: 1. Severe Comminuted (impacted) Fracture involving the entire calcaneus (heel bone). Multiple fractured pieces are present. 2. Mildly displaced fracture of the Lateral Malleolus (lower portion of the fibula where it meets the Talus)." Further review of the hospital records for Resident #155 found an entry at 8:01 p.m., for Safety Measures comment: "Pt states he wanted to leave the place where he lived, so he opened a window, hung off window ledge, and dropped to the ground; baker acted because they say he was trying to hurt himself; swelling and pain in left ankle; small cut on right hand near wrist. Resident's cognition and speech was documented to be clear and coherent; in general, awake and oriented x2. His psychiatric was documented to be cooperative with appropriate mood and affect." 3. A review of the facility profile revealed that the facility is a 152 bed facility. During the survey conducted on 03/04/14 thru 03/07/14, the facility provided documentation of the bed capacity of a secure unit of 32 beds which is located at the west side of the building on the second story. During the survey, it was observed that in order to access the 2nd story secure unit, a person could utilize one of 2 stair wells or an elevator. Once a person was on the 2nd floor secure area, a staff member would have to punch in a code for either the stair wells or the elevator in order to leave the secure unit. 4. A review of Resident #155's clinical chart documented that the resident was initially admitted to the facility 12/17/13, a [AGE] year old male. [DIAGNOSES REDACTED]." Resident #155 was admitted to the secure unit in the facility. During an interview conducted on 03/05/14 at 3:41 p.m., the, Business Development Coordinator, confirmed that the family member of Resident #155 toured the secure unit and wanted Resident #155 placed on the unit. 5. A review of a local hospital admission History and Physical, dated 12/09/13, documented: "The patient is a [AGE] year old ...who presented to the hospital, brought in by EMS. He was placed on a Baker Act by the ER physician for wandering from his home and confusion. There was a concern that he was unable to care for himself. On exam today, the patient reports he is uncertain why he is here, how he got here or what the purpose of his being here is. I spoke with his (family member), who reports that she has noticed some problems with his memory over the past few years. His Neighbors were mentioning problems with his memory as far back as 3 years ago. Over the past couple of weeks he has seemed more confused. She tried taking him to another hospital a week or 2 ago, but he wandered away early in the morning. He has since been sitting at home, not eating and not caring for himself. She consulted with his primary care doctor who convinced her to bring him into the hospital by calling EMS. She does state she has noticed worsening memory problems recently. General: The patient is a [AGE] year old ...who appears reasonably healthy with good hygiene. Mental status examination: Patient is alert and oriented times 4. He is dressed in clean personal attire with good grooming ...his mood is reported to be ok with a mildly irritable affect. His thought process is organized and goal directed, but there is no ability for abstract reasoning ...Insight and judgments are poor ... Assessment and Plan: ...gentleman with what appears to be worsening cognitive function, currently living on his own. At the present point in time, the patient does not appear to have the capacity to live on his own and likely poses a threat of self-neglect were he to be discharged back home, given that his mental status has changed in recent weeks ...daughter who is concerned about finding him placement ..." 6. An interview was conducted 03/05/14 at 3:41 p.m. with the Business Development Coordinator; ( Admissions Director), who stated, "We do not advertise the secure unit. Our local hospital calls; I limit to accepting residents from our (local) area. It is a secure unit; they have to be exit seeking; that is the main characteristic of the resident; (I) do not have a check list; someone can have dementia and not be exit seeking. I do not document the assessment or the information that the resident is going to the secure." 7. An interview was conducted on 03/06/14 at 3:25 p.m. with the Director of Nursing regarding the criteria for admission to the secured unit. She stated it is usually for residents who are coming from the community with a history of wandering. We look at the H & P, the referral information, family information etc. to determine if they need the secured unit. She stated the residents need to be ambulatory there too. 8. Review of the record for Resident # 155 revealed that an admission Minimum Data Set (MDS) assessment was completed on 12/26/13 with an assessment reference date of 12/26/13. Review of the assessment revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 and was able to participate in the assessment. Under Section E Behavior, the resident was assessed as having no behavioral symptoms, including wandering. Review of a Psychosocial History and Assessment, completed on 12/18/13 by the Social Worker, revealed that the resident was oriented to place and time and that orientation fluctuated. Cognitive skills for decision making were noted to be moderately impaired. Mood and behavior were checked as "pleasant" and the behavior of "wandering" was not checked as applying to this resident. Review of an Admission data assessment, completed by a Registered Nurse on 12/19/13, revealed that the resident was noted to be oriented to person, place, time and situation. Under the section for Mood and Behavior, the resident was noted to exhibit Elopement Risk Factors of "Angry at placement" and "History of drug or alcohol abuse." The question "Is the resident on a secured unit?" was checked as "yes." 9. A review of Resident #155's care plan, initiated on 12/20/13, documented a focus area of Elopement and that the resident was an elopement risk/ wanderer. "Resident presents with cognitive impairment and is independently mobile. The goal of the focus area was that the resident would not exit the facility without staff knowledge and staff would monitor whereabouts on an ongoing basis." Further review of the care plan revealed that it described interventions to be used by staff such as: "Secured unit; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs pictures and memory boxes; Identify pattern of wandering: Is wandering purposeful, aimless or escapist: Is resident looking for something: Does it indicate the need for more exercise: Intervene as appropriate; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book." 10. A review of the Neuropsychiatric consultation for Resident #155, dated 12/31/13, documented, "Patient looks for elevator to leave. ...still thinks he can be independent." A review of the Neuropsychiatric consultation for Resident #155, dated 01/13/14, documented: "wish to leave. Exit seeking. Says his day ok, but doesn ' t like it here. Says he feels very depressed." 11. A review of nursing progress notes documented the following: 12/21/13 at 7:55 p.m.: " ...is pleasant, says I don ' t belong here. I have been here 3 weeks already ..." 12/30/13 at 3:30 p.m.: "Resident got on the elevator after a family member came up ...Resident angry saying he wants to leave." 01/02/14 at 9:38 p.m.: "Exit seeking earlier with another resident, waiting by elevator and stairwells." 01/04/14 at 4:14 p.m. " ....up in day room all night refusing to go to bed stating he is afraid his roommate is going to hurt him. Unable to convince him that he won't hurt him stating he feels safer in the dayroom tonight." 01/31/14 at 9:15 a.m.: "Resident #155 noted slamming his room door, and standing by the window with a spoon trying to lift it up, this writer asked resident what are you doing, resident stated, "I am locked up like a prisoner and I am trying to get out of here." This writer was able to redirect the resident by asking him to speak with his daughter first, resident handed the spoon to this writer ...Dr (_), ARNP called, new order received for 1:1 until she gets here in 15 minutes." 01/31/14 at 9:21 a.m.: "1:1 maintained by staff, resident remains standing by his window on 1:1 in place." 02/01/14 at 22:22: "Resident is alert with confusion. ...Did tell nurse he tried to leave because his daughter did not pay rent on his apt. ...but, says he is not bad off like "these guys." 02/02/14 at 1:20 p.m. " ...1 on 1 maintained by staff ... " I feel like I am in jail " ..." 02/02/14's entry at 11:11 p.m. documented the resident's breaking the window and jumping out the window. 12. During an interview conducted on 03/06/14 at 12:57 p.m. with the Risk manager, she confirmed that Resident #155 was on the event log for behaviors that occurred on 02/02/14, that he went out to the hospital for behaviors and fracture; busted a window, then went out the window, then got a fracture. 13. Review of the staffing pattern for the 3 p.m. to 11 p.m. for 02/02/14, revealed one Licensed Practical Nurse, Staff member H, and 3 Certified Nursing Assistants, Staff members I, J, K. Review of the facility staffing for the Secure Unit revealed that the census for 02/02/14 was 30 residents. 14. A review of the facility Elopement Standard, effective date of 01/06, documented the facility elopement definition as follows: "Elopement occurs when a Resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]." 15. Interviews were conducted with the 3 CNAs and the one LPN that were on duty during the 02/02/14 event with Resident #155. During the interviews, it was noted that the after the Resident #155 was found to have broken the glass out of his bedroom window, staff were able to have the resident exit the bedroom and staff reported that the resident was located at one point in front of the shower room (observed to be approximately 23 feet from the entry of the residents' bed room door); that somehow the resident was able to re- enter the room (seen by staff member I); but, no staff member could confirm that they had witnessed the resident going out the newly created exit area of the broken window and dropping to the parking lot, 2 stories below. 16. A review of the facility census for 02/02/14 revealed that 29 residents were residing on the secure unit and per an interview conducted on 03/06/14 at 3:25 p.m. with the DON confirmed that residents residing on the unit were "wanderers" or exit seeking. 17. Interviews were conducted with the staff present during the 02/02/14 event: a. An interview was conducted on 03/06/14 at 9:20 a.m., with Staff member K, CNA: "Around dinner time, we were serving dinner in the dining room, Staff member I, and I and we heard glass break, we proceeded to Resident #155's room and we saw that the glass was broken and Resident #155 had glass in his hand, it was approximately ? the size of the chart. He was standing at the end of the window bed; the glass in the window was not totally broke; it was the lower pane. Staff member I was in the room trying to calm the resident down, (the nurse was right there with her med cart) he started coming toward us with the glass; "Resident #155, if you calm down I will take you out for a smoke break"; he laid the glass down and he walked out of the room with me; we were in the hall way; he stated that if I took him downstairs he would not come back up. We were standing in the hall way with Resident #155. I used the dialogue with the resident to get the glass out of his hands. I went back into the dining room. Resident #155 did not come with me. I let the nurse and the other aide (Staff member I) take care of it, because I had to go and serve the (other) residents. I do not know what took place after that; I was serving the residents (in the main dining room). The nurse went and called 911 to baker act the resident; I went down to let the police officers in and when I stepped off the w/ ramp, I heard a (she clapped her hands for a sound); I ran over to him; he tried to get up and run; I saw that his ankle caused him to go down; he was immobile; I put my hands on his shoulders so he could not move to endanger himself with movement. The officers came; they took over; I went upstairs. b. An interview was conducted on 03/06/14 at 10:04 a.m. with Staff member I, CNA: "We were in the ending stages of the dinner and he (Resident #155) had been on a 1:1, he had been taken off. I heard a loud noise/ glass breaking; we (the nurse and I) both got to the room at the same time.. He had picked up a piece of glass and came toward the nurse. We tried to calm him down. We were able to get him to leave the room to have a cigarette; then the nurse had gone to call the police; I went in to clean up the glass; the resident had gone with the CNA (Staff member K); then as I was going out of the room with a piece of glass in my hands and, he was walking back in the room. I moved out of the way, because I had the glass in my hands, I turned, he was inside the room; I wanted to find someone to help me; I did not exit the room; I did not want to leave him by himself; he was about to walk into the glass. I did not see him jump out the window. I did not close the door after he exited the room the first time." c. An interview was conducted on 03/06/14 at 10:18 a.m. via phone with Staff member J, CNA. She confirmed that she was present on the secure unit the date of the event, 02/02/14. "I was in the dining room (small dining room)., serving the residents their dinner; I did not see him go out the window; not too much I can tell you. I usually work in the secure unit; I have worked there for [AGE] years. I heard one of the CNA's (Staff member I) come to the nurse and say that the resident had gone out the window. The nurse, I am not sure where she was. We were all on the floor; Staff member K was probably in the dining room; but, I do not know. I did not hear the glass breaking. I probably saw Resident #155 before dinner, but, I was too busy in the small dining room with the (other) residents." d. An interview was conducted with Staff member H, LPN, on 03/06/14 at approximately 10:20 a.m.: "He was in his room, they were serving dinner, he did not want to eat in the main dining room, he wanted to go home, he was upset, his daughter did not pay his rent; he did not want to be with the other folks; I took his tray into his room; I sat with him for a while. I think we had picked up the tray from his room; I heard the glass breaking, I was right across from his room, I was passing medications. I heard the glass break; I ran into the room to see what was going on; he had a large piece of glass in his hand; he was coming forward toward us with the glass; I felt that he really did not want to hurt us that he wanted to get out. CNAs I, J and K came running. Resident #155 put the glass down; he came towards me and then went out of the room. I knew it was not over because he was tearing things off the wall as he went down the hallway. I closed the door; I asked Staff member K to go let the police in; I asked Staff member I to follow Resident #155. And Staff member J was keeping the other residents away from the glass and everything else that was going on. I went to the nurse's station, called 911; just as I was hanging up the phone, Staff member I came in and told me the resident jumped out the window. The last time I saw the resident; he was standing in front of the shower room. The one thing that could have happened that did not happen; we could have called for help, from downstairs, possibly keeping Resident #155 under more control. For the amount of staff we did our best." e. During the interviews with the facility staff, it was revealed that they did not classify the event as an elopement event. The facility acknowledged that they had a resident leave a secure area unwitnessed by staff and found by staff in the parking lot with a broken heel bone. Interviews with staff that were present during the event revealed a lack of ownership to offer the resident an immediate diversion and supervision once the resident was removed from the bed room. The lack of direct oversight allowed for the resident to reenter the bed room and exit an unsecure window (unwitnessed by staff) and drop the parking lot. The facility staff felt they could not do anything different to prevent such an event from happening again which places all the resident on the secure unit at risk. 18. An observation was conducted on 03/05/14 at approximately 10:45 a.m. of Resident #155's bed room. The tiles in the floor were 12" tiles, from the bedroom door to the window was 16 tiles, thus 16 feet. A second observation was conducted at this time of the shower room door on the hall near Resident #155's room (Staff had reported that at one point the resident was next to the shower room door during the event; this shower room door is to the left as you exit Resident #155's bedroom.) The distance between the shower room and the bedroom door was approximately 23 feet. Thus, Resident #155 crossed a total of 39 feet through an open bedroom door and made an un-witnessed and unauthorized exit thru a 2nd story window to drop to the parking lot to attempt leave the facility grounds. 19. The Risk manager confirmed that "he left a secure area." When the RM was asked if he was an elopement, she stated, "No, he was an attempted elopement." The RM stated that she thought that the staff did everything in their power to protect Resident #155, that Staff member I was right there in the doorway (resident room). "Don't think leaving the door (bedroom) open or closed would have made a difference." Think that Staff member I should have cleaned up the glass (in the bedroom) like he did to keep everyone safe." When asked about the location of the other residents on the secure unit during the event, the RM was not able to answer if all of the other residents were located in the dining room during the event. No information was provided in regards to how the resident broke the window. No information was provided in regards to how long the resident was in the bed room alone prior to breaking the window. 20. Interviews were conducted on 03/07/14 at approximately 2:01 p.m. with the Regional Nurse which revealed, "Regarding the resident (#155) who had unfortunate time dealing with issues on unit. It was a quick response and proud of the staff the way they responded. It did not meet the state definition for an elopement. He was on the premises and he had supervision." The Regional Nurse confirmed during this interview that "No one visually saw him get to the window and get out." 21. During the interviews with the facility staff, during the survey, it was revealed that they did not classify the event as an elopement event. The facility acknowledged that they had a resident leave a secure area unwitnessed by staff and found by staff in the parking lot with a broken heel bone. Interviews with staff that were present during the event revealed a lack of ownership to offer the resident an immediate diversion and supervision once the resident was removed from the bed room. The lack of direct oversight allowed for the resident to reenter the bed room and exit an unsecure window (unwitnessed by staff) and drop the parking lot. The facility staff felt they could not do anything different to prevent such an event from happening again which places all the resident on the secure unit at risk.

Based on observations, record review and interviews, the facility failed to be managed in a manner that enabled it to use its resources effectively to maintain the highest practicable physical & psychosocial well-being for 1 (#155) of 5 sampled residents, residing on a secure unit, who was identified as needing closer supervision due to exit seeking behaviors. The administration did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and facilities policies for resident supervision and providing a safe environment, free of hazards as evidenced by the following: Resident #155 broke a window in his bedroom, located in a "Secure Unit", the resident walked out of the bedroom and down the hall approximately 23 feet, the resident returned and re-entered the unsecured bedroom and exited the bedroom (unwitnessed by staff) through an unsecured window exit. The resident then dropped from the 2nd story window to the parking lot, during which he broke his ankle and proceeded to attempt to leave the facility grounds unauthorized. During four of four staff interviews (Staff I, J, K, and H), no staff claimed responsibility or ownership for the resident's supervision from the point that he exited the bedroom and was located in a hall way near the shower room door; no one claimed to be responsible for his supervision after he made a verbalization that if he went down stairs, he was not coming back. CNA, K went back to the dining room; CNA I reported he went into the Resident's room to clean the glass; CNA J reported that she did not come out of the small dining room, only that she heard about the event; Nurse H, stated that she went back to the nurses station. The lack of ownership for closely supervising an agitated resident who was identified with elopement risk behaviors, precipitated an environment where the unwatched resident could re-enter an area with broken glass and proceed to climb through a broken window unwitnessed by staff. Further, based on a review of the Job Description for the Nursing Home Administrator, interviews with the Resident's family member and the facility staff, and review of the resident's medical record, facility policies, and facility admission agreement, it was determined that the Administrator failed to ensure that the necessary services to honor a resident's Advanced Directives and provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) were provided for one (#144) of 76 residents identified as having orders to be Fully Resuscitated according to an audit of all current resident records performed by the facility on [DATE]. The Administrator did not ensure that the facility honored the wishes of the Resident's family or the physician's orders [REDACTED]. The administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and facility policies for advanced directives, the identification of residents who are full code and the administration of cardio [MEDICAL CONDITION] resuscitation (CPR). The failure to ensure that staff properly implemented interventions related to resident supervision, implemented interventions to maintain a hazard free environment and the failure to ensure the provision of services to ensure resident safety for all residents and failure of the facility staff to honor the wishes of a resident and family to provide CPR when the resident was found without a pulse or respirations, led to the findings of Immediate Jeopardy on [DATE], which is on-going. Findings Include: A review of the job description for the Nursing Home Administrator, provided by the facility as the current description, documented a Summary of the position: "The Nursing Home Administrator is responsible for maintaining appropriate guidelines and regulations to assure the highest degree of attention and care is provided to all residents." The essential duties and responsibilities included: "Plans, develops, organizes, implements and directs the facility programs and activities. Ensures that the most current resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations and guidelines are available and followed." Supervisory responsibilities: "Supervises staff whether directly or indirectly in accordance with company policies and procedures. Responsible for hiring, selection, training and coaching of employees." 1. a. A review of Resident #155's clinical chart was conducted; Resident #155 was determined to have an event that occurred on [DATE]. While residing on the secure unit, Resident #155 climbed out of the second story window, unwitnessed by staff. A review of Nursing Notes, dated [DATE] at 11:11 p.m. revealed: "ARNP visited with resident at approx. 5:30 p.m. ARNP spoke with resident who has been calm so far this shift. 1:1 was d/c'd and other orders were written. Asked resident how he felt, says upset ...Resident did not want to eat in dr (dining room), was left sitting on his bed with meal on bedside table feeding self. At 7:00 p.m. heard noise like glass breaking. Upon entering room, found resident standing with large piece of glass in hands, coming towards nurse and CNA who also responded to the glass breaking. Asking resident to please put the glass down and to not hurt himself or anyone else. Cont ...Resident did drop the glass. As nurse backed up, resident ran out of room toward shower room. Asked CNA, Staff member K to go downstairs to let 911 in. CNA, staff member J was keeping other residents away and safe. CNA, Staff member I ran into nurses station and states he jumped out of the window while I was cleaning up the glass. The nurse ran down stairs to assist resident, ...resident sitting on bottom with knees bent facility the street. CNA, staff member K and the police present. Resident transferred to local hospital." b. A review of the [DATE] local hospital record at 7:46 p.m. found: "Chief Complaint: Fall-no LOC ( loss of consciousness); left ankle pain; patient hung from second story window and dropped to the ground; BA52 because they said he was trying to hurt himself; pt states he was trying to get away from the "jail" where he lives. Impression: 1. Severe Comminuted (impacted) Fracture involving the entire calcaneus (heel bone). Multiple fractured pieces are present. 2. Mildly displaced [MEDICAL CONDITION] Malleolus (lower portion of the fibula where it meets the Talus)." c. Further review of the hospital records for Resident #155, found an entry at 8:01 p.m., for Safety Measures comment: "Pt states he wanted to leave the place where he lived, so he opened a window, hung off window ledge, and dropped to the ground; baker acted because they say he was trying to hurt himself; swelling and pain in left ankle; small cut on right hand near wrist. Resident's cognition and speech was documented to be clear and coherent; in general, awake and oriented x2. His psychiatric was documented to be cooperative with appropriate mood and affect." d. A review of the facility profile revealed that the facility was a 152 bed facility. During the survey conducted on [DATE] thru [DATE], the facility provided documentation of the bed capacity of the secure unit of 32 beds which is located at the west side of the building on the second story. During the survey, it was observed that in order to access the 2nd story secure unit, a person could utilize one of 2 stair wells or an elevator. Once a person was on the 2nd floor secure area, a staff member would have to punch in a code for either the stair wells or the elevator in order to leave the secure unit. e. A review of Resident #155's clinical chart documented that the resident was initially admitted to the facility [DATE], a [AGE] year old male. [DIAGNOSES REDACTED]." Resident #155 was admitted to the secure unit in the facility. f. During an interview conducted on [DATE] at 3:41 p.m., the Business Development Coordinator, confirmed that the family member of Resident #155 toured the secure unit and wanted Resident #155 placed on the unit. g. A review of a local hospital admission History and Physical, dated [DATE], documented: "The patient is a [AGE] year old ...who presented to the hospital, brought in by EMS. He was placed on a Baker Act by the ER physician for wandering from his home and confusion. There was a concern that he was unable to care for himself. On exam today, the patient reports he is uncertain why he is here, how he got here or what the purpose of his being here is. I spoke with his (family member), who reports that she has noticed some problems with his memory over the past few years. His Neighbors were mentioning problems with his memory as far back as 3 years ago. Over the past couple of weeks he has seemed more confused. She tried taking him to another hospital a week or 2 ago, but he wandered away early in the morning. He has since been sitting at home, not eating and not caring for himself. She consulted with his primary care doctor who convinced her to bring him into the hospital by calling EMS. She does state she has noticed worsening memory problems recently. General: The patient is a [AGE] year old ...who appears reasonably healthy with good hygiene. Mental status examination: Patient is alert and oriented times 4. He is dressed in clean personal attire with good grooming ...his mood is reported to be ok with a mildly irritable affect. His thought process is organized and goal directed, but there is no ability for abstract reasoning ...Insight and judgments are poor ... Assessment and Plan: ...gentleman with what appears to be worsening cognitive function, currently living on his own. At the present point in time, the patient does not appear to have the capacity to live on his own and likely poses a threat of self-neglect were he to be discharged back home, given that his mental status has changed in recent weeks ...daughter who is concerned about finding him placement ..." h. An interview was conducted [DATE] at 3:41 p.m. with the Business Development Coordinator; ( Admissions Director), who stated, "We do not advertise the secure unit. Our local hospital calls; I limited to accepting residents from our (local) area. It is a secure unit; they have to be exit seeking; that is the main characteristic of the resident; (I) do not have a check list; someone can have dementia and not be exit seeking. I do not document the assessment or the information that the resident is going to the secure." i. An interview was conducted on [DATE] at 3:25 p.m. with the Director of Nursing regarding the criteria for admission to the secured unit. She stated it is usually for residents who are coming from the community with a history of wandering. We look at the H & P, the referral information, family information etc. to determine if they need the secured unit. She stated the residents need to be ambulatory there too. j. A review of Resident #155's care plan, initiated on [DATE], documented a focus area of Elopement and that the resident was an elopement risk/ wanderer. AEB "Resident presents with cognitive impairment and is independently mobile." The goal of the focus area was that the resident would not exit the facility without staff knowledge and staff would monitor whereabouts on an ongoing basis. Further review of the care plan revealed that it described interventions to be used by staff such as: "Secured unit; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs pictures and memory boxes; Identify pattern of wandering: Is wandering purposeful, aimless or escapist: Is resident looking for something: Does it indicate the need for more exercise: Intervene as appropriate; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book." k. A review of the Neuropsychiatric consultation for Resident #155, dated [DATE], documented "Patient looks for elevator to leave. ...still thinks he can be independent. A review of the Neuropsychiatric consultation for Resident #155, dated [DATE], documented: "wish to leave. Exit seeking. Says his day ok, but doesn't like it here. Says he feels very depressed." l. A review of nursing progress notes, leading up to the exit from the second story on [DATE], documented the following: [DATE] at 7: 55 p.m.: "...is pleasant, says I don't belong here. I have been here 3 weeks already ..." [DATE] at 3:30 p.m.: "Resident got on the elevator after a family member came up ...Resident angry saying he wants to leave." [DATE] at 9:38 p.m.: "Exit seeking earlier with another resident, waiting by elevator and stairwells." [DATE] at 4:14 p.m. "....up in day room all night refusing to go to bed stating he is afraid his roommate is going to hurt him. Unable to convince him that he won ' t hurt him stating he feels safer in the dayroom tonight." [DATE] at 9:15 a.m.: "Resident #155 noted slamming his room door, and standing by the window with a spoon trying to lift it up, this writer asked resident what are you doing, resident stated "I am lock up like a prisoner and I am trying to get out of here." This writer was able to redirect the resident by asking him to speak with his daughter first, resident handed the spoon to this writer ...Dr (_), ARNP called, new order received for 1:1 until she gets here in 15 minutes." [DATE] at 9:21 a.m.: "1:1 maintained by staff, resident remains standing by his window on 1:1 in place." [DATE] at 22:22: Resident is alert with confusion. "...Did tell nurse he tried to leave because his daughter did not pay rent on his apt. ...but, says he is not bad off like "these guys." [DATE] at 1:20 p.m. "...1 on 1 maintained by staff ... "I feel like I am in jail" ..." [DATE]'s entry at 11:11 p.m. documented the resident's breaking the window and jumping out the window. m. An interview was conducted on [DATE] at 12:57 p.m. with the Risk manager. She confirmed that Resident #155 was on the event log for behaviors that occurred on [DATE], that he went to the hospital for behaviors and fracture; busted a window, then went out the window, then got a fracture. n. Review of the staffing pattern for the 3 p.m. to 11 p.m. for [DATE], revealed 1 Licensed Practical Nurse, Staff member H, and 3 Certified Nursing Assistants, Staff members I, J, K. Review of the facility staffing for the Secure Unit revealed that the census for [DATE] was 30 residents, including Resident #155. o. A review of the facility Elopement Standard, effective date of ,[DATE], documented the facility elopement definition as follows: "Elopement occurs when a Resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. p. Interviews were conducted with the 3 CNA's and the one LPN that were on duty during the [DATE] event with Resident #155. During the interviews, it was noted that the after the Resident #155 was found to have broken the glass out of his bedroom window, staff were able to have the resident exit the bedroom and staff reported that the resident was located at one point in front of the shower room (observed to be approximately 23 feet from the entry of the residents' bed room door); that somehow the resident was able to re- enter the room (seen by staff member I); but, no staff member could confirm that they had witnessed the resident going out the newly created exit area of the broken window and dropping to the parking lot, 2 stories below. q. A review of the facility census for [DATE] revealed that 29 residents were residing on the secure unit, after the Resident #155's exit, and, per an interview conducted on [DATE] at 3:25 p.m. with the DON, confirmed that residents residing on the unit were "wanderers" or exit seeking. r. Interviews were conducted with the staff present during the [DATE] event: An interview was conducted with Staff member K, CNA, on [DATE] at 9:20 a.m.: "Around dinner time, we were serving dinner in the dining room, Staff member I, and I and we heard glass break, we proceeded to Resident #155's room and we saw that the glass was broken and Resident #155 had glass in his hand, it was approximately ? the size of the chart. He was standing at the end of the window bed; the glass in the window was not totally broke; it was the lower pane. Staff member I was in the room trying to calm the resident down, (the nurse was right there with her med cart) he started coming toward us with the glass; "Resident #155, if you calm down I will take you out for a smoke break"; he laid the glass down and he walked out of the room with me; we were in the hall way; he stated that if I took him downstairs he would not come back up. We were standing in the hall way with Resident #155. I used the dialogue with the resident to get the glass out of his hands. I went back into the dining room. Resident #155 did not come with me. I let the nurse and the other aide (Staff member I) take care of it, because I had to go and serve the (other) residents. I do not know what took place after that; I was serving the residents (in the main dining room). The nurse went and called 911 to baker act the resident; I went down to let the police officers in and when I stepped off the w/ ramp, I heard a (she clapped her hands for a sound); I ran over to him; he tried to get up and run; I saw that his ankle caused him to go down; he was immobile; I put my hands on his shoulders so he could not move to endanger himself with movement. The officers came; they took over; I went upstairs." s. An interview was conducted on [DATE] at 10:04 a.m. with Staff member I, CNA: "We were in the ending stages of the dinner and he (Resident #155) had been on a 1:1, he had been taken off. I heard a loud noise/ glass breaking; we (the nurse and I) both got to the room at the same time. He had picked up a piece of glass and came toward the nurse. We tried to calm him down. We were able to get him to leave the room to have a cigarette; then the nurse had gone to call the police; I went in to clean up the glass; the resident had gone with the CNA (Staff member K); then as I was going out of the room with a piece of glass in my hands and, he was walking back in the room. I moved out of the way, because I had the glass in my hands, I turned, he was inside the room; I wanted to find someone to help me; I did not exit the room; I did not want to leave him by himself; he was about to walk into the glass. I did not see him jump out the window. I did not close the door after he exited the room the first time. " t. An interview was conducted on [DATE] at 10:18 a.m. via phone with Staff member J, CNA. She confirmed that she was present on the secure unit the date of the event, [DATE]. "I was in the dining room (small dining room), serving the residents their dinner; I did not see him go out the window; not too much I can tell you. I usually work in the secure unit; I have worked there for [AGE] years. I heard one of the CNA's (Staff member I) come to the nurse and say that the resident had gone out the window. The nurse, I am not sure where she was. We were all on the floor; Staff member K was probably in the dining room; but, I do not know. I did not hear the glass breaking. I probably saw Resident #155 before dinner, but, I was too busy in the small dining room with the (other) residents." u. An interview was conducted with Staff member H, LPN, on [DATE] at approximately 10:20 a.m.: "He was in his room, they were serving dinner, he did not want to eat in the main dining room, he wanted to go home, he was upset, his daughter did not pay his rent; he did not want to be with the other folks; I took his tray into his room; I sat with him for a while. I think we had picked up the tray from his room; I heard the glass breaking/I was right across from his room, I was passing medications. I heard the glass break; I ran into the room to see what was going on; he had a large piece of glass in his hand; he was coming forward toward us with the glass; I felt that he really did not want to hurt us that he wanted to get out. CNAs I, J and K came running. Resident #155 put the glass down; he came towards me and then went out of the room. I knew it was not over because he was tearing things off the wall as he went down the hallway. I closed the door; I asked Staff member K to go let the police in; I asked Staff member I to follow Resident #155. And Staff member J was keeping the other residents away from the glass and everything else that was going on. I went to the nurse's station, called 911; just as I was hanging up the phone, Staff member I came in and told me the resident jumped out the window. The last time I saw the resident; he was standing in front of the shower room. The one thing that could have happened that did not happen; we could have called for help, from downstairs, possibly keeping Resident #155 under more control. For the amount of staff we did our best." v. An observation was conducted on [DATE] at approximately 10:45 a.m. of Resident #155's bed room. The tiles in the floor were 12inch tiles, from the bedroom door to the window was 16 tiles, thus 16 feet. A second observation was conducted at this time of the shower room door on the hall near Resident #155's room (Staff had reported that at one point the resident was next to the shower room door during the event; this shower room door was to the left as you exited Resident #155's bedroom.) The distance between the shower room and the bedroom door was approximately 23 feet. Thus, Resident #155 crossed a total of 39 feet through an open bedroom door and made an un-witnessed and unauthorized exit through a 2nd story window to drop to the parking lot to attempt leave the facility grounds. w. During an interview conducted on [DATE], at 12:57p.m., the Risk manager confirmed that "he (Resident #155) left a secure area." When the RM was asked if he was an elopement, she stated "No, he was an attempted elopement." The RM stated that she thought that the staff did everything in their power to protect Resident #155, that Staff member I was right there in the doorway (resident room). "Don't think leaving the door (bedroom) open or closed would have made a difference." The Risk Manager thought that Staff member I should have cleaned up the glass (in the bedroom) like he did to keep everyone safe." When asked about the location of the other residents on the secure unit during the event, the RM was not able to answer if all of the other residents were located in the dining room during the event. No information was provided in regards to how the resident broke the window. No information was provided in regards to how long the resident was in the bed room alone prior to breaking the window. x. Interviews conducted on [DATE] at approximately 2:01 p.m. with the Regional Nurse revealed, "Regarding the resident (#155) who had an unfortunate time dealing with issues on unit, it was a quick response and proud of the staff the way they responded. It did not meet the state definition for an elopement, He was on the premises and he had supervision." The Regional Nurse confirmed during this interview that "No one visually saw him get to the window and get out." 2. a. Review of Resident # 144's medical record [DATE] Daily Skilled Note revealed: Resident noted with no respirations, no blood pressure, physician and son called, new order received to release the body to the funeral home of choice. The note was signed by Employee L. There was no indication in the nurse's notes or the medical record that Cardio [MEDICAL CONDITION] Resuscitation (CPR) was performed or an attempt was made to resuscitate the resident. b. Further review of Resident #144's medical record revealed a verbal physician's orders [REDACTED]. c. An interview was conducted on [DATE], at 9:29 a.m., with the Administrator. He stated that he had been working as the Administrator for this facility since [DATE] and was the interim Administrator from October to December of 2013. He outlined the facility's immediate action plan that began within 2 hours of discovery of the incident on [DATE]. He stated that the management staff conducted a conference call at 4:30 p.m. that day and carried out the following actions: suspension of the four staff members directly involved; 24 hour management supervision in the building; reeducation of staff; audit of CPR certification for all staff; review of staff education in the past year on Cardio [MEDICAL CONDITION] Resuscitation (CPR)/Do Not Resuscitate (DNR)/Code response; Code Blue drills; an audit of all resident charts to verify complete and accurate DNR documentation and review of all care plans advanced directive section. He stated a long range action plan will be developed at the next Quality Assessment and Assurance (QA&A) meeting to be held the following week, the week of [DATE]. d. Review of the Resident Admissions Agreement provided by the facility revealed section B. Consent to Treatment: The resident and/or legal representative hereby authorizes the appropriate staff at the Facility to perform such functions as are necessary to maintain the well-being of the Resident, including but not limited to assistance with bathing and hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medication and treatments, and the performance of therapies, as prescribed by the Resident's physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided the Resident by federal and state law. e. Review of the facility's Policy and Procedure - Florida titled "Code Status Orders & Response ADM 11.1, no effective date, revealed the following: "Policy, The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. The facility provides Basic Life Support CPR only. No advanced life support services are offered in the facility or by facility staff. DNR order - the resident/patient will receive medically appropriate care; however, cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. Code status orders will be reviewed quarterly, PRN and with any change of condition by the interdisciplinary team. Code status orders will be renewed by physician's review and signature on monthly orders. Each resident/patient will have their elected code status documented in the medical record. Code status documentation will be filed as the first documents within the medical record. An incomplete 1896 document should not be placed in the resident's chart as the DNRO is not valid." "Procedure for initiating CPR: Personnel First nurse on the scene Procedure 1. Confirms cardiac/or respiratory arrest. 2. Calls for help. 3. Checks airway and pulse and connect the oxygen if available while awaiting the emergency cart. 4. Checks medical record for code status. 5. Begins CPR at 30 compressions to 2 breaths until 911 arrives and takes over care of the patient. Point of Emphasis Call HELP loudly, even is no one is in sight. CODE status must be confirmed by checking the medical record." f. Review of the medical record for Resident #144 revealed a Psychosocial History and assessment dated [DATE] by the Social Services Director, the Advanced Directives section indicated the Resident's code status was "Full Resuscitate"; the Resident's son was listed as her family support person. g. A telephone interview with the Resident #144's son on [DATE], at 10:15 a.m. revealed that he was not aware that the facility did not perform CPR on his mother when she was found without a pulse or blood pressure. He stated he did not want his mother to be a Do Not Resuscitate (DNR) that she would open her eyes and look over when you talked to her and she was getting slightly better. He stated we (he and his brother) definitely wanted them to resuscitate her. h. An interview was conducted with the Social Services Director on [DATE] at 8:06 a.m. She stated that Resident #144's record reflected that her status was "FULL CODE" and "FULL CODE" was also written in the care plan. She reviewed the Activities Assessment and relayed the information that the Resident was born in Kentucky, was a waitress, a home health aide and a Spiritual reader, Methodist; she was divorced and had three children. She stated that she had spoken to the family on the Resident's first admission on [DATE] and that if the family had wanted a Do Not Resuscitate (DNR) status in place they would have made sure the facility knew about it. She was aware from her conversations with the Resident's two sons that they wanted their mother to receive CPR. They had told her that their mother had been very ill before and had bounced back and they were holding on to hope for her. She stated again that if they were ready for the DNR status they would have made sure she had a DNR in place. i. Review of the medical record face sheet dated [DATE] for Resident #144 indicated that she was [AGE] years old and the admitted was [DATE]. The responsible party listed for the Resident was herself and two sons were listed as emergency contacts. Review of the [DATE] Minimum Data Set (MDS) assessment revealed the Resident was admitted from an acute care hospital, the Resident did not participate in the assessment. The family or significant other participated. Her [DIAGNOSES REDACTED]. Her functional status was total dependence on staff with two persons assist for transfers, dressing, toileting and hygiene. j. An Admission Minimum Data Set Assessment was completed for the Resident on [DATE]. The question "Does the Resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?" was answered NO. k. An interview was conducted with the Risk Manager on [DATE], at 9:29 a.m., a Registered Nurse (RN), who has worked for the facility for [AGE] years, 4 years as the Risk Manager. She stated that as a result of her investigation she had determined that a Certified Nursing Assistant (CNA) had found the Resident was not breathing and called to a nurse in the hallway. The nurse assessed the Resident and called the supervisor. The supervisor arrived on the unit in less than 5 minutes. She stated that neither the nurse nor the supervisor initiated CPR. She stated that the nurse assigned to the Resident admitted that she did not look in the chart to determine if the resident was to receive CPR or not. She also stated that the Resident's resuscitation status was clear; there were no discussions in progress with family as to wanting the resident to have an advanced directive status of Do Not Resuscitate (DNR) status. l. An interview was conducted by phone on [DATE], at 11:32 a.m., with Employee O, the CNA assigned to the Resident. She stated that she had worked for the facility for 5 and ,[DATE] years and had been a CNA since 2001. She previously worked in another department. She worked full time on the ,[DATE] shift and worked all the units in the facility. She stated she was familiar with the Resident, that the Resident had a [MEDICAL CONDITION]; she opened her eyes but did not talk. She stated that she performed patient care on the Resident around 9:00 a.m. with Employee N. The Resident was breathing at that time. She stated that at approximately 11:00 a.m. she entered the resident's room to put linens in the room. The Resident was breathing at that time. She then went on her lunch break. She stated that when she returned from lunc