Every finding on record at Aspire at Evans

Based on observation, clinical record review and staff interviews, the facility failed to provide the necessary assistance with activities of daily living to meet the needs of 1 (Resident #999) of 3 sampled residents dependent on staff for grooming and dressing. The findings included:Review of the clinical record for Resident #999 revealed a readmission date of 6/24/24. Diagnoses included vascular dementia, aphasia (neurological communication disorder), anxiety, major depressive disorder and diastolic heart disease.Review of the Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 7/1/26 revealed Resident #999's cognitive skills for daily decision making were severely impaired (The resident never/rarely made decisions). The MDS noted that Resident #999 was dependent on staff for personal hygiene (Ability to maintain personal hygiene, including shaving), shower/bathe self (Ability to bathe self, including washing, rinsing and drying self), putting and taking off footwear (Ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility).Review of the physician orders revealed to apply TED Stockings (Compression stockings) to bilateral feet daily for edema (Swelling caused by excess fluid trapped in body tissues).The instructions on the Certified Nursing Assistant (CNA) Resident Care Kardex (Provides instructions for care) included:Apply [NAME] stockings as ordered and as resident tolerates. The resident needs their nails kept short to reduce risk of scratching or injury from picking at skin. ADL Prefer Bed Bath - Bathing Tuesday and Friday 7-3 --- Per daughter take resident into the shower.Review of the CNA task documentation for August 2026 revealed Resident #999 received a shower on 8/4/26, a bed bath on 8/7/26 and 8/10/26.On 8/12/26 at 9:55 a.m., Resident #999 was observed in his room, in bed. He had approximately 2 days of facial hair growth. Resident #999 was not wearing the TED stockings as ordered. The fingernails on the resident's right hand extended approximately 1/2 inch from the fingertips. A brown substance was observed under the nails. Resident #999 did not respond to interview questions.On 8/12/26 at 12:12 p.m., in an interview Certified Nursing Assistant (CNA) Staff F said Resident #999 was dependent for all care and did not speak. CNA Staff F said that they shave male residents and clean their nails on shower days. She said they file the residents' nails as needed.On 8/12/26 at 3:32 p.m., Resident #999 was observed in bed. He remained unshaven. His legs were swollen and had multiple areas of discoloration. He was not wearing the compression stockings as ordered.Review of the Medication Administration Record (MAR) for August 2026 revealed the licensed nurse placed a check mark (Administered) on 8/12/26 at 9:00 a.m. for, Apply TED Stockings to bilateral feet daily for edema every day shift and removed per schedule.On 8/13/26 at 9:35 a.m., Resident #999 was observed in bed. He remained unshaven. His nails remained untrimmed with a brown substance under the nails. His legs looked swollen and he was not wearing the compression stockings as ordered.On 8/13/26 at 11:05 a.m., review of the MAR revealed that Licensed Practical Nurse (LPN) Staff G signed that the compression stockings were applied.On 8/13/26 at 11:29 a.m., an observation of Resident #999 was done with Unit Manager LPN Staff B and CNA Staff E. Resident #999 remained unshaven. His nails remained untrimmed with a brown substance under the nails. The resident's legs were swollen, and he was not wearing the TED stockings as ordered. In an interview, Unit Manager LPN Staff B confirmed Resident #999's legs were swollen and he did not have the TED stockings on.On 8/13/26 at 12:10 p.m., in an interview LPN Staff G said, I don't know about the stockings, are they not on? I will put them on.

Based on observations, clinical record review and staff interviews, the facility failed to provide appropriate care and services for contracture management (loss of normal range of motion of a joint) for 1 (Resident #999) of 3 residents reviewed for decline in range of motion.The findings included:Review of the clinical record for Resident #999 revealed a readmission date of 6/24/24. Diagnoses included vascular dementia, aphasia (neurological communication disorder), anxiety, major depressive disorder and diastolic heart disease.Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 3/31/26 revealed that Resident #999 had functional limitation in range of motion to both upper extremities (shoulder, elbow, wrist, hand) and both lower extremities (hip, knee, ankle, foot).Review of the Annual MDS Assessment with an Assessment Reference Date of 7/1/26 revealed Resident #999's cognitive skills for daily decision making were severely impaired (The resident never/rarely made decisions). The MDS noted that Resident #999 had no functional limitation in range of motion of the upper or lower extremities.The current physician's orders included:Apply Podus boots daily as tolerated to bilateral lower extremities to prevent further contractures (Specialized medical device used to lift the heel completely off the bed and keep the foot in a proper position).Review of Resident #999's care plan revealed the resident had alteration in usual functional performance in self-care related to multiple diagnoses, including decreased mobility. The care plan noted that the resident's level of assistance varied based on daily functional ability, fluctuations in pain, fatigue, and underlying physical deconditioning. The interventions included to apply podus boots to bilateral lower extremities, right elbow and hand splints as ordered for contracture management. The instructions on the Certified Nursing Assistant (CNA) Resident Care Kardex (Provides instructions for care) included: Apply bilateral lower extremity [sic] podus boots, right elbow and hand splints as ordered for contracture management.On 8/12/26 at 9:55 a.m., and at 3:32 p.m., and on 8/13/26 at 9:35 a.m., Resident #999 was observed in his room, in bed. The resident was not wearing the right elbow splint or the podus boots as ordered. Resident #999 did not respond to interview questions.On 8/13/26 at 11:05 a.m., review of the Medication Administration Record (MAR) revealed that Licensed Practical Nurse (LPN) Staff G signed that on 8/13/26, the heel protectors were applied and that the skin to Resident #999's feet was checked before and after podus boots.On 8/13/26 at 11:29 a.m., an observation of Resident #999 was done with Unit Manager Licensed Practical Nurse (LPN) Staff B and CNA Staff E. Unit Manager LPN Staff B confirmed Resident #999 was not wearing the splint to the right elbow, and he did not have the podus boots on.On 8/13/26 at 12:10 p.m., in an interview LPN Staff G verified that she did not apply the podus boots for Resident #999 and signed on the MAR that the boots were on. She said, Yes, I signed the MAR that the boots were on because he always has them on.

Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to provide adequate supervision and implement appropriate resident centered interventions to prevent avoidable accidents for 1 (Resident #999) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including falls with injuries.The findings included:Review of the facility provided policy N-1259 Fall Management effective 11/30/14 (revised 7/29/19) documented, Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk . Unless there is evidence adjusting otherwise, when a resident is found on the floor, a fall is considered to have occurred.Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury.Process: Fall Mitigation: Residents to be evaluated for fall risk on admission/readmission, quarterly, annually or upon identification of a significant change in status.Fall risk is based off residence results of the Fall Risk Evaluation; Contributing factors i.e. ( example) medications, diagnosis; Environmental factors i.e. lighting.Fall mitigation strategies: Develop resident centered interventions based on resident risk factors. Update the residents' care plan and the Nurse Aide Kardex (Provides instructions for care) with interventions; On admission/re-admission; Quarterly; With a significant change in status.Post Fall Strategies . Re-evaluate fall risk utilizing the Post Fall Evaluation. Update Care Plan and Nurse Aide Kardex with intervention(s). Interdisciplinary Team to review fall documentation and complete root cause analysis. Update plan of care with new interventions as appropriate. Review resident weekly X 4 (Times four). Review fall trends monthly during QAPI (Quality Assurance Performance Improvement).Review of the clinical record revealed Resident #999 was an [AGE] year-old-male admitted on [DATE], with a readmission date of 7/7/26. The resident's diagnoses included, Dementia, Parkinson's disease (brain disorder that affects movement, causing signs like tremors, stiffness and slow movements), lack of coordination, anxiety, rib fracture, dysphagia (swallowing difficulty), enteral feeding tube, falls, depression, mood disorder, muscle wasting, and physical debility.Review of the Admission/readmission Data Collection dated 4/14/26 documented Resident #999 had no history of falls.The care plan initiated on 4/15/26 documented that Resident #999 was at risk for falls. The goal was to minimize the risk for falls. The interventions included to anticipate and meet the resident's needs (Date initiated 4/15/26). Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date initiated 4/15/26). Bed in low position (Date initiated 5/18/26). Ensure that the resident is wearing appropriate nonskid socks/footwear when ambulating or mobilizing in wheelchair (Date initiated 4/15/26).The clinical record documented Resident #999 had 7 falls in 3 months (4/23/26, 5/8/26, 5/16/26, 5/21/26, 5/26/26, 6/27/26, and 6/29/26).Fall #1:On 4/23/26 at 5:13 p.m., a nursing progress note documented that Resident #999 fell in the dining room today around 2:00 p.m. The resident slipped out of the wheelchair and laid on floor. He did not hit his head and did not have any visible injuries during the assessment. Resident #999 was placed into bed. The Director of Nursing (DON) was notified and the physician placed Resident #999 on every 15 minutes check. A Dycem (non-slip pad) was placed on the wheelchair (w/c) seat.The nursing description of the fall dated 4/23/26 at 2:00 p.m., noted, witnessed fall, slide out of w/c and onto floor in B-wing dining room Resident proceeded lay on side while on floor. He did not hit his head. Assessed resident, no injuries noted. Picked him up and put him back into w/c, wheeled him to his room and placed him in bed. Immediate intervention was Dycem to w/c.The predisposing physiological factors listed, Confused, impaired memory. The predisposing situation factors listed, Ambulating without assist.On 4/24/26, a care plan was initiated with a focus that Resident #999 had an actual fall related to generalized weakness and history of falls. The goal was for the resident to resume usual activities and minimize the risk of further incident through the next review date. The target date was 7/21/26. The intervention initiated on 4/24/26 was to monitor/document/report to the physician as needed for 72 hours, signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. The care plan did not list the Dycem to the wheelchair.Fall #2:On 5/8/26 at 8:00 a.m., documentation in the clinical record showed Resident #999 had an unwitnessed fall in his room. The incident was, Not witnessed for I was giving report and certified nursing assistant came to me and the nurse getting report to tell me that resident was on the floor. Patient states that he has no pain and was trying to get up to his chair. Resident to be kept in common areas while awake as allowed.The predisposing environmental factors listed Noise. The predisposing physiological factors listed, Confused, Gait imbalance, Impaired memory. Overestimate his ability was noted under Other info. Noise was listed in the predisposing Environmental Factors. On 5/11/26, the care plan was updated with, Staff to keep resident in common areas while awake, as tolerated.Fall #3:On 5/16/26 at 8:30 a.m., documentation in the clinical record showed Resident #999 was found on the floor next to his bed, he was lying on his right side. Resident was unable to state how or why he fell. Resident assisted to bed via [brand name full body mechanical lift]. It is noted that the resident was clean, recently fed. Resident didn't express pain. A perimeter mattress (raised perimeter mattress) was put on the bed.On 5/19/26, the fall care plan was updated with the intervention of Bed in low position.Fall #4:On 5/21/26 at 6:00 a.m., documentation in the clinical record showed Resident #999 sustained a fall in his room. The resident was noted lying on his left side on the floor next to bed. The bed was in lowest position, non-skid socks were on, the call light was within reach. Resident #999 was placed back in bed via mechanical lift. Immediate actions taken were vital signs (Temperature, pulse, respiration, blood pressure), neuros initiated (neurological checks), and toileting before meals and at bedtime. No injuries were observed at the time of the incident.The predisposing physiological factors listed were , Confused, impaired memory, weakness/Fainted. Unassisted transfer was listed in other info.On 5/21/26, the fall care plan was updated with the intervention to, Toilet resident before and after meals, and before bedtime.Fall #5On 5/26/26 at 9:25 p.m., documentation showed that Resident #999 had a fall in the activity room. Nursing description noted, This writer walked past the day room and looked inside to find the resident lying on his right side on the floor to the left of his chair facing the doorway entrance. Nonskid socks were noted fitted to the resident's feet. Urine noted to the resident's pants and surrounding ground. Resident unable to give description.The immediate actions noted that the resident was toileted and placed back in his chair using a full body mechanical lift, Will continue to place in common areas while awake and offer toileting after meals and before bedtime. IDT (Interdisciplinary Team) interventions: medication review to include psych eval for review of psych meds, neuro consult d/t (due to) frequent falls and dx (diagnosis) Parkinson's. No injuries observed at time of incident.The predisposing physiological factors listed, Confused, gait imbalance, weakness/fainted. The predisposing situation factors listed, Wanderer, ambulating without assist. The form listed in Other info contributing factors of diagnosis of Parkinson's, dementia, hypertension and lack of coordination.On 5/27/26, the care plan was updated with interventions of, Neuro consult d/t frequent falls; Pharmacy consult to evaluate medications; Psych eval for medication review.Fall #6:On 6/27/26 at 10:10 a.m., documentation showed that Resident #999 sustained a fall in the activity room. The nursing description noted that the resident was at the TV room on A wing and fell. I was passing medication at the corridor when a cleaning staff call me to see resident was on the floor. Resident unable to give description.Under Immediate Action taken, the licensed nurse documented that the resident was assessed for injuries. Two skin tears were noted on the right lower dorsal arm. A small skin tear was also noted on the right knee. A hematoma (pooled collection of blood) was noted to the right upper arm. The resident denied pain. The resident was then positioned in the wheelchair and left watching TV comfortably. Intervention: Dycem to the wheelchair.The predisposing physiological factors included, Confused, gait imbalance, impaired memory, weakness/fainted.On 6/29/26, the fall care plan was updated with the intervention, Dycem to wheelchair while resident is in wheelchair as tolerated.Fall #7:On 6/29/26 at 1:50 p.m., documentation showed that Resident #999 sustained a fall in his room. The nursing description noted that therapy staff notified the nurse that he found the resident laying on the floor face down on the left side of the bed. Resident #999 was not able to give description.The licensed nurse documented to following immediate actions taken: Resident #999 was assessed and found to be alert and oriented X 2 (baseline). The resident was able to understand the situation and was cooperative throughout the assessment. The resident was assessed for injuries. Slight bruising noted above the eyebrow on the left side of the head. The resident was safely transferred to the bed and then to his wheelchair via a full body mechanical lift. Neurological checks were initiated at this time. Immediate Intervention: Perimeter mattress. On 6/30/26, the fall care plan was updated with interventions for Perimeter mattress for bed boundaries and/or safety with turning. Tilt in space wheelchair to be used when resident is out of bed as resident tolerates.Further review of the clinical record revealed that on 7/2/26 Resident #999 was sent to a local emergency room for replacement of his enteral feeding tube. A chest x-ray obtained revealed a displaced right lateral 4th and 5th rib fractures not vigilant visualized in the field of view. Question of non-displaced fracture of the right lateral 6th rib deformity not definitely appreciated in the CT chest. Impression: Acute displaced overriding fracture of the right lateral 4th rib. Comminuted segmental displaced fracture of the right lateral 6th rib. Small right hemothorax effusion.On 7/17/26 the fall care plan was updated with the intervention of hourly monitoring per facility policy.On 7/20/26 at 9:20 a.m., Resident #999's observation revealed his room was the farthest from the nursing station, at the end of a hallway. The bedroom door was closed. Upon knocking Resident #999's roommate came to the door and permitted entry. Resident #999 was observed in bed with the blankets pulled over his head. The call light and bed control were observed in the drawer of the nightstand. One floor mat was observed on the floor to the left side of the bed. Resident #999 did not respond when his name was called.On 7/20/26 at 9:30 a.m., in an interview, Licensed Practical Nurse (LPN) Staff A said Resident #999 spoke Spanish but seemed to understand some English but she didn't know how much he really understood. She said that Resident #999 was non ambulatory and had some recent falls.On 7/20/26 at 10:44 a.m., Resident #999's room door was observed closed. Upon knocking and entering the room, the resident was observed in bed, awake. Resident #999 made eye contact with a blank look but did not respond to any interview question in English. The resident's call light remained in the drawer of the nightstand.On 7/20/26 at 10:50 a.m., in an interview, Unit Manager LPN Staff B said Resident #999 spoke only Spanish but understood some English at times. She said there was a Certified Nursing Assistant (CNA) who spoke Spanish on another Unit but staff had a Spanish interpretation hot line for interpretation that they could use.On 7/20/26 at 11:00 a.m., an attempt was made to interview Resident #999, using CNA Staff C to translate. CNA Staff C said that Resident #999 said his face hurts but he was ok. The resident had a blank look on his face and his speech was mumbled. CNA Staff C said she did not think he understood the questions. Most answers were yes/no.On 7/20/26 at 12:15 p.m., in an interview the Director of Nursing (DON) said that as soon as they were alerted to the fractures, they started an investigation. They placed Resident #999 on one-to-one supervision when he returned from the hospital. They then began to decrease it and currently, Resident #999 is checked every hour. She said she believed the root cause to the resident's multiple falls was his restlessness. She said that the resident is anxious and restless. Psych has been adjusting his psych medications and he is doing better. She said she didn't think the resident really understood, even in Spanish. She said when he is out of bed, they keep him in a supervised area, meaning staff can walk by and look in on him to ensure he is safe. They have the fall mat and the perimeter mattress. The previous falls occurred after his family visits because they would take him back to his room and leave him there. He would then and then try to find them. The DON said that the care plan was updated after each fall, she didn't know the root cause but he is restless. On 7/20/26 at 1:25 p.m., in an interview, Unit Manager Staff B said Resident #999 was originally residing on Unit B unit so she didn't know anything before he came to Unit A about a month ago. His family visited several times a week, at different times but never said he had pain. She never noticed Resident #999 with facial grimacing or yelling out to indicate pain. Unit Manager Staff B said that the resident sustained a fall on 6/29/26 with no injuries. She explained that they let the resident sleep and they get him up and put him in the common area when he is awake. She has asked the activity department to provide him with a busy blanket but they have not yet provided it to him. They provide tactile items for him and he keeps busy in the day room.On 7/20/26 at 1:38 p.m., in an interview, the Director of Rehab (DOR) said that Resident #999 is receiving therapy 5 times a week. They have a therapist who speaks Spanish and the resident seems to do well with him. The Director of Rehab said that Resident #999 is very restless and thinks that is why he was falling. The DOR said that the resident does not understand most of what is said to him, in English or in Spanish. He is able to stand with a walker and they were working on getting him to ambulate 10 feet. The DOR said, I'm not sure if ambulating is a good or a bad thing for him because of the falls but as therapists that is what we are supposed to do. I know the facility has put interventions into place for him.On 7/20/26 at 1:47 p.m., in an interview LPN Staff D said that Resident #999 was always restless pulling at his feeding tube and trying to get up all the time, he is agitated. He was always trying to get out of the wheelchair. When his family was here he was fine but the minute they left he would get restless again. They keep him where they can see and watch him but he is quick, You turn your back on him and he would be on the floor.On 7/20/26 at 3:30 p.m., in an interview, Unit Manager LPN Staff B said there was no staff member assigned to monitor residents in the television (TV) room. Unit Manager, LPN Staff B said, They are in there so we can keep an eye on them. Each time someone walks by, we look in at them to make sure they are safe. But no, there is no staff assigned to monitor the residents in the TV room.On 7/20/26 at 3:35 p.m., Resident #999 and one other resident were observed unsupervised in the TV room. Resident #999 was in his wheelchair facing the television but appeared to be sleeping.Review of the Fall Risk Assessment for Resident #999 dated 4/14/26 revealed a score of 75 (High risk, implement high risk fall prevention interventions. On 7/20/26 at 4:20 p.m., in an interview the DON said the Fall Risk Assessment scores are used to determine the residents' risk for falls. She said if a resident is at risk for falls, they make sure to put things in place. The baseline care plan and interventions are put in place. She said she did not know what the Fall Risk Assessment scores meant. She said, High risk is high risk. I don't know what the high risk fall prevention interventions would be. I don't know if we have a policy on the use of fall risk assessments.When asked about supervision provided to Resident #999 to minimize the risk of avoidable falls and fall related injuries, the DON said that Resident #999 was placed on one-to-one supervision when he returned from the hospital and was currently monitored hourly by staff. The DON did not provide documentation of the one-to-one monitoring or hourly checks for Resident #999. The DON said that they kept Resident #999 by the nurse's cart, in front or behind the nursing desk. They have been doing medication adjustments and if he is antsy in his wheelchair he has to be right there with someone. She said that Resident #999 was never left alone in the TV room. The observation of Resident #999 left unsupervised in the TV room was shared with the DON. The DON said, I find that hard to believe.The DON said they had an Ad-Hoc (unplanned) QAPI meeting since Resident #999 returned from the hospital to discuss his falls. She said she was not sure what the root cause for each fall was but noticed a pattern. The incidents occurred after his family left from visiting him.The DON said that an internal packet is completed for each fall. They review each fall in morning meeting, determine the root cause and update the care plan. When asked to review Resident #999's falls, including interventions in place at the time of each fall, root cause and rationale for new interventions, the DON said that it was an internal document and would not provide the information for each fall.

Based on record review, resident and staff interview the facility failed to ensure 3 (Residents #1, #4 and #6) of 4 residents reviewed with Baseline Care Plans, had those Care Plans developed and completed appropriately to include instructions needed to provide effective and person-centered care within 48 hours of the residents being admitted to the facility. The findings included: The facility's Plan of Care Policy and Procedures N-1015 dated 11/30/14, with a revision date of 9/25/17, stated the facility would develop and implement an Individualized Person-Centered Baseline Plan of Care within 48 hours of admission that included, but not limited to, initial goals based on the admission Orders, Physician Orders, Dietary Orders, Therapy Services, Social Services if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs were met appropriately until the Comprehensive Plan of Care was completed. 1. On 2/25/26 a review of Resident #1's medical record revealed he was admitted to the facility on [DATE] for rehabilitation services after a fall at home. Review of Resident #1's Baseline Care Plan revealed it was blank except for Resident #1's wife signature on page 4. The Baseline Care Plan did not contain the initial goals and instructions to provide effective care, to ensure Resident #1's needs were met prior to the completion of the comprehensive plan of care. The baseline care plan did not address his history of falls or identify goals and interventions to prevent further falls.2. On 2/26/26 a review of Resident #4's medical record revealed he was admitted to the facility on [DATE] from the hospital with a discharge diagnosis of chest pain and transferred to a skilled nursing facility for rehabilitation services. Review of Resident #4's Baseline Plan of Care, dated 1/26/26, revealed page 1 was not completed, and the goal for falls/safety was circled but the interventions for that goal were not identified required. 3. On 2/26/26 a review of Resident #6's medical record revealed she was admitted to the facility 2/06/26 from the hospital with a discharge diagnosis of acute respiratory failures with hypoxia and was transferred to a skilled nursing facility for rehabilitation services. Review of Resident #4's Baseline Plan of Care dated 2/06/26 revealed page 1 was not completed, and the goals for falls/safety, oral/dental, pain, and anticoagulant use were circled but the interventions for those goals were not identified as required. On 2/26/26 at 11:01 a.m. in an interview with Staff A Unit Manager, she said when a resident was admitted to the facility, the admitting nurse was required to complete a Comprehensive Assessment to include a personalized Baseline Care Plan at that time. The next day she would review all resident(s) admitted the day prior to ensure the residents' Physician Orders were completed and in the computer, the admission Assessment was completed, and the Baseline Care Plan was completed to include the goals and personalized interventions for each goal as required. Staff A reviewed Residents #1, #4 and #6's admission Baseline Care Plan and confirmed their Baseline Care Plans were not completed appropriately with goals and interventions to ensure each goal was addressed as required. On 2/26/26 at 1:10 p.m. in an interview with the Director Of Nursing, she confirmed the facility's Plan of Care Policy stated the facility would develop and implement an Individualized Person-Centered Baseline Plan of Care within 48 hours of admission that included, but not limited to, initial goals based on the admission Orders, Physician Orders, Dietary Orders, Therapy Services, Social Services if applicable, and other areas needed to provide effective care of the resident that met professional standards of care to ensure that the resident's needs were met appropriately until the Comprehensive Plan of Care was completed. The DON said after she reviewed Residents #1, #4, and #6's Baseline Care Plan, she confirmed they were incomplete and did not identify the required goals and their interventions to ensure each resident needs were appropriately met until the Comprehensive Plan of Care was completed for that resident.

Based on staff interviews and resident medial record review, the facility failed to ensure 1 (Resident #1) of 4 residents reviewed with admission orders for an occupational, physical, and speech therapy evaluation and treatment as indicated had the assessments/services provided as ordered by the physician to evaluate the need for therapy and to treat as indicated by the assessment. The findings included:On 2/25/26 a review of Resident #1's medical record revealed the Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form dated 1/14/26 stated Resident #1's primary diagnosis at the time of discharge from the hospital was a closed head injury and he was being discharged to a skilled facility for rehabilitation. Resident #1 was transferred to the skilled nursing facility on 1/15/26 with Physician Orders dated 1/16/26, for occupational therapy, physical therapy, and speech therapy evaluations and to treat as indicated. On 2/25/26 at around 11:30 a.m. in a phone interview with Resident #1's daughter, she said her father was admitted to the hospital after falling at home and was discharged to the skilled nursing facility to receive rehabilitation therapy prior to going home but was informed by Resident #1 and her mother, the rehabilitation therapy would not be started until 2/02/26. On 2/25/26 at 12:35 p.m. in an interview with the Director of Therapy, she confirmed Resident #1 was admitted to the facility on [DATE] with physician orders dated 1/16/26 for occupational therapy, physical therapy, and speech therapy evaluations and to treat as indicated. She said when a resident was admitted to the facility with orders for a therapy evaluation and treatment, the therapy department would normally complete the ordered evaluation within 48 hours. She said they had conducted a wheelchair evaluation for Resident #1 on 1/16/26 and provided him with a wheelchair on 1/16/26. She said they did not conduct a therapy evaluation for physical, occupational, and speech therapy as ordered on 1/16/26 but had scheduled those evaluations to be completed on 2/02/26. She said she had spoken to Resident #1 and his wife after his admission to the facility, and they agreed to conduct Resident #1 physical, occupational, and speech therapy evaluations on 2/02/26. She said the physical, occupational and speech therapy evaluations were not completed on 2/02/26 because Resident #1 was sent to the hospital on 2/02/26 for a change in mental status. She confirmed the therapy evaluations were not conducted as ordered on 1/16/26.On 2/25/26 at 1:35 p.m. in an interview with the Director of Nursing (DON), she confirmed Resident #1 was admitted to the facility on [DATE] after having a fall at home in December 2025. She confirmed Resident #1 had physician orders dated 1/16/26 to include occupational therapy, physical therapy, and speech therapy evaluations and to treat as indicated which were acknowledged by Resident #1's primary care physician on 1/21/26. She confirmed Resident #1's Physician Orders for occupational therapy, physical therapy, and speech therapy evaluations were not completed as ordered by the physician.

Based on observation, review of facility policy and procedures, resident and staff interviews, the facility failed to maintain an effective pest control program to ensure an environment free from pests for 2, (Resident #400 and #500), of 97 residents residing in the skilled nursing facility.The findings included:The facility Policy and Procedure, HL-200 (11/30/14) specified the facility will maintain a pest control program which includes inspection, reporting and prevention.Procedure: Treatment will be rendered as required to control insects and vermin. Any unusual occurrence or sighting of insects should be reported immediately to the Supervisor. Proper action will be taken. On 9/4/25 at 9:04 a.m., during an initial tour of the facility two brown bugs were observed crawling up the wall in the bathroom of an occupied resident room. Licensed Practical Nurse (LPN) Staff J noted the observation and left the room. Certified Nursing Assistant (CNA) Staff A was present and said, All the time, they are everywhere, all the time. You tell them and they are spray, and they are still here. On 9/4/25 at 9:20 a.m., in an interview Resident #400 said, I see roaches here every night. I've been telling everyone there is a problem here. Last night one crawled on my bedside table during the meal, it came right on up. On 9/4/25 at 9:30 a.m., in an interview Registered Nurse (RN) Staff E said, Oh yeah bugs are everywhere in here, real bad. But the Administrator said he got someone to come and spray last week. On 9/4/25 at 9:44 a.m., in an interview Resident #500 said, I told the management here and I've asked to be transferred to another facility, but they are trying to talk me into staying. I have been here three weeks, and I see roaches all over the floor, they run under the bed. I saw three last night and I had to stomp on one with my foot.On 9/4/25 at 10:08 a.m., in an interview CNA Staff D said, There are a lot of bugs and roaches in this whole building. They mostly are in the resident drawers, and they come out from the air-conditioning units. I have seen that. On 9/4/25 at 10:12 a.m., in an interview the Maintenance Assistant said, Yes I have seen roaches in here, but they come and spray every Tuesday. Review of the facility Pest Sighting Log located on each of the three nursing units documented:On the 300 unit the following was reported: 6/16/25 roaches, staff breakroom. 8/6/25 roaches in rooms.On the 100 unit the following was reported: Roaches observed on 7/24/25, 8/1/25, 8/2/25, 8/6/25, 8/19/25, 8/21/25, 9/1/25, 9/2/25 in resident rooms.On the 200 unit the following was reported: 7/16/25 ants in bed, 7/28/25 ants in Director of Nursing office, 8/11/25 ants in bed, 8/14/25 roaches in rehab gym, 8/16/25 roaches in rooms, 8/18/25 roaches in rooms, 8/19/25 roaches in activity room and on my desk and coming out of each table in the C wing dining room. On 9/2/25 ants in rooms crawling on the beds and in drawers. On 9/4/25 ants and roaches seen in rooms. Review of the pest control logs from [NAME] Exterminators:On 9/2/25- Exterior rodent station, roof rats-gnawing. Rodent droppings were found. Interior of the building documented no activity for roaches and ants.On 8/11/25- Bed bug treatment for room on B Wing. The exterminator provided a Bed bug Customer Preparation Checklist. A service agreement was signed on 8/4/25 to treat bed bugs in Wing B.On 8/5/25 the interior of the facility was treated for roaches with no activity noted.On 7/31/25 documented Having issues with roaches and fruit flies in kitchen. On 9/4/25 at 12:04 p.m., in an interview with the Maintenance Director, he said he was aware of the bug problem and pest control comes every other Tuesday and he reports it. He was informed of the bugs observed during the tour of the facility today. He said, I have the staff write down in the pest log when and where they see them and the pest control will check the logs. I check them daily but there is nothing I can do; we have nothing to spray them with. If I call the pest control, they will come if they can, sometimes they are booked up and can't come.

Based on record review, and staff interviews, the facility failed to ensure a licensed nurse was designated to serve as charge nurse on all shifts. This failure resulted in the inability of nursing staff to know who would provide oversite for patient care, ensure safety and compliance and serve as a leader to support staff on the evening shifts.The findings included:On 9/4/25 a review of the daily assignment sheets from 8/31/25 to 9/3/25 on the three nursing units revealed no documented Charge Nurse was assigned on the 3:00 p.m., to 11:00 p.m., or 11:00 p.m., to 7:00 a.m. shifts. On 9/5/25 at 8:45 a.m., in an interview the Director of Nursing (DON) said there is no charge nurse at night, all the nurses are in charge and work together. There is an assigned Weekend Supervisor here 12 hours each weekend day. There is not an assigned charge nurse at night. On 9/5/25 at 8:55 a.m., in an interview the Assistant Director of Nursing (ADON) said I spoke with the Administrator, and he wanted me to tell you when a Registered Nurse (RN) is on duty at night, they are automatically the Supervisor for the night, and it is written on the assignment sheet. On 9/5/25 at 9:50 a.m., in an interview Licensed Practical Nurse (LPN) Staff I said she did not know who the evening or night supervisor was. She said it should be in the schedule. I know there is a Unit Manager during the day and a weekend supervisor, but I honestly don't know how you would know who the supervisor is. On 9/5/25 at 9:56 a.m., in an interview LPN Staff J said she did not know of a night supervisor. I know there is a weekend supervisor, but at night, I don't know how to know that. On 9/5/25 at 10:04 a.m., in an interview the Administrator said the Supervisor is listed on the daily assignment sheets. This writer showed him the daily assignment sheets from the three nursing units that did not document who was in charge on any unit. He said, I would have to ask the Director of Nursing (DON). On 9/5/25 at 10:10 a.m., in an interview the DON said going forward we will put a C next to the nurse assigned to be a charge nurse. The DON confirmed there was currently not a licensed nurse assigned to be the supervisor on the evening shifts.

Based on record review, review of facility policy and procedures, staff and resident interviews, the facility failed to protect the resident's right to be free from physical, and verbal abuse for 1(Resident #999) of 3 residents reviewed for abuse.The findings included: Review of the facility policy N-1265 Abuse, Neglect, Exploitation and Misappropriation effective 11/30/14 (revised 11/16/22) documented It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse . Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse . No employee may at any time commit an act of physical, psychological, or emotional abuse . against any resident . Acts of abuse directed against residents are absolutely prohibited. Any action that may cause or causes actual physical, psychological or emotional harm which is not caused by simple negligence, constitutes abuse . All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Review of the clinical record revealed Resident #999 was a [AGE] year-old, Spanish speaking female with an admission date of 5/10/25. Diagnoses included displaced fracture of fifth cervical (neck) vertebra, peg tube (a tube inserted into the stomach to provide nutrition and hydration) placement, type 2 diabetes mellitus, hypothyroidism, and pain. Review of the Medicare 5 day Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/22/25 documented Resident #999 was dependent to go from sitting to standing and for transfers. The MDS noted Resident #999 scored 06 on the Brief Interview for Mental Status, indicating the resident's cognitive skills for daily decision making were severely impaired.On 7/7/25 at 9:09 a.m., Resident #999 was interviewed with the assistance of Registered Nurse (RN) Staff E translating in Spanish. The resident said a male therapist came to her room and yelled at her because she had pain in her back. He was very angry for no reason. She said he pulled her from the wheelchair (w/c) and forcibly put her into bed. She did not know why he did not take her to the therapy room. She does not speak English, did not understand him and did not offer her a translator. The resident said the therapist was fine when he came in but got angry with her, because she did not understand the instructions he gave her. When he put her in bed, she hurt her cervical area, she had a fracture there and had recently had surgery. She said she told the therapist he had hurt her, he smiled at her. Resident #999 said the therapist used a gait belt to lift her up out of the wheelchair and he threw her into bed. The resident said there was no other person in the room when the male therapist was providing care. She said she was yelling and crying. A female therapist and the nurse came into her room when they heard her yelling.She said when she started to yell and cry, the therapist left her room; he was very angry. He did not say anything to me. He told her about the therapy, and she did not understand him.Resident #999 said after it happened, she was anxious and fearful, she did not expect that to happen to her. She was screaming and crying because he had hurt her.Review of the facility's incident investigations revealed on 6/13/25 the facility initiated a physical and verbal abuse investigation for Resident #999.Review of the investigation revealed:On 6/13/25 at 3:30 p.m., Physical Therapy Assistant (PTA) Staff A and Occupational Therapist (OT) Staff D were assisting Resident #999 to transfer from her bed to the wheelchair. During the transfer PTA Staff A grabbed the resident's arms and started to yell at her and shake her for not following his directions for the transfer.Registered Nurse (RN) Staff C in her statement said on 6/13/25 at approximately 3:25 p.m., she was one room down the hallway and heard Resident #999 screaming out. She went to the resident's room and saw a male therapist with his hands on both of the resident's arms yelling and shaking her and he stated very loudly I told you not to do this. This is why you keep getting hurt. The resident was crying and stated that he hurt her and was pointing to her peg tube area.RN Staff C had a certified nursing assistant stay with the resident while she went to report the abuse.PTA Staff A said in his written statement that around 3:00 p.m., when he arrived in Resident #999's room, the resident was upset and started to complain in rapid Spanish which he didn't understand. The PTA gave her detailed instructions on how to transfer from the bed to the wheelchair and how to place her hands. After detailed instructions, the resident grabbed the wrong armrest and started to twist her arm and gave out a loud scream. PTA Staff A asked why, in a loud voice, she grabbed the wrong armrest despite all instructions given. That's when RN Staff C came into the room and witnessed the PTA's question to the resident and said, This is patient abuse.OT Staff D in her statement said she was in the room assisting PTA Staff A with Resident #999's transfer. The resident was positioned properly and educated numerous times by PTA Staff A on safe transfer techniques. The resident grabbed the wrong armrest, would not let go, started screaming and was very fearful. PTA Staff A became very loud and upset at Resident #999 stating she needed to listen to him so that she doesn't get hurt.The investigation noted on June 13, 2025, at approximately 3:45 p.m., the Administrator interviewed PTA Staff A and asked the PTA what happened with Resident #999. PTA Staff A replied, You can fire me now. I lost my cool and was rough with the patient and yelled at the patient. He went on to describe and show how he was attempting to get Resident #999 to transfer from the bed to the wheelchair.The facility verified the allegation of abuse.On 7/7/25 at 11:39 a.m., in a telephone interview OT Staff D said she had provided treatment to Resident #999 for a couple weeks. OT Staff D said she was standing nearby when PTA Staff A went to transfer Resident #999. Once the resident had transferred to the wheelchair, PTA Staff A yelled at her loudly that she needed to listen to him. She left the room when he was yelling. OT Staff D said PTA Staff A raised his voice because Resident #999 did not understand and did not listen. PTA Staff A spoke with the resident in some Spanish. OT Staff D said Resident #999 understands English way better then she pretends. She said they had done the transfer many times before. The resident gets very scared, he explained the procedure. PTA Staff A was frustrated because Resident #999 was screaming. OT Staff D said after the resident got into the wheelchair, I decided I did not need to be there. The door was open, and I left. The nurse came after the fact, she was not there to see anything, I don't know what she saw. I left the room to document the therapy provided. I was involved with the initial transfer into the wheelchair. I was not there when he transferred her to bed.On 7/7/25 at 12:32 p.m., in a telephone interview, RN Staff C said she was working on 6/13/25 and was administering medications. RN Staff C said, [Resident #999] yelled out and I thought they were probably moving her. The resident yelled again, extremely loud and I walked to her room. I was two doors away. When I entered the room I saw [PTA Staff A] had both hands on the resident's arms and he was shaking her. I asked him what the hell are you doing? The resident was yelling and crying. He said, this is what we have to do with her. I saw [OT Staff D] standing across the hall, looking in the room. I went to her and I asked her, are you going to let him do that to her? She put a piece of paper in front of her face and said, I see nothing, and I hear nothing. I went to the Administrator right away and I told him, and we went together to the resident's room. The resident was in her bed. The Administrator had a Spanish speaking staff member to translate, and the resident said, He threw me in the bed.RN Staff C said she did not witness PTA Staff A put the resident in bed. She said, I witnessed the therapist shaking her and yelling at her, he was very angry. The resident was crying. The resident was in the wheelchair when he was shaking her. He was shaking her, and he was so angry with her. I left the room and went to the Administrator. I did not see him put her into bed.RN Staff C said, I notified the resident's son. He came to the facility and wanted her sent to the emergency room. We did what he asked.On 7/7/25 at 1:20 p.m., in a telephone interview PTA Staff A said, I think I want to give a background first. I worked with the resident for 8 or 9 sessions, and I was very aware of her function and abilities and how she communicates. I think we had good communication and relationship. I had her up and taking 3-4 steps the day before. Her goal was to walk 30 to 40 feet with a walker and assistance. Her right leg and arm are pretty strong; her left leg is weaker. She was able to stand the day before. The resident was in bed supine (on her back). I greeted her and I said let's go and she said yes. I gave her maximum assistance to sit on the edge of the bed. I placed my gait belt around her under her buttocks because of the peg tube. She was very willing to transfer. I placed the wheelchair on her right side. I asked her to place her hand on the far side not the near side, it was very important that she placed her hand on the far side. I gave her a 1,2,3 count, and maximum assistance. She grabbed onto the near side of the arm rest and she started to scream. I thought she was very uncomfortable, it made me nervous because I never heard her screaming like that. She was screaming at the top of her lungs. I thought she was hurting. I kind of shook her hand a little to see if she had pain, and she said no. A nurse came into the room because she heard the resident scream, she said this was patient abuse. Maybe I was shaking her hands at that time, or checking the gait belt, or checking something. No one else was in the room with me, only the patient. I asked her if she was in pain and she said no. I raised my voice asking her why did you put your hand here. That is my one regret, I raised my voice with her. I never yelled at any patient. I shook her hand; I was checking her. If that is deemed shaking, I never shook her body. I was shaking her hand and arm to see if she was okay, to see did she have pain. She was crying, she was sitting in the wheelchair. I put her into bed after that, I thought she was okay. Her right side was stronger, and she was able to stand and get to the edge of the bed. She was losing her balance, and she was screaming again. No one was watching me at all. I think the resident got so scared and was very afraid. I think that is why she screamed. I did not ask her why she was screaming. They think I abused the resident, but I do not think from my point of view that I abused her.On 7/7/25 at 1:47 p.m., in an interview the Director of Nursing (DON) said she was not at the facility when it happened. The Administrator started the investigation. She said, The PTA was not here long and he had a short fuse I guess. The DON said, I do know the resident is not the easiest person to give directions to. She is timid, scared and hesitant to do tasks. The DON said something was going on with the PTA to cause him to have this reaction.

Based on observation, record review and interview, the facility failed to ensure residents were free from abuse, including but not limited to physical restraint not required to treat the resident's medical symptoms for 1 (Resident #1) of 1 resident reviewed for physical restraint. The findings included: Facility policy titled Abuse, Neglect, Exploitation & Misappropriation Revision date 11/16/2022 indicated Abuse is the willful infliction of injury. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the clinical record revealed Resident #1 was re-admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance. The admission Minimum Data Set (MDS) assessment noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 00. On 6/12/25, record review of Resident #1's chart revealed a progress note dated 6/11/25 reading: When I came back to the unit from B wing, I heard the resident yelling in the dining room. I went in to see what was going on and I saw one CNA holding the resident head and chest and the other by her arm trying to keep her in the chair. She would try to kick the other cna. They were trying to put her socks on. I told them to leave her alone and I assisted her to get out of the chair. It was noted that she had a bruise on her chest and on her Right arm and hand. On 6/12/25 at 10:14 a.m., Resident #1 was observed lying in bed with red and purple bruising noted to her chest approximately 3 inch x 2 inch, bruising to the left forearm and hand, and bruising to the right forearm and hand. On 6/12/25 at 10:40 a.m., Staff C Unit Manager said on 6/11/25 she came on shift and a different nurse told her that Staff D Registered Nurse (RN) walked in and found Resident #1 was screaming and she found one aide holding her with her palm on her forehead and her palm on her chest. There were 2 aides in the room at the time, Staff C said she went and checked Resident #1 as soon as she was told. She said Resident #1 now has a bruise on her chest. She said Staff D was still there charting and she had her write an incident, informed the Administrator and called the Director of Nursing (DON). On 6/12/25 at 10:54 a.m., in a telephone interview Staff D (RN) said she went in and 2 Certified Nurse Assistants (CNA) were holding Resident#1 in the chair. One CNA had her by the head and the chest, and the other CNA was holding her hand at first and then her feet. Resident #1 started kicking at the CNA and she let go. Staff D said Resident #1 was agitated and screaming. Staff D said she told the CNA's to leave her alone and don't touch her. Staff D said she has had abuse training and she didn't like the way the CNA's were holding her. She said Resident #1 sustained bruises. Staff D said they are not allowed to restrain residents, and they were restraining her. Staff D said she guessed they were trying to keep her in the chair because she was trying to get up. I walked in and the one CNA backed off, I said what are you doing? On 6/12/25 at 10:57 a.m., in a telephone interview Staff E (CNA) said Resident #1 didn't want to sit and she helped her to sit down and the other CNA called the nurse. Staff E said, We did nothing wrong. Trying to get her to sit, she don't want to, she try to get up, I help for her to sit down. Staff E said she has had abuse and has never done nothing like that. Review of the facility's incident investigations revealed on 6/11/25 Staff F (CNA) said Resident #1 had been screaming in her bed, left her bed and entered the hallway. Staff F said Resident #1 was screaming and she tried to get her to sit down but she got up again and was screaming so she called the nurse to come see her. On 6/12/25 at 12:23 p.m., the DON said was out of the building at the time of the incident, but if they were truly holding her, it would be considered a restraint. DON said it was all still in the investigation phase and she didn ' t have all the facts, a lot of pieces still haven't been completed, but it would not be right to hold someone physically down in a chair. On 6/12/25 at 2:26 p.m., the Administrator said they are considering the incident as abuse. He said the investigation was still in progress and is an ongoing process at this time.

Based on record review and interview, the facility failed to ensure required documentation was completed in the event of transfer or discharge for 3 (Resident #2, #3 and #6) of 3 residents reviewed for transfer and discharge. The findings included: Facility policy titled Transfer/Discharge Notification & Right to Appeal, last revised 4/28/25 indicated: Policy: Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. Procedure: Emergency transfers to Acute Care: Residents who are sent emergently to an acute care setting, must be permitted to return to the center. If the center initiates a discharge while the resident is in the hospital, the center must show evidence that the resident's status at the time of the return to the center meets the criteria listed above (A-D). a. The transfer or discharge is necessary for the resident's welfare and the residents needs cannot be met in the center. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the center. c. The safety of individuals in the center is endangered due to clinical or behavioral status of the resident. d. The health of individuals in the center would otherwise be endangered. Facility policy further indicated: Documentation: When the center transfers or discharges a resident under any of the circumstances listed above the facility will ensure that the transfer or discharge is documented in the resident's medical record. Notice Before Transfer: Center must notify the resident and resident representative of the transfer or discharge and the reason for the move in writing. Review of the discharge list provided by the facility on 6/12/25 indicated Resident #2 had been discharged /transferred to another hospital on [DATE]. Resident #6 had been discharged /transferred to another hospital on 5/29/25. Resident #3 was not found on the discharge list, but review of his Electronic Health Record indicated he had been discharged on 2/20/25. 1. On 6/12/25 a record review of Resident #2's chart revealed no progress notes indicating why she had been sent out on 11/8/24 or where she went following discharge/transfer. On 6/12/25 at 12:40 p.m., the Director of Nursing (DON) said Resident #2 went out to the hospital in November, then she went to a Long Term Acute Care hospital (LTAC). DON said Resident #2 wasn't ready to return until sometime at the end of December or January, but the facility didn't have any beds at that time. DON said she did not know where Resident #2 went from the LTAC. DON said when a resident was sent out they should go with a face sheet, med orders, Advanced Directives, bed hold and transfer/discharge/ombudsman notice. DON said she could not provide bed hold or transfer and discharge notice for Resident #2 as they were having a problem with that at the time. On 6/12/25 at 3:46 p.m., the DON provided a SBAR communication form (Situation, Background, Assessment, Recommendation: is a communication tool to share medical information and factors contributing to current situation clearly and concisely) which indicated fall. The DON explained Resident #2 did not actually have a fall but had been lowered to the floor with a hoyer lift as staff thought she was having a seizure. DON said Resident #2 would not let them pick her back up, so the firemen came and picked her back up. She was having muscle spasticity and shaking. DON said Resident #2 refused to go to the hospital and they placed her in a Broda chair. DON said later, Resident #2 complained about pain and was sent out to the hospital. DON said the SBAR was the only documentation of what occurred that caused Resident #2 to be sent out. On 6/12/25 at 1:49 p.m., the Admissions Coordinator said she believed Resident #2 had gone to another Skilled Nursing Facility in the area. She said she honestly could not tell me why the facility didn't take Resident #2 back in December/January, but it had been a Corporate decision and she had not made the decision herself. She said she was unable to pull up the dialogue between herself and the hospital as it was too long ago. On 6/12/25 at 2:28 p.m., the Administrator said he could not say for sure why the facility did not take Resident #2 back, did not know if it was bed availability and could not say for sure why they did not take her back. He said he did not know why she had been sent out, but it had something to do with medical, because they sent her to the hospital. He said he believed she had been at the hospital for a while, and they probably filled her bed. He said he was not aware a bed hold or transfer/discharge notice had not been completed. On 6/12/25 3:08 p.m., the Administrator said Resident #2 went to a LTAC. He said they had filled her bed, and was unsure if they had any other beds available. Administrator was asked for a census for the day Resident #2 was to return and he said he didn't know what date that was. The Administrator said no 30 day notice of discharge had been issued to Resident #2. On 6/12/25 at 4:20 p.m., the Administrator said he was unable to find out any further about what day she was able to come back to skilled nursing, but he did find out it was something to do with her trach. He agreed Resident #2 had been at the facility for years and the trach was not something new for her. He said it had become more complicated and the nurses there wouldn't be able to deal with it, but could not say what that was. 2. On 6/12/25 a record review of Resident #3's chart revealed he had been discharged on 2/20/25. A progress note dated 2/20/25 indicated around 6 p.m. Resident #3 complained of chest pain, had been given nitroglycerin, pain continued and he was sent out to the hospital. A further progress noted dated 2/11/25 indicated the nurse had called the hospital, would remain in their care, cardiology would examine and determine next action. There was no further documentation in Resident #3's chart indicating what had happened with Resident #3. On 6/12/25 at 12:40 p.m., the DON said Resident #3 had been sent to the hospital, and then discharged to a facility on the East Coast be closer to his girlfriend. The DON said the facility would have taken him back. On 6/12/25 at 1:49 p.m., the Admissions Coordinator said the facility had been trying to put restrictions on Resident #3 from smoking in front of the building, and then Resident #3 chose to go to a facility on the East Coast. When the dialogue between the hospital and facility was reviewed, it revealed the facility had told the hospital they were unable to accept patient, care needs exceed current capacity, patient is a danger to himself and others. (photo obtained) On 6/12/25 at 3:46 p.m., the DON said Resident #3 was never [NAME] acted. DON said she didn't necessarily know that he was a threat to himself or others, he just didn't like following rules while he was here, complained about everything and pushed the rules, like not supposed to smoke at this time, he would smoke, if dining room not open he would go in there, he just liked to be confrontational. DON said he was not involved in any physical altercations, he was just all talk. She said as far as she could see in his chart, he was never [NAME] Acted since admission on [DATE]. On 6/12/25 at 2:28 p.m., the Administrator was asked why Resident #3 didn't return to the facility. He said it was probably in the chart and said Resident #3 was a heavy smoker, refused to give them his lighter, and was non-compliant. Administrator said he didn't recall if he was given a notice of discharge. Administrator said the decision to take someone back or not is a team decision that includes himself, the DON, Social Services, Business Office and maybe even the regional team was involved. On 6/12/25 at 3:08 p.m., the Administrator said no 30 day notice of discharge had been issued to Resident #3. 3. On 6/12/25 a record review of Resident #6's chart revealed he had been discharged on 5/29/25. Progress note dated 5/29/25 indicated his gastrointestinal bag was leaking and there were two openings on his stomach. Resident #6 was sent to the hospital. There was no further documentation in Resident #6's chart indicating what had happened with Resident #6. No documentation of a bed hold was found in the chart. On 6/12/25 at 1:49 p.m., the Admissions Coordinator said the facility had been willing to accept the patient back however he chose to go to a different facility. This was verified on on review of the dialogue between the hospital and facility. On 6/12/25 at 2 p.m.,tThe Regional Nurse said there was no bed hold documentation found for Resident #2, #3 or #6.

Based on record review and interview, the facility failed to permit residents to remain in the facility and allow residents to return to the facility following hospitalization for 2 (Residents #2 and #3) of 3 residents reviewed following hospitalization. The findings included: Facility policy titled Transfer/Discharge Notification & Right to Appeal, last revised 4/28/25 indicated: Policy: Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. Procedure: Emergency transfers to Acute Care: Residents who are sent emergently to an acute care setting, must be permitted to return to the center. If the center initiates a discharge while the resident is in the hospital, the center must show evidence that the resident's status at the time of the return to the center meets the criteria listed above (A-D). a. The transfer or discharge is necessary for the resident's welfare and the residents needs cannot be met in the center. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the center. c. The safety of individuals in the center is endangered due to clinical or behavioral status of the resident. d. The health of individuals in the center would otherwise be endangered. Review of the facility assessment tool updated 2/6/25 indicated the facility cared for residents which included psychiatric/mood disorders, heart/circulatory conditions, neurological conditions and respiratory conditions. The facility assessment further indicated it treated special treatments and conditions including tracheostomy care and behavioral health needs. Review of the discharge list provided by the facility on 6/12/25 indicated Resident #2 had been discharged /transferred to another hospital on [DATE]. Resident #3 was not found on the discharge list, but review of his Electronic Health Record indicated he had been discharged on 2/20/25. 1. On 6/12/25 a record review of Resident #2's chart revealed no progress notes indicating why she had been sent out on 11/8/24 or where she went following discharge/transfer. On 6/12/25 at 12:40 p.m., the Director of Nursing (DON) said Resident #2 went out to the hospital in November, then she went to a Long Term Acute Care hospital (LTAC). DON said Resident #2 wasn't ready to return until sometime at the end of December or January, but the facility didn't have any beds at that time. DON said she did not know where Resident #2 went from the LTAC. DON said when a resident was sent out they should go with a face sheet, med orders, Advanced Directives, bed hold and transfer/discharge/ombudsman notice. DON said she could not provide bed hold or transfer and discharge notice for Resident #2 as they were having a problem with that at the time. On 6/12/25 at 3:46 p.m., the DON provided a SBAR communication form (Situation, Background, Assessment, Recommendation: is a communication tool to share medical information and factors contributing to current situation clearly and concisely) which indicated fall. The DON explained Resident #2 did not actually have a fall but had been lowered to the floor with a hoyer lift as staff thought she was having a seizure. DON said Resident #2 would not let them pick her back up, so the firemen came and picked her back up. She was having muscle spasticity and shaking. DON said Resident #2 refused to go to the hospital and they placed her in a Broda chair. DON said later, Resident #2 complained about pain and was sent out to the hospital. DON said the SBAR was the only documentation of what occurred that caused Resident #2 to be sent out to the acute care hospital. On 6/12/25 at 1:49 p.m., the Admissions Coordinator said she believed Resident #2 had gone to another Skilled Nursing Facility in the area. She said she honestly could not tell me why the facility didn't take Resident #2 back in December/January, but it had been a Corporate decision and she had not made the decision herself. She said she was unable to pull up the dialogue between herself and the hospital as it was too long ago. On 6/12/25 at 2:28 p.m., the Administrator said he could not say for sure why the facility did not take Resident #2 back, did not know if it was bed availability and could not say for sure why they did not take her back. He said he did not know why she had been sent out, but it had something to do with medical, because they sent her to the hospital. He said he believed she had been at the hospital for a while, and they probably filled her bed. He said he was not aware a bed hold or transfer/discharge notice had not been completed. On 6/12/25 3:08 p.m., the Administrator said Resident #2 went to a LTAC. He said they had filled her bed, and was unsure if they had any other beds available. Administrator was asked for a census for the day Resident #2 was to return and he said he didn't know what date that was. On 6/12/25 at 4:20 p.m., the Administrator said he was unable to find out any further information about what day she was able to come back to skilled nursing, but he did find out it was something to do with her trach. He agreed Resident #2 had been at the facility for years and the trach was not something new for her. He said it had become more complicated and the nurses there wouldn't be able to deal with it, but could not say what that was. 2. On 6/12/25 a record review of Resident #3's chart revealed he had been discharged on 2/20/25. A progress note dated 2/20/25 indicated around 6 p.m. Resident #3 complained of chest pain, had been given nitroglycerin, pain continued and he was sent out to the hospital. A further progress noted dated 2/11/25 indicated the nurse had called the hospital, would remain in their care, cardiology would examine and determine next action. There was no further documentation in Resident #3's chart indicating what had happened with Resident #3. On 6/12/25 at 12:40 p.m., the DON said Resident #3 had been sent to the hospital, and then discharged to a facility on the East Coast be closer to his girlfriend. The DON said the facility would have taken him back. On 6/12/25 at 1:49 p.m., the Admissions Coordinator said the facility had been trying to put restrictions on Resident #3 from smoking in front of the building, and then Resident #3 chose to go to a facility on the East Coast. When the dialogue between the hospital and facility was reviewed, it revealed the facility had told the hospital they were unable to accept patient, care needs exceed current capacity, patient is a danger to himself and others. (photo obtained) On 6/12/25 at 2:00 p.m., the Regional Nurse said there was no bed hold documentation for Resident #3. On 6/12/25 at 3:46 p.m., the DON said Resident #3 was never [NAME] acted. DON said she didn't necessarily know that he was a threat to himself or others, he just didn't like following rules while he was here, complained about everything and pushed the rules, like not supposed to smoke at this time, he would smoke, if dining room not open he would go in there, he just liked to be confrontational. DON said he was not involved in any physical altercations, he was just all talk. She said as far as she could see in his chart, he was never [NAME] Acted since admission on [DATE]. On 6/12/25 at 2:28 p.m., the Administrator was asked why Resident #3 didn't return to the facility. He said it was probably in the chart and said Resident #3 was a heavy smoker, refused to give them his lighter, and was non-compliant. Administrator said he didn't recall if he was given a notice of discharge. Administrator said the decision to take someone back or not is a team decision that includes himself, the DON, Social Services, Business Office and maybe even the regional team was involved. On 6/12/25 at 3:08 p.m., the Administrator said no 30 day notice of discharge had been issued to Resident #3.

Based on observations, records review and interviews, the facility failed to carry out activities of daily living (ADLs) including nail care and showers for 2 dependent residents, 12 and #16, of 5 residents reviewed for ADLs. The findings included: Review of facility policy titled Bathing / Showering revised 9/1/2017 which stated, Assistance with showring and bathing will be provided at least twice a week and PRN (as needed) to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. This schedule will take precedence over the twice a week and PRN cleansing. The resident's frequency and preferences for bathing will be reviewed at least quarterly during care conference. Review of clinical records for Resident #12 documented admission to the facility on 3/6/25. The most recent Brief Interview for Mental Status (BIMs) score on 5/9/25 was 0 indicating severe cognitive impairment. Shower / bath days are Mondays and Thursdays. Review for shower bed bath documentation showed only 4 bed baths provided between 5/1/25 and 6/12/25. Most recent bed bath was documented on 6/2/25. Review of clinical records for Resident #16 documented admission to the facility on 4/19/25. Shower / bath days are Mondays and Thursdays, and resident is care planned as dependent with one or 2 staff to assist with tub/ shower transfer. Documented in the clinical record shows Resident #16 prefers showers. Review of shower or bed bath documentation showed only 2 showers were provided between 5/1/25 and 6/12/25 otherwise bed baths were given despite documented preference. On 6/12/25 at 11:30 a.m., Resident #12 was observed in bed dressed in a hospital gown. The resident's hair was disheveled and appeared greasy. The resident's fingernails on her left hand were approximately an inch long, the fingernails on the resident's right hand were slightly shorter. Fingernails on both hands were observed to have dark brown debris under the nails and dark brown crusty debris around the cuticles of the fingernails. The resident was confused and unable to answer questions. On 6/12/25 at 11:50 a.m., during an interview Certified Nursing Assistant (CNA) Staff G said she had cleaned up Resident #12 that shift but had not given her a bed bath. CNA Staff G said when asked about Resident #12 fingernails, No they are not acceptable. They are too long and dirty. CNA Staff G said she did not know the routine for providing nail care for the residents. On 6/12/25 at 12:05 p.m., Licensed Practical Nurse (LPN) Staff H confirmed Resident #12's fingernails were too long and dirty. LPN was asked what was under her nails and replied, I don't know dirt or poop. We will clean her up. On 6/12/25 at 12:15 p.m., LPN Staff I, assigned to care for Resident #12 for the shift, looked at the resident's nails and said, Yes, they are very dirty, the left-hand nails are longer than the other hand. Asked what the process was for cleaning and trimming nails. LP, Staff I, replied, We have a binder to let podiatry know when to cut the nails. Confirmed she has not cut the residents assigned to her nails. On 6/12/25 at 12:30 p.m., Unit Manager LPN Staff C said staff should be looking at the residents daily head to toe. Confirmed nurses may cut fingernails and the CNAs can clean and file nails. If the residents are diabetic, then we have podiatry do the toenails. Unit Manager LPN Staff C observed Resident #12 fingernails and said, They are filthy. They need to be cleaned out and trimmed. The Unit manager said nail care is to be done with the shower or bath twice a week and as needed. On 6/12/25 at 12:45 p.m., Resident #16 was observed in bed with disheveled greasy hair and long dirty nails. Debris noted under the nails of both hands. LPN Staff I viewed Resident #16 nails and said, Yes, they are also too long and dirty. They should have been trimmed. Sometimes the resident will eat with her hands that might be what is under the nails. On 6/12/25 at 12:55 p.m., Unit Manager LPN Staff C observed Resident #16 and said, Yes, her hair is dirty, and her nails are too long with dirt under them. We will get her cleaned up. On 6/12/25 at 1:30 p.m., during an interview the Director of Nursing (DON) confirmed residents' nails should be clean and trimmed saying nail care is provided on shower or bath day. The DON confirmed the process is that nurses can trim nails and CNAs can file them. The DON reviewed the clinical records for Resident #12 and Resident #16 and confirmed there are no refusals documented for either resident related to showers or nail care. On 6/12/25 at 2:40 p.m., the facility Administrator said, I expect the CNAs to clean and trim nails and provide showers as scheduled. It's part of their job.

Based on record review, and staff interviews the facility failed to ensure consistent documentation of meal intake for 2 (Residents #3 and #9) of 3 sampled residents with significant weight loss to determine the effectiveness of nutritional interventions. The findings included: Review of Resident #3's medical record revealed an admitted [DATE] from an acute care hospital where she was admitted for altered mental status, dehydration and abnormal laboratory results. Review of the Registered Dietitian's (RD) Admission Nutritional Review dated 10/30/24 revealed documentation Resident #3's current weight was 207 pounds (lbs.). The resident's ideal body weight was 135 pounds. The RD noted there were no issues with chewing or swallowing and Resident #3 verbalized no difficulties with chewing or swallowing. The goals were for the stabilization of weight and for meal intake to be greater than 50% for all three meals. On 11/6/24 the RD wrote in a progress note the Unit Manager informed her Resident #3's family was requesting a nutritional supplement related to Resident #3's poor appetite. The resident's current diet was a regular diet, pureed texture, and nectar-thickened liquids. Resident #3's food intake varied from 0% to 100%. The RD added eight ounces of nectar-thickened milk at each meal (8 oz provided 170 kilocalories and 8 grams of protein). The current plan of care would be continued. On 11/08/24 the RD wrote Resident #3's daughter requested to speak with the RD. She reported her mother did not like the pureed diet. Resident #3's daughter was requesting a possible appetite stimulant, and nursing was notified. Review of Resident #3's weight flow sheet revealed the following weights were documented: 10/20/24: 207.0 pounds (lbs.) 11/01/24: 206.4 lbs. 11/11/24: 180.0 lbs. 11/27/24: 177.8 lbs. On 11/17/24 the RD wrote in a weight loss nutritional review Resident #3 triggered a significant weight loss of 13.0% or 27 pounds in 2 weeks that was an unplanned and undesirable. The weight loss was documented to be a likely variable meal intake, and wounds. Nutritional interventions were put into place on 11/06/24. The RD noted on 11/08/24, the family had requested a possible appetite stimulant and nursing was notified. The IDT (interdisciplinary team) and the MD (Medical Doctor) were made aware of the weight loss, current nutritional interventions and new recommendations made. The RD documented they would continue to monitor nutritional status, including meal intake, weight status, diet compliance, labs when available and skin integrity as needed. On 1/08/25 at 2:49 p.m., in an interview the RD she said she came to the facility three days a week. She did nutritional evaluation/assessment for newly admitted residents, residents' monthly and quarterly weight reviews, and any resident who triggered for a significant weight loss or weight gain. She said she used multiple tools to evaluate a resident's nutritional status to include resident and family interviews, resident intake during mealtime observations, staff interviews and staff documentation related to meal intake percentage to assist her with dietary recommendations for each resident. The RD said after reviewing Resident #3's medical record and her progress notes, she confirmed Resident #3 was admitted on [DATE] weighing 207.0 pounds. She said she wrote a progress note on 11/06/24 stating the Unit Manager reported the family was requesting to speak with the RD. She said she spoke with Resident #3's daughter who told her she would like her mother to receive a nutritional supplement due to her poor appetite. She said Resident #3's current meal intake was 0% to 100% so she added 8 oz nectar-thickened milk to each meal. She said on 11/8/24 she spoke to Resident #3's daughter who told her Resident #3 did not like her pureed diet. She was requesting her mother's diet be changed to mechanical soft and asked if her mother could have an appetite stimulant. She told Resident #3's daughter, she would inform the speech therapist of her request to upgrade her mother's diet to mechanical soft. She would inform nursing Resident #3's daughter's request for an appetite stimulant due to her mother not eating. The RD said she informed nursing, and the therapy department of Resident #3's daughter's request to upgrade her mother's diet to a mechanical soft diet and to add an appetite stimulant due to poor intake. The RD said on 11/17/24 she reviewed Resident #3's weights and noted Resident #3's weight was documented on 11/11/24 as 180.0 pounds, which was a 27.0 pound weight loss since her admission, and was a significant weight loss of 13% which was an unplanned and undesirable weight loss. The RD said she had notified the therapy department and nursing on 11/8/24 of Resident #3's daughter's request for a change in diet and an appetite stimulant as she had documented in her 11/8/24 progress note. On 1/9/25 a review of Resident #3's medical record revealed from 11/1/24 through 11/17/24 the nursing staff had not document Resident #3 meal percentage intakes 37 times out of 51 meals as required. Further review of Resident #3's meal intake percentages from 11/23/24 through 12/11/24 revealed the nursing staff did not document 44 meal percentage intakes out of 57 meals. On 1/9/25 at 3:03 p.m., in an interview with the Director of Nursing (DON) after she reviewed Resident #3's medical record, she confirmed Resident #3 was admitted to the facility on [DATE]. She confirmed the RD came to the nursing facility three days a week and did the nutritional evaluation/assessment for newly admitted residents, the residents' monthly and quarterly weight reviews, and any residents who triggered for a significant weight loss or weight gain. She said for continuity the RD reviewed all residents' weekly weights to ensure all significant weight loss and gains were caught and addressed timely. She said the RD as part of her resident nutritional assessment reviewed the resident's medical record and talked with the staff, resident and family and was required to bring her concerns to the IDT meetings. The DON confirmed the nursing staff did not document Resident #3's meal intake percentages 37 times from 11/1/24 through 11/17/24 and 44 times from 11/23/24 through 12/11/24 as required. She said the RD did not inform the IDT in their morning meetings that the nursing staff were not documenting Resident #3's required meal intake percentage as required. She also said the RD did not inform the IDT Resident #3's daughter had requested on 11/8/24 for her mother diet to be upgraded to a mechanical soft diet and the daughter's request for an appetite stimulant for her mother due to her mother's poor food intake as required. 21322 2. Review of the clinical record for Resident #9 revealed an admitted [DATE]. Diagnoses included alcohol dependence, alcoholic cirrhosis of the liver. Review of the resident's weight record revealed on 9/12/24 the resident's weight was 179.89 pounds (lbs.) On 9/25/24 the resident's weight was 188.8. lbs. On 10/2/24 the resident's weight was 177.0 lbs. On 12/5/24 the resident's weight was 174.0 lbs. On 12/12/24 the resident's weight was 154.6 lbs. On 12/13/24 the resident's weight was 155.8 lbs. Review of the progress notes revealed on 11/4/24 the Registered Dietitian documented Resident #9 triggered for a significant weight loss of 10.8 lbs. in one month that was unplanned and undesirable following a weight gain of 8.9 lbs. The RD noted she met with the resident who stated that he can feed himself but sometimes had trouble getting food/utensil up to his mouth. The goals listed included weight stabilization and meal intake greater than 50% for three meals. On 12/11/24 the RD documented Resident #9 triggered for a significant weight loss of 14.8 lbs. in three months that was unplanned and undesirable likely related to variable intake/fair appetite. The resident reported having a fair appetite. He generally does well with breakfast. The resident also felt like his current weight was not accurate. He reported having difficulty reaching the plate on the bedside table tray. On 12/13/24 the RD documented a reweight was obtained and showed a 19.4 lbs. weight loss in one week. Per the interdisciplinary team, the resident was to have one to one feedings, he was a dependent eater. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 12/16/24 noted Resident #9's weight was 156 lbs. The MDS coordinator checked no or unknown for weight loss of 5% or more in the last month. On 12/18/24 the RD documented the resident continued to have a poor appetite, generally consuming one meal per day. Order for mirtazapine (antidepressant that can be used for appetite stimulant). The resident's weight was 155.8 lbs. The RD noted the resident had a significant weight loss documented on 12/11/24 and 12/13/24. The interventions included to increase fortified foods to all meals, add snack twice a day. Review of the resident's meal intake for December 2024 showed no meal intake documented for breakfast or lunch on 12/2/24, 12/5/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24, 12/10/24, 12/11/24, 12/16/24, 12/22/24, 12/24/24, 12/26/24, 12/28/24, 12/29/24, 12/30/24, and 12/31/24. The meal percentage was not documented for dinner on 12/22/24. On 1/9/25 at 8:15 p.m., Resident #9's dinner was observed uneaten on a meal cart across from the nurse's station. On 1/9/25 at 8:24 p.m., in an interview Unit Manager Licensed Practical Nurse Staff I verified Resident #9 did not eat his dinner meal. She said a couple of weeks ago, she notified the physician of the resident's poor appetite. The physician ordered mirtazapine 7.5 milligrams at bedtime for appetite stimulant. The Unit Manager said the Certified Nursing Assistants were supposed to document meal intakes and notify her when a resident refused a meal. On 1/9/25 at 8:30 p.m., Unit Manager Staff I looked at the meal intake documentation and verified the CNAs were not consistently documenting the percentage of meals for Resident #9. She verified no meal intake was entered for dinner for 1/9/25 and no one notified her the resident refused dinner. She said without consistent and accurate documentation of meal intakes, it was not possible to determine the effectiveness of the appetite stimulant. The Unit Manager provided a list of weight for January 2025. Resident #9's weight was listed as 141.2 lbs. A review of the Center for Medicare and Medicaid Services Roster/Sample Matrix form (used to document residents relevant care categories) failed to identify Resident #9's excessive weight loss without a prescribed weight loss program. On 1/9/25 at 8:40 p.m., in an interview the DON said she was not aware the CNAs were not consistently documenting meal intakes. She did not know why Resident #9's excessive weight loss was not captured on the Roster Matrix. She said the nurses were supposed to ensure the meal percentage was documented before the CNA leaves. The Unit Managers supervise the nurses and the Assistant Director of Nursing (ADON) supervises the Unit Managers. The DON said she did not review the CNAs or the nurse's documentation unless a problem is reported to her. She said the ADON routinely in-serviced the CNAs and documentation is addressed in the in-services. The DON provided a Mandatory Clinical Meeting document dated 12/18/24 and 12/19/24 which she said was an in-service provided to the CNAs. The document noted All of your charting needs to be completed prior to the end of your shift . Either you did it or you didn't. Nurses will be checking prior to shift end and following up with you. Management will call you back in and [sic] you do not come finish it will be a corrective action moving forward. Corrective actions will start to be given this month for the CNA not completing and the nurse not following up . Any refusals of . snacks . etc. they need to be documented, then try again after a while. If they still refuse then get nurse and document refusal again. Nurse is to try and if still refused then nurse documents also . The DON said she did not have documentation the in-service was given to the CNAs on 12/18/24 and 12/19/24.

Based on observation, record review, review of facility's policy and procedure, staff, and family interview the facility failed to implement a systemic approach to identify risk factors and implement appropriate supervision and interventions to prevent avoidable falls with serious injuries for 3 (Resident #10, #69 and #30) of 5 residents sampled with falls or fall related injuries. The findings included: The facility policy N-1259 Fall Management documented Residents are evaluated for fall risk. Patient centered interventions are initiated based on resident risk. A fall refers to unintentionally coming to rest on the ground floor or other lower level but not as the result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his or her balance and would have fallen if not for another person or if he or she had not caught him or herself is considered a fall unless there is evidence suggesting otherwise when a resident is found on the floor a fall is considered to occur. Purpose: Is to identify residents at risk for falls and establish or modify interventions to decrease the risk of a future fall and minimize the potential for a resulting injury. 1. Review of the clinical record revealed Resident #10 was admitted to the facility from an acute care hospital on 3/1/23 after a fall and fall related fractures to the nasal bones, right maxilla, facial bone and right radius (forearm) fracture. Admitting diagnoses included difficulty walking, dementia, anxiety, repeated falls and Alzheimer's disease. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 3/6/24 documented the resident ambulated independently. The MDS noted Resident #10's cognitive skills for daily decision making were severely impaired. The Fall Risk Evaluation dated 5/13/24 documented a score of 50 indicating the resident was at a low risk for falls. The care plan initiated 12/26/23 revised 4/18/24 identified Resident #10 was at risk for further falls and fall related injuries due to decreased physical mobility, poor communication/comprehension, unaware of safety needs, and dementia. The goal was to minimize risk of minor injury through next review. The interventions included anticipate and meet the resident's needs. Physical Therapy to evaluate and treat as ordered or as needed. Be sure call light is within reach and encourage the resident to use it. Bed in low position. Review of the nursing progress note dated 5/13/24 at 11:40 a.m., documented Resident #10 had a fall hitting the back of her head causing bleeding, fell in the doorway of [room #]. She was transferred to the local emergency room for evaluation. Per emergency department fracture nose. A nursing progress note on 5/13/24 at 11:45 a.m., documented resident with swelling, bruising and bleeding to face. Rt [Resident] walked into [room #] to visit another resident. She was walking out and fell . She hit her face on the floor causing, bruising, swelling and bleeding. 911 was called and Rt transferred to the ER [emergency room ]. Results of x ray showed fracture of the nose. Resident returned to facility on 5/13/23. The emergency room discharge paperwork documented diagnosis: closed fracture of nasal bone, contusion of chest wall and fall. The Fall Investigation Form dated 5/13/24 provided by the facility noted the unwitnessed fall happened during the 7:00 a.m., to 7:00 p.m. shift. Resident #10 was found laying face down in the hallway. The form did not list the time of the fall. The interview section of the form noted: Resident: Why they think the fall happened: Maybe I was pushed. First Responder: Location: Hallway; What happened: Fall; Why they think the fall happened: Resident slipped on items on floor. The form listed the root causes as lack of safety awareness, anxiety, walkway unclear. The updated intervention was to educate staff to ensure walkways are clear. Review of the only witness statement obtained from Licensed Practical Nurse (LPN) Staff C documented Resident #10 went into [Room #], the resident in [Room #] told her to get out of the room. She was walking out of the room and fell hard on the floor. She landed on her face; her nose was bleeding. I called 911. The witness statement did not document how the information for the unwitnessed fall was obtained. There was no documentation the facility considered Resident #10's statement that maybe she was pushed as a possible cause of the fall. The care plan was updated on 5/14/24 after the fall with the new intervention, Inservice staff to keep hallways/walkways clear of clutter. Requests for the education provided to staff, resident nursing notes and fall assessments were not provided at the time the survey ended. On 8/21/24 at 12:07 p.m., in an interview LPN Staff C said she was the only one on the floor at the time of the resident's fall on 5/13/24. Staff C said Resident #10 went into (Room #) and she feel in the doorway. Resident #10 said the resident in the room pushed her but the resident she said pushed her was in the bathroom at that time. Staff C said there was a sheet on the floor and she thinks Resident #10 may have tripped on it. She said she spoke with the other resident who said she just told Resident #10 to get out of her room but denied pushing her. Staff C said, We have a lot of wandering residents on this unit and some of them go into other residents' rooms. She said Resident #10 is always saying someone pushed her but she has never seen that. On 8/21/24 at 12:39 p.m., in an interview the Director of Nursing (DON) said she was at the facility and completed the investigation when Resident #10 fell and broke her nose. She said Resident #10 said she was pushed but she always says she was pushed, regardless of what happens to her. She said she has never witnessed anyone pushing Resident #10. She likes to be by herself and is afraid other residents will take her things. She said Resident #10 always carries her things with her because she is afraid someone is going to take what's hers. The DON said, We do have residents who get into verbal yelling matches because it is a secured dementia unit. We do have wandering residents who like to take things from other resident rooms. When asked about the unwitnessed fall, the DON said, As for the fall, no one pushed her. There was something on the floor a blanket or sheet and she slid on it and fell . 2. Review of the clinical record revealed on 8/9/24 Resident #69 sustained a fall resulting in a right wrist fracture requiring surgical intervention. Resident #69 was readmitted to the facility on [DATE]. Diagnoses included vascular dementia, anxiety disorder, Alzheimer's disease, restlessness and agitation. The Quarterly MDS dated [DATE] documented the resident had daily wandering behavior. The MDS noted Resident #69's cognitive skills for daily decision making were severely impaired. The care plan initiated 11/26/21 and revised 11/29/23 identified the resident was at risk for falls due to incontinence, unaware of safety needs, wandering and attempts to stand unassisted. The goal for the resident was to minimize the risk of falls. The interventions specified, Anticipate and meet the resident's needs. Ensure that the resident is wearing appropriate foot ware/nonskid socks when ambulating or mobilizing in w/c (wheelchair). On 8/9/24 the care plan was updated with the interventions to, Perform medication review. Resident sent to ER for eval per MD (Physician) orders. The intervention were to be implemented upon readmission to facility. On 8/18/24 at 10:05 a.m., Resident #69 was observed in the dining room sitting at a table s holding her right hand with the left across her chest. Her right hand and wrist were noted to be very swollen and bruised. Resident #69 has an expression of discomfort on her face with furrowed brow and was rubbing the right hand. On 8/18/24 at 10:10 a.m., in an interview LPN Staff F said the resident fell approximately a week ago and fractured her arm. Staff F said she did not know exactly when or how the resident fell and sustained the fracture. Staff F said Resident #69 had an order for a splint to the right hand but she would not keep it on. On 8/18/24 at 10:14 a.m., Resident #69 was observed at a table in the dining room with grip sock on. Resident #69 stood up unassisted from the table and left the dining room unsupervised. Resident #69 was observed wandering the hallway without staff supervision or redirection. On 8/18/24 at 5:09 p.m., in a telephone interview Resident #69's family member said she did not understand why Resident #69 keeps falling. She said the resident had dementia and wanders. She said, She will wander and will walk until she is fatigued, but they just let them do whatever they want on that unit. They don't do activities. The residents just sit or they walk. No one pay attention. The family member said last year Resident #69 had broken fingers and sutures to her hand but no one could tell her how or why it happened. She said then last October Resident #69 had a broken hip and they did not know what happened. They just told said she had pain when she was ambulating. The family member said, I don't care if you have dementia, if you break a hip you are going to yell out in pain. She said now she broke her wrist, had to have surgery again and once again no one could tell me what happened. She said when Resident #69 returned from the hospital, she told the nurse it was very important to keep the stiches covered and the doctor said she needed to keep the brace on her arm. She said on 8/15/24 the nurse called and said the splint was missing and no one could locate it. She said the surgical incision also looked infected and they contacted the physician for an order for antibiotics. The family member said, I am very upset right now over all of this. It is a small unit for dementia residents. Who is supervising them? On 8/19/24 at 8:38 a.m., in an interview LPN Staff C said on the day Resident #69 broke her wrist I found her sitting on the floor in room [ROOM NUMBER] (not her room) yelling. I knew her arm was broken; I could tell right away. I called the physician and we sent her to the emergency room . She said she did not know where the resident's splint was. She said she was off for two days. When she came back to work on 8/15/24 the splint was missing. They searched for the splint and could not find it. Staff C said, she won't keep it on anyway. She takes it and the dressing off. On 8/19/24 at 8:40 a.m., Resident #69 was observed sitting at a table in the dining room. She had her right sleeve pulled up and was picking at the sutures on the right wrist. There was no dressing in place. The skin surrounding the wound was red and there was an area that was missing the top layer of skin. Staff in the dining room did not intervene or redirect the resident from picking at the sutures. Resident #69 got up and exited the dining room. On 8/19/24 at 10:09 a.m., Resident #69 was observed wandering unsupervised on the unit. Her gait was noted to be very unsteady. On 8/19/24 at 3:18 p.m., review of the incident log revealed 28 incidents of falls from 12/1/23 through 8/19/24 in the secured unit. On 8/19/24 at 4:21 p.m., a meeting was held with the Administrator, the DON, and the Regional Nurse Consultant to discuss Resident #69's fall and supervision necessary to prevent avoidable falls. Resident #69's care plan for falls revised on 11/29/23 noted the risk for falls was related to incontinence, unaware of safety needs, wandering, attempts to stand unassisted. The care plan noted at times the resident refused staff assistance with ambulation. The interventions listed included a medication review (8/9/24), anticipate the resident's needs (11/26/21), and ensure the resident is wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheelchair. The care plan did not include adequate supervision to prevent avoidable falls and fall related injuries. The Administrator, the DON, and the Regional Nurse Consultant verified the care plan did not include specific measures, including necessary supervision to prevent avoidable falls. On 8/20/24 at 12:22 p.m., in an interview Unit Manager LPN Staff G said she was the manager for B wing and C wing (Memory Care Unit). She said, I go to the memory care unit daily, but the majority of my time is spent on B wing because it is the skilled unit. There are two CNA's, and one nurse assigned for each shift on the secured unit. We don't do anything special for the wandering residents except to try and redirect them to activities but most of them don't sit. The Unit Manager said when she is not on the unit, the nurse is responsible to supervise the unit. On 8/20/24 at 12:49 p.m., in an interview CNA Staff E said when a resident is wandering, they just go, you can't always get them to sit. They get up and they walk, and you try and redirect them but most of them do not do anything, there is nothing back here for them to do. With Resident #69 you can sit her down and she will get right back up. On 8/20/24 at 1:00 p.m., in an interview the DON said Resident #69 does not keep the dressing or anything on the right wrist. She will not sit down and when she does it is only for short periods. She is up and down all the time. She does not sit for activities. On 8/20/24 at 4:48 p.m., in an interview the Regional Nurse Consultant said the facility had no policy to address the needs for the residents on the memory care unit and no policy indicating the requirements for placement on the unit. 37256 3. Resident #30 was admitted [DATE] with diagnosis to include muscle wasting and atrophy, unspecified dementia, longstanding persistent atrial fibrillation, sick sinus syndrome, repeated falls and unsteadiness on feet. The care plan for falls initiated on 7/15/24 noted Resident #30 was at risk for falls related to confusion, incontinence, unaware of safety needs and wandering. The goals were to minimize risk for falls, minimize risk of minor or serious injury and minimize the side effects of medication contributing to increasing residents fall risk. The interventions included to educate the resident/resident's representative/caregivers about safety reminders and what to do if a fall occurs, ensure that the resident is wearing appropriate footwear/nonskid socks when ambulating and physical therapy evaluate and treat as ordered or as needed. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 had a severe cognitive impairment and MDS section E for behaviors indicated Resident #30 exhibited Wandering behavior daily. A change of condition progress note dated 8/3/24 at 8:38 p.m. indicated Resident #30 had a fall and was sent to the emergency room (ER) for evaluation. Review of the incident report created 8/3/24 at 10:15 p.m., indicated the Certified Nursing Assistant notified the nurse Resident #30 was lying on the floor. The Nurse arrived and observed resident sitting up against the wall. Injuries were noted to left eyebrow, left arm skin tear. The resident was limping on the left side when tried to walk. Review of the ER discharge paperwork for encounter date 8/3/24 located in the chart revealed she had received stitches to the injury on the left eyebrow. A progress note dated 8/4/24 at 07:10 am noted: while walking at the hallway resident lost her balance and fell , hitting her head. Resident was wearing nonskid sock. Head to toe assessment done, resident placed on neuro checks. Resident returned back to ed x 2 persons. MD and family notified. Review of the incident report created 8/4/24 at 7:10 a.m., had the same information as progress note and indicated Resident #30 sustained an abrasion to top of scalp, but was not taken to the hospital. A progress note dated 8/5/24 at 5:51 p.m. noted: Resident was walking in the hallway by the nurses. She turned around fast and lost her balance and fell . She hit the left side of her forehead on the floor causing a hematoma. She has no other signs of injury. Moves all extremities normally. Alert and oriented x 1 as is normal for this resident . Resident was transported to Hospital ER for evaluation. Review of the incident report created 8/5/24 at 5:35 p.m., indicated same information as progress note and indicated Resident #30 was sent to the hospital for evaluation of hematoma on left upper forehead. Review of the ER discharge paperwork for encounter date 8/5/24 located in the chart revealed she was discharged from the ER with a primary encounter diagnosis of Fall and closed head injury. A progress note dated 8/5/24 at 11:58 p.m. noted: While sitting at the nursing we heard a thump. Went into Resident #30's room saw resident face down on the floor on the L side of her bed. Blood was coming from the L side of her head. Resident was transferred to her bed from the floor and assessed for other injuries. None noted. Unable to obtain vitals as resident fighting . Received order to send resident to ER. 911 called. Review of the incident report created 8/5/24 at 11:10 p.m., indicated same information as progress note and indicated Resident #30 was taken to the hospital with a laceration to the top of her scalp. Review of the hospital paperwork for encounter date 8/6/24 located in chart revealed Resident #30 had been admitted to the hospital for critical care management of a subarachnoid hemorrhage. Resident #30 did not return to the facility. On 8/19/24 at 2 p.m., LPN Staff C said Resident #30 was very demented and had fallen several days in a row. Staff C explained Resident #30'stypical behavior was she could be resistant to care and liked to do things her way. She said Resident #30 could walk well, had nonslip socks and wandered a lot. On 8/19/24 at 2:05 p.m. Staff E Certified Nurse Assistant (CNA) said Resident #30 used to wander around a lot, room by room, and she would mess up everything in the other residents room. Staff E said when she did that they just told the nurse. Staff E said she wasn't aware of any interventions for falls for Resident #30, nor did she have bedside mats. On 8/19/24 at3:39 p.m., LPN Staff F said Resident #30 wandered all day, room to room digging in stuff, taking clothes from one room to another. She said sometimes Resident #30 would sit down for a few minutes but then she would get up and just go again. Staff F said Resident #30 did have fall mats or a scoop mattress. She said Resident #30 was not one to stay still, unless she was tired she would go lay down, but she was always active wandering around. On 8/19/24 12 p.m., the Director of Nursing (DON) said Resident #30 was identified as a fall risk/wandering in her care plan. DON said somehow it was a miss with implementing any interventions specific to Resident #30 for falls/wandering. DON said in their analysis of Resident #30's falls they identified part of the root cause was she had no fall interventions in place for her falls and wandering behavior.

Based on observation, staff interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. The findings included: The facility policy titled Food Storage: Cold Foods Policy last revised 2/2023 states all time/temperature control for safety foods, frozen and refrigerated, will be appropriately stored in accordance with the guidelines of the FDA Food Code. Procedures include: All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Equipment Policy provided by facility stated, All foodservice equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials; All staff members will be properly trained in the cleaning and maintenance of all equipment; All food contact equipment will be cleaned and sanitized after every use; All non-food contact equipment will be clean and free of debris; the dining services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. On 8/18/24 at 9:15 a.m., the Initial kitchen tour was conducted with the Dietary Manager who said he has been at the facility since January 2024. The following were observed: Unlabeled and undated food items, including a meat in a storage bag were stored in the walk-in refrigerator. The Manager verified the observation and said without a label he could not tell what the food was. He said it probably was leftovers from the previous night but couldn't tell. Photographic evidence obtained. Dietary Aide Staff J was observed washing dishes using the dishwasher. The Manager said the dishwasher was originally a high temp dishwasher. They were unable to fix it so it was converted to a low temp sanitizing dishwasher. In an interview Staff J said she has used the dishwasher almost every day since she started work at the facility six months ago but has never been shown how to use the test strips to test the sanitizer. She said she did not know how to test and ensure the dishwasher had the appropriate amount of sanitizing agent. Review of the dishwasher's log for August 2024 showed Staff J's initials for 8/18/24 and several other days. No entry was documented for the sanitizer, only the water temperature. Dietary Staff K was observed testing the sanitizer in the dishwasher. The test strip bottle's label was worn off, the expiration date was not legible. The values for the sanitizing agent was not legible making it impossible to verify the test strip results to the value listed on the bottle. The Dietary Manager verified the label of the test trip bottle was worn out making it impossible to read the expiration date and compare the test strip to the value listed on the label. The Dietary Manager discarded the bottle of test strips. Photographic evidence obtained. Two large black plastic covers covered in dust and debris were observed stored on the bottom shelf of the steam table located in the kitchen. The Manager picked up the covers and showed that they were the lids used to cover the clean plates in the plate rack. The ceiling tiles and air conditioning vents over the food preparation area and the clean dish storage were dirty, dusty, and covered in black bio growth. The Manager said the maintenance department was in charge of cleaning the vents and he did not know the last time they were cleaned. There was also a missing ceiling tile and stained dark area on another tile by entryway. Photographic evidence obtained. On 8/19/24 at 10:00 a.m., in an interview the Representative from the company who converted the high temp dishwasher to a low temp sanitizing dishwasher said the dishwasher was made to be used as a high or low temp dishwasher. He said he maintains the dishwasher and that it is working appropriately. He said the staff had only been checking the water temperature of the dishwasher and not the sanitizer. On 8/21/2024 at 1:30 p.m., in an interview the Maintenance Director said he has been employed at the facility for three months now. He said he cleaned the air conditioning vents and ceiling tiles in the kitchen after the observation made on 8/18/24. He said it was maintenance's responsibility to check and clean them monthly, but he has been too busy since he started employment at the facility. He said he did not know the last time the vents and tiles were cleaned.

Based on observation, family and staff interview, review of facility policy and procedure, and record review the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 6 (Residents #10, #23, #48, #69, #79 and #96) of 21 residents reviewed for involvement in the activity program on the secured memory care unit. The findings included: The facility policy Community Life Overview effective date 11/1/21 documented Activity programs are developed and implemented to meet the individualized physical, mental, and psychosocial /emotional needs of the resident as well as promoting self-expression of choice. Activities refer to any endeavor other than routine activities of daily living in which a resident participates that enhances his/ her sense of well-being and that promotes or enhances physical, cognitive, and emotional health. Review of the August 2024 activity calendar for the memory care unit documented the following activities: 8/18/24 at 10:30 a.m., Courtyard time. 1:00 p.m., Hydration. 2:00 p.m., Socialize with friends. 8/19/24 at 10:00 a.m., Courtyard time. 10:30 a.m., Hydration. 2:30 p.m., massage/lotion. 3:00 p.m. Fall Craft. 8/20/24 at 10:00 a.m., Courtyard time. 10:30 a.m., Hydration. 2:30 p.m., Sing-along. 3:00 p.m. fruit cup. 1. Review of the clinical record revealed Resident #10 had an admitted [DATE]. Diagnoses included repeated falls with major injuries, Alzheimer's disease, anxiety, major depressive disorder and dementia. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 3/6/24 documented the resident's daily preferences, included listening to music, being around pets, keeping up with the news, and religious services were somewhat important to the resident. Participating in things with a group of people, doing your favorite activities, and going outside to get fresh air were very important to Resident #10. The MDS noted Resident #10's cognitive skills for daily decision making were severely impaired. On 8/18/24 at 10:08 a.m., Activity Aid Staff H was not adequately supervising five residents engaged in a coloring activity in the dining room of the secured memory care unit. Resident #10 and four other residents were seating at a table in the dining room with crayons and coloring books. Resident #10 picked up a crayon and put it into her mouth and took a bite of the crayon. Upon request, Staff H intervened and retrieved the crayon from the resident's mouth. On 8/18/24 at 12:10 p.m., and 8/19/24 at 2:29 p.m., Resident #10 was observed in the dining room of the memory care unit. The television (TV) was on at times playing music. No structured activities were in progress. There were no items of interest at the table for Resident #10 and the other residents seated in the dining room. 2. Review of the clinical record revealed Resident #23 had an admitted [DATE], with diagnoses including dementia, major depressive disorder, mood disorder, anxiety disorder and insomnia. The Quarterly MDS dated [DATE], documented the behavior wandering occurred daily. The MDS noted Resident #23's cognitive skills for daily decision making were severely impaired. The care plan initiated 4/7/21, (revised 2/25/24) specified Resident #23 was dependent on staff for meeting emotional, intellectual, physical and social needs due to cognitive deficits. The goal for Resident #23 was for her to maintain involvement in cognitive stimulation, and social activities as desired. The interventions for Resident #23 specified to encourage resident participation in activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as listening to music, coloring, and simple puzzles. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. On 8/18/24 at 9:20 a.m., and 12:21 p.m., Resident #23 was observed wandering on the unit, going in and out of the dining room. Staff did not redirect the resident. There was no structured activity in progress. On 8/19/24 at 9:21 a.m., Resident #23 was observed in the dining room wandering from table to table as other residents were having breakfast and the staff did not redirect her. On 8/20/24 at 12:02 p.m., Resident #23 was observed in the dining room wandering to other tables and taking food and drinks from other residents plates. There was no staff intervention provided. On 8/20/24 at 1:55 p.m., Resident #23 was observed wandering in and out of other residents' rooms taking their personal items. The staff on the secured unit did not redirect the resident or offer an activity. 3. Review of the clinical record revealed Resident #48 had an admitted [DATE] with diagnoses including major depressive disorder, anxiety disorder, dementia, seizures and macular degeneration. The care plan revised 7/12/24 identified Resident #48 was dependent on staff for meeting emotional, intellectual, physical and social needs due to cognitive deficits. The care plan goal for Resident #48 was to maintain involvement in cognitive stimulation, social activities as desired through next review. The care plan interventions specified for staff to assist the resident to engage in simple, structured activities such as listening to music, coloring, simple puzzles, and structured arts and crafts. Encourage Resident participation in scheduled activities, engage in simple structured activities. On 8/18/24 at 10:05 a.m., Resident #48 was observed sitting at the dining room table for over one hour. Her back was to the TV, and she had nothing in front of her to provide mental or physical stimulation. There was no group activity in progress. On 8/18/24 at 10:54 a.m., in an interview Resident #48's family member said, The only issue I have on the secured memory unit is the residents sit a lot. There are no activities. All they do here is sit or wander. On 8/18/24 at 12:00 p.m., and 8/19/24 at 9:39 a.m., Resident #48 was observed wandering on the unit, ambulating in and out of the dining room and in the hallways with no intervention or redirection provided. There was no activity in progress and 13 residents who reside on the unit were sitting in the dining room. On 8/20/24 at 2:00 p.m., Resident #48 was observed ambulating on the unit, wandering back and forth in the hallway with no purpose or direction. There was no activity in progress. 4. Review of the clinical record revealed Resident #69 had a readmitted [DATE] with diagnoses including vascular dementia, anxiety disorder, Alzheimer's disease, restlessness and agitation. The Quarterly MDS dated [DATE] identified the resident had the behavior of wandering occurring daily. The MDS noted Resident #69's cognitive skills for daily decision making were severely impaired. On 8/18/24 at 10:11 a.m., Resident #69 was observed sitting in the dining room at a table. Activity aid Staff H was with a group of 4 residents coloring at a table. She said Friday 8/16/24 was her first day and she did not know any of the residents on the memory care unit. Music was playing on the TV. Residents were wandering in and out of the dining room. On 8/18/24 at 5:11 p.m., in a phone interview Resident #69's family member said I come on weekends to visit and there are never any activities. The residents just sit and do nothing in the dining room, or they get up and wander and no one stops them or does anything with them. It is a small unit, do something with the residents, but they do nothing. On 8/19/24 at 8:40 a.m., Resident #69 was observed sitting at a table in the dining room, her had her right sleeve pulled up and was observed picking at the sutures on her right wrist from a recent surgical procedure. There was no dressing in place. The skin surrounding the wound was red and there was an area that was missing the top layer of skin. No intervention was made to redirect the resident. Resident #69 then got up from and table and ambulated out of the dining room without anyone redirecting her. On 8/19/24 at 10:09 a.m., Resident #69 was observed wandering unsupervised on the unit. On 8/19/24 at 3:00 p.m., Resident #69 was observed in the dining room sitting at a table. The TV was on, but her back was facing the TV. Activity aid Staff D was at a table making paper chains. Four residents of the 11 residents in the dining room were involved with the activity. There were no books or other items offered to the 11 residents who were not participating in making paper chains. 6. Review of the clinical record revealed Resident #79 had a readmitted [DATE] with diagnoses including dementia, chronic diastolic heart failure, adjustment disorder, and falls. Review of the Admission MDS dated [DATE] documented listening to music you like and doing things with groups of people were somewhat important to the resident. While getting fresh air and going outside were very important. The MDS noted Resident #79's cognitive skills for daily decision making were severely impaired. The care plan revised on 7/12/24 identified Resident #79 was an elopement risk/wanderer due to dementia with impaired safety awareness. The resident wandered aimlessly. The goal for Resident #79 was to demonstrate happiness with daily routine. The interventions instructed to provide structured activities, walking inside and outside, reorientation, strategies including signs, pictures and memory boxes. On 8/18/24 at 10:04 a.m., Resident #79 was observed seated at a table with another resident. The TV was on but Resident #79 was not able to see the TV from her seat. Activity Aid Staff H was in the dining room coloring with four residents at a table. She did not attempt to engage Resident #79 in the coloring activity or offer an alternative. On 8/18/24 at 10:35 a.m., Resident #79 was observed in her wheelchair wandering on the memory care unit. There was no activity in progress. On 8/18/24 at approximately 10:40 a.m., in an interview Staff H said, Let's see what I can get for everyone, and left the unit. Staff H returned with a pitcher of juice and offered small amounts to the residents in the dining room. On 8/20/24 at 1:08 p.m., in an interview Certified Nursing Assistant(CNA) Staff E said Resident #79 was able to walk with a walker when she wants but uses the wheelchair daily. She doesn't really do anything. Staff E said sometimes the resident will sit in the dining room during an activity, or she will wander. Resident #79 was observed seated at a table in the dining room with her back towards the TV. On 8/20/24 at 2:00 p.m., Resident #79 was observed seating at the same spot at the table with no activity in progress. In an interview Resident #79 said there was nothing going on and she liked some things to do. 6. Review of the clinical record revealed Resident #96 had an admitted [DATE] with diagnoses including dementia, adjustment disorder, depression, and mood disorder. Review of the admission MDS dated [DATE] documented going outside for fresh air was very important to the resident. The care plan initiated on 5/3/24 identified Resident #96 was an elopement risk, and wanderer due to dementia. The goal for the resident was her safety will be maintained. The interventions instructed to provide structured activities, walking outside, and reorientation strategies including signs, pictures and memory boxes. On 8/18/24 from 9:30 a.m., to 10:37 a.m., during observation on the memory care unit, Resident #96 was observed wandering on the unit with no redirection from the staff and no activity program in progress. Resident #96 walked over to the dining room and slammed the door shut loudly. The nurse seated at the desk looked at the resident and made no attempt to redirect her. Resident #96 continued to wander on the unit, using obscenities and talking to herself very loudly. Music was playing in the dining room, but no staff were present. On 8/19/24 at 9:29 a.m., in an interview Licensed Practical Nurse (LPN) Staff C said Resident #96 was on one-to-one supervision because of her behaviors. Staff C said the day before on 8/18/24, Resident #96 struck another resident's family member. Staff C said Resident #96 had episodes of hitting other residents but never a visitor. On 8/19/24 at 9:45 a.m., Resident #96 was observed wandering the halls with a CNA, there was no structured activity is in progress. On 8/19/24 at 2:36 p.m., the observation of staff not providing activities listed on the activity calendar for the memory care unit on 8/18/24 and 8/19/24 was reviewed with the Activity Director. In an interview the Activity Director (AD) said she has two part time activity aids, one started two days ago. She said the activity Courtyard time was on the calendar daily but had not happened in a month or so. She said it was too hot outside, and the residents did not want to go outside. The AD confirmed she did not change the calendar to replace the activity. The AD said Hydration was listed as an activity and not part of the resident's daily care because the activity aid will sit and talk to the residents, it's not just give them juice and go. The AD said she was going to have her assistant go to the memory care unit now. She said when she has group activities only four to eight of the 21 current residents stay for the activity. She said she did not do anything special for the wandering residents on the unit. On 8/19/24 at 2:53 p.m., Activity Aid Staff D was on the memory care unit seated in the dining room with a group of four Residents making a paper chain. Staff D said three residents came to the activity and left. She said it was usually the group that participates in activities. Eight other residents were observed seating in the dining room not participating in the activity. Several other residents were observed wandering in the hallway, going in and out of the dining room. Staff D said she worked 22 hours a week and was responsible for all the activities in the facility. She said, I try to do everything on the calendar but some days I just don't get to all three of the units. The only time I can get the wandering residents to stay in the dining room for an activity is if it involves snacks. There were no activities, books or other items offered to the other residents seated in the dining room. Staff D confirmed she did not do any activity for the residents who wander on the unit.

Based on review of facility job description and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents who participate in activities. The findings included: The facility Job Description for Director of Therapeutic and Recreational Services documented The primary purpose of the director of therapeutic and recreational services (activity director) position is to plan organize develop and direct the overall operation of the activity department in accordance with current federal state and local standards guidelines and regulations our established policies and procedures and as may be directed by the executive director to ensure that an ongoing program of activities is designed to meet in accordance with the comprehensive assessment the interest and the physical mental and psychosocial well-being of each resident. Education: Must possess a minimum of bachelor's degree in therapeutic recreation or equivalent training /experience. Experience: Must possess a minimum of two years' experience in therapeutic recreation. On 8/20/24 at 11:27 a.m., a request was made to Human Resources for a copy of the Activity Director's qualifications/certificates. On 8/20/24 at 11:33 a.m., the Human Resources Director (HRD) provided the Activities Director employee file and verified the lack of documentation the current Activities Director had the required qualifications for the position. The HRD said the acting Activity Director Staff B was in training to get her certification and was working under the direction, and supervision of the Administrator. The HRD said Staff B has been the Activity Director for several months but did not have a certification in therapeutic activities. The HRD said Staff B accepted the position after the previous Activity Director left but she did not know the exact date the previous Activity Director had left. The HRD confirmed nothing in the employee file showed Staff B met the requirement for the Activities Director position. On 8/20/24 at 11:54 a.m., in an interview the Administrator confirmed Staff B has been the Activity Director Staff for more than six months without the required qualifications for the position.

Based on staff interviews and record review the facility failed to ensure 5 facility Staff (E, N, O, P, and Q) out of 5 facility staff nursing aids reviewed, had the required in-service training for continuing competency education of no less than 12 hours per year. Failure to provide staff with continuing yearly in-service training on a yearly basis could lead to staff not having knowledge and training on how to provide the appropriate services to resident with cognitive impairments. The findings included: On 8/21/24 a review of Staff E, Certified Nursing Aid (CNA) employee files revealed she was hired 5/5/08. Further review revealed no documentation, Staff E had completed a minimum of 12 hours of continuing competency education in 2023, as required on a yearly basis. On 8/21/24 a review of Staff N, CNA employee files revealed she was hired 5/24/05. Further review revealed no documentation, Staff E had completed a minimum of 12 hours of continuing competency education in 2023, as required on a yearly basis. On 8/21/24 a review of Staff O, CNA employee files revealed she was hired 8/29/01. Further review revealed no documentation, Staff E had completed a minimum of 12 hours of continuing competency education in 2023, as required on a yearly basis. On 8/21/24 a review of Staff P, CNA employee files revealed she was hired 1/23/07. Further review revealed no documentation, Staff E had completed a minimum of 12 hours of continuing competency education in 2023, as required on a yearly basis. On 8/21/24 a review of Staff Q, CNA employee files revealed she was hired 4/8/21. Further review revealed no documentation, Staff E had completed a minimum of 12 hours of continuing competency education in 2023, as required on a yearly basis. On 8/21/24 at 12:38 a.m., in an interview with Human Resource Director (HRD) confirmed the hire dates for Staff E, Staff N, Staff O, Staff P, and Staff Q. She further said she was unable to find documentation Staff (E, N, O, P, and Q) had completed the required competency education/in-services for 2023. On 8/21/24 at 12:48 a.m., in an interview with HRD and Assistance Director of Nursing (ADON)/Staffing Coordinator, she said the CNAs were required to complete a minimum of 12 hours of continuing competency education on a yearly basis, between January through December of each year. The HRD said she would routinely send email reminders throughout the year to the CNAs, reminding them to complete their mandatory competency education training on educational portal on the computer. The HRD said she thought the ADON was responsible to ensure the CNAs were completing their mandatory competency education/in-services on a yearly basis. The ADON/Staffing Coordinator said, she was not responsible to monitor the CNAs mandatory competency education/in-services on a yearly basis. She thought the HRD was monitoring the CNAs education/in-services because she was sending the reminders to the CNAs to complete their mandatory yearly education in the education portal on the computer. The HRD and ADON said they were unable to find documentation Staff E, Staff N, Staff O, Staff P, and Staff Q had completed a minimum of 12 hours of continuing competency education for the calendar year of 2023 as required.

Based on observation, record review and staff interviews, the facility failed to ensure staff provided care and services with respect and dignity to 2 (Residents #69 and #23) of 21 cognitively impaired residents observed on the memory care unit. The findings included: 1. Review of the clinical record revealed Resident #69 was readmitted to the facility from an acute care hospital on 8/12/24. Diagnoses included fracture and surgical repair of the right wrist, vascular dementia, anxiety disorder, Alzheimer's disease, restlessness and agitation. The hospital discharge orders dated 8/12/24 included Xeroform (non-adherent dressing), dry dressing and volar (immobilizes and allows room for swelling) splint to right wrist daily and as needed. The order specified for the splint to remain in place for two weeks. On 8/18/24 at 10:05 a.m., Resident #69 was observed in the dining room sitting at a table with other residents. Resident #69 was holding her right hand across her chest. The right hand and wrist were noted to be very swollen and bruised. Resident #69 was rubbing her right hand with an expression of discomfort on her face. She was not wearing a dressing or splint to the right wrist as ordered. On 8/18/24 at 10:10 a.m., in an interview Licensed Practical Nurse (LPN) Staff F said the resident fell and fractured her arm a week ago. Staff F said Resident #69 had a splint, but she would not keep it on. LPN Staff F left the dining room and returned with a medication. She gave the medication to the resident and instructed her to take it for the pain in her arm. The instructions were clearly audible to the other residents sitting at the table. On 8/18/24 at 10:25 a.m., Staff F was observed placing wound supplies on the counter in the dining room. She proceeded to dress Resident #69's incision line to the right wrist in the dining room while the resident was sitting at a table with other residents. Resident #69 became agitated, stood up and attempted to leave the dining room. Staff F stood in the doorway, blocked the resident's exit and applied an ace wrap to the resident's right hand and wrist. Staff F said she wrapped the resident's arm to prevent her from picking at the sutures. 2. Review of the clinical record revealed Resident #23 had an admitted [DATE]. Diagnoses included dementia, major depressive disorder, mood disorder, anxiety disorder and insomnia. On 8/18/24 at 9:37 a.m., Resident #23 was observed in the dining room of the memory care unit after the breakfast meal. Resident #23 was barefoot and was not able to respond appropriately to simple interview questions. On 8/18/24 at 10:48 a.m., Resident #23 was observed standing barefoot at the nurse's station with no shoes or socks on her feet. When asked about her socks and shoes, Resident #23 mumbled and began to walk back to the dining room. On 8/19/24 at 8:35 a.m., Resident #23 was observed wandering on the memory care unit with mismatched socks (one green, and one yellow) on. She wandered past staff who made no attempt to assist her with wearing matching socks. On 8/19/24 at 9:14 a.m., Resident #23 was observed during breakfast in the dining room of the memory care unit. Resident #23 was walking from table to table and grabbing food items from other residents' plates. Two Certified Nursing Assistants (CNAs) were in the dining room and did not redirect Resident #23 as she continued to take food from other residents. On 8/19/24 at 9:24 a.m., in an interview CNA Staff A said, She does it all the time, as Resident #23 continued to go from table to table taking other residents' food from their plates. CNA Staff A walked over to the resident and redirected her. Resident #23 was observed wandering out of the dining room and into other residents' rooms taking their personal items. Staff did not redirect the resident. On 8/21/24 at 12:24 p.m., Resident #23 was observed walking in the memory care unit with a Certified Nursing Assistant. Resident #23 was wearing mismatched (one blue and one yellow) socks. The Director of Nursing was present during the observation and verified Resident #23 was wearing mismatched socks.

Based on observation, review of facility policy and procedure and staff interview the facility failed to provide housekeeping and maintenance services to ensure a clean, safe and comfortable environment for 9 (Rooms #302, #304, #306, #307, #308, #309, #310, #312, and #313) of 13 rooms and the dining room of the memory care unit. The findings included: The facility policy M-200 Maintenance effective 11/30/14 documented the facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. On 8/18/24 at 12:36 p.m., observation of the Memory Care Unit with the Regional Director of Maintenance (RDM) revealed: The Memory Care Unit had a strong musty odor with a foul smell of urine, and feces. The RDM verified the presence of the strong foul odor and said he would have housekeeping address the issue. room [ROOM NUMBER]: The ceiling tile above the toilet in the bathroom had a layer of thick black substance. The bathroom mirror was missing. room [ROOM NUMBER]: Exposed wires were coming from the wall and electrical outlet box. The RDM said they were cable wires and said they should be capped. Photographic evidence obtained. room [ROOM NUMBER]: The closet doors were missing. Photographic evidence obtained. Exposed wires were sticking out of the wall. The toilet paper holder was broken and missing the front covering. Photographic evidence obtained. room [ROOM NUMBER]: The closet door was missing. Photographic evidence obtained. room [ROOM NUMBER]: The cover plate of the paper towel holder in the bathroom was missing, and plastered areas on the wall needed to be painted. room [ROOM NUMBER]: The paper towel holder and toilet paper holder in the bathroom were missing the front covers. Photographic evidence obtained. The closet doors were missing. Photographic evidence obtained. There were exposed wires coming from an outlet on the wall. Photographic evidence obtained. There were white plaster patches on the wall in need of paint. Photographic evidence obtained. room [ROOM NUMBER]: There was a large hole in the wall under the sink in the bathroom. Photographic evidence obtained. The closet doors were missing. room [ROOM NUMBER]: The closet doors were missing. room [ROOM NUMBER] A: The closet was missing the handles and did not close properly. Photographic evidence obtained. The wood molding was pulled away from the entrance wall in the dining room, exposing large cracks. Photographic evidence obtained. The Regional Maintenance Director confirmed the findings observed during the tour and verified the identified areas of concerns needed to be addressed. On 8/20/24 at 9:00 a.m., in an interview Registered Nurse (RN) Staff R said staff are supposed to write areas in need of repair in the maintenance book. On 8/20/24 at 9:15 a.m., in an interview RN Staff I said the facility did not have a Maintenance Director for a while, and the previous one did not fix anything. On 8/20/24, review of the maintenance repair request log showed the last maintenance request was dated 6/27/24.

Based on record review, hospice and facility staff interview, the facility failed to provide cardiopulmonary resuscitation (CPR) to a resident requiring such emergency care for 1 (Resident #1) of 3 residents reviewed for appropriate emergency care. The facility failed to meet the resident's needs for emergency care without a resuscitation attempt, and the resident died . There were 68 residents in the facility who desired full code status and 37 of 46 hospice residents who were full code status. The Immediate Jeopardy began on [DATE]. On [DATE] at 5:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE] when corrective actions were verified in place, lowering the scope and severity of F689 to a D, isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: A review of the facility policy and procedure Florida Cardiopulmonary Resuscitation (CPR), N-301, dated [DATE], showed CPR would be provided to all residents who were identified to be in [MEDICAL CONDITION] unless such resident had a valid Do Not Resuscitate (DNR) order. In the event of [MEDICAL CONDITION], immediately call for assistance. Two licensed nurses were to verify: resident identity and current physician order for [REDACTED]. Procedures: 1. In the event of [MEDICAL CONDITION], immediately call for assistance. 2. Two licensed nurses were to verify: resident identity and current physician order for [REDACTED].>3. Use the paging system and call Code Blue to Room Number_, three times (or location of event). 4. In the absence of a physician's order for DNR the facility would immediately begin CPR. 5. Center staff would continue performing CPR until Emergency Medical Technicians assumed responsibility for CPR, or may be discontinued if the resident responds. 6. Notify the physician and resident representative/legal representative. 7. Document in the medical record. Record review showed an Advance Directives Discussion Document had been signed by Resident #1's Power of Attorney on [DATE] and indicated CPR should be provided. The Care Plan for Resident #1 indicated the resident wished to be a full code. Resident #1 was admitted to hospice services on [DATE] as a full code. A hospice form was in front of Resident #1's chart identifying the resident was under hospice care. The form also indicated Hospice patient is a full code. Call 911. A nursing progress note by Licensed Practical Nurse (LPN) Staff A dated [DATE] at 4:45 a.m., indicated Resident #1 was noted to be non-responsive, with no pulse or blood pressure and hospice was notified. Staff A noted the hospice nurse arrived at 5:10 a.m. There was no documentation Resident #1's code status reviewed, CPR started, or 911 was called. On [DATE] at 10:37 a.m., in an interview, the Director of Nursing (DON) said she was aware Resident #1 passed away on [DATE] and when staff found her unresponsive did not initiate CPR. The resident was a hospice patient and the documentation on the chart from hospice identified the resident was a full code. The DON said LPN Staff A never checked the chart for Resident #1's code status. On [DATE] at 12:28 p.m., in a telephone interview the hospice nurse confirmed Resident #1 was listed as a full code. On [DATE] at 12:52 p.m., in a telephone interview LPN Staff A said when she found Resident #1 was unresponsive, she checked the chart and called Hospice. Staff A said the [MEDICATION NAME] hospice form was in the chart identifying Resident #1 as a hospice patient, but she overlooked the resident was a full code. Staff A didn't realize the Resident #1 was a full code. Staff A said she did not provide CPR to Resident #1. On [DATE] at 2:03 p.m., in a telephone interview, LPN Staff A said there was another nurse in the building on [DATE] but she did not notify them when she found Resident #1 unresponsive. Staff A said she was trained in the facility CPR policy and knew two nurses were supposed to check code status. On [DATE] at 2:00 p.m., in a telephone interview Certified Nursing Assistant (CNA) Staff E said on [DATE] she went into the Resident #1's room to get her ready for morning care. When she called Resident #1's name there was no response. CNA Staff E said she went to get the assistance of CNA Staff F, and they still could get no response from Resident #1. She said they left the room and reported to the charge nurse LPN Staff A who went to the room and called the residents name with no response. CNA Staff E said LPN Staff A exited the room, went to the nurse's station to use the telephone, but did not know who the nurse called. CNA Staff E said she waited for instructions from the nurse, but was not told anything so she went to assist other residents with care The Immediate Jeopardy was removed on [DATE] at 4:00 p.m., after the facility took immediate action to remove the immediate threat. The immediate actions included all staff were provided education related to CPR and code status. The facility verified all licensed nurses participated in mock CPR drills which were conducted on all shifts. Interviews were conducted to ensure staff understood the content of the education.

Based on facility record review and staff interviews, the facility failed to effectively attain and maintain the highest practicable physical, medical, and psychosocial well-being regarding the facility processes impacting 1 (Resident #1) of the 6 residents' records reviewed. The review of these records revealed the facility failed to formulate an Advance Directive (AD) as requested by the resident's guardian. This resulted in 1 (Resident #1) of 6 residents' records reviewed, being without a completed DNR order and a health status documented as dying. The facility failed to provide effective coordination of social services with the Hospice agency to promote and ensure the health and well-being of all facility residents. The facility failed to provide social services resulting in a continuation of the systems' failure regarding facility approaches and all staff had demonstrated understanding of facility expectations in the implementation of facility policy and procedures related to AD and DNR, notification of the physician regarding condition changes, the implementation of full code in the absence of a DNR. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE], was identified on [DATE] The findings include: Resident #1 was a [AGE] year-old who was admitted to the facility for the third time on [DATE], with a status of post [MEDICAL CONDITION]. The resident had a court-appointed legal guardian who, at that time, requested Resident #1 be a full code. A review of the Nursing note, dated [DATE] (time unknown), documented the legal guardian (LG) was updated on the resident's declining condition, agreed to Hospice consult, does not want any changes on code status at this time, however will discuss with Hospice. A review of the facility Social Work note, dated [DATE], at 10:00 a.m., documented informed by nursing of a Hospice Consult for today. Continued to be no AD other than Power of Attorney (POA). Nursing to initiate consult. During an interview with Employee A on [DATE], at 10:35 a.m., he said when residents are admitted to the facility, he completes a form that includes information about Advanced Directives. If the resident has Advance Directives, he places a copy on the medical record. If a resident does not have Advance Directives, he offers to assist them to formulate some and then documents a summary of the conversation in the social work notes. He said this process should be completed within 72 hours after admission. He said if the resident is going on Hospice, then Hospice usually completes the DNR order. When asked if all Hospice residents are DNRs, he said no. When asked if he had been made aware of the deteriorating condition of Resident #1, with no DNR in place, he said he was not working during this time and not involved in this case after Hospice became involved. Hospice Social Work (SW) note, dated [DATE], documented the legal guardian (LG) wants notification and updates, wants comfort measures. LG understands plan of care (POC). LG wants palliative care, no invasive tests or treatments and no hospitalization s. DNR agreed to; awaiting copy signed from LG. During an interview with the Hospice SW on [DATE], around 1:25 p.m., he said there is no confirmation the DNR paperwork was sent to the LG for completion. He said Hope Hospice had received the admission paperwork from the LG, but did not include the DNR. He said he was waiting for the DNR paperwork to be placed into his box so he could put a copy into Resident #1's medical record. The Hospice SW said normally he does the paperwork face-to-face with the resident and/or family. He said this case was an exception in that he was faxing or e-mailing the paperwork back and forth. He said there is not a process in place at Hospice to ensure the paperwork (Advance Directives/DNR) is received back in a timely manner. There is no documentation by the facility social worker after [DATE] or by Hospice social worker after [DATE], following up on Advanced Directives and/or status of the DNR order. A review of the Physician readmission note, dated [DATE], time unknown, documented Pt. is signed up with Hospice Care for Comfort Care. Nursing note, dated [DATE], at 12:00 p.m., documented Hospice nurse came to unit to assess resident, stated resident was stable and comfortable, no need for inpatient Hospice room within facility (GIP); may move to long-term bed. The note documented DNR is in process by Hospice as guardian does not want resident sent out to hospital, comfort measures only. Nursing note, dated [DATE], at 3:00 p.m., documented Resident #1 with labored breathing, unresponsive, not able to swallow food and fluids, not able to swallow medication. The nurse gave report, "she is dying." Draining large amount of serous fluid from the staple site on left hip and stage 4 coccyx area. Not responsive to painful stimuli, head of bed elevated 60 degrees. At 10:00 p.m., same condition - no change in status. There is no documentation the physician or LG was notified regarding the deteriorating condition of the resident. Hospice note, dated [DATE], at 1704 (5:04 p.m.) documented Pt. is semi-comatose and would not swallow fluids at lunch today. Not appropriate for GIP bed, no symptoms to manage currently. Message left for attorney to inform of decline in status and possible med changes. Awaiting return call (there is no mention of the DNR not being completed). Hospice note, dated [DATE], 1704 (5:04 p.m.), TC (telephone call) from pt.'s guardian returning Hospice nurse's call..... 1706 courtesy page sent to PCN (primary care nurse) ....PCN F/U NEEDED. No additional follow up noted by Hospice. During an interview with Hospice nurse (E), on [DATE], around 10:15 a.m., she said she was called by the Hospice Triage nurse to go to Evans for a death call. She said she arrived at Evans around 12:45 a.m., and pronounced Resident #1 dead. She called the legal guardian at 0110 (1:10 a.m.) to inform him of the death and called the resident's daughter at 0115 (1:15 a.m.). She then went to the nurses' station and asked Employee C if Resident #1 had a DNR order. They discovered Resident #1 was a full code. Hospice nurse E said Employee C called 911 and she and Employee D initiated CPR until EMS came told them to terminate CPR and called the medical examiner. Hospice nurse E stated, during this interview, she knew that this was not right and reported the incident to her supervisor (Hospice nurse F). This concern was not communicated to anyone at Evans Health Care. Hospice nurse E said she was confused about how to document the change in time of death. Her supervisor, Hospice nurse F, told her to put the time of death as when the paramedics came and terminated CPR and then to document the incident in her notes. During an interview with Employee D, on [DATE], at 12:40 p.m., she said she was in the nurses' station with Employee C and Hospice nurse E and was asked to get the crash cart and help with Resident #1. She said she and the Hospice nurse initiated CPR. She said when EMS arrived they called off the code. During an interview with Employee C, on [DATE], at 11:42 a.m., she said at 0005 she went into the room and found Resident #1 without a pulse, but she was breathing. Employee C said she did chest compressions and after about 15 compressions the resident got a pulse and stopped CPR and called Hospice at that time. She did not call 911. She said the Hospice sheet in the record said Resident #1 was not to be sent to the hospital so that is why she did not call 911. Employee C said she did not chart this in the record. Hospice triage nurse documented receiving a call from Evans Health Care stating Resident #1 had expired at 0005 (12:05 a.m.) on [DATE]. Nursing note by Employee C, dated [DATE], at 0005 (5 minutes after midnight), documents resident restless. Hospice notified of change, resident appears in crisis at this time. There is no other documentation until 1:30 a.m. Nursing note, dated [DATE], at 01:30 a.m., Nurse was called to room by CNA (certified nursing assistant) to check resident. Observed resident in supine position, skin warm upon touch, unable to obtain pulse no respiration - CPR was initiated by two nurses (Employee D and Hospice staff E). 911 was called, CPR continued until their arrival, Paramedics took over and stated resident had expired. Hospice and facility physicians were notified. Hospice nurse was present. Employee C documented this note, however she said during an interview on [DATE], at 11:42 a.m., she was not present in Resident #1's room during this. During an interview with Hospice nurse F, on [DATE], at 12:50 p.m., she said she received a call from Hospice nurse E early in the morning on [DATE]. She said Hospice nurse E told her she arrived at Evans for a death visit and found there was conflicting information on the record. She said there was no DNR, and a note saying a DNR was in process. She said Hospice nurse E was concerned that CPR had not been initiated. She said she instructed Hospice nurse E to document her findings. She said she recalls reviewing the documentation, but did not discuss this with anyone at Evans. A review of Hospice nurse E note, dated [DATE], documented LG notified at 0110 and daughter at 0115. Facility nurse (C) discovered there was no DNR on chart and she called EMS and started CPR. EMS declared TOD (time of death) of 0131 A review of the corporation owner, LaVie Care Centers, policies and procedures, dated ,[DATE], regarding Advance Directives- Admissions/Social Service documents: Policy - The facility Social Service staff will abide by resident advance directives, if known. Procedure - 1. Upon admission, Social Services must communicate residents, family member or responsible parties of: a) Their right to make choices concerning health care and treatments, including life sustaining treatments. b) Determine whether the resident has an advance directive and, if not, determine whether the resident wishes to establish an advance directive. c) Define and clarify medical issues and present the information regarding relevant health care issues to the resident or his/her legal representative. d) Identify and assess medical issues where life-sustaining treatments are potential options and implement choices related to health care decisions. 6. After admission, Social Services must be aware of expressions by the resident or responsible party regarding changes or revocation of any advance directives and communicate these desires to Administration and Medical and Nursing staff for discussion and further action. This is especially critical when dealing with residents who may be incompetent or who may appear to have become incompetent. During an interview with the Director of Nursing (DON) around noon, on [DATE], she said when she came into the facility the morning of [DATE] and was notified of the death of Resident #1, she said she was concerned why CPR was initiated and the DNR had not been completed. There was no further investigation of the concern. During an interview with the DON in the late afternoon of [DATE], during the investigation of the incident, she said she had contacted Hospice and there was confusion over whether the DNR was pending a signature from the physician or from the LG. She had contacted the LG, who stated he was awaiting a court order to complete the DNR paperwork. The court ordered Plenary Guardianship paperwork was completed on [DATE]. The immediate jeopardy was removed upon exit around 4:00 p.m., on [DATE], based upon the following: During an interview with the regional clinical nurse, on 12/ ,[DATE], in the late afternoon around 3:00 p.m., she said the facility administration staff had met with the facility social worker and Hospice social worker. It was decided that the facility initiates and is responsible for obtaining all Advanced Directives within 72 hours of admission. It was understood by all parties if Hospice takes the lead for Advanced Directives, the facility is ultimately responsible. All resident records in the facility have been audited for completion of Advanced Directives and completed DNR orders. There were no discrepancies identified. Random review of 6 records validated Advance Directives to be in place. The regional clinical nurse said the facility's social worker is responsible for tracking the completion of Advanced Directives and is in the process of developing a tracking system. The regional clinical nurse said residents who are in a declining state without Advanced Directives will be noted on the 24-hour report which is reviewed at least 5-days-a-week by the clinical staff. If follow up is needed it will be given to staff as a homework sheet. The DON and Administrator will follow up on the homework sheet to ensure completion. It was decided that Advance Directives will be reviewed at all care plan meetings held on admission, quarterly, annually and with change of condition. Although immediate jeopardy was removed, deficient practice continues since the facility has not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained: ? The facility Administration has to review the facility's social worker responsible for tracking the completion of Advanced Directives and the process of developing a tracking system. ? The facility Administration has to monitor the review of Advance Directives at all care plan meetings held on admission, quarterly, annually and with change of condition. The monitoring results will have to be reported to the Quality Assurance Committee to identify effectiveness in addressing resident Advance Directive needs. ? The facility Administration has to monitor the review of residents who are in declining states without Advanced Directives noted on the 24-hour report reviewed by the clinical staff. The monitoring for the effectiveness of identifying the need for follow up and the use of the homework sheet by the DON and Administrator reviewed by the Quality Assurance Committee. Ongoing noncompliance is at the Scope and Severity Level of D.

Based on facility record review and staff interviews, the facility failed to effectively attain and maintain the highest practicable physical, medical, and psychosocial well-being regarding the facility processes impacting 1 (Resident #1) of the 6 residents' records reviewed. The review of these records revealed the facility failed to ensure the facility social worker failed to resolve the Advance Directives as requested by the resident's guardian. This resulted in one, Resident #1, of 6 residents' records, being without a completed DNR order from [DATE] until death on [DATE]. The facility failed to provide effective social services and nursing services resource management to promote and ensure the health and well-being of all facility residents. The facility failed to provide medical social services resulting in a continuation of the systems' failure regarding facility approaches and all staff had demonstrated understanding of facility expectations in the implementation of facility policy and procedures related to Advance Directives and DNR, notification of the physician regarding condition changes, the implementation of full code in the absence of a DNR and the coordination of Hospices Services. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE]. The findings include: Resident #1 was a [AGE] year-old who was admitted to the facility for the third time on [DATE], with a status of post hip fracture. The resident had a court-appointed legal guardian who requested Resident #1 be a full code. A review of the Nursing note, dated [DATE] (time unknown), documented the legal guardian (LG) was updated on the resident's declining condition, agreed to Hospice consult, does not want any changes on code status at this time, however will discuss with Hospice. A review of the facility Social Work note, dated [DATE], at 10:00 a.m., documented informed by nursing of a Hospice Consult for today. Continued to be no AD other than Power of Attorney (POA). Nursing to initiate consult. During an interview with Employee A on [DATE], at 10:35 a.m., he said when residents are admitted to the facility, he completes a form that includes information about Advanced Directives. If the resident has Advance Directives, he places a copy on the medical record. If a resident does not have Advance Directives, he offers to assist them to formulate some and then documents a summary of the conversation in the social work notes. He said this process should be completed within 72 hours after admission. He said if the resident is going on Hospice, then Hospice usually completes the DNR order. When asked if all Hospice residents are DNRs, he said no. When asked if he had been made aware of the deteriorating condition of Resident #1, with no DNR in place, he said he was not working during this time and not involved in this case after Hospice became involved. Hospice Social Work (SW) note, dated [DATE], documented the legal guardian (LG) wants notification and updates, wants comfort measures. LG understands plan of care (POC). LG wants palliative care, no invasive tests or treatments and no hospitalization s. DNR agreed to; awaiting copy signed from LG. During an interview with the Hospice SW on [DATE], around 1:25 p.m., he said there is no confirmation the DNR paperwork was sent to the LG for completion. He said Hope Hospice had received the admission paperwork from the LG, but did not include the DNR. He said he was waiting for the DNR paperwork to be placed into his box so he could put a copy into Resident #1's medical record. The Hospice SW said normally he does the paperwork face-to-face with the resident and/or family. He said this case was an exception in that he was faxing or e-mailing the paperwork back and forth. He said there is not a process in place at Hospice to ensure the paperwork (Advance Directives/DNR) is received back in a timely manner. There is no documentation by the facility social worker after [DATE] or by Hospice social worker after [DATE], following up on Advanced Directives and/or status of the DNR order. A review of the corporation owner, LaVie Care Centers, policies and procedures, dated ,[DATE], regarding Advance Directives- Admissions/Social Service documents: Policy - The facility Social Service staff will abide by resident advance directives, if known. Procedure - 1. Upon admission, Social Services must communicate residents, family member or responsible parties of: a) Their right to make choices concerning health care and treatments, including life sustaining treatments. b) Determine whether the resident has an advance directive and, if not, determine whether the resident wishes to establish an advance directive. c) Define and clarify medical issues and present the information regarding relevant health care issues to the resident or his/her legal representative. d) Identify and assess medical issues where life-sustaining treatments are potential options and implement choices related to health care decisions. 6. After admission, Social Services must be aware of expressions by the resident or responsible party regarding changes or revocation of any advance directives and communicate these desires to Administration and Medical and Nursing staff for discussion and further action. This is especially critical when dealing with residents who may be incompetent or who may appear to have become incompetent. During an interview with the Director of Nursing (DON) around noon, on [DATE], she said when she came into the facility the morning of [DATE] and was notified of the death of Resident #1, she said she was concerned why CPR was initiated and the DNR had not been completed. There was no further investigation of the concern. During an interview with the DON in the late afternoon of [DATE], during the investigation of the incident, she said she had contacted Hospice and there was confusion over whether the DNR was pending a signature from the physician or from the LG. She had contacted the LG, who stated he was awaiting a court order to complete the DNR paperwork. The court ordered Plenary Guardianship paperwork was completed on 9 [DATE]. The immediate jeopardy was removed upon exit around 4:00 p.m., on [DATE], based upon the following: During an interview with the regional clinical nurse, on 12/ ,[DATE], in the late afternoon around 3:00 p.m., she said the facility administration staff had met with the facility social worker and Hospice social worker. It was decided that the facility initiates and is responsible for obtaining all Advanced Directives within 72 hours of admission. It was understood by all parties if Hospice takes the lead for Advanced Directives, the facility is ultimately responsible. All resident records in the facility have been audited for completion of Advanced Directives and completed DNR orders. There were no discrepancies identified. Random review of 6 records validated Advance Directives to be in place. The regional clinical nurse said the facility's social worker is responsible for tracking the completion of Advanced Directives and is in the process of developing a tracking system. The regional clinical nurse said residents who are in a declining state without Advanced Directives will be noted on the 24-hour report which is reviewed at least 5-days-a-week by the clinical staff. If follow up is needed it will be given to staff as a homework sheet. The DON and Administrator will follow up on the homework sheet to ensure completion. It was decided that Advance Directives will be reviewed at all care plan meetings held on admission, quarterly, annually and with change of condition. Although immediate jeopardy was removed, deficient practice continues since the facility has not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained: ? The facility Administration has to monitor the effectiveness of the instruction provided to nursing staff on Hospice and when a full code must be initiated if the resident has cardiac or respiratory arrest. The nurses were instructed that if a Hospice patient is a full code, all change in treatment or condition should be directed to the attending physician, not Hospice staff. The nurses were given a handout entitled "Resuscitate (Green Light) (or) Do Not Resuscitate Status (DNR)- (Red Light) At-A- Glance. ? The facility Administration has to continue to finalize the coordination of contracted services with the Hospice Care agency. ? The facility Administration has to review the facility's social worker responsible for tracking the completion of Advanced Directives and the process of developing a tracking system. ? The facility Administration has to monitor the review of Advance Directives at all care plan meetings held on admission, quarterly, annually and with change of condition. The monitoring results will have to be reported to the Quality Assurance Committee to identify effectiveness in addressing resident Advance Directive needs. ? The facility Administration has to monitor the review of residents who are in declining states without Advanced Directives noted on the 24-hour report reviewed by the clinical staff. The monitoring for the effectiveness of identifying the need for follow up and the use of the homework sheet by the DON and Administrator reviewed by the Quality Assurance Committee. Ongoing noncompliance at the Scope and Severity Level of D.

Based on facility record review and staff interviews the facility failed to effectively attain and maintain the highest practicable physical, medical, and psychosocial well-being regarding the facility processes impacting 1 (Resident #1) of the 6 residents' records reviewed. The review of these records revealed the facility failed to ensure staff was coordinating care with contracted Hospice services and failed to ensure Advance Directives and DNR orders were being completed and implemented. The facility failed to coordinate care between Hospice and the facility resulted in one, Resident #1, of 6 residents' records reviewed, being a full code against the wishes of the legal guardian and failed to coordinate care with Hospice to ensure the DNR order for Resident #1 was completed in a timely manner. The facility failed to coordinate care to ensure Resident #1 had comfort measures in place during the process of dying. This resulted in the staff initiating chest compressions at 12:05 a.m., chest compressions at 12:45 a.m., then full CPR again at 1:30 a.m. The facility failed to provide coordination of services resulting in a continuation of the systems' failure regarding facility approaches and all nursing staff had demonstrated understanding of facility expectations in the notification of the physician regarding condition changes, the implementation of full code in the absence of a DNR and the coordination of Hospice Services. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE], was identified on [DATE]. The findings include: Resident #1 was a [AGE] year-old who was admitted to the facility for the third time on [DATE], with a status of post [MEDICAL CONDITION]. The resident had a court-appointed legal guardian who requested Resident #1 be a full code. A review of the Nursing note, dated [DATE] (time unknown), documented the legal guardian (LG) was updated on the resident's declining condition, agreed to Hospice consult, does not want any changes on code status at this time, however will discuss with Hospice. A review of the facility Social Work note, dated [DATE], at 10:00 a.m., documented informed by nursing of a Hospice Consult for today. Continued to be no AD other than Power of Attorney (POA). Nursing to initiate consult. During an interview with Employee A on [DATE], at 10:35 a.m., he said when residents are admitted to the facility, he completes a form that includes information about Advanced Directives. If the resident has Advance Directives, he places a copy on the medical record. If a resident does not have Advance Directives, he offers to assist them to formulate some and then documents a summary of the conversation in the social work notes. He said this process should be completed within 72 hours after admission. He said if the resident is going on Hospice, then Hospice usually completes the DNR order. When asked if all Hospice residents are DNRs, he said no. When asked if he had been made aware of the deteriorating condition of Resident #1, with no DNR in place, he said he was not working during this time and not involved in this case after Hospice became involved. Hospice Social Work (SW) note, dated [DATE], documented the legal guardian (LG) wants notification and updates, wants comfort measures. LG understands plan of care (POC). LG wants palliative care, no invasive tests or treatments and no hospitalization s. DNR agreed to; awaiting copy signed from LG. During an interview with the Hospice SW on [DATE], around 1:25 p.m., he said there is no confirmation the DNR paperwork was sent to the LG for completion. He said Hope Hospice had received the admission paperwork from the LG, but did not include the DNR. He said he was waiting for the DNR paperwork to be placed into his box so he could put a copy into Resident #1's medical record. The Hospice SW said normally he does the paperwork face-to-face with the resident and/or family. He said this case was an exception in that he was faxing or e-mailing the paperwork back and forth. He said there is not a process in place at Hospice to ensure the paperwork (Advance Directives/DNR) is received back in a timely manner. There is no documentation by the facility social worker after [DATE] or by Hospice social worker after [DATE], following up on Advanced Directives and/or status of the DNR order. A review of the Physician readmission note, dated [DATE], time unknown, documented Pt. is signed up with Hospice Care for Comfort Care. Nursing note, dated [DATE], at 12:00 p.m., documented Hospice nurse came to unit to assess resident, stated resident was stable and comfortable, no need for inpatient Hospice room within facility (GIP); may move to long-term bed. The note documented DNR is in process by Hospice as guardian does not want resident sent out to hospital, comfort measures only. Hospice note, dated [DATE], at 2:19 p.m., documented symptoms to be managed in the GIP right now. (Resident #1 was never in the GIP). She is scheduled to be seen (by Hospice) tomorrow. Nursing note, dated [DATE], at 3:00 p.m., documented Resident #1 with labored breathing, unresponsive, not able to swallow food and fluids, not able to swallow medication. The nurse gave report, "she is dying." Draining large amount of serous fluid from the staple site on left hip and stage 4 coccyx area. Not responsive to painful stimuli, head of bed elevated 60 degrees. At 10:00 p.m., same condition - no change in status. There is no documentation the physician or LG was notified regarding the deteriorating condition of the resident. Hospice note, dated [DATE], at 1704 (5:04 p.m.) documented Pt. is semi-comatose and would not swallow fluids at lunch today. Not appropriate for GIP bed, no symptoms to manage currently. Message left for attorney to inform of decline in status and possible med changes. Awaiting return call (there is no mention of the DNR not being completed). Hospice note, dated [DATE], 1704 (5:04 p.m.), TC (telephone call) from pt.'s guardian returning Hospice nurse's call..... 1706 courtesy page sent to PCN (primary care nurse) ....PCN F/U NEEDED. No additional follow up noted by Hospice. During an interview with Hospice nurse (E), on [DATE], around 10:15 a.m., she said she was called by the Hospice Triage nurse to go to Evans for a death call. She said she arrived at Evans around 12:45 a.m., and pronounced Resident #1 dead. She called the legal guardian at 0110 (1:10 a.m.) to inform him of the death and called the resident's daughter at 0115 (1:15 a.m.). She then went to the nurses' station and asked Employee C if Resident #1 had a DNR order. They discovered Resident #1 was a full code. Hospice nurse E said Employee C called 911 and she and Employee D initiated CPR until EMS came, told them to terminate CPR and called the medical examiner. Hospice nurse E stated, during this interview, she knew that this was not right and reported the incident to her supervisor (Hospice nurse F). This concern was not communicated to anyone at Evans Health Care. Hospice nurse E said she was confused about how to document the change in time of death. Her supervisor, Hospice nurse F, told her to put the time of death as when the paramedics came and terminated CPR and then to document the incident in her notes. During an interview with Employee D, on [DATE], at 12:40 p.m., she said she was in the nurses' station with Employee C and Hospice nurse E and was asked to get the crash cart and help with Resident #1. She said she and the Hospice nurse initiated CPR. She said when EMS arrived they called off the code. During an interview with Employee C, on [DATE], at 11:42 a.m., she said at 0005 she went into the room and found Resident #1 without a pulse, but she was breathing. Employee C said she did chest compressions and after about 15 compressions the resident got a pulse and stopped CPR and called Hospice at that time. She did not call 911. She said the Hospice sheet in the record said Resident #1 was not to be sent to the hospital so that is why she did not call 911. Employee C said she did not chart this in the record. Hospice triage nurse document received a call from Evans Health Care stating Resident #1 had expired at 0005 on [DATE]. Nursing note by Employee C, dated [DATE], at 0005 (5 minutes after midnight), documents resident restless. Hospice notified of change, resident appears in crisis at this time. There is no other documentation until 1:30 a.m. A review of the Nursing note, dated [DATE], at 01:30 a.m., Nurse was called to room by CNA (certified nursing assistant) to check resident. Observed resident in supine position, skin warm upon touch, unable to obtain pulse no respiration - CPR was initiated by two nurses (Employee D and Hospice staff E). 911 was called, CPR continued until their arrival, Paramedics took over, stated resident had expired. Hospice and facility physicians were notified. Hospice nurse was present. Guardian and daughter notified. Remains released to Horizon funeral services. Employee C documented this note, however she said during an interview on [DATE], at 11:42 a.m., she was not present in Resident #1's room during this. During an interview with Employee G, certified nursing assistant, on [DATE], at 1:55 p.m., she said at about 12 midnight on [DATE], the nurse asked her to take vital signs on Resident #1. Vital signs unknown - not documented. She said Employee C did some chest compressions on Resident #1 and she was better. She said the nurse told her to check on Resident #1 every 15 minutes. Employee F said at about a quarter to 1 (12:45 a.m.), the resident was breathing slower and looked blue and she called Employee C into room. She said Employee C did some additional chest compressions and called Hospice. The Hospice nurse then arrived at the facility and she said she (Employee G) left the room. Employee G said she did not return to the room until later after Resident #1 was dead and cleaned her up. During an interview with Hospice nurse F, on [DATE], at 12:50 p.m., she said she received a call from Hospice nurse E early in the morning on [DATE]. She said Hospice nurse E told her she arrived at Evans for a death visit and found there was conflicting information on the record. She said there was no DNR, and a note saying a DNR was in process. She said Hospice nurse E was concerned that CPR had not been initiated. She said she instructed Hospice nurse E to document her findings. She said she recalls reviewing the documentation, but did not discuss this with anyone at Evans. A review of the Lee County Emergency Medical Services Pre-hospital Care Report documented incident dated [DATE], Disposition, canceled on scene (No patient Contact), responses delay: other, staff delay. Call received noted as 01:19, at scene at 01:32. The report does not have a resident's name only a call number. A review of Hospice nurse E note, dated [DATE], documented LG notified at 0110 and daughter at 0115. Facility nurse (C) discovered there was no DNR on chart and she called EMS and started CPR. EMS declared TOD (time of death) of 0131. EMS spoke with ME (medical examiner) who released patient. Horizons Funeral Home was contacted and picked up body at 0300. No family members were present at nursing home. A review of the corporation owner, LaVie Care Centers, policies and procedures, dated ,[DATE], regarding Advance Directives- Admissions/Social Service documents: Policy - The facility Social Service staff will abide by resident advance directives, if known. Procedure - 1. Upon admission, Social Services must communicate residents, family member or responsible parties of: a) Their right to make choices concerning health care and treatments, including life sustaining treatments. b) Determine whether the resident has an advance directive and, if not, determine whether the resident wishes to establish an advance directive. c) Define and clarify medical issues and present the information regarding relevant health care issues to the resident or his/her legal representative. d) Identify and assess medical issues where life-sustaining treatments are potential options and implement choices related to health care decisions. 6. After admission, Social Services must be aware of expressions by the resident or responsible party regarding changes or revocation of any advance directives and communicate these desires to Administration and Medical and Nursing staff for discussion and further action. This is especially critical when dealing with residents who may be incompetent or who may appear to have become incompetent. During an interview with the Director of Nursing (DON) around noon, on [DATE], she said when she came into the facility the morning of [DATE] and was notified of the death of Resident #1, she said she was concerned why CPR was initiated and the DNR had not been completed. There was no further investigation of the concern. During an interview with the DON in the late afternoon of [DATE], during the investigation of the incident, she said she had contacted Hospice and there was confusion over whether the DNR was pending a signature from the physician or from the LG. She had contacted the LG, who stated he was awaiting a court order to complete the DNR paperwork. The court ordered Plenary Guardianship paperwork was completed on 9 [DATE]. The immediate jeopardy was removed upon exit around 4:00 p.m., on [DATE], based upon the following: During an interview with the regional clinical nurse, on 12/ ,[DATE], in the late afternoon around 3:00 p.m., she said the facility administration staff had met with the facility social worker and Hospice social worker. It was decided that the facility initiates and is responsible for obtaining all Advanced Directives within 72 hours of admission. It was understood by all parties if Hospice takes the lead for Advanced Directives, the facility is ultimately responsible. All resident records in the facility have been audited for completion of Advanced Directives and completed DNR orders. There were no discrepancies identified. Random review of 6 records validated Advance Directives to be in place. The regional clinical nurse said the facility's social worker is responsible for tracking the completion of Advanced Directives and is in the process of developing a tracking system. The regional clinical nurse said residents who are in a declining state without Advanced Directives will be noted on the 24-hour report which is reviewed at least 5-days-a-week by the clinical staff. If follow up is needed it will be given to staff as a homework sheet. The DON and Administrator will follow up on the homework sheet to ensure completion. It was decided that Advance Directives will be reviewed at all care plan meetings held on admission, quarterly, annually and with change of condition. The nursing staff were instructed that if a resident is on Hospice and a full code, a full code must be initiated if the resident has cardiac or respiratory arrest. The nurses were instructed that if a Hospice patient is a full code, all change in treatment or condition should be directed to the attending physician, not Hospice staff. The nurses were given a handout entitled "Resuscitate (Green Light) (or) Do Not Resuscitate Status (DNR) - (Red Light) At-A- Glance. Random licensed staff interviews by surveyors validated an understanding of the instruction. The administrative staff spoke with Hospice staff regarding reporting issues of concern to the DON or the Administrator in order to resolve any issues. Hospice nurses will document on the 24-hour daily report what they have done for the resident. The nurse on the floor is responsible for documenting coordination of care with Hospice staff in the progress notes. The facility completed an investigation of the incident and completed a Federal 1-day report for allegation of neglect. The Abuse Hotline was contacted and the report was accepted. Nurse C was given individual instruction regarding initiating CPR for residents who have a full code status. Random personnel record reviews revealed there was a process in place to ensure competency for licensed nurses and current CPR certification. Although immediate jeopardy was removed, deficient practice continues since the facility has not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained: ? The facility Administration has to monitor the effectiveness of the instruction provided to nursing staff on Hospice and when a full code must be initiated if the resident has cardiac or respiratory arrest. The nurses were instructed that if a Hospice patient is a full code, all change in treatment or condition should be directed to the attending physician, not Hospice staff. The nurses were given a handout entitled "Resuscitate (Green Light) (or) Do Not Resuscitate Status (DNR)- (Red Light) At-A- Glance. ? The facility Administration has to continue to finalize the coordination of contracted services with the Hospice Care agency. ? The facility Administration has to review the facility's social worker responsible for tracking the completion of Advanced Directives and the process of developing a tracking system. ? The facility Administration has to monitor the review of Advance Directives at all care plan meetings held on admission, quarterly, annually and with change of condition. The monitoring results will have to be reported to the Quality Assurance Committee to identify effectiveness in addressing resident Advance Directive needs. ? The facility Administration has to monitor the review of residents who are in declining states without Advanced Directives noted on the 24-hour report reviewed by the clinical staff. The monitoring for the effectiveness of identifying the need for follow up and the use of the homework sheet by the DON and Administrator reviewed by the Quality Assurance Committee. Ongoing noncompliance at the Scope and Severity Level of D.

Based on facility record review and staff interviews, the facility Administrator failed to effectively attain and maintain the highest practicable physical, medical, and psychosocial well-being regarding the facility processes impacting 1 (Resident #1) of the 6 residents' records reviewed. The review of these records revealed the facility administration failed to identify the potential for inappropriate facility process integrity related to failure to ensure staff was coordinating care with contracted Hospice services and failed to ensure Advance Directives were being completed and implemented. This resulted in one, Resident #1, of 6 residents' records reviewed, being a full code against the wishes of the legal guardian, and having chest compressions and CPR initiated 3 different times. The facility Administrator failed to provide effective social services and nursing staff and Quality Assurance & Performance Improvement resource management to promote and ensure the health well-being of all facility residents. The Administrator failed to provide administrative oversight to ensure a complete and thorough investigation was conducted resulting in the lack of Quality Assurance and Performance Improvement examination and root cause analysis resulting in a continuation of the systems' failure regarding facility approaches and all nursing staff had demonstrated understanding of facility expectations in the notification of the physician regarding condition changes, the implementation of full code in the absence of a DNR and the coordination of Hospices Services. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE]. The immediate jeopardy was removed around 4:00 p.m., on [DATE] based upon the implementation of corrective action. The findings include: The facility Administration failed to formulate an Advance Directive as requested by Resident #1's guardian. This resulted in Resident #1 being without a completed DNR order and her health status documented as dying. The resident was given chest compressions twice at the facility during the night followed by full CPR over a 90-minute period of time. The resident was pronounced deceased by the paramedics at the facility. Cross reference to F155. The facility Administration failed to ensure social worker formulated Advance Directives as requested by Resident #1's guardian. This resulted in Resident #1 being without a completed DNR order from [DATE] until her death on [DATE], being given chest compressions twice at the facility during the night followed by full CPR. This occurred over a 90-minute period of time. Resident #1 was pronounced deceased by the paramedics at the facility. Cross reference to F250. The facility Administration failed to ensure the coordination of care with Hospice staff to ensure the DNR order for Resident #1 was completed in a timely manner. The facility failed to coordinate care to ensure Resident #1 had comfort measures in place during the process of dying. This resulted in the staff initiating chest compressions at 12:05 a.m., chest compressions at 12:45 a.m. then full CPR again at 1:30 a.m. Cross reference to F309. During an interview with the Director of Nursing (DON), around 12:00 p.m., on [DATE], she said when she came into the facility the morning of [DATE] she was notified of the death of Resident #1. The DON said she was concerned why CPR was initiated and the DNR had not been completed. There was no further investigation of the concern, until the compliant survey was in process. The facility Administrator failed to ensure systems to provide notification of the physician regarding a change of condition and medical social services to obtain order for a DNR as requested by the legal guardian for Resident #1. The facility administration was unable to provide evidence of appropriate analysis including root-cause and facility-process evaluations. The facility administration was aware of facility practice inconsistencies and failed to institute quality indicator investigations and inform the Quality Assurance Committee to evaluate facility practices and to correct and prevent future incidents. The facility identified the error regarding the documentation medical and nursing provided to Resident #1 regarding her death per interview with the administrator and DON on [DATE] at 12:00 p.m. The administration of the facility did not provide a root-cause analysis due to the identification of the incident as a Hospice agency responsibility, the Quality Assurance Committee failed to evaluate multiple systems and practice failure on a continuum. The immediate jeopardy was removed upon exit around 4:00 p.m., on [DATE], based upon the following: During an interview with the regional clinical nurse, on 12/ ,[DATE], in the late afternoon around 3:00 p.m., she said the facility administration staff had met with the facility social worker and Hospice social worker. It was decided that the facility initiates and is responsible for obtaining all Advanced Directives within 72 hours of admission. It was understood by all parties if Hospice takes the lead for Advanced Directives, the facility is ultimately responsible. All resident records in the facility have been audited for completion of Advanced Directives and completed DNR orders. There were no discrepancies identified. Random review of 6 records validated Advance Directives to be in place. The regional clinical nurse said the facility's social worker is responsible for tracking the completion of Advanced Directives and is in the process of developing a tracking system. The regional clinical nurse said residents who are in a declining state without Advanced Directives will be noted on the 24-hour report which is reviewed at least 5-days-a-week by the clinical staff. If follow up is needed it will be given to staff as a homework sheet. The DON and Administrator will follow up on the homework sheet to ensure completion. It was decided that Advance Directives will be reviewed at all care plan meetings held on admission, quarterly, annually and with change of condition. The nursing staff were instructed that if a resident is on Hospice and a full code, a full code must be initiated if the resident has cardiac or respiratory arrest. The nurses were instructed that if a Hospice patient is a full code, all change in treatment or condition should be directed to the attending physician, not Hospice staff. The nurses were given a handout entitled "Resuscitate (Green Light) (or) Do Not Resuscitate Status (DNR) - (Red Light) At-A- Glance. Random licensed staff interviews by surveyors validated an understanding of the instruction. The administrative staff spoke with Hospice staff regarding reporting issues of concern to the DON or the Administrator in order to resolve any issues. Hospice nurses will document on the 24-hour daily report what they have done for the resident. The nurse on the floor is responsible for documenting coordination of care with Hospice staff in the progress notes. The facility completed an investigation of the incident and completed a Federal 1-day report for allegation of neglect. The Abuse Hotline was contacted and the report was accepted. Nurse C was given individual instruction regarding initiating CPR for residents who have a full code status. Random personnel record reviews revealed there was a process in place to ensure competency for licensed nurses and current CPR certification. Although immediate jeopardy was removed, deficient practice continues since the facility has not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained: ? The facility Administration has to monitor the effectiveness of the instruction provided to nursing staff on Hospice and when a full code must be initiated if the resident has cardiac or respiratory arrest. The nurses were instructed that if a Hospice patient is a full code, all change in treatment or condition should be directed to the attending physician, not Hospice staff. The nurses were given a handout entitled "Resuscitate (Green Light) (or) Do Not Resuscitate Status (DNR)- (Red Light) At-A- Glance. ? The facility Administration has to continue to finalize the coordination of contracted services with the Hospice Care agency. ? The facility Administration has to review the facility's social worker responsible for tracking the completion of Advanced Directives and the process of developing a tracking system. ? The facility Administration has to monitor the review of Advance Directives at all care plan meetings held on admission, quarterly, annually and with change of condition. The monitoring results will have to be reported to the Quality Assurance Committee to identify effectiveness in addressing resident Advance Directive needs. ? The facility Administration has to monitor the review of residents who are in declining states without Advanced Directives noted on the 24-hour report reviewed by the clinical staff. The monitoring for the effectiveness of identifying the need for follow up and the use of the homework sheet by the DON and Administrator reviewed by the Quality Assurance Committee. Ongoing noncompliance at the Scope and Severity Level of D.