Every finding on record at Aviata at Brooksville

Based on observation, interview, and record review the facility failed to ensure an environment that is free from accident hazards in 1 of 2 shower rooms, in a resident therapy room and in 2 of 3 residents' rooms, Resident #36, Resident #70, sampled for accidents and hazards. Findings include: 1) During an observation on 08/3/1/26 at 09:33 AM, a razor was observed in Resident #70's bathroom on the ledge of the sink. During an observation on 09/02/26 at 08:47 AM, a razor was observed in Resident #70's bathroom in a basket on the ledge of the sink. Review of Resident #70's Quarterly Minimum Data Set (MDS) dated [DATE] Section C Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Summary Score of 3 out of 15. Section GG Functional Abilities documented Resident #70's performance for personal hygiene as set-up or clean-up assistance – Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. During an interview on 09/02/26 at 08:48 AM, Staff D, Licensed Practical Nurse (LPN), stated that residents are not allowed to keep razors in their rooms. During an interview on 09/02/26 at 09:04 AM, Staff E, LPN, stated that residents cannot have razors in their rooms unless staff are present in the room with them performing care. During an interview on 09/02/26 at 03:27 PM, the Director of Nursing (DON) stated that the facility does not have a policy regarding razors and residents keeping razors in their rooms. Review of the facility's Safety Precautions – Nursing Services Policy and Procedure dated 11/30/14 read, safety precautions for the nursing units shall be followed by all personnel involved in the provision of nursing care; follow established policies and procedure for discarding used needles, syringes, and all sharps. 2) During an observation of Resident #36 on 08/31/2026 at 9:44AM a razor was on the bedside table with cover off sitting in a bowl. During an observation of Resident #36 on 09/02/2026 11:11 AM, he was up in his wheelchair in his room watching TV. Nail clippers were on the over bed table, and razor was present on nightstand in a bowl with debris stuck on the bottom interior and sides in various spots. During an interview with Resident #36 on 09/02/2026 11:13 AM he stated he was waiting for his lunch, and he does not shave himself or use the nail clippers himself, they do it for him. Resident #36 was unable to remember which staff had performed ADL's (Activities of Daily Living) today. Review of Resident #36's admission record read, Diagnosis: Persistent Mood Disorder, Insomnia (sleep disorder), Major Depressive Disorder, Bipolar (difficulty in thinking with extreme shifts in mood), Encephalopathy,(brain disorder the disrupts brain function) and Vascular Dementia(decline in thinking by reduced blood flow to brain). During an interview on 09/02/2026 at 11:15 AM, the DON stated if it is a personal razor they need to put it in a safe area. If it is a blue disposable one, it goes into the sharps container, a reusable goes in the bedside drawer, is a locked area, or a locked box. The same thing with nail clippers. During an interview on 09/2/02/2026 at 11:14 AM, Staff N, CNA (Certified Nursing Assistant) stated razors are not supposed to be kept in the resident's room or nail clippers. I do not know how that got in there we shave him in the shower room. During an interview with the Administrator on 09/02/2026 at 3:27 PM, they stated there is no policy for sharps in the residents' rooms. During an interview with DON on 09/02/2026 4:25 PM, she stated it is a Resident's right to have a razor in their room. That is why we have no policy for it. 3.) During an observation on 9/1/26 at 8:50 AM, an unlocked room located at the beginning of A Hall was inspected. The room was accessible to residents and contained a refrigerator. Inside the refrigerator were two containers labeled as laundry scent-booster products. One container was open and empty. The second container contained multiple multicolored plastic pegs. The containers and plastic pegs were unsecured and accessible to residents. During an interview on 9/1/26 at 9:00 AM, Staff U stated that the room is used to help residents transition to a home-like environment and normally remains unlocked. When asked whether a resident could enter the room, open the refrigerator, and remove the items, she stated, Yes, they could come in and grab them. She further stated, They should not be there. 4) During an observation on 9/1/26 at 8:40 AM, a shower bed located in the facility's shower room was observed with loose metal support pipes. The screws needed to secure the pipes were missing, and sections of the shower bed's support frame were disconnected. During an interview on 9/1/26 at 9:00 AM, the Maintenance Director was asked whether he was aware that the shower bed needed repair. He stated, I was very busy yesterday and did not get to it. Review of the facility policy, titled, Maintenance, reviewed on 1/28/26 read, Policy: 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 or repair. Procedure: The Director of Environment Services will follow all policies regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition.

Based on observation, interview, and record review, the facility failed to ensure opened and prepared food items were properly labeled and dated and failed to remove food that was past the manufacturer's Best if Used By date or showed signs of deterioration. This deficient practice was identified in the stand-up freezer, dry-storage area, walk-in refrigerator, and B Hall pantry and had the potential to affect residents who received food prepared or stored by the facility.Findings included: During an observation of the kitchen food-storage area on 8/31/26 at 9:09 AM, one opened undated plastic bag containing peeled, hard-boiled eggs was observed. During an observation of the stand-up freezer on 8/31/26 at 9:10 AM, one opened undated bag of frozen peas was observed in its original packaging. During an observation of the dry-storage area on 8/31/26 at 9:15 AM, one opened bag of brown gravy mix was observed. The original packaging identified the product; the bag was not labeled with the date opened or a use-by or discard date. During an observation of the dry-storage area on 8/31/26 at 9:20 AM, one case containing 10 individual boxes of cornstarch was observed. The boxes displayed a manufacturer's Best if Used By date of May 10, 2025. During an observation of the walk-in refrigerator on 8/31/26 at 9:24 AM, one 32-ounce plastic container of chopped garlic in water was observed. The container was labeled with an opened date of 6/3/26 and displayed a manufacturer's Best if Used By date of 8/10/26. During an observation of the walk-in refrigerator on 8/31/26 at 9:26 AM, two blocks of sliced yellow cheese were observed inside a plastic food-storage bag. The bag was not labeled with the name of the item, the date opened or prepared, or a use-by or discard date. During an observation of the walk-in refrigerator on 8/31/26 at 9:28 AM, two bags of grapes were observed inside an open produce box marked with the date 8/21/26. The grapes appeared soft and discolored, with brown areas and moisture visible inside the bags. During an interview on 8/31/26 at 9:29 AM, after the kitchen food-storage concerns were brought to Staff F attention, she stated, These items should have been discarded and/or labeled. During an interview on 9/2/26 at 11:34 AM, Staff H was asked what staff were required to do when opening a food item. He stated, They should label it with the date they opened it. Review of the facility's policy titled, Food Storage Guidelines revised on 1/28/26 read, All items sent to the pantries were required to be dated. All perishable food items were required to be discarded after three days. Food stored in a refrigerator for a resident's personal use was required to be labeled with the resident's name and date. Perishable food stored for a resident's personal use was also required to be discarded after three days. All foods should be dated upon receipt before being stored. Food labels must include: The food name. The date of preparation/receipt/removal from freezer. The use by date as outlined in the attached guidelines Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing, should be labeled with the date of removal from the freezer and an appropriate use by date as outlined in the Retention Guide attached. (Example: A tube of ground beef ) Leftovers must be labeled and dated with the date they are prepared and the use by date.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 3 residents, Resident #105, reviewed for accidents. Findings include:During an observation on 08/31/26 at 12:48 AM, a single fall mat was observed on the floor at the right side of Resident #105's bed.During an observation on 09/01/26 at 12:48 AM, a single fall mat was observed on the floor at the right side of Resident #105's bed. Resident #105 was observed sitting in bed, eating lunch in an upright position.During an observation on 09/02/26 at 08:55 AM a single fall mat was observed on the floor at the right side of Resident #105's bed. Resident #105 was observed sitting in bed, eating breakfast in an upright position.Review of Resident #105's care plan focus dated 11/06/25 read, [Name of Resident #105] is at risk for falls r/t [related to] Deconditioning, Gait/balance problems, Incontinence, psychotropic medications, and included an intervention dated 07/30/25 that read, floor mat on both sides of the bed.During an interview on 09/02/26 at 08:57 AM, Staff E, Licensed Practical Nurse (LPN) - Unit Manager confirmed that Resident #105 had one fall mat placed in the room. He stated that [Resident #105's Name] should have bilateral fall mats and confirmed this with the care planning team.During an interview on 09/03/26 10:07 AM, the Minimum Data Set (MDS) Coordinator stated that care plan interventions are usually communicated to herself and if it's in the care plan, yes fall mats on both sides should be in place.During an interview on 09/03/26 at 11:01 AM, the Director of Nursing stated that she expects staff to follow interventions specified in resident care plans.Review of the facility's Plans of Care Policy and Procedures dated 09/25/17 read, develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary team.

Based on observation, interview and record review the facility failed to Implement resident-directed care and treatment consistent with the professional standards of practice in 1 (Resident #50) out of 6 Resident reviewed for quality of care.Findings include: During a medication administration observation on 09/02/2026 at 3:10PM, Staff O failed to flush the PICC(peripherally inserted central catheter) line with Normal Saline before administering an antibiotic into Resident #50's PICC line. During an interview on 09/02/2026 at 3:14 PM, Staff O she stated she had the flush available and was just so nervous she forgot.Review of facility policy titled, Flushing Central Venous and Midline Catheters, last revised on 01/28/2026 read, Policy:Midline and central line access devices (CVAD's) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. Flushing Protocol: 1. Flush catheters at regular intervals to maintain patency AND before and after the following: b. Administration of Medications. 4. Use only normal saline for flushes

Based on observation, interview, and record review the facility failed to implement the proper storage of Aerosol drug delivery systems (nebulizer) used for respiratory treatments in 2 out of 3 Residents, Resident #94 and #130 reviewed for Respiratory Care.Findings Include: 1.) During an observation on 08/29/2026 at 10:22AM, Resident #94's nebulizer mouthpiece was not in a bag. The mouth piece was sitting on the nightstand. During interview with ADON, Infection Control Nurse on 09/03/2026 at 9:19 AM, she stated Nebulizer pipes are to be cleansed and put back into a bag after every use. The tubing and the bag are the changed every Saturday. Review of Medical Diagnosis for Resident #94 read, Moderate Persistent Asthma(chronic inflammation of the airways) Review of Resident #94's physician order dated 05/13/2024 read, Pulmicort Inhalation Suspension 0.25 MG(milligram)/2ML(milliliters) (Budesonide (Inhalation))2 ml inhale orally two times a day for respiratory treatment rinse mouth and expectorate after use. 2) During an observation on 8/31/2026 at 12:39 PM Resident #130 was lying in bed. Nebulizer mask was dated 8/29 and was not bagged. During an interview on 8/31/2026 at 12:39 PM with Resident #130 stated, The last time I had a treatment was last night. During an observation on 9/1/2026 at 10:20 AM Resident #130 resting with eyes closed. Nebulizer mask was lying on top of the bed side table dated 8/29 not bagged. Review of Resident #130 physician order dated 8/25/2026 read, Budesonide Inhalation Suspension 0.5 MG/2ML [milligram per milliliter] 2 ml inhale orally two times a day for COPD [Chronic obstructive pulmonary disease]. Review of Resident #130 physician order dated 8/25/2026 read, Ipratropium Bromide Inhalation Solution 0.02% 3 ml inhale orally every 6 hours as needed for COPD. During an interview on 9/2/2026 at 9:10 AM with Staff D Licensed Practical Nurse (LPN) stated, The nebulizer mask should be bagged when not in use. [Resident #130's name] does not have any behaviors. During an interview on 9/2/2026 t 9:11 AM with Staff E LPN Unit Manager , she stated nebulizer mask should be stored in a bag. If the mask is found unbagged it should be replaced. [Resident #130's name] is particular about her style. She is not able to get out of bed on her own. During an observation on 9/2/2026 at 9:16 AM Staff E LPN entered Resident #130's room, there was a bedside table position at the right side of the resident's bed far from reach of the resident. The nebulizer mask was lying on top of the bedside table not bagged. During an interview on 9/2/2026 at 3:02 PM with the Director of Nursing stated, The nebulizer mask should be begged when not in use. Review of the facility policy and procedure titled, Equipment Change Schedule, last revision date 01/28/2026 read, Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. Aerosol Tubing and Nebulizer: Once every seven (7)days Nebulizer Set up: Once, every seven(7)days along with equipment bag labeled with name, date, and room number.

Based on observation, interview, and record review, the facility failed to ensure a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible for 1 of 2 residents, Resident #9, reviewed for urinary catheters. Findings include: Findings include:During an observation on 09/01/26 at 12:55 PM, Resident #9 was observed sitting upright in her bed. She was observed to have a catheter bag attached to her bed on her left side.During an interview on 09/01/26 at 12:55 PM, Resident #9 stated that last week she was told about getting her Foley catheter removed and starting bladder training. She stated that no one has followed up with her since. She stated that she was looking forward to getting the catheter removed, so she can go home.Review of Resident #9's physician's order dated 08/27/26 read, D/C [Discontinue] Foley catheter. Monitor for void within 6 hours. Bladder scan after first void or if unable to void. Notify provider for PVR [post-void residual] >300 mL [milliliters], no void in 6 hours, or signs/symptoms of urinary retention. Straight cath [catheter] per facility protocol if bladder scan >400 mL and unable to void. Document voids, PVR, and interventions.Review of Resident #9 physician progress note dated 08/27/26 read, Foley catheter precautions remain listed in recent therapy documentation. The Foley catheter discontinuation and voiding-trial order was reviewed today. Foley catheter is to be discontinued, with monitoring for spontaneous void within 6 hours, bladder scan after first void or sooner if unable to void, and escalation per order parameters; her goal remains discharge home with her son when therapy goals and safety needs are met; I reviewed the care plan with nursing and therapy staff regarding Foley catheter removal, voiding-trial parameters.During an interview on 09/02/26 at 09:04 AM, Staff E, Licensed Practical Nurse (LPN) - Unit Manager, stated that Resident #9's care team wanted to keep her foley in because she has limited mobility and they wanted to see improvement in her mobility before they removed the foley. He explained that Resident #9 is making progress in therapy, but he didn't know that there was a note from the Nurse Practitioner (NP) and an order to discontinue the catheter. He stated, If I was notified, I would've talked with the patient and informed her of the plan and removed the foley. She was supposed to transition to using a bed pan.During an interview on 09/02/26 at 11:42 AM, Advanced Registered Nurse Practitioner #1 stated that she remembered speaking to the patient about discontinuing the foley, writing the note and order, and that she notified a nurse. She explained that she was also present during a nursing meeting and notified the supervisor as well. She stated, I didn't know that the order wasn't completed. I haven't seen the patient yet today.During an interview on 09/03/26 at 10:57 AM, Staff V, LPN, stated that she remembered having a conversation with the nurse practitioner about discontinuing Resident #9's catheter. She explained that the next day, the resident moved to a different hallway, and she wasn't her patient anymore and did not follow-up on the order to discontinue the catheter.During an interview on 09/02/26 at 10:38 AM, the Director of Nursing explained that the nurse practitioner input the order to discontinue the catheter in the facility's electronic health record without connecting the order to the Medication Administration Record, where the nurses would usually see the order while passing medications. She confirmed that the order to discontinue the catheter was not administered as ordered. She stated that if a nurse is notified about an order, or reviews resident orders, she expects that the order is followed.A facility policy on following physician orders was not provided by the facility.

Based on observation, interview and record review, the facility failed to examine and clean the insertion site in order to identify, lessen or resolve possible skin irritation for 1 out of 2 Residents reviewed for stoma care, Resident #15.Findings Include: During an observation conducted on 08/31/2026 at 9:35AM, Resident #15 was observed to have tube feeding turned off and a basin of emesis on the bedside table in front of her. During an observation of Resident #15's tube feeding on 09/02/2026 at 12:39PM, Jevity 1.5 dated 09/02/2026 was running at a rate of 60ml/hour(milliliters) Site observed after permission received from Resident. The surrounding tissue of the site was red with yellow drainage noted around tube insertion site with no dressing present. During an interview with the ADON (Assistant Director of Nursing), Infection Control Nurse on 09/03/2026 at 9:00 AM, a photo of Resident #15 was shown to ADON and she stated, Yes ma'am, that is something the Doctor should be notified about. The care to cleanse a stoma when ordered daily is to at least wash and dry the site to visualize it and document what was observed. I expect the CNA to report back to the nurse any redness and swelling or anything abnormal that has been seen during showering or brief changes. Review of Resident #15's admission record read, Medical Diagnosis: Gastrostomy Status (surgical created opening/stoma connecting the stomach to the abdominal wall) Dysphagia Oropharyngeal (difficult moving food from mouth to throat) Phase following Cerebral Infarction (blocked blood vessel stop oxygen from reaching the brain). During an interview with Staff M, RN (Registered Nurse), acting unit manager on 09/02/2026 at 12:41 PM, she stated she was not aware of [Resident #15's Name] having drainage around the base of the feeding tube insertion site. During an interview with Staff K, LPN (Licensed Practical Nurse) on 09/02/2026 at 12:52 PM, she stated she knows that [Resident #15's Name] has cleaning around the tube on her TAR (treatment administration record), she just had not gotten around to it. She does have some discharge, that is normal for her nothing we would report to the Doctor. During an interview with the DON on 09/02/2026 at 4:17 PM, she stated that the original order should have stated the same thing as the order she called the doctor for and put in today. Clean site with soap and water and dress with split square. The site should have never gotten to the point it needed triple antibiotic ointment. Review of Resident #15's physician orders read, Cleanse G/T (Gastronomy Tube) site with soap and water, apply triple antibiotic ointment and cover with a split gauze daily every day shift related to GASTROSTOMY STATUS (Z93.1) for 10 Days, dated 09/02/2026, Skin Prep Wipes Miscellaneous (Ostomy Supplies) two times a day Enteral: Tube Feeding Jevity 1.5@60ml/hrx20hrs, dated 06/22/2026, and Enteral: Stoma care Q shift every shift, dated 06/20/2025.Review of the facility policy and procedures titled, Ostomy care-Stoma, last revised 01/28/2026 read, Procedure, Assemble the equipment: Mild soap. Cleanse area around stoma with warm tap water. Any skin treatment ordered should be done at this time.

Through observation, interview and record review the facility failed to assure that Resident #9, #50 and #94 receives an accurate assessment, reflective of the resident's medical status in 3 out of 9 Residents reviewed for Minimum Data Set. Findings include: 1) Review of Resident #50's MDS (minimum data set) Medicare 5-day assessment dated [DATE], Section O IV Medications Read, Yes, Antibiotic, IV Access, Peripheral, Yes. Review of Resident #50's physician order dated 07/28/2026 reads, Cephazolin Sodium Injection Solution Reconstituted 1 GM (Cefazolin Sodium) Use 1 gram intravenously every 8 hours for POST SURGICAL until 09/02/2026. IVs: Type of Access (PICC) During an observation of Resident #50 on 08/31/2026 at 10:30AM, a bag of cefazolin tubing dated 8/30 and labeled 2200 was hanging on a pole at bedside. During an observation of Resident #50 on 08/31/2026 at 11:20AM, Resident smoking on the patio with PICC line dressing dated 08/29 in left upper inner arm. During interview with Staff J MDS nurse on 09/02/2026 at 12:15 PM, she stated she did contact her regional nurse, and it was her who marked it Peripheral on the MDS and it should have been Central Line. 2) During an observation of Resident #94 on 08/31/2026 at 10:15AM, Resident had on a nasal cannula delivering oxygen at 3 liters per minute and tubing dated 8/28/2026. On the night stand was a nebulizer machine and a Bi-PAP machine. Review of Resident #94's admission Record reads, Medical diagnosis: chronic respiratory failure with hypoxia (body tissue does not get enough oxygen to function), and obstructive sleep apnea (throat muscles relax and repeatedly block your airway during sleep). Review of Resident #94's physician orders dated 05/06/2025 read, Respiratory: Oxygen - 3LPM (liters per minute) via N/C (nasal cannula) PRN (as Needed) every shift for sob(shortness of breath), an order dated 04/24/2025- Duration and frequency of therapy BiPAP On at HS(hour of sleep) and on off on am(morning) as tolerated every night shift for r/t(related to) BiPAP, Mode of Therapy BiPAP every shift for BiPAP, and an order dated 05/13/2024- Pulmicort Inhalation Suspension 0.25 MG(milligrams)/2ML(milliliters) (Budesonide (Inhalation))2 ml inhale orally two times a day for respiratory treatment rinse mouth and expectorate(force out of mouth) after use. Review of Resident #94's MDS Quarterly assessment dated [DATE], Section O documents only, Occupational Therapy, Physical therapy. During an interview with Staff O MDS nurse, on 09/02/2026 at 3:15 PM, she stated, Yes, we should have included Oxygen and Bi-PAP for [Resident #94's Name] on the most recent MDS even if it is PRN(as needed). 3) Review of Resident #9's care plan revealed a focus dated 08/05/26 which read, [Name of Resident #9] has Indwelling Catheter: Neurogenic bladder. Review of Resident #9's physician's order dated 08/24/26 read, Foley Catheter 18Fr [French], 10cc [cubic centimeters] r/t [related to] Neuromuscular Dysfunction of the bladder. Review of Resident #9's physician progress note dated 08/27/26 read, 2. Urinary retention; Foley catheter management â?? [sic] chronic, clinically stable. Evidence: Urinary retention required Foley catheter placement during hospitalization with 900 mL [milliliter] return. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] Section I Active Diagnoses did not document neurogenic bladder diagnosis. During an interview on 09/02/26 at 12:25 PM, the MDS Coordinator stated that the neurogenic bladder diagnosis was missed on the 08/06/26 MDS and should be added to Section I. Review of the facility's MDS Policy and Procedures dated 09/25/17 revealed, The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including but not limited to: the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or stated required RAI (Resident Assessment Index).

Based on interview and record review, the facility failed to provide residents with limited range of motion referrals to a functional maintenance program after being discharge from therapy for 1 (Resident #1) of 3 residents reviewed for rehabilitation services. Findings include: During an interview on 8/31/2026a t 11:44 AM with Resident #1 Family Representative stated, [Resident #1's name] was taken off therapy due to her 100 days and I would like to know when they will put her back on or exercise her. Review of Resident #1 Physical Therapy Discharge Summary for Date of Service dated 5/5/2026 through 8/10/2026 read, Discharge Recommendations and Status: Functional Maintenance: Functional Maintenance Program Established /Trained: Ambulation Program, Range of Motion Program, Transfer Program, Bed mobility program. Review of Resident #1 medical record did not document a referral for the functional maintenance program. During an interview on 9/2/2026 at 10:02 AM with the Director of Rehabilitation stated, [Resident #1's name] was just discharge from case load not too long ago. She reached her max functional level. She was discharge to the functional program who is over seen by [Staff B's name] she is a nurse. At the beginning it was really rough but then she [Resident #1] was good. She also reached her 100 days. Usually we will write up the referral and give to [Staff B's name] and then put it the system as an order.During an interview on 9/2/2026 at 3:37PM with Staff B Licensed Practical Nurse stated, I have just gotten the referral form today. I am not sure why. Obviously, people get busy and make mistakes. The referral should have relatively quickly after discharge of therapy. She [Director of Rehabilitation] is fairly new. I have [Staff C Certified Nursing Assistant's name] and she does the functional maintenance program. She will be dedicated to ambulating patients who are not able to do so independently. Yes, the referral should have happened sooner than today. I don't know where she [Director of Rehabilitation] got the form. Restorative services is seven days a week documented weekly notes and there will be a goal for the patient to improved. Functional Maintenance is a step down. [Staff C's name] was not helping the [Resident #1] ambulate. She is not a patient that can self-ambulate. There is no policy for the Functional Maintenance program.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications and treatment supplies were securely stored to prevent unauthorized access and expired medications were removed from use for 3 residents (Residents #2, #7, and #14). Findings include: 1). During an observation on 8/31/26 at 10:26AM in Resident #2's room, a bottle of wound cleanser was observed next to Resident #2 and readily accessible. The wound cleanser was not secured or stored in the medication cart. During an interview on 9/3/26 at 9:54AM The Director of Nursing stated, wound cleanser should be stored in the medication cart and should not be left in the resident's room. The wound cleanser should only remain in the room if the resident has an infection. Review of the facility policy and procedure titled Medication Storage with a last review date of 1/28/2026 read, Policy: Medication will be store in a manner that maintains the integrity of the product and ensure the safety of the residents and is in accordance with FL Department of Health Guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 2) During an observation on 8/31/2026 at 1:11 PM Resident #7 was sitting up in bed eating lunch. There was a bottle of Chloraseptic Sore Throat Spray on top of the nightstand. During an interview on 8/31/2026 at 1:11 PM, Resident #7 stated, My throat was hurting a couple of weeks ago and I would spray it myself. During an interview on 8/31/2026 at 1:14 PM, Staff E Licensed Practical Nurse Unit Manager stated, [Resident #7's name] does not have an evaluation for medication self-administration. Residents should not have medications at the bedside. During an interview on 9/2/2026 at 3:03 PM with the Director of Nursing stated, [Resident #7's name] is not able to self-administer medication. There is a form that is filled out and the intradisciplinary reviews it. Then the medication is stored where other residents are not able to get to it. 3)During cart review of A Wing Back Hall Cart on 09/02/2026 at 7:56 AM, One medication on cart found to be expired for Resident #14 Novolog Inj (injectable) FlexpenLabeled as opened 8/01/2026. Labeled as expires 08/29/2026 During an interview Staff P, LPN(Licensed Practical Nurse) on 09/02/2026 at 8:00AM assigned to A Wing Back Hall Cart on 09/02/2026 at 7:56AM stated, I just got back from vacation. I work all the carts and have not even given any medications yet today. Pharmacy keeps up on the carts for expired medications. During an interview with Staff Q, unit manager on 09/02/2026 at 8:07 AM stated we have more available for [Resident #14's Name]. I will change the pen out. Expired meds are not to be on the cart. During an interview with the DON on 09/03/2026 at 10:59 AM, she stated the carts are audited by the unit manager, the ADON or the DON weekly or biweekly. The pharmacy comes monthly. The nurse on the cart should be checking each medication before it is administered for the expiration date. Review of Resident #14's admission record read.Diagnosis: Type 2 Diabetes Mellitus(chronic condition where the body resists insulin or does not make enough). Review of Orders for Resident #14: NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (millileters)(Insulin Aspart) Inject subcutaneously three times a day related to TYPE 2 Diabetes mellitus Can use Humulin R in place of Novolog until Novolog is available 03/11/2026. Review of facility policy and procedure titled, Medication Storage, last revision date 01/28/2026 read, Policy: Medication will be stored in a manner that maintains the integrity of the product and ensures the safety of the resident and is in accordance with FL Department of Health guidelines. Procedure: F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.

Based on observations, interview and record review the facility failed to provide ordered nutrition supplements for 1 (Resident #26) of 6 residents reviewed for dining observations. Findings include: During an observation on 8/31/2026 at 1:48 PM Resident #26 was eating in room independently. The meal tray contain pasta salad, ground meat, milk, apple sauce. The tray did not include a magic cup. During an observation on 9/1/2026 at 12:57 PM Resident #26 was eating lunch in the common dining room of the unit. The tray contain mask potatoes, ground meat, milk and pudding. The meal tray did not contain a magic cup. and the Review of Resident #26 physician order dated 8/4/2026 read, Magic Cup Am ordered PO in add direct two times a day for MNA 8- malnutrition risk with lunch and dinner. During an interview on 9/1/2026 at 1:10 PM with Staff A Licensed Practical Nurse stated, The magic cup comes on the meal tray. She does not have one on her meal tray. I do not know why. The magic cup is not listed on the ticket. It should be listed on the ticket in order for the kitchen to know she gets one. During an interview on 9/2/2026 at 12:35 PM with the Registered Dietitian stated, The magic cup was not showing up in the meal ticket. I put it in the wrong spot in the meal tracker. I was told that staff were coming to the kitchen requesting it that should have trigger the kitchen to add it to the meal tracker. During an interview on 9/2/2026 at 3:57 PM Kitchen Manager stated, If the magic cup does not show on the meal ticket the kitchen staff will not know that the resident needs one. No staff have come to the kitchen requesting a magic cup for [Resident #26's name]. During an interview on 9/3/2026 at 10:38 AM with the Assistant Director of Nursing stated, There is no policy for nutrition. During an interview on 9/3/2026 at 11:08 AM with the Director of Nursing stated, The kitchen should make sure that the magic cup is included in the tray.

Based on interview and record review the facility failed to accurately document medication administrations and treatments for 2 (Resident #9 and #14) of 8 residents reviewed for medication management. Findings include: 1)Review of Resident #14's physician order dated 7/17/2026 read, Insulin Glargine Solostar Subcutaneous Solution Pen-Injection 100 Unit/ML (Insulin Glargine) Inject 30 unit subcutaneously every morning and at bedtime for DM (Diabetes Mellitus) Review of Resident #14's Medication Administration Record for the Month of August 2026 documented a blank entry on 8/2/2026 at 0600 [6:00 AM]. Review of Resident #14's Medication Record for the Month of July 2026 blank entry on 7/22/2026 at 06:00. Review of Resident #14's physician order dated 3/11/2026 read, Novolog FlexPen Subcutaneous Solution Pen-Injector 100 UNIT/ML. Review of Resident #14's Medication Administration Record for the Month of August 2026 documented a blank entry on 8/2/2026 at 0600 [6:00 AM]. Review of Resident #14's Medication Administration Record for the Month of July 2026 documented a blank entry on 8/6/2026 at 0600 [6:00 AM] and 7/22/2026, 7/25/2026. Review of Resident #14's physician order dated 4/9/2026 read, Lantus Solostart Subcutanos Solution Pen Injector 100 Unit/ML inject 30 unit subcutaneously every morning and at bedtime for DM. Review of Resident #14's Medication Administration Record for the Month of July 2026 documented a blank entry on 8/6/2026 at 0600 [6:00 AM]. During an interview on 9/2/2026 at 11:59 AM, Advanced Practice Registered Nurse #1 stated, The staff need to document more accurately. During an interview on 9/3/2026 at 10:04 AM with Staff G Licensed Practical Nurse stated, I absolutely gave the insulin and checked blood sugar. It gets a bit crazy and it might have been my mistake that I did not document. 2) Review of Resident #9 physician's order dated 08/01/26 read, Monitor Vital Signs every shift. Review of Resident #9's Medication Administration Record for the month of August 2026 revealed vitals documented as NA for Day Shift (12 hours) on 08/01/26, 08/02/26, 08/04/26, 08/06/26, 08/07/26, 08/11/26, 08/20/26, 08/29/26, and 08/30/26. Vitals were documented as NA for Night Shift (12 hours) on 08/02/26, 08/05/26, 08/07/26, 08/10/26, 08/12/26, 08/15/26, 08/19/26, 08/20/26, 08/24/26, 08/26/26, 08/29/26, and 08/30/26. During an interview on 09/02/26 at 02:55 PM, Staff D, Licensed Practical Nurse (LPN) stated that that NA means she took vitals down on paper and put NA as a placeholder, but didn't have time to go back and put the vitals in before the papers are shredded daily. During an interview on 9/3/2026 at 11:08 AM with the Director of Nursing stated, I expect staff to document accurately the medications and treatments provided. Facility did not provide a policy on documentation.

Number of residents sampled: Number of residents cited: Findings include: During an observation on 9/1/2026 at 12:57 PM Resident #68 door was closed. The door had an enhanced barrier sign and personal protective equipment bag hanging on the door. When surveyor knocked and open the door Staff H Certified Nursing Assistant was standing at the bedside and stated she was providing patient care. Staff H CNA was only wearing gloves and no gown. At 1:01 PM Staff H CNA stated she was finishing and only had to empty the urinary catheter only wearing gloves and no gown. Review of Resident #68's physician order dated 8/17/2026 read, Enhanced Barrier Precautions r/t [related to] Foley Catheter every shift for r/t Foley Catheter.During an interview on 9/2/2026 at 1:51PM, the Infection Preventionist stated, Any type of one-on-one care with the resident the chair a brief change or bed bath or wound care if they are going to provide peg tube or iv any direct care. Hand hygiene, gown and gloves. They have to treat the linen has to be treated like a person. Yes, dealing with body fluids.During an interview on 9/2/2026 at 3:05 PM with the Director of Nursing stated, Staff should don a gown and gloves when providing direct care to the residents who are under enhanced barrier precautions. During an interview on 9/3/2026 at 10:33 AM with Staff H CNA stated, I was providing care to [Resident #68's name] . I was emptying the foley and changing the brief. For enhance barrier precautions i should wear gown and gloves. When asked if she forgot to don a gown Staff H stated, Yes, I forgot. Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 1/28/2026 read, Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high contact residents care activities.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection for not maintaining infection prevention and control practices in the management of intravenous catheters for 1 of 3 residents, Resident 3, reviewed for IV (intravenous) therapy.Findings include: During an observation on 6/25/2025 at 9:40 AM, Resident #3's PICC (peripherally inserted central catheter) line on his right upper arm had a dressing that was dated 6/22/25. The dressing was comprised of a transparent semi-permeable membrane, with pieces of square gauze pads directly over the insertion site preventing observation of the site. During an observation on 6/25/2025 at 12:07 PM, Staff A, Licensed Practical Nurse (LPN), flushed Resident #3's PICC line with normal saline solution and disconnected the syringe, leaving the end of the connection exposed. Resident #3 was observed resting his upper right arm; with the connection against his body. Staff A prepared the IV antibiotic medication and attached the IV tubing to the distal end of the PICC line connection, without wiping the connection prior to attaching the IV tubing. During an interview on 6/25/2025 at approximately 12:15 PM, Staff A, LPN stated, I should have wiped the tip of Resident #3's PICC line with the alcohol wipe before I connected the IV tubing for the antibiotics. During an interview on 6/25/2025 at 1:30 PM, the Assistant Director of Nursing stated, The expectation for central line care is that the nurses would scrub the hub [the practice of disinfecting the connection point (hub) of an intravenous (IV) catheter or needleless connector before accessing it with a syringe or other device. This technique is crucial for preventing infections, by reducing the risk of introducing bacteria or other pathogens into the bloodstream] before connecting a syringe or IV tubing to the catheter. Review of the facility policy and procedures titled Catheter Insertion and Care - Central Venous Catheter Dressing Changes with an effective date of 1/17/2019 read, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings . General Guidelines . 5. If gauze is used, it must be changed every 2 days . 7. Catheter site care and dressing changes will include . b. Observation and evaluation of the catheter - skin junction and surrounding tissue.

Based on observations, interviews, and record review, the facility failed to ensure food was safely and properly thawed, stored, and labeled in accordance with professional standards for food service safety. Findings include: An the initial tour of the kitchen on 4/21/25 at 9:10 AM with the Dietary Manager (DM), an observation was made in the walk-in cooler of 4 rolls (5 lbs. each) of thawed ground beef sitting in a deep pan of red watery liquid, 4 bags (10 lbs. each) of thawed raw chicken in a deep pan of red watery liquid 4 fully cooked hams (5 lbs. each) on a sheet pan and 4 raw turkey breasts all without a label for a pulled or use by date. During an interview on 4/21/25 at 9:20 AM, the DM state that he placed the meats on the rack in the cooler Friday when the truck delivered the food and should have been labeled the meats with the pull and used by date and the meal it was for. Review of the policy titled, Labeling and Dating Inservice, last reviewed on 12/18/2024 read, Purpose: To educate all new hires and current employees on the importance of and guidelines for proper labeling and dating. Guidelines for Labeling and Dating. All foods should be dated upon receipt before being stored. Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date if removal from the freezer and an appropriate use by date as outlined in the retention guide. Review of the document title, Food Storage Retention Guide, not dated read, Raw Meat/Poultry/Seafood: (Once Thawed). Fish, seafood, ground meat and all poultry. 1-2 days. Beef or pork roast, steaks or chops. 3-5 days.

Based on an interviews, and record reviews, the facility failed to develop and implement a care plan for 1 (Resident #38) of 2 residents reviewed for respiratory care. Findings include: During an observation on 4/21/2025 at 9:48 AM, Resident #38 was lying in raised bed with head of the bed elevated watching television. CPAP device is in a labeled bag on top of dresser close to the wall and back from the bed out of reach of resident on right side of the bed. The Resident is bed bound and cannot move about in bed without assistance. Resident #38 has oxygen administered via nasal cannula at 4 liters per minute. During an interview on 4/21/2025 at 9:48 AM, Resident #38 stated, I have not been receiving CPAP therapy every night because some nurses forget to place the CPAP on me. I will wake up at 2 or 3 in morning and not have CPAP on me. Review of physician's orders on 4/23/2025 at 5:00 PM, Resident #38 did not have any orders for CPAP. During interview on 4/24/2025 at 11:25 AM, the Director of Nursing confirmed the care plan should include the use of a CPAP device for [Resident #38's Name]. Review of policy and procedure titled, Plans of Care, with a review date of 12/18/2024, reads, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing ,mental and psychosocial needs that are identified in the comprehensive assessment. The Individualized Person Centered plan of care may include but is not limited to the following: Resident's strengths and needs, Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements, individualized interventions that honor the resident's preferences and promote achievement of the resident's goals.

Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care was provided, consistent with professional standards of practice for 2 (Resident #38, #44) of 2 residents review for oxygen therapy and CPAP (Continuous Positive Airway Pressure) devices. Findings include: During an observation on 4/21/2025 at 10:35 AM, Resident #44 was sitting on the side of his bed with oxygen at 4 liters per minute per nasal cannula. During an observation on 4/22/2025 at 10:55 AM, Resident #44 had oxygen at 4 liters per minute per nasal cannula. During an observation on 4/23/2025 at 12:10 PM, Resident # 44 had oxygen at 4 liters per minute per nasal cannula. Review of Resident #44's admission record documented the resident was admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the physician's orders for Resident #44 dated 8/28/2024 read, Respiratory: Oxygen - 3L PRN (3 liters as needed) via nasal cannula. During interview on 4/23/2025 at 2:45 PM, Staff A, B Hallway Nurse Manager stated, [Resident #44's Name] should have his oxygen set as ordered at 3 liters per minute per nasal cannula not at 4 liters per minute per nasal cannula. During interview on 4/24/2025 at 8:40 AM, the Director of Nursing stated, It is expected that if the oxygen order is for 3 liters per minute per nasal cannula, the physician order should be followed. 2) During an observation on 4/21/2025 at 9:48 AM, Resident #38 was lying in raised bed with head of the bed elevated watching television. CPAP device is in a labeled bag on top of dresser close to the wall and back from the bed out of reach of resident on right side of the bed. The Resident is bed bound and cannot move about in bed without assistance. Resident #38 has oxygen administered via nasal cannula at 4 liters per minute. During an interview on 4/21/2025 at 9:48 AM, Resident #38 stated, I have not been receiving CPAP therapy every night because some nurses forget to place the CPAP on me. I will wake up at 2 or 3 in morning and not have CPAP on me. During an observation on 4/22/2025 at 9:50 AM, Resident #38 was sleeping with oxygen per nasal cannula at 4 liters per minute. During an observation on 4/23/2025 at 12:12 PM, Resident #38 was awake watching TV with oxygen per nasal cannula at 4 liters per minute. Review of Resident #44's admission record documented the most recent readmitted [DATE] with diagnosis that included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of the physician's order for Resident #44 dated 12/7/2024 read, Respiratory: Oxygen - Continuous at 3 L (liters), may take off intermittently. During interview on 4/23/2025 at 2:45 PM, Staff A, B Hallway Nurse Manager stated [Resident #38's Name] should have her oxygen set as ordered at 3 liters per minute per nasal cannula not at 4 liters per minute. I did speak with [Resident #38's Name] about her not having her CPAP device placed on her at night. Review of physician's orders on 4/23/2025 at 5:00 PM, Resident #38 did not have any orders for CPAP. During interview on 4/23/2025 at 5:50 PM, the Director of Nursing confirmed there was not an order for CPAP for [Resident #38 Name] and stated, Resident should have an order for CPAP if therapy is being administered. During interview on 4/24/2025 at 8:40 AM, the Director of Nursing stated, It is expected that if the oxygen order is for 3 liters per minute per nasal cannula, the physician order should be followed for [Resident #38's Name]. Review of the policy and procedure titled, Physician Orders, last review date 12/18/2024, reads: Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Review of the policy and procedure titled, Oxygen Therapy, last review date 12/18/2024, reads: Policy: Oxygen therapy is the administration of a FiO2 [estimation of the oxygen content a person inhales], greater than 21%, by means of various administration devices to: raise the resident's PaO2 [measure the pressure of oxygen in the blood] to an acceptable baseline using he lowest FIO2, to treat arterial hypoxemia, to decrease work of breathing, to reverse and prevent tissue hypoxia, and/or to decrease myocardial work. Procedure: Physician's order for oxygen therapy shall include: Administration modality, FIO2 or liter flow, Continuous or PRN (as needed), PRN orders must include specific guidelines as to when the resident is to use the oxygen. Review physician's order . Start O2 flowrate at the prescribed liter flow or appropriate flow for administration device.

Based on record review and interview, the facility failed to ensure the quality assurance and assurance committee consisted of the required members in 3 of 4 quarters during 2023. Findings include: Review of the QAPI (Quality Assurance Performance Improvement) agenda attendance rosters for 2023 showed the Medical Director did not attend the QAPI meeting 3 of 4 quarters for months which an attendance roster was available. Review of the QAPI agenda attendance rosters for 2023 showed there were no attendance rosters maintained for 4 of 12 months of 2023. During an interview on 2/1/2024 at 10:05 AM, the Administrator in Training confirmed the former Medical Director had not attended the facility QAPI as required. Review of the facility policy and procedures titled Quality Assurance Performance Improvement Program (QAPI) last reviewed on 2/1/2024 showed the policy read, Procedure . 6. QAA [Quality Assessment and Assurance] Committee include but are not limited to: a) Executive Director, b) Medical Director/designee, c) Director of Nursing/designee, d) Infection Preventionist.

Based on observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered, labeled, or dated in the area of the kitchen coolers and refrigerators. Findings include: During an observation on 1/29/2024 at 9:00 AM, at the time of walk-through of the dietary department with the Certified Dietary Manager (CDM), the CDM and the Male Dietary Aide had beard or mustache with no covering. In the reach-in cooler, there was a 5-gallon container without an identifying label or date, and a large stainless steel bowl with a yellow pudding type substance with no covering, label or date. The microwave had a buildup of food debris and splatters on the door and the inside top of the microwave. During an interview on 1/29/2024 at 9:10 AM, the Certified Dietary Manager (CDM) stated the 5-gallon container was iced tea and should have had a label and date, and the large stainless steel bowl was pudding made for nursing staff to pass meds and should have been covered, labelled, and dated. The CDM stated that the microwave should have been cleaned the night before and was left dirty. The CDM stated that he and the Male Dietary Aide should follow the policy for all hair covering. During an observation of the kitchen with the CDM on 1/30/2024 at 7:33 AM, there were 14 glasses of a juice type drink in the reach-in cooler with no identifying label or date and 4 clear swirl cups with a fruit type dessert with no cover, date or identifying label. The microwave had numerous areas of rust inside on the sides, top and base. There was a dented can of light tuna on a shelf in the stock room along with approximately 46 cans of assorted foods with no dates that had been removed from the original container. During an interview on 1/30/2024 at 7:38 AM, the CDM confirmed that the observed food products did not have a label and identified them as orange juice that should have been labeled and dated and a leftover fruit dessert from the previous evening that should have been covered, dated and labeled according to the policy. Review of the facility policy and procedures titled Labeling and Dating Inservice last reviewed on 2/1/2024 showed the policy read, Guidelines for Labeling and Dating: All foods should be dated upon receipt before being stored . Leftovers must be labeled and dated with the date they are prepared and the use by date. Review of the policy and procedures titled Receiving last reviewed on 2/1/2024 showed the policy read, Procedures . 4. All canned goods will be appropriately inspected for dents, rust, or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. Review of the facility policy and procedures titled Staff Attire last reviewed on 2/1/2024 showed the policy read, Procedures: 1. All staff members will have their hair off the shoulders, confirmed in a hair net or cap, and facial hair properly restrained.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 4 of 6 medication carts. Findings include: During an observation of A Hall Front Cart on [DATE] at 9:00 AM with Staff B, Licensed Practical Nurse (LPN), there were one opened Aspart insulin pen with no opened or expiration dates, one opened Lantus insulin vial with no opened or expiration dates, two opened Humalog insulin pens with no opened or expiration dates, two opened Glargine insulin vials with no opened or expiration dates, one opened Fluticasone Propionate/Salmeterol Diskus inhaler with no opened or expiration dates, two containers of Prednisolone eye drops with no opened or expiration dates, one container of Ciprofloxacin eye drops with no opened or expiration dates, and one opened container of Latanoprost eye drops with no opened or expiration dates. During an interview on [DATE] at 9:05 AM, Staff B, LPN, stated, Medication should be dated with an opened and expiration date. During an observation of A Hall Back Cart on [DATE] at 9:11 AM with Staff C, LPN, there were one expired Ketorolac Tromethamine ophthalmic drops container with an opened date of [DATE], one opened Breo Ellipta inhaler with no opened or expiration dates, and one opened Wixela inhaler with no opened or expiration dates. During an interview on [DATE] at 9:16 AM, Staff C, LPN, stated, Medications should be dated when opened, and expired medication should be removed from medication cart. During an observation of B Hall Front Cart on [DATE] at 9:23 AM with Staff D, LPN, there were one unopened Humalog insulin pen with a pink sticker to refrigerate, one opened Prostat with no opened or expiration dates, one expired Wixela inhaler with an expiration date of ,d+[DATE], and one opened Breo Ellipta with no opened or expiration dates. During an interview on [DATE] at 9:25 AM, Staff D, LPN, stated, The insulin pen will not be used this morning maybe in the afternoon. It should be stored in the refrigerator until it is ready to use. Medication, when opened, should be labeled with opened date. If medication is expired, it should be removed from the medication cart. During an observation of B Hall Back Cart on [DATE] at 9:29 AM with Staff E, LPN, there were one opened Trelegy Ellipta inhaler with no opened or expiration dates, one opened Humalog insulin pen with no opened or expiration dates, and one unopened Lantus insulin vial with a pink sticker to refrigerate. During an interview on [DATE] at 9:35 AM, Staff E, LPN, stated, Medication should be dated when opened with an opened date and insulin should be refrigerated until ready to use. The Lantus will not be used until night time. During an interview on [DATE] at 10:05 AM, the Director of Nursing stated, Medication should be labeled with the opened and expiration date. If the medication is expired, it should be disposed of accordingly and removed from the medication cart. Insulin that is not open and is not going to be used right away should be stored in the refrigerator. Review of the facility policy and procedures titled Medication Storage last reviewed on [DATE] showed the policy read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL [Florida] Department of Health guidelines. Procedure . F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. G. Medications will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling . H. Medication requiring refrigeration will be stored in a refrigerator that is maintained between ,d+[DATE] degrees Celsius (36 to 46 degrees F). Review of the facility policy and procedures titled Insulin Pen Labeling & Packaging last reviewed on [DATE] showed the policy read, Procedure . 2. Insulin Pens are placed in a resealable bag with the following labels/stickers . b. Refrigerate until opened sticker and d. A yellow Date/Expiration sticker.

Based on resident record review, interview, and facility policy and procedure review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers, Resident #4. Findings include: Review of the admission record for Resident #4 documented diagnoses including multiple sclerosis, mild intermittent asthma, heart failure unspecified, unspecified atrial fibrillation, unspecified convulsions, idiopathic normal pressure hydrocephalus, rheumatoid arthritis, age-related osteoporosis, essential primary hypertension, COVID-19, personal history of malignant neoplasm of ovary, hyperlipidemia, primary open angle glaucoma, and acute embolism and thrombosis of deep veins of upper extremity bilateral. Review of the form titled Pressure Ulcer Wound Rounds dated 5/31/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 2 centimeters, Depth: [blank], Stage II . Notes/Recommendations from Doctor: Resident admitted from hospital with wound. Cleansed with NS [Normal Saline] and covered with a silicone bordered dsg [dressing]. Review of the form titled Pressure Ulcer Wound Rounds dated 6/9/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 1 centimeter, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 6/12/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Right buttock, Type: Pressure, Length: 1.5 centimeters, Width: 0.5 centimeters, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 6/14/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3 centimeters, Width: 1 centimeter, Depth: 0.1 centimeters, Stage II. Review of the form titled Pressure Ulcer Wound Rounds dated 7/12/2023 for Resident #4 reads, A. Initial Identification, 1. Present on Admission, 2. Location: Sacrum, Type: Pressure, Length: 3.5 centimeters, Width: 4.5 centimeters, Depth: 0.2 centimeters, Stage III. Review of Resident #4's medical records revealed no skin evaluations or documentation of the wound length, width, or depth from 6/14/2023 until 7/12/2023. Review of Resident #4's physician order dated 5/31/2023 reads, Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound. Review of Resident #4's Treatment Administration Record (TAR) for June 2023 revealed no entries documented under Wound Care: Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound for 6/14/2023, 6/18/2023, 6/21/2023, 6/22/2023, 6/27/2023, 6/28/2023, and 6/29/2023. Review of Resident #4's TAR for July 2023 revealed no entries documented under Wound Care: Right upper buttock: Cleanse with NS, apply honey ointment and cover with silicone foam dsg daily and as needed every day shift for wound for 7/2/2023, 7/10/2023 and 7/11/2023. Review of Resident #4's physician order dated 7/13/2023 reads, Right upper buttock: Cleanse with NS, alginate and cover with silicone foam dsg daily and as needed every day shift for wound. Review of Resident #4's TAR for July 2023 revealed no entries documented under Right upper buttock: Cleanse with NS, alginate and cover with silicone foam dsg daily and as needed every day shift for wound for 7/13/2023, 7/14/2023, 7/20/2023, and 7/26/2023. During an interview on 7/27/2023 at 2:25 PM, the Director of Nursing (DON) stated, I don't know why the nurses are not documenting wound care. If these have not been documented, it means they are not done. I can't tell you why the resident has not had any wound evaluations or wound measurements or skin assessments between 6/14 and 7/12. The nurses should be doing weekly skin assessments and that would include documenting the wound size and drainage and anything else. [Name of the Wound Care Consultant Company] should have been seeing the wound weekly. I really can't tell you why there are no weekly skin assessments completed. There is no documentation of the wound sizes. The resident was not out of the facility. Her wound did progress from a stage II to a stage III, so I guess that is harmful to the resident. We did not follow our policies and procedures and we should have. We did not follow doctor's orders for wound care when we don't document that the care was done or have wound care evaluate the wounds per the orders, we should be following the orders for care. During an interview on 7/27/2023 at 2:50 PM, Staff A, Licensed Practical Nurse (LPN), stated, I don't know why [Resident #4's name] wasn't seen by [Name of the Wound Care Consultant Company] or the wound nurse did not document her wound sizes. I don't know why the TAR is not documented on. I was taking care of her. Maybe those were the days that the students were here. It is my responsibility to make sure that the wound care treatments are done. If they are not documented, that means they were not done. We should be following doctor's orders for the wound care and to have the wound care team see the residents. During an interview on 7/27/2023 at 3:18 PM, the Assistant Director of Nursing (ADON) stated, I don't do the daily dressing changes to the wounds. I document wound size and progression weekly. I can't say for certainty that the staff were doing the treatments because there is no documentation that they measured the wounds. I did not see the resident because it was not necessary. The nurses were doing the wound care and they should have documented the wound progression. I was told that wound care did not see any pressure wound unless it was a stage III wound. I don't know who told me that. We started seeing her again and the wound was a stage III when we started seeing the wound again. It was worse when we started to see it again. I guess it would be considered harm if it worsened and the wound wasn't measured and not all of the wound care was documented as done. We should have been measuring the wound. We should have had the resident seen by wound care and we should have documented when we did the dressing changes. Review of the facility policy and procedure titled Skin Evaluation with last revision date of 4/1/2017 and an approval date of 1/2023 reads, Policy: A Licensed Nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas, and skin problems. Procedure: 1. A Licensed Nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. 2. The evaluating nurse must date and sign each review. 3. If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas complete the Pressure Injury Record. For all other skin conditions, complete the Non-Pressure Skin Condition Record . 5. The Licensed Nurse will document the observations on the skin evaluation form. Review of the facility policy and procedure titled Dressings, Sterile with a revision date of September 2013 reads, Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage. 3. The name and title (or initials) of the individual changing the sterile dressing . 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.

Based on record review, interview, and policy and procedure review, the facility failed to act in accordance with a resident's advance directive and to honor the resident's wishes of Do Not Resuscitate (DNR) for 1 of 3 residents, Resident #1, when found unresponsive and absent of vital signs. This has the potential to affect 46 residents with advance directives of do not resuscitate. The findings include: Review of the medical record for Resident #1, documented the resident was admitted into the facility on [DATE] at 5:53 PM with diagnosis to include chronic kidney disease, stage 4 severe, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, peripheral vascular disease, diabetes mellitus type 2, major depressive disorder, chronic respiratory failure with hypercapnia [happens when you have too much carbon dioxide in your blood, if your body can not get rid of the carbon dioxide, a waste product, there is not room for your blood cells to carry oxygen], and gastroesophageal reflux disease. Review of the State of Florida Do Not Resuscitate Order documented the form was dated [DATE] and signed by [responsible party's name] and [physician's name]. Review of the physician orders dated [DATE] at 00:57 [12:57 AM] reads, DO NOT RESUSCITATE. Advance Directive Status: Current and Verified. Order Type: Advanced Directive. Review of the nursing progress note completed by Staff B, RN (Registered Nurse) dated [DATE] at 00:10 [sic 12:10 AM] read, Approximately at 0110 AM [1:10 AM] on [DATE] the nurse assigned to patient called me to the Pt's [Patient] room, she stated Pt had a change in condition. Dr. was being notified of this change when the CNA [Certified Nursing Assistant] came to the desk and stated conditioning worsening. The patient was noted to be a DNR but initially we could not locate it. 911 was called, Reassessment of patient was done and was found without a pulse and no respirations were noted. CPR [cardiopulmonary resuscitation] was initially started. Upon finding DNR compressions were stopped. 911 arrived and pronounced deceased at 01:37 [AM]. Review of the nursing progress note completed by Staff, A, LPN (Licensed Practical Nurse) dated [DATE] at 02:21 AM read, At 0110 this nurse noticed a change in patient condition and put a call out to the doctor, while speaking to the NP [Nurse Practitioner] regarding this patient the CNA came to the desk reporting worsening distress. This nurse noted patient to be a DNR, but could not initially find the DNR, upon assessment of patient this nurse noted the patient was without pulse, and respirations, 911 called, CPR initiated while 2nd nurse looked for DNR, DNR found, CPR stopped, 911 arrived and declared at 0137 [1:37 AM]. Review of the Discharge Summary completed by [physician's name] on [DATE] at 5:44 AM for [name of physician's office] read, Death Diagnoses: Congestive heart failure, coronary artery disease, chronic kidney disease, COPD, diabetes mellitus. Death Summary: Patient was admitted to Herons pt. SNF [skilled nursing facility] status post hospitalization [DATE]. Per review of nursing documentation it appears the patient had a change of condition at 1:10 AM on [DATE]. It appears the patient was DNR however DNR documentation could not be initially found and CPR was initiated. 911 was called and EMS arrived to the scene. After the DNR documentation was eventually found BLS [basic life support] protocol was stopped and the patient was pronounced by 911 services at 1:37 AM. Medical service was notified after all events occurred and patient expired. During an interview on [DATE] at 9:41 AM the Director of Nursing (DON) stated, My nurses, we had a situation where the pt came in on the 13th [May] at 5:37 PM around that time. The pt. admitted , the chart didn't get put together, they put the orders in. The night nurse put the DNR in PCC [Point Click Care]. This means she would have seen the yellow sheet. It happened on Mother's Day night the status of the resident changed. The chart was not put together. The agency nurse couldn't find the code status. There was a call made to the doctor who gave an order to send the resident to the hospital. The resident coded while the nurse was on the call. The nurse tried to find the DNR and couldn't find it. Our nurse that was on that was an RN made the decision to perform CPR. They only had the code status in PCC. She initiated CPR. It was a couple of minutes later the nurse came down to the room after she got off the phone with 911 and took over CPR. Another nurse from the other wing then took over and did CPR until 1:35 AM when EMS arrived and took over CPR. One of nurses went to the station to get the paperwork ready for transfer. When she pulled the chart there was a packet at the back of the chart that fell out and she went through the packet, and this is when she saw the DNR. She immediately took the DNR to EMS. EMS stopped CPR and EMS called the time of death at 1:37 AM. She came in on the weekend. The chart was not put together. That was determined by our root cause analysis. CPR should not have been started. We did not honor her wishes [Resident #1], her advance directives, and initiated CPR. During an interview on [DATE] at 10:07 AM the Medical Director stated, Usually, when we discuss with the patient and with medical, we have a meeting if we have patients or family asking for a DNR or POA we talk about it. If there is a DNR, then the no CPR order is to be followed. That is what I would expect. If CPR is done it can cause harm to occur. What can happen is broken ribs, trauma, a lot of emotional and psychological harm for the patient and with the family. During a telephone interview on [DATE] at 3:56 PM Staff B, RN stated, The nurse that was assigned to her [Resident #1] came to me and said that she was unresponsive. I went to the chart to find the DNR. The chart had not been put together. I couldn't find the DNR, so I started CPR. I didn't see it in PCC [code status]. I won't say that it wasn't there, but I didn't see it, you are in a rush when this happens. It wasn't in the chart where it should have been. All we had was this big stack of papers and we were shuffling through them as fast as we could. Time is of the essence, so I said we are going to start CPR because if they wanted CPR and it wasn't started; I erred on the side of caution. It could have gone the other way. In the moment there is not a lot of time to waste, we did proceed. Normally, the DNR is the first page [in the chart], you flip and there it is. In this case it wasn't there. During a telephone interview on [DATE] at 12:43 PM Staff A, Agency LPN stated, I had training when I started to work there about DNR and the yellow DNR and the verification process. During report, I was told that she [Resident #1] has some respiratory issues and that she was on oxygen at 3 liters. I finished report, and all that, and I went to check on her and she was resting. At around 11:30 PM I went in and repositioned her to make her comfortable. There were no medications for her that were ordered during my shift. I went and took care of others and then went and checked on her at around 12:30 PM. She said she was thirsty, and I raised the head of the bed and gave her some thickened liquids. She then said she wanted her head lowered. I put a pillow under her head and her heels. She seemed to be breathing harder. I spoke with another nurse about where I could find the doctor's number to tell her about [Resident #1's name] and asked the nurse to check on her [Resident #1]. I called the doctor and left a message. I went in with the nurse to check on her [Resident #1] and the ARNP [Advanced Registered Nurse Practitioner] called back as I was going to the desk to call 911. The ARNP asked if I had called 911 and I told her I was going to call now. Got off the phone with her and I called 911. I went to check the resident's chart because I know the DNR form is supposed to be in the front of the chart. I couldn't find it. The computer said she was a DNR, but I wanted to check the form. I went back to the room and the other nurse had already started CPR. EMS arrived and they took over. They said they needed a face sheet. I went to the chart to find the face sheet and that is when I saw the DNR form at the back of the chart. I took the form to EMS, and they stopped CPR, and they pronounced her. Review of the Policies and Procedures titled, Florida Do Not Resuscitate (DNR) last reviewed on [DATE] read, Policy: The center will follow Florida law regarding obtaining and honoring Do Not Resuscitate orders. Procedure: 2. When the resident has executed a DNRO, the form shall be printed on yellow paper and have the words DO NOT RESUSCITATE ORDER printed in black and displayed across the top of the form. DH Form 1896 may be duplicated, provided that the content of the form is unaltered, the reproduction is of good quality, and it is duplicated on yellow paper. The shade of yellow does not have to be an exact duplicate. 3. The properly executed DNRO will be placed in the resident's medical record. Review of the Policies and Procedure titled, Florida Cardiopulmonary Resuscitation (CPR) Last reviewed [DATE] read, Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: Resident identification. Fully executed Florida Do Not Resuscitate order (DH 1896), located in the advanced directive section of the medical record. 3. Use the paging system and call Code Blue to Room Number or location of the event three times. Review of the Plan to Remove Immediate Jeopardy dated [DATE] reads: As of [DATE] an advance directive quality review of current residents was conducted by [Social Services Director's name]. As of [DATE] Staff A, LPN, Staff B, RN, and Staff C, LPN were suspended pending investigation. Staff B, RN received 1:1 education on [DATE] from [DON's name] r/t [related to] resident rights, abuse policy and procedure, following physician orders, plans of care, admission process, code blue/CPR, advanced directives, Florida DNR, Nurse Practice Act. On [DATE] a Performance Improvement Plan (PIP) was developed and initiated based upon Root Cause Analysis. It was determined a patient who had an active Florida DNR was provided CPR due to the nurses being unable to locate the yellow copy of the Florida DNR in the chart. The chart was not assembled and organized per internal admission process with the Florida DNR on yellow paper in the front of the chart. [DATE] a review of current licensed nurses CPR certification completed by [DON's name] and completed on [DATE]. As of [DATE] all nurses were in compliance. On [DATE], Seventeen (17) Administrative staff were educated related to Advanced Directives, Florida DNR, Code Blue Policies and procedures and chart organization. Eighty-five (85) facility staff to include but not limited to licensed, certified, housekeeping, dietary, reception, and clerical staff received education on procedure for Code Blue, FL [Florida] yellow DNRO sheets -2 nurses validating code status and advanced directives completed upon admission to the center and placed in the front of the chart and chart organization following internal admissions process. Internal process for chart organization with emphasis on the FL DNR being located in the front of the chart. Current Licensed Nursing staff including agency staff received education by [DON's name and additional administrative staffs' names] beginning on [DATE] regarding: procedure for Code Blue, FL yellow DNRO sheets - 2 nurses validating code status and advanced directives completed upon admission to the center and placed in the front of the chart and chart organization following internal admissions process. Internal process for chart organization with emphasis on the FL DNR being located in the front of the chart. [NAME] Pointe Health & Rehab currently has 31 licensed nurses including 9 agency nurses [who have been educated] related to DNR, Code Blue Policy and Procedures and chart organization since [DATE]. Twentynine/thirty-one (,d+[DATE]) had education beginning on [DATE] that was completed on [DATE]. Current rate of education compliance for licensed nurses [as of [DATE]] is: 94%. The 2 remaining licensed nurses are out and not able to come into the facility, but will complete their education prior to returning to accept an assignment. Current rate of education compliance for licensed nurses is: 94% as of [DATE]. (94%) nursing staff beginning [DATE] attended mock code drills on various shifts to include the ,d+[DATE], ,d+[DATE], and ,d+[DATE] shifts. Mock code drills will continue to be held twice weekly on all shifts to include weekends. Licensed nurses, agency nurses and CNAs were given a post-test r/t Florida DNRO after education was provided. All scoring greater than 80%. One hundred five (105) residents of [NAME] Pointe Health & Rehab had the potential to be affected by the deficient practice and potentially suffer a serious outcome as a result of their code status wishes not being honored due to non-compliance with current policies and procedures surround validating code status that honor the residents/resident representatives wishes. On [DATE] @ 3:15pm no harm longer existed for the residents of [NAME] Pointe Health & rehab. Newly hired staff will receive education in orientation. As part of the quality review the advanced directives discussion document was competed for current residents. Based upon the wishes of the resident/resident's responsible party the below was completed: FL Yellow DNRO form for those who wish for CPR to be withheld. Form placed in front of the medical record. EHR/PCC [electronic health record] checked to ensure order accuracy. CP [care plan] reviewed to ensure accuracy. Actions to prevent further deficient practice r/t code status began on [DATE] are as follows: education for current licensed nurses as stated above, mock code drills conducted on various shifts/various days to include the weekends, quality review of advanced directives discussion form, quality review of current residents to ensure their code status is honored, orders are correct in the EHR/PCC and the CP is current. An ADHOC [created or done for a particular purpose as necessary] Quality Improvement Performance Committee meeting was held on [DATE] to review the results of facility wide quality reviews completed. The following team members were in attendance: Executive Director, Regional Director of clinical Services, Medical Director, activities Director, and Assistant Director of Clinical Services. The ADHOC QAPI [Quality Assurance and Performance Improvement] Committee approved the recommendations. All plans put in place, are effective and we respectfully request that the immediacy of likelihood of serious harm and/or death to be removed as of [DATE]. Review of the PIP revealed: PIP-Not Following Advance Directives [NAME] Pointe Date: [DATE]. Objective & Goal: Immediate correction and attaining and maintaining regulatory compliance regarding Advanced Directives Center wide. 1. Immediate corrections to ensure safety of affected Patient(s)/Resident(s). 2. Identification of any other Patient(s)/Resident) (s) who may be affected or at risk. 3. Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: Full census wide quality review performed of code status. Responsible Person(s) ED, SSD, DON. Target Date: [DATE]. Status: 100% completed. Staff Interviews conducted for anyone involved. Document on Witness Statements. Responsible Person(s): ED, DON. Target Date: [DATE]. Status: 100% Completed. Establish DNR list from full chart review. Responsible Person(s): ED, DON, SSD. Target Date: Blank. Status: 100% Completed. Complete and validate DNRO Quality Review. Responsible Person(s): ED, SSD. Target Date: Blank. Status: 100% Completed. Educate staff regarding: Internal Tool/Centers Practice: Advanced Directives (SS-124). Policy/Procedure CPR (N302). Responsible Person(s). ADON. Target Date: Blank. Status: 98% Clinical/Non-clinical in building. 100% HSG (Housekeeping/Dietary) Staff. 100% Therapy Department. Educate staff regarding policy/procedures: Abuse/Neglect. Resident Rights. Responsible Person(s): ADON [Assistant Director of Nursing]. Target Date: Blank. Status: 98% Clinical/Non-clinical in building. 100% HSG (Housekeeping/Dietary) Staff. 100% Therapy Department. Educate staff regarding following physician orders, following care plan: Responsible Person(s) ADON. Status: 98% of Clinical/Non-Clinical in building. 100% HSG (Housekeeping/Dietary) Staff, 100% Therapy Department. Educate Licensed Nursing staff regarding Nurse Practice Act. (No staff member will be permitted to work on the floor until all in-services are completed. This would include all facility employees and agency Staff): Responsible Person(s) ADON. Status: 98% Clinical Nurses, 100% non-Clinical. Newly hired nursing staff will receive education to include 'Advanced Directives' during the orientation period. Responsible Party: ADON. Status: No New Hires. Review CPR certification for all licensed nurses. Responsible Person(s): HR [Human Resources], DON. Target Date: [DATE]th started. Status: 100% Completed. Conduct MOCK code drills q [every] shift until all licensed nurses have attended and competency is documented. Responsible Person(s) DON, ADON. Target Date: [DATE]. Status: Conducted MOCK code drills Q shift. On-going. Establish detailed 'TIMELINE': Responsible Person(s): ED [Executive Director]. Status: 100% Completed. Root Cause Analysis: Determined that the Internal Tool/Center Practice was not followed prior to starting CPR to ensure residents choice were followed. Responsible Person(s) ED, DON, Medical Director. Target Date: [DATE]th, 2023. Status: 100% Completed. Ad Hoc QAPI with IDT [Interdisciplinary Team] & Medical Director. QAPI Ongoing: DNRO Quality Reviews. Social Services and ED will conduct. Findings of these Quality Reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly. Responsible Person(s) ED, DON, Medical Director. Target Date: [DATE]. Status: 100% Completed. Decision: Reportable Event (Immediate, 5 Day, Adverse). Responsible Person(s) ED, DON. Target Date [DATE]. Status: The Initial Report Completed. The investigation started. Review RTH [Return to Hospital] and Death medical records x previous 3 months to audit code procedures. Responsible Person(s) DON. Status: 100% Completed. Full census wide quality review performed of code status. Responsible Person(s) ED, SSD [Social Service Director], DON. Target Date: [DATE]. Status: 100% Completed. Staff Interviews conducted for anyone involved. Document on 'Witness Statements'. Responsible Person(s): ED, DON. Target Date: [DATE]. Status: 100% Completed. Establish DNR list from full chart review. Responsible Person(s): ED, DON, SSD. Status: 100% Completed. Complete and validate DNRO Quality Review. Responsible Person(s): ED, SSD. Status: 100% Completed. Weekend/After Hours Admissions & Chart Audit Compliance Tool. Responsible Person(s) DON. Target Date: [DATE]. Status: 100% Completed. Agency Staff Education/Orientation Compliance Process. Responsible Person(s): DON/Staff Coordinator. Target Date: [DATE]. Status: On-going. Review of the audits for residents' advanced directives documented 100% of the residents' advanced directives were audited dated [DATE] for a total of 102 residents. Review of the current employees' roster did not document Staff B, RN as an active employee. Review of the do not return list documented Staff A, LPN and Staff C, LPN on the list. Review of the in-service sign in sheet dated [DATE] documented [Staff B's name] received training on Nurse Practice Act/Scope of Practice with summary of training sessions: Be sure to know your nursing scope of practice @ all times. You can find your Care Plans, abuse, neglect, [NAME] Pointe has an admission process that includes all nurses (initially the admitting nurse) assistance to thoroughly review the chart and put chart together. You can use the to Nursing Resource Binder located @ each nurses station to guide you through the process. This is a 24 hr. facility - pick up where left off. All physician orders must be carried out appropriately including advanced directives/code status. Two nurses will verify code status during a code blue.: Review of the QAPI Five Whys Tool For Root Cause Analysis dated [DATE] documented: Problem Statement: CPR preformed on Resident with DNR in place. Why? Advanced Directives not followed. Why? Code status discrepancy between PCC and paper chart. Why? DNR form not able to be located in resident's chart. Why? Resident chart not assembled appropriately. Why? Internal admission process failure. Root Cause(s) 1. Internal admission process failure. 2. Not abiding to facility internal practice and processes in handling of Admissions processes. 3. Orientation and staff education for agency. Review of the CPR Certification audits for licensed staff for the period of [DATE] through [DATE] documents audits were conducted daily for all licensed nursing staff for a 22 of 22 licensed staff. Review of the CPR Certification of Agency staff documented 16 agency staff were audited for up-to-date CPR and were audited daily for the period of [DATE] to [DATE]. Review of the in-service sign in sheet titled, Florida DNR dated [DATE] documented the administrative staff signed as having attended the training to include the Dietary, CDM/CFPP [Certified Dietary Manager, Certified Food Protection Professional], Staffing Coordinator, MDS, Social Services Director, Medical Records Director, Assistant Director of Nursing, Director of Maintenance, two Unit Managers, AIT [Associate Information Technology], the Account Manager for Housekeeping; 17 signed in as having attended the training. Review of the in-service sign in sheet titled, Abuse, Neglect, Exploitation, Misappropriation dated for the period of [DATE] through [DATE] 113 staff signed as having attended the training r/t the facilities P & P [Policy and Procedures] tilted, Abuse, Neglect, Exploitation, Misappropriation to include licensed staff, administrative staff, housekeeping staff, laundry staff, therapy staff, certified staff, and agency staff. Review of the in-services sign in sheets titled, Advanced Directives and Florida DNR dated [DATE] with training of the P & P and chart organization documented 85 staff members signed as having attended the training. Consisting of 10 RNs, 21 CNAs, 13 LPNs, 1 PCA, BOM, 9 housekeeping staff, 2 social services, Dietary Manager, MDS, medical records, Director of Maintenance, AIT, Admissions, 6 to include the Activities Director, Central Supply, 11 Dietary personnel, 2 smoking monitors, receptionist, and 1 clerical. Review of the agency staffing Post Test-Florida DNRO to include the Orientation Checklist: Agency Staff and Full or Part Time Contractors (Agency Nursing Staff, Therapy, Dietary, Housekeeping, and Laundry) dated [DATE] through [DATE] documented 98 staff completed the post-test. Review of the Code Blue Quality Assurance Drills documented [DATE] drills were conducted on the ,d+[DATE]-,d+[DATE] shift and the ,d+[DATE] shift. Dated [DATE] drills were conducted on the 7-,d+[DATE]-11 and ,d+[DATE] shifts. Dated [DATE] a drill was conducted on the 7-,d+[DATE]-11 shift. Review of the Timeline dated [DATE] documented the sequence of events related to the incident for Resident #1 for the period of time of the start of the event to the notification family and removal of the deceased . Review of the interviews and witness statements documented for the period of [DATE] through [DATE] Staff A, LPN, Staff B, LPN, Staff C, LPN, and additional staff were interviewed and completed witness statements. Interviews were conducted on [DATE] to [DATE] with 1 Patient Care Assistant, 7 CNAs to include 2 agency CNAs, 9 LPNs to include 3 agency LPNs, 3 RNs to include 1 agency RN, 1 housekeeper, the Rehabilitation Director, Business Office Manager, Assistant Social Services Director, Social Services Director, and Director of Maintenance for a total of 26 interviews from three shifts to verify participation in training, understanding of training, with explanation of the implementation of Advance Directive location and what actions would be taken in the future if the Advance Directive was documented in PCC, but not in the hard copy record. Review of the Weekend/After Hours Admissions & Chart Audit Compliance Tool documented audits were conducted for four week-end admissions dated [DATE]. Review of a new admission record provides a Check List guide for the chart organization. Review of the seven new admissions since [DATE] found the records were organized and provided for advanced directives. Review of the Admission/Discharge To/From Report for the period of [DATE] through [DATE] documented there were three deaths that occurred in the facility, and each was investigated. There were no deaths that occurred in the facility since [DATE]. Review of Human Resources records for the period of [DATE] through [DATE] revealed there were no new hires for this period of time. Review of the Ad Hoc Quality Assurance Performance Improvement Meeting dated [DATE] documented the Administrator, DON, Medical Director, Social Services, Activities Director, Dining/Nutrition, MDS [Minimum Data Set], Plant Services, Business Development, Housekeeping/Laundry, Business Office, and six additional attendees signed in as having attended the meeting. Reason for Ad Hoc Meeting: this space is blank. Opportunity for Improvement: Re-Implementation of all company policies. Newly hired nursing staff will receive education to include 'Advance Directives' during the orientation period. Conduct MOCK code drills Q shift. Educate staff-Following Physician orders & following Care Plans educate Licensed staff regarding Nurse Practice Act. Data: Not abiding to company policy and procedures in the Admission process of new admits. Analysis (Root Cause Analysis) PCC (EMAR System) was noted with an order for DNR. The yellow Florida DNR form was not found in the residents chart. Because the Florida DNR form was not in the chart, CPR was initiated on the resident. Plan: In-servicing of all departments and staff. (Please refer to Performance Improvement Plan of [DATE] which is attached to QAPI Ad hoc). Responsible Team Members: Clinical Team: DON, ADON, Unit Managers, Nurses, CNAs, Admissions Team. Housekeeping Team, Dietary Team, Social Services Team, Maintenance Team Administration.

Based on record review, interview, and the facility policy and procedure review, the facility failed to act in accordance with a resident's advance directive and to honor the resident's wishes of Do Not Resuscitate when found unresponsive and without respirations or a pulse for 1 of 2 residents, Resident #1. This has the potential to affect 45 residents with advance directives of do not resuscitate. The findings include: Review of the medical record for Resident #1, [AGE] year-old, revealed an admitted into the facility on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Florida Living Will, recorded and signed by Resident #1 on [DATE], listed Resident #1's daughter as her Health Care Surrogate and Power of Attorney. Review of Resident #1's Florida Do Not Resuscitate Order revealed it was signed by Resident #1's daughter on [DATE]. Review of Resident #1's care plan, dated [DATE] read, Resuscitate: No CPR/DNR [cardiopulmonary resuscitation/do not resuscitate]. Goal: To follow the resident's advanced directive. Review of nursing progress notes/change in condition, dated [DATE] at 8:30 AM, revealed Resident #1 was found unresponsive, CPR was initiated. Noted to have gurgling with thready pulse. Resident expired at 9:00 AM. During an interview on [DATE] at 10:00 AM, the Administrator confirmed on [DATE], the date of the event, Resident #1's nurses did not follow protocol and started CPR prior to checking the resident's code status. They later discovered Resident #1 was a DNR. During an interview on [DATE] at 9:50 AM, Staff B, Licensed Practical Nurse (LPN), stated, I was working down the hall from [Staff A's name] the day [Resident #1's name] passed away. I heard [Staff A's name] yell 'I have a code blue.' I ran down to give assistance. [Staff A's name] said [Resident #1's name] was a full code and asked that CPR begin immediately. I went over and verified there were no breath sounds and I checked for a pulse. There was no pulse and no breath sounds. I began chest compressions. I completed three sets of 30 chest compressions when [Staff C's name] came in to give assistance. [Staff C's name] completed 30 sets of compressions while I assisted with the Ambu bag providing air/O2 [oxygen] to the resident. At the end of the 30 compressions, both [Staff C's name] and I heard gurgling sounds coming from the resident. We stopped CPR and thought we felt a thready pulse, so we sat her upright and began to suction her mouth. That is when another staff came in and stated the resident had a DNRO in place. At that time EMS [Emergency Medical Services] arrived in the hallway. CPR was not continued. During an interview on [DATE] at 9:31 AM, Staff C, LPN, stated, I responded to a Code Blue on [DATE]. [Staff A's name] directed me to assist with CPR in [Resident #1's name] room. I assisted with CPR until we began to hear gurgling sounds coming from the resident's throat, and a thready pulse was identified. The resident was sat up for suctioning. A nurse came to the door and announced [Resident #1's name] had a DNRO. I did not check the chart. I should have checked the chart prior to assisting with CPR, but got caught up in the business of the situation and did not follow protocol. During an interview on [DATE] at 11:35, the Social Services Director (SSD) stated, residents' advance directives are reviewed and discussed upon admission and during care plan meetings. The resident's code status/DNR is kept in the resident's chart under the advance directive tab. There is a DNR book that is kept on the units. Resident #1's last care plan meeting was [DATE], which her daughter attended. Resident #1's advance directive was do not resuscitate. The Social Services Director stated to her knowledge Resident #1's advance directive did not change. During an interview on [DATE] at 8:39 AM, Staff E, Certified Nursing Assistant (CNA) stated, she was familiar with Resident #1. On [DATE] I notified her nurse [Staff A's name] that [Resident #1's name] did not look right and the nurse had come in the room and called a code. During an interview on [DATE] at 10:55 AM Staff F, MDS (Minimum Data Set) Coordinator stated, I was in my office the morning of [DATE] when someone came and told me there was a Code Blue on the unit. I walked over to the unit to assist. When I got over to the unit, [Staff A's name] was at the desk copying paperwork from the resident's chart. I asked what I could do to help. She told me I could help copy some of the chart that would need to go to the hospital with the resident. As I was going through the chart, I came across the DNRO for this resident and told [Staff A's name] and went over to the resident's room and told the nurses in the room that the resident was a DNR. Review of the statement handwritten by Staff A, RN on [DATE] read, On Sept. 24, 2021 at 8:30 AM I gave [Resident #1's name] her AM meds, crushed with liquid med into her mouth. Res. Not swallow, did try to say something. So I swept med and milk out of her mouth. I was afraid she might have some still in her throat. I looked for a suction machine and couldn't find one. I call [Staff C's name] to bring one. She did. The CNA came out and said she was having trouble breathing. I called code blue, staff brought in the cart I called 911 and started a change of condition to send with her. I got her chart and looked in the front and saw the DNR. Another nurse was already coping paperwork- when I realized she had a DNR. I yell to staff to not start code. I had automatically thought her daughter, who was there twice a day feeding her and very concerned with her wouldn't have gotten a DNR. I again called 911 to tell them she had the DNR. She said she would tell them. [Staff B and C's names] came out, said she had no vital signs. I called the daughter and told her that her mother expired. Review of the policy and procedure titled, Advanced Directives, dated [DATE] and last revised on [DATE], read, The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. Process: 1. Upon admission, Social Service Director or Business Development Coordinator/designee will: . b) Determine whether the resident has an advance directive and, if not, determine whether the resident wishes to establish an advance directive . 4. Upon completion of Advanced Directives Discussion Document, Social Services or nurse will notify the Physician of the resident's wishes and procure a state approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record. Review of the policy and procedure titled, Florida Do Not Resuscitate (DNR), dated [DATE], read, The center will follow Florida law regarding obtaining and honoring Do Not Resuscitate orders. Procedure: . 2. When the resident has executed a DNRO, the form shall be printed on yellow paper and have the words Do Not Resuscitate Order printed in black and displayed across the top of the form. 3. The properly executed DNRO will be placed in the resident's medical record. Review of the Performance Improvement Plan (PIP) dated [DATE] read: Identified Area for Assessed Improvement (A): Not following Advanced Directives. Plan (P) What is Being Done? Ensure all residents Advanced Directives are followed. Action Steps To Implement Plan (I): 1. File immediate report. Objective Measures To Evaluate Plan Effectiveness (E): Ensure all federal reporting is completed timely. Person (s) Responsible For Oversight: ED [Executive Director/Administrator]. 2. Audit Advanced Directives in facility to ensure all match today. Objective Measures To Evaluate Plan Effectiveness (E): Advanced Directive audit verified by ED & DCS. Person (s) Responsible For Oversight: SSD/ED/DCS. 3. Perform Advanced Directive audit weekly. 4. Education of all staff to ensure P & P is followed on advanced directives-with post test. Objective Measures To Evaluate Plan Effectiveness (E): Post-test for Advanced Directives. Person (s) Responsible For Oversight: DCS/ADCS [Director of Clinical Services/Assistant Director of Clinical Services]. 5. Code blue drills every shift within 24 hours. 6. Code blue drills 3 times a week on alternating shifts x 1 month. 7. Audit all care plans to ensure all residents have an Advanced Directives care plan & they are accurate for the resident. 8. AD HOC QAPI with Medical Director. Objective Measures To Evaluate Plan Effectiveness (E) Care Plan audit weekly to ensure Advanced Directives are correct in Residents Care plan. Person (s) Responsible For Oversight: MDS/DCS/ADCS/ED. Priority Level: High. Date To Be Complete: Education [DATE]. Audits-on going. Review of the Performance Improvement Plan Date: [DATE] reads: Objective & Goal: Immediate correction and attaining and maintaining regulatory compliance regarding Advanced Directives Center wide. Initiative: 1. Immediate corrections to ensure safety of affected Patient(s)/Resident(s). 2. Identification of any other Patient(s)/Resident(s) who may be affected or at risk. 3. Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. Action Steps: Full census wide quality review performed of code status. Responsible Person(s): ED/SSD/DON. Target Date: [DATE]. Status: Completed. Action Steps: Staff Interviews conducted for anyone involved. Document on 'witness Statements'. Responsible Person(s): ED/DON. Target Date: [DATE]. Status: Completed. Action Steps: Establish DNR list form full chart review. Responsible Party(s): ED/DON/SSD. Target Date: [DATE]. Status: Completed. Action Steps: Complete and validate DNRO Quality Review. Responsible Person(s): ED/SSD. Target Date: [DATE]. Status: Completed. Educate staff regarding Policy/Procedure: Advanced Directives (SS-124). Policy/Procedure CPR (N302). Responsible Person(s): ED/ADON/Designee. Target Date: [DATE] [completed [DATE]]. Status: On-Going. Educate Staff regarding Policy/Procedure: Abuse/Neglect/Resident Rights. Responsible Person(s): ED/ADON/Designee. Target Date: [DATE] [completed [DATE]]. Status: On-Going. Action Steps: Educate staff regarding crash cart/Resident Rights. Responsible Person(s): ED/ADON. Target Date: [DATE] [completed [DATE]]. Status: On-Going. Action Steps: Educate Licensed Nursing staff regarding Nurse Practice Act (Unprofessional Conduct). Responsible Person(s): ED/ADON. Target Date: [DATE] [completed [DATE]]. Status: In Progress. Action Steps: Newly hired nursing staff will receive education to include 'Advanced Directives' during the orientation period. Responsible Person(s): ADON. Target Date: On-going. Status: On Going. Action Steps: Review CPR certification for all licensed nurses. Responsible Person(s): HRC. Target Date: [DATE]. Status: Completed. Action Steps: Conduct MOCK code drills every shift until licensed nurses have attended and competency is documented. Responsible Person(s): DON/ADON. Target Date: [DATE]. Status: On Going Monthly all 3 shifts. Action Steps: Audit all 'Crash Carts': equipment/supplies available and properly functioning. Code Blue Documentation readily available. Responsible Person(s): ADON/Unit Managers. Target Date: [DATE]. Status: Completed. Action Steps: Establish detailed 'TIMELINE'. Responsible Person(s): ED. Target Date: [DATE]. Status: Completed. Action Steps: Root Cause Analysis. Responsible Person(s): ED/DON/Medical Director. Target Date: [DATE]. Status: Completed. Action Steps: Ad Hoc QAPI with IDT & Medical (Medical Director signature). QAPI Ongoing: DNRO Quality Reviews. Social Services and ED will conduct. Findings of these Quality Reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly. Responsible Person(s): ED/DON/Medical Director. Target Date: [DATE]. Status: Completed. Action Steps: Decision: Reportable Event. Responsible Person(s): ED. Target Date: [DATE]. Status: Completed. Action Steps: Notifications. Responsible Person(s): ED. Target Date: [DATE]. Status: Completed. Action Steps: Review RTH and Death medical records x previous 3 months to audit code procedures. Responsible Person(s): ADON/Designee. Target Date: [DATE]. Status: On Going/In Progress. Relating to staff competency, the following has been implemented: As of [DATE] staff members will be educated prior to assuming their shifts. Completed: Nursing Staff have been reeducated by the Director of Nursing/Assistant Director of Nursing or Regional Director of Nursing regarding the process of checking and following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of current staff members will be educated prior to assuming their shifts. Completed and On-Going: Nursing Staff have been reeducated by the Director of Nursing/Assistant Director of Nursing or Regional Director of Nursing by performing Mock Code Drills. Current staff members will be reeducated prior to assuming their shifts. Newly hired nursing staff members will receive education and training with return demonstration, during the orientation period upon hire, by the DON/ADON/SDC. Newly hired Licensed Nursing staff members' CRP certifications will be verified upon hire by the DON/ADON/SDC upon hire to ensure it is current, prior to providing patient care. Review of the implementation of the Performance Improvement Plan revealed: Review the Immediate Report revealed it was submitted on [DATE]. Review of the DNR Chart Audit and resident roster dated [DATE] revealed 76 of the 76 residents' charts were reviewed and completed on [DATE]. Review of the Advanced Directive ongoing audits and resident roster revealed dated [DATE] 77 of 77 residents' charts were reviewed. Review of the education of all staff to ensure P & P is followed on advanced directives with post test revealed dated [DATE] and [DATE] titled, Education In-Service Attendance Record Topic: CPR/DNR/Code Status, Presented by: [Administrator's name], Summary of training session: Review P & P of code status. Code status review. Calling code status. Staff responsibility for code status. The sign in sheets and comparison to the current employee roster of 66 employees revealed 59 currently employed staff completed the training and the post test. Review of the Code Blue Quality Assurance Drills dated [DATE] revealed a mock drill was conducted to encompass the ,d+[DATE] and ,d+[DATE] shifts during shift change at 10:55 PM. Eight staff signed to indicate participation in the mock drill. A mock drill was conducted on [DATE] at 2:00 PM. Eight staff signed to indicate participation in the mock drill. Review of the Code Blue Quality Assurance Drill ongoing audits revealed dated [DATE] at 9:30 AM six staff signed to indicate participation in the mock drill. Dated [DATE] at 3:45 PM six staff signed to indicate participation in the mock drill. Dated [DATE] at 10:00 AM eight staff signed to indicate participation in the mock drill. Review of the Care Plan Audits revealed dated [DATE]; 76 of 76 residents' care plans were audited per attestation by the Social Service Director. Review of a sample of ten residents' facility medical records was conducted to verify the completion of the audit. Verification of the employee roster revealed the facility has not conducted new hire orientation between the period of [DATE] through the survey ending date of [DATE]. Review of the Timeline Investigation read: [Resident #1's name]. Date of Event: [DATE]. Type of Event: Code Status. Date: [DATE]. Time: 830a-9-a. Event: Nurse attempted to administered medication to resident. CNA reported that resident didn't appear well to nurse. Nurse assessed resident and began suctioning. Resident's mouth was swept out removing medication and debris. Time: 9a. Event: Code Blue called by nurse. Chest compressions and CPR initiated by nurses. EMS contacted. CPR stopped when it was discovered that resident was a DNR. EMS did not enter the room and did not take the body upon leaving. Review of the Ad Hoc Quality Assurance Performance Improvement Meeting revealed, Start Time: 1:30 PM. Date: [DATE]. Reason for Ad Hoc Meeting: Advanced directives - not followed - Abuse/neglect. Opportunity for Improvement: 1. Advanced directives - following protocol/procedure regarding DNR/full code. 2. Abuse/neglect/resident rights. Data (Assess Current Situation-what were the results/trend): 1. No trend identified - isolated incident on [DATE] (see attached P/P). Analysis (root Cause Analysis) 1. Root cause - determined that P & P not followed prior to starting CPR to ensure residents choices were followed. Plan: 1. Educate staff - abuse/neglect - advanced directives - crash carts. 2. Audit code statuses. 3. Mock drills. 4. Reviewed plan of correction. Responsible Team member(s). ED. DON. ADON. IDT. SSD. Signed and dated by the Administrator on [DATE]. Review of the QAPI schedule revealed the next QAPI meeting is scheduled for [DATE]. Review of the agenda revealed the finding of the audits will be evaluated.