Every finding on record at Aviata at Bryan Dairy

Based on review of the facility policy, interviews and record review, the facility failed to ensure advanced directives were implemented in a timely manner and failed to ensure the residents' wishes were honored related to full code status for one resident (#5) of three residents sampled. On [DATE] at 1:09 a.m., Staff B, Licensed Practical Nurse (LPN) obtained Resident #5's oxygen saturation level (Sp02) which was 84% with supplemental oxygen by nasal cannula. According to emedicinehealth oxygen saturation levels below 95% are considered abnormal, and the brain may be affected when SpO2 levels drop below 80 to 85 percent. https://www.emedicinehealth.com/what_is_a_good_oxygen_rate_by_age/article_em.htm retrieved on [DATE]. Staff B, LPN did not notify the medical provider or document interventions regarding the change in condition. At approximately 3:15 a.m., Staff B, LPN found Resident #5 pulseless and not breathing. The staff member summoned Staff I, Certified Nursing Assistant (CNA) and Staff C, LPN to the resident's room. Staff C, LPN assessed Resident #5 and confirmed the resident did not have a pulse or respirations. Staff B, LPN and Staff I, LPN reviewed Resident #5's electronic health record (EHR) for resuscitation orders and the paper chart for a Do Not Resuscitate (DNR) form. Staff C, LPN stated Resident #5 had an order for full code and confirmed there was no DNR form in the chart. Staff B, LPN reviewed the full code order and failed to act on it. Staff B, LPN said he was confused because on [DATE], when Resident #5 was readmitted from the hospital, the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Agency for Healthcare Administration (AHCA) form, 3008), documented DNR status for the resident. Staff B, LPN called the administration, hospice, and Resident #5's medical team, which delayed chest compressions and ventilation for approximately 45-60 minutes. This failure created a situation in which Resident #5's wishes for cardiopulmonary resuscitation (CPR) were not honored, resulting in death, which resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #5's admission record showed an initial admission date of [DATE], and a readmission of [DATE], with diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension. A review of Resident #5's order summary report showed, as of [DATE], Full Code order, dated [DATE]. A review of Resident #5's annual minimum data set (MDS), dated [DATE], section C- cognitive pattern, showed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Section B- hearing, speech, and vision shows the resident can express ideas and wants. Section Q- participation in assessment and goal setting showed active participation in the assessment process. A review of Resident #5's care plan showed a focus area of advanced directive full code, initiated on [DATE], created by the Social Worker. The intervention for this care plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code. A review of Resident #5's social service progress note dated [DATE] showed .patient wishes to continue with full code status . A review of Resident #5's progress notes showed the following:- On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified. - On [DATE] at 7:30 p.m. authored by Staff A, LPN, [Resident #5] was seen and admitted to hospice today. Code changed to DNR waiting for paperwork . - On [DATE], showed a BIMS summary score of 15 During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's electronic health record (EHR) for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the Director of Nursing (DON) about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/Unit Manager (UM) because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events. During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when EMS was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code. During a telephone interview on [DATE] at 11:00 a.m. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. On [DATE] at approximately 3:15 a.m. Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She there was, Confusion about the code status. During an interview on [DATE] at 11:46 a.m. Staff H, LPN/UM, said on [DATE] at 4:05 a.m. Staff B, LPN, called and told her Resident #5, Expired 45 to 50 minutes ago. Staff H, LPN/UM, said two nurses are expected to review the residents' orders and check the chart for a DNR form. If there is a discrepancy staff are expected to follow physician's orders. We expect the Code Blue Documentation Tool [form] to be completed and signed by all the staff members who participated. Nurses have been instructed to complete a progress and/or a change in condition note. During an interview on [DATE] at 12:08 p.m., the NHA said she contacted the emergency medical service (EMS) provider who responded to Resident #5's emergency event on [DATE]. She said, according to their report, on [DATE] at 4:17 a.m. the facility notified EMS, at 4:25 a.m. EMS arrived at the facility, and at 5:05 a.m. Resident #5 was pronounced onsite. On [DATE] at 4:01 p.m., an interview was conducted with the NHA, Assistant NHA, DON and RNC. The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form and MD order they are to initiate CPR, and he should notify the doctor and hospice. A review of the facility policy titled Advanced Directives, effective [DATE] and a revision date of [DATE], showed the following: Policy: The center will abide by state and federal laws regarding advanced directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. 4. Upon completion of the 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. 5. Any changes to Advanced Directives will require a new Advanced Directives Discussion Document to be completed and place in the medical record. The previous document to be filed in the thinned record. 5. Upon notification from resident and/or resident representative of the desire to change or revoke an advance directive, or any issue concerning the capacity, the physician will be notified, and the medical record will be modified accordingly. The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending the facility's investigation.- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the recommendations made from the root cause analysis. The team members in attendance were the medical director, executive director, director of nursing, and the assistant administrator.- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses are 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.- From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on interviews and record reviews, the facility failed to protect the resident's right to be free from deprivation of goods and services by failing to ensure timely Cardiopulmonary Resuscitation (CPR) was provided, per the resident's wishes, and failed to notify the physician of a change in condition for one resident (#5) out of three residents sampled for advance directives.On [DATE] at 1:09 a.m., Staff B, Licensed Practical Nurse (LPN) obtained Resident #5's oxygen saturation level (Sp02) which was 84% with supplemental oxygen by nasal cannula. According to emedicinehealth oxygen saturation levels below 95% are considered abnormal, and the brain may be affected when SpO2 levels drop below 80 to 85 percent. https://www.emedicinehealth.com/what_is_a_good_oxygen_rate_by_age/article_em.htm retrieved on [DATE]. Staff B, LPN did not notify the medical provider or document interventions regarding the change in condition. At approximately 3:15 a.m., Staff B, LPN found Resident #5 pulseless and not breathing. The staff member summoned Staff I, Certified Nursing Assistant (CNA) and Staff C, LPN to the resident's room. Staff C, LPN assessed Resident #5 and confirmed the resident did not have a pulse or respirations. Staff B, LPN and Staff I, LPN reviewed Resident #5's electronic health record (EHR) for resuscitation orders and the paper chart for a Do Not Resuscitate (DNR) form. Staff C, LPN stated Resident #5 had an order for full code and confirmed there was no DNR form in the chart. Staff B, LPN reviewed the full code order and failed to act on it. Staff B, LPN said he was confused because on [DATE], when Resident #5 was readmitted from the hospital, the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Agency for Healthcare Administration (AHCA) form, 3008), documented DNR status for the resident. Staff B, LPN called the administration, hospice, and Resident #5's medical team, which delayed chest compressions and ventilation for approximately 45-60 minutes. This failure created a situation in which Resident #5's wishes for CPR were not honored, resulting in death, which resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #5's admission record showed an initial admission date of [DATE], and a readmission of [DATE], with diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension. A review of Resident #5's order summary report showed the following:- As of [DATE] Full Code order, dated [DATE].- Pulse oximetry (ox) every shift for monitoring, dated [DATE].- Respiratory: Oxygen-via Nasal Canula (NC) continuous every shift for (oxygen) 02 dated [DATE].A review of Resident #5's care plan showed a focus area of advanced directive full code, initiated on [DATE], created by the Social Worker. The intervention for this care plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed.A review of Resident #5's annual minimum data set (MDS), dated [DATE], section C-cognitive pattern, showed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Section B- hearing, speech, and vision shows the resident can express ideas and wants. Section Q- participation in assessment and goal setting showed active participation in the assessment process.A review of Resident #5's progress notes showed the following:- On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified.- On [DATE] at 7:30 p.m. authored by Staff A, LPN, [Resident #5] was seen and admitted to hospice today. Code changed to DNR waiting for paperwork .- On [DATE], showed a BIMS summary score of 15.- On [DATE] showed Resident #5 was admitted to the facility from a local hospital.- On [DATE] social service progress note showed, .patient wishes to continue with full code status .A review of Resident #5's AHCA form, 3008, section H, advanced care planning section showed Resident #5's had DNR status. Review of Resident #5's orders did not show physician orders for DNR status. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code.A review of Resident #5's hospice patient care notes, dated [DATE], showed, Bedside visit with patient, [family member] on speaker phone. Pt [patient] is unresponsive s/s [signs and symptoms] [of] imminence per [doctor].A review of Resident #5's hospice protocol for, Patients Enrolled in Hospice Medicare Benefit form, showed the following, .please notify [name] Hospice if .changes occur in the patient's physical or mental status.During an interview on [DATE] at 12:25 p.m., Staff A, LPN said on [DATE] at approximately 7:00 p.m., during the shift change report, she told Staff B, LPN Resident #5 was a full code until a signed DNR form was received.During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's EHR for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the DON about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/Unit Manager (UM) because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events.During a telephone interview on [DATE] at 3:20 p.m., Staff D, LPN, said when she entered Resident #5's room on [DATE] Staff B, LPN, was performing chest compressions and asked if someone, Would take over. Staff D, LPN said she assisted with compressions until the Emergency Medical Technicians (EMT) arrived. On [DATE] at 4:01 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Assistant NHA, DON, and Regional Nurse Consultant (RNC) to review the facility's initial investigation of the reported event for Resident #5. The NHA reviewed three witness statements provided by Staff C, LPN on [DATE], [DATE]. and [DATE]. The NHA reported, Staff C, LPN reported on [DATE] at approximately 3:50 a.m., Staff B, LPN said there was a change in Resident #5's condition and requested her to check the resident. Staff C, LPN verified there was breathing or a heartbeat, checked the EHR for an order and the paper chart for a DNR form, and determined Resident #5 was a full code. Staff C, LPN told Staff B, LPN, We needed to start a code blue, and Staff B, LPN was argumentative. Staff B, LPN, told Staff C, LPN, Resident #5's code status was DNR because it was on the AHCA 3008 form, dated [DATE], sent from the hospital. Staff C, LPN told Staff B, LPN, to call the DON and later Staff H, LPN/UM because she would know Resident's 5's code status. Staff C, LPN overhead paged code blue in Resident #5's room, called 911, and entered the resident's room to start compressions. At approximately 4:20 a.m., she left Resident #5's room to prepare for EMS's arrival. Staff C, LPN reported a code blue documentation tool was not completed for Resident #5. The NHA reported, Staff B, LPN reported on [DATE] at 2:00 a.m., during rounds, Resident #5 was awake, breathing and receiving oxygen by nasal cannula, and no abnormality was observed. At 3:55 a.m., Staff B, LPN, found Resident #5's body lifeless and asked Staff C, LPN to evaluate Resident #5. After evaluating Resident #5, Staff C, LPN told him Resident #5 was a full code and to start CPR. Staff B, LPN called the DON because a DNR form was not found in Resident #5's chart. After the call with the DON, Staff B, LPN called Staff H, LPN/UM because he was confused about Resident #5's code status. He reported Staff H, LPN/UM said Resident #5 was a full code and to start CPR. Staff C, LPN called 911 while Staff D, LPN assisted with chest compressions and Staff G, CNA provided ventilation. The NHA reported, Staff G, CNA reported on [DATE] at 4:00 a.m. there was an overhead page to go to Resident #5's room. Resident #5 was not responsive, and staff was trying to find out if she was a full code. Staff G, CNA reported she asked Staff I, CNA, who was assigned to Resident #5, to assist with postmortem care. Staff C, LPN said they must start a code and Staff B, LPN, gave her the Ambu bag to provide ventilatory support. Staff G, CNA reported compressions were started between 4:15 a.m. and 4:45 a.m. Staff G, CNA said postmortem care was provided for 10-15 minutes before CPR was started.During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted, and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when EMS was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code.During a telephone interview on [DATE] at 11:00 a.m., Staff I, CNA said on [DATE] at approximately 11:15 p.m. she checked on Resident #5. She said she offered Resident #5 water and emptied the urine bag. At 1:00 a.m., Staff I, CNA said, She [Resident #5] was asleep, her chest was moving, she was breathing. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. She said at approximately 3:15 a.m., Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She said there was, Confusion about the code status. During this time Staff I, CNA said another CNA, she could not recall their name, assisted with checking Resident #5's oxygen saturation level and temperature.On [DATE] at 4:01 p.m., an interview was conducted with the NHA, Assistant NHA, DON and RNC. The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form and MD order they are to initiate CPR, and he should notify the doctor and hospice.During an interview on [DATE] at 11:46 a.m., Staff H, LPN/UM said on [DATE] at 4:05 a.m. Staff B, LPN, called and said Resident #5 had expired 45 to 50 minutes earlier. Staff H, LPN/UM said she screamed and told Staff B, LPN, Resident #5 was a full code and to start CPR. Staff H, LPN/UM said two nurses are expected to review the residents' orders and check the chart for the DNR form. She said if there was a discrepancy, staff are expected to follow physician's orders. In reference to Resident #5's oxygenation saturation level of 84%, Staff H, LPN/UM said staff are expected to stabilize the oxygen level, call the doctor, and make changes as ordered. She said Staff B, LPN did not follow the process. Staff H, LPN/UM said a Code Blue Documentation Tool [form] is expected to be completed and signed by all the staff members who participated, and the nursing staff should complete a progress and/or a change in condition note. Staff H, LPN/UM confirmed they did not follow this process.During an interview on [DATE] at 12:08 p.m., the NHA said she contacted the Emergency Medical Services (EMS) provider who responded to Resident #5's emergency event on [DATE]. She said, according to their report, EMS was called on [DATE] at 4:17 a.m. EMS arrived at the facility at 4:25 a.m. On [DATE] at 5:05 a.m. Resident #5 was pronounced onsite. During an interview on [DATE] at 2:15 p.m., Staff A, LPN said on [DATE] at approximately 7:00 p.m., she told Staff B, LPN, Resident #5 was on hospice service, and the hospice staff said the resident representative had signed a DNR form. Staff A, LPN said they were waiting for the physician to sign the order. She stated, Resident #5 is full code until the signed DNR form is received.During a telephone interview on [DATE] at 2:30 p.m., Resident's #5's physician said he was her provider for a long time. He said the resident had been declining and chose to be a full code as a, Last ditch effort. During the interview and a review of Resident #5's physician orders, to include discontinued and completed, showed Resident #5 had full code status. The physician said, That's interesting. The physician did not address why there was confusion regarding code status for Resident #5. When asked about Resident #5's oxygen saturation level of 84% on [DATE] at 1:09 a.m., Resident #5's physician said a member of his team or hospice should have been notified. He said as an expectation DNR forms can be completed by the resident's physician or the hospice physician. Resident #5's physician could not confirm if he had signed a DNR form for Resident #5.A review of the facility policy titled, Abuse, Neglect, Exploitation, & Misappropriation, with an effective date of [DATE] and a revision date of [DATE], showed the following: Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. No employee may at any time commit an act of physician, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Neglect is the failure of the center, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to; . Failure to notify a resident's legal representative in the event of a significant change in the resident's physical, mental or emotional condition that a prudent person would recognize. Procedure: . Non-action, results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and humane care and treatment of the resident. A review of the facility's policy and procedure titled Notification of Change in Condition, with a revision date of [DATE], showed the following: Policy: The Center to promptly notify the Patient/ Resident, the attending physician, and the resident representative when there are changes in status or condition. Procedure: The nurse to notify the attending physician and the resident representative (RR)when there is a(n):- significant change in the patient/resident's physical, mental, or psychosocial status. - In the event of an emergency situation, 911 to be called and the attending and the RR to be notified as soon as possible. - The nurse to complete an evaluation of the patient/resident. Document evaluation in the medical record. - Document resident/ patient change in condition on 24-hour report.- Complete SBAR as indicated. A review of the facility policy titled Medical Care/Standards of Practice, with an effective date of [DATE] and a revision date of [DATE], showed the following: Procedure: . Significant changes in medical status are reported to the attending physician. Nursing Services will be responsible for notifying the appropriate physicians, giving emergency care within the scope of their license, . and when appropriate, calling emergency medical services. Basic life support and/or first aid measures needed to minimize any deterioration of the resident's condition will be provided prior to transferring to an acute care hospital.A review of the facility's policy and procedure titled oxygen therapy, with a revision date of [DATE], showed the following: Policy: Oxygen therapy is the administration of a Fi02 (fraction of inspired oxygen) greater than 21% by means of various administration devices to: Raise the resident's PaO2 (partial pressure of oxygen) to an acceptable baseline using the lowest Fi02 . Procedure: Physician's orders for oxygen therapy shall include- Administration modality, Fi02 or liter flow, and Continuous or PRN .Documentation shall include: . Liter flow or Fi02 .A review of the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE], showed the following: 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 event of cardiac arrest, immediately call for assistance. a. Two licensed nurses are to verify: Resident identificationb. Fully executed Florida Do Not Resuscitate Order (DH1896), located in the advanced directive section of the medical record. e to 2. Use the paging system to call Code Blue to Room Number or location of the event three times. 3. In the absence of a fully executed Florida Do Not Resuscitate Order (DH1896), the facility will immediately begin CPR. 4. Will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: a. The resident responds b. Notify the physician and the resident representative/ legal representative. c. Document in the medical record. A review of the facility policy titled Advanced Directives, effective [DATE] and a revision date of [DATE], showed the following: Policy: The center will abide by state and federal laws regarding advanced directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. 4. Upon completion of the 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. 5. Any changes to Advanced Directives will require a new Advanced Directives Discussion Document to be completed and place in the medical record. The previous document to be filed in the thinned record. 5. Upon notification from resident and/or resident representative of the desire to change or revoke an advance directive, or any issue concerning the capacity, the physician will be notified, and the medical record will be modified accordingly. A review of the facility policy titled Resident Rights, effective [DATE], showed the following: Policy: It is the policy of The Company to: 1. Make residents and their legal representatives aware of residents' rights. 2. Ensure that residents' rights are known to staff. 5. Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations. The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending the facility's investigation. - An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the recommendations made from the root cause analysis. The team members in attendance were the medical director, executive director, director of nursing, and the assistant administrator.- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses are 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.- From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on review of the facility policy, interviews and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR), was implemented in a timely manner and failed to ensure the residents' wishes were honored related to full code status for one resident (#5) of three residents sampled. Resident #5 had active physician orders for full code status and had expressed wishes to be resuscitated. On [DATE] at 1:09 a.m., Staff B, Licensed Practical Nurse (LPN) obtained Resident #5's oxygen saturation level (Sp02) which was 84% with supplemental oxygen by nasal cannula. According to emedicinehealth oxygen saturation levels below 95% are considered abnormal, and the brain may be affected when SpO2 levels drop below 80 to 85 percent. https://www.emedicinehealth.com/what_is_a_good_oxygen_rate_by_age/article_em.htm retrieved on [DATE]. Staff B, LPN did not notify the medical provider or document interventions regarding the change in condition. At approximately 3:15 a.m., Staff B, LPN found Resident #5 pulseless and not breathing. The staff member summoned Staff I, Certified Nursing Assistant (CNA) and Staff C, LPN to the resident's room. Staff C, LPN assessed Resident #5 and confirmed the resident did not have a pulse or respirations. Staff B, LPN and Staff I, LPN reviewed Resident #5's electronic health record (EHR) for resuscitation orders and the paper chart for a Do Not Resuscitate (DNR) form. Staff C, LPN stated Resident #5 had an order for full code and confirmed there was no DNR form in the chart. Staff B, LPN reviewed the full code order and failed to act on it. Staff B, LPN said he was confused because on [DATE], when Resident #5 was readmitted from the hospital, the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Agency for Healthcare Administration (AHCA) form, 3008), documented DNR status for the resident. Staff B, LPN called the administration, hospice, and Resident #5's medical team, which delayed chest compressions and ventilation for approximately 45-60 minutes. This failure created a situation in which Resident #5's wishes for CPR were not honored, resulting in death, which resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #5's admission record showed an initial admission date of [DATE], and a readmission of [DATE], with diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension. A review of Resident #5's order summary report showed, as of [DATE], Full Code order, dated [DATE]. A review of Resident #5's annual minimum data set (MDS), dated [DATE], section C-cognitive pattern, showed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Section B- hearing, speech, and vision shows the resident can express ideas and wants. Section Q- participation in assessment and goal setting showed active participation in the assessment process. A review of Resident #5's care plan showed a focus area of advanced directive full code, initiated on [DATE], created by the Social Worker. The intervention for this care plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code. A review of Resident #5's social service progress note dated [DATE] showed .patient wishes to continue with full code status . A review of Resident #5's progress notes showed the following: - On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified. During a telephone interview on [DATE] at 11:00 a.m. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. On [DATE] at approximately 3:15 a.m. Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She there was, Confusion about the code status. During an interview on [DATE] at 11:46 a.m. Staff H, LPN/Unit Manager (UM), said on [DATE] at 4:05 a.m. Staff B, LPN, called and told her Resident #5, Expired 45 to 50 minutes ago. Staff H, LPN/UM, said two nurses are expected to review the residents' orders and check the chart for a DNR form and if there was a discrepancy, staff are expected to follow physician's orders. She said the Code Blue Documentation Tool [form] should be completed and signed by all the staff members who participated. Staff H, LPN/UM said nurses have been instructed to complete a progress and/or a change in condition note. During an interview on [DATE] at 12:08 p.m., the Nursing Home Administrator (NHA) said she contacted the Emergency Medical Services (EMS) provider who responded to Resident #5's emergency event on [DATE]. She said, according to their report, EMS was called on [DATE] at 4:17 a.m. EMS arrived at the facility at 4:25 a.m. On [DATE] at 5:05 a.m. Resident #5 was pronounced onsite. During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's EHR for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the Director of Nursing (DON) about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/UM because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events. During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted, and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when EMS was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code. On [DATE] at 4:01 p.m., an interview was conducted with the NHA, Assistant NHA, DON and Registered Nurse Consultant (RNC). The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form follow the MD order to initiate CPR and notify the doctor and hospice. A review of the facility's Policy and Procedure titled Florida Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE], showed the following: 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 event of cardiac arrest, immediately call for assistance. a. Two licensed nurses are to verify: Resident identification. b. Fully executed Florida Do Not Resuscitate Order (DH1896), located in the advanced directive section of the medical record. e to 2. Use the paging system to call Code Blue to Room Number or location of the event three times. 3. In the absence of a fully executed Florida Do Not Resuscitate Order (DH1896), the facility will immediately begin CPR 4. Will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: a. The resident responds. b. Notify the physician and the resident representative/ legal representative.c. Document in the medical record. The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending the facility's investigation.- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the incident, discuss corrective actions and provide recommendations. The team members in attendance were the medical director, executive director/NHA, director of nursing, and the assistant administrator/ANHA .- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses work 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.- From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on record review, interviews, and facility documentation and policy review, the facility failed to ensure nursing staff were competent in identifying resident's code status, providing timely Cardiopulmonary Resuscitation (CPR) and responding to a Change in Condition (CIC) for one resident (#5) out of three residents sampled. On [DATE] at 1:09 a.m., Staff B, Licensed Practical Nurse (LPN) obtained Resident #5's oxygen saturation level (Sp02) which was 84% with supplemental oxygen by nasal cannula. According to emedicinehealth oxygen saturation levels below 95% are considered abnormal, and the brain may be affected when SpO2 levels drop below 80 to 85 percent. https://www.emedicinehealth.com/what_is_a_good_oxygen_rate_by_age/article_em.htm retrieved on [DATE]. Staff B, LPN did not notify the medical provider or document interventions regarding the change in condition. At approximately 3:15 a.m., Staff B, LPN found Resident #5 pulseless and not breathing. The staff member summoned Staff I, Certified Nursing Assistant (CNA) and Staff C, LPN to the resident's room. Staff C, LPN assessed Resident #5 and confirmed the resident did not have a pulse or respirations. Staff B, LPN and Staff I, LPN reviewed Resident #5's electronic health record (EHR) for resuscitation orders and the paper chart for a Do Not Resuscitate (DNR) form. Staff C, LPN told Staff B, LPN that Resident #5 had an order for full code and a there was no DNR form in the chart. Staff B, LPN reviewed the full code order and failed to act on it. Staff B, LPN said he was confused because on [DATE], when Resident #5 was readmitted from the hospital, the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Agency for Healthcare Administration (AHCA) form, 3008, documented DNR status for the resident. Staff B, LPN called the Director of Nursing (DON), Staff H, LPN/Unit Manager (UM), paged hospice, and Resident #5's medical team which delayed chest compressions and ventilation for 45-60 minutes. This failure created a situation in which Resident #5's wishes for CPR were not honored, and resulted in death, and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #5's admission record showed an initial admission date of [DATE], and a readmission of [DATE], with diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension. A review of Resident #5's order summary report showed the following:- As of [DATE] Full Code order, dated [DATE].- Pulse oximetry (ox) every shift for monitoring, dated [DATE].- Respiratory: Oxygen-via Nasal Canula (NC) continuous every shift for (oxygen) 02 dated [DATE].A review of Resident #5's care plan showed a focus area of advanced directive full code, initiated on [DATE], created by the Social Worker. The intervention for this care plan focus is to, Discuss [Resident #5's] advanced directives with his or her representative as needed. A review of Resident #5's Treatment Administration Record (TAR), dated [DATE], showed the pulse ox reading was documented for two out of five opportunities.A review of Resident #5's annual minimum data set (MDS), dated [DATE], section C-cognitive pattern, showed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Section B- hearing, speech, and vision shows the resident can express ideas and wants. Section Q- participation in assessment and goal setting showed active participation in the assessment process. A review of Resident #5's progress notes showed the following:- On [DATE] at 5:35 a.m. authored by Staff B, LPN showed, The resident was coded, resuscitation was performed on her as protocol demands, 911 was called and all needed medical attention was given. At 0500 [5:00 a.m.] the resident was pronounced dead. MD [medical doctor] was notified.- On [DATE] at 7:30 p.m. authored by Staff A, LPN, [Resident #5] was seen and admitted to hospice today. Code changed to DNR waiting for paperwork .- On [DATE] showed a BIMS summary score of 15.- On [DATE] showed Resident #5 was admitted to the facility from a local hospital.- On [DATE] social service progress note showed, .patient wishes to continue with full code status .A review of Resident #5's AHCA form, 3008, section H, advanced care planning section showed Resident #5's had DNR status. Review of Resident #5's orders did not show physician orders for DNR status. A review of Resident #5's care conference participation record and summary, dated [DATE], showed advance directives: full code.A review of Resident #5's hospice patient care notes, dated [DATE], showed, Bedside visit with patient, [family member] on speaker phone. Pt [patient] is unresponsive s/s [signs and symptoms] [of] imminence per [doctor].A review of Resident #5's hospice protocol for, Patients Enrolled in Hospice Medicare Benefit form, showed the following, .please notify [name] Hospice if .changes occur in the patient's physical or mental status.During an interview on [DATE] at 12:25 p.m., Staff A, LPN said on [DATE] at approximately 7:00 p.m., during the shift change report, she told Staff B, LPN Resident #5 was a full code until a signed DNR form was received.During a telephone interview on [DATE] at 5:57 p.m., Staff B, LPN said he had been employed at the facility for more than one year. He said Resident #5, Is one of my residents. The resident was declining, not feeling well, and was evaluated by hospice on [DATE]. Staff B, LPN said on [DATE] his shift began around 7:00 p.m. He said during his first rounds, She [Resident #5] was okay .her speech was not clear. At midnight, Staff B, LPN, said he checked Resident #5's vital signs, she was receiving oxygen at 4 Liters (L) via NC and administered intravenous antibiotics. He said on [DATE] at 2:00 a.m., he observed her chest rise and fall. Staff B, LPN said, At 3:55 a.m., [Resident #5] was not breathing. There was no pulse, nothing. Staff B, LPN called Staff C, LPN to verify his evaluation. Staff B, LPN said he, Consulted the chart and checked the system and found conflicting information. He said, I was trying to get information from someone more superior. He called the DON and was told to call hospice and asked if the resident representative had been notified. Staff B, LPN said, I did not get the answer I wanted and he called Staff H, LPN/UM who told him to, Start CPR. He said he told Staff C, LPN to call the code. Staff B, LPN, said when he entered Resident #5's room the CNAs were getting ready to take care of the body and he does not know who told them to do that. Staff B, LPN said he did not document the time CPR was started or when Emergency Medical Services (EMS) was notified and their arrival time. He said EMS arrived sometime between 4:00 a.m. and 5:00 a.m. Staff B, LPN said Resident #5's order was full code.During a telephone interview on [DATE] at 3:08 p.m., Staff C, LPN said Staff B, LPN, called her to Resident #5's room to check for a pulse and respirations. Staff C, LPN, said she used her stethoscope to confirm Resident #5 did not have a pulse. She checked the resident's EHR for full code orders and the paper chart for a DNR form. Staff C, LPN, found Resident #5 had an order for full code and did not find a DNR form in the chart. Staff C, LPN told Staff B, LPN, We need to run a code, I kept saying we need to run a code. Staff B, LPN told her Resident #5 was a DNR. Staff C, LPN, told Staff B, LPN to call the DON about the situation as, I could not find any paperwork to show Resident #5 was a DNR. After contacting the DON, Staff B, LPN paged hospice and the doctor. Staff B, LPN stated they were waiting for hospice to return their call. Staff C, LPN told Staff B, LPN to call Staff H, LPN/UM because, She will know Resident #5's code status. Staff C, LPN said she overhead paged code blue in Resident #5's room. She said she retrieved the crash cart, entered the room, and started chest compressions. Staff B, LPN, followed her into Resident #5's room and took over providing compressions. Staff G, CNA provided ventilations using the artificial manual breathing unit (Ambu) bag. Staff C, LPN could not recall the timeline of the events.During a telephone interview on [DATE] at 11:00 a.m., Staff I, CNA said on [DATE] at approximately 11:15 p.m. she checked on Resident #5. She said she offered Resident #5 water and emptied the urine bag. At 1:00 a.m., Staff I, CNA said, She [Resident #5] was asleep, her chest was moving, she was breathing. Staff I, CNA said, I always start preparing water to pass out at 3:00 a.m. She said at approximately 3:15 a.m., Staff B, LPN told her Resident #5 had expired and called her to the resident's room. Staff I, CNA said, Everyone was scrambling, and she asked if she needed to call a code blue. She said there was, Confusion about the code status. During this time Staff I, CNA said another CNA, she could not recall their name, assisted with checking Resident #5's oxygen saturation level and temperature.On [DATE] at 4:01 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Assistant NHA, DON and Regional Nurse Consultant (RNC). The DON said they had not interviewed or obtained a witness statement for Staff I, CNA. The NHA said the investigation was ongoing. The DON said on [DATE] at 3:56 a.m., Staff B, LPN called to inform her Resident #5 expired and there was confusion about the code status. Staff B, LPN told the DON Resident #5's hospital paperwork, form 3008, showed a DNR status, and the EHR showed an order for full code. The DON said she told Staff B, LPN, without the [DNR] form follow the MD order, initiate CPR, and notify the doctor and hospice.On [DATE] at 8:27 a.m., an interview was conducted with the Human Resource Director of Training (HRDT), RNC, NHA, and the DON to review employee records for training/education and competency validation about advanced directives, code blue status, and change in condition. A review of a facility orientation form for Staff B, LPN, titled, new hire orientation, all staff mandatory/information to be provided form, dated [DATE], revealed an incomplete form. The orientation form did not show Staff B, LPN received education/training for topics to include: advanced directives/state specific DNR orders, hospice and end of life, respiratory care (oxygen therapy), vital signs and complete change in condition and situation background assessment recommendations (SBAR). The form showed a signature and date area which was left blank. The DON said she did not know why the orientation form was blank as it was prior to her employment and she could not speak to the process at that time. The NHA said the expectation was for all spaces on the orientation form to be checked and initialed to indicate training was completed.On [DATE] at 12:59 p.m., a follow-up interview was conducted with the HRDT and the NHA. The NHA said the facility could not locate the orientation form for Staff C, LPN in the employee file. They could not confirm if Staff C had received training.During an interview on [DATE] at 11:46 a.m., Staff H, LPN/UM stated not knowing how to confirm if nursing staff had received CPR/advanced directive competency/training. Staff H, LPN/UM, said before [DATE] the training did not include code blue drills.A review of the facility's onboarding action items, completed during new hire orientation, showed topics to include: - understanding resident rights facilitated by the executive director -abuse and neglect facilitated by self-paced modules - resident rights essentials facilitated by self-paced modules - advanced directives and state specific do not resuscitate orders (DNRO) facilitated by director of nursing - change in condition SBAR facilitated by director of nursing. A review of the facility policy and procedure titled, Notification of Change in Condition, with a revision date of [DATE], showed the following: Policy: The Center to promptly notify the Patient/ Resident, the attending physician, and the resident representative when there are changes in status or condition. Procedure: The nurse to notify the attending physician and the resident representative (RR)when there is a(n):- significant change in the patient/resident's physical, mental, or psychosocial status. - In the event of an emergency situation, 911 to be called and the attending and the RR to be notified as soon as possible. - The nurse to complete an evaluation of the patient/resident. Document evaluation in the medical record. - Document resident/ patient change in condition on 24-hour report.- Complete SBAR as indicated.A review of the facility policy titled, Medical Care/Standards of Practice with a revision date of [DATE], showed the following: Procedure: . Significant changes in medical status are reported to the attending physician. Nursing Services will be responsible for notifying the appropriate physicians, giving emergency care within the scope of their license, . and when appropriate, calling emergency medical services. Basic life support and/or first aid measures needed to minimize any deterioration of the resident's condition will be provided prior to transferring to an acute care hospital.A review of the facility's policy and procedure titled oxygen therapy, with a revision date of [DATE], showed the following: Policy: Oxygen therapy is the administration of a Fi02 (fraction of inspired oxygen) greater than 21% by means of various administration devices to: Raise the resident's PaO2 (partial pressure of oxygen) to an acceptable baseline using the lowest Fi02 . Procedure: Physician's orders for oxygen therapy shall include- Administration modality, Fi02 or liter flow, and Continuous or PRN .Documentation shall include: . Liter flow or Fi02 .A review of the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE], showed the following: 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 event of cardiac arrest, immediately call for assistance. a. Two licensed nurses are to verify: Resident identification b. Fully executed Florida Do Not Resuscitate Order (DH1896), located in the advanced directive section of the medical record. e to 2. Use the paging system to call Code Blue to Room Number or location of the event three times. 3. In the absence of a fully executed Florida Do Not Resuscitate Order (DH1896), the facility will immediately begin CPR.4. Will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: a. The resident responds. b. Notify the physician and the resident representative/ legal representative. c. Document in the medical record. A review of the facility policy titled Resident Rights, effective [DATE], showed the following: Policy: It is the policy of The company to 1. Make residents and their legal representatives aware of residents' rights. 2. Ensure that residents' rights are known to staff. 5. Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations.The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending investigation.- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the recommendations made from the root cause analysis. The team members in attendance were the medical director, executive director, director of nursing, and the assistant administrator.- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee. The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills. The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE]. Licensed nurses are on 12-hour shifts. Thirteen code blue drills had been completed with 115 staff members. Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.- From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency. Eleven licensed nurses completed the training. - The Human Resource Director will ensure during new hire orientation, newly hired nurses and CNAs are educated on the facility policy related to advanced directives, CPR and the completed road map from orientation will be signed acknowledging the education received.- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts. The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills. The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews and facility document review, the facility failed to ensure an effective pest control program was in place in three rooms (124 B, 126 B and 204 A/B) out of 11 rooms observed.Findings included:During an observation of room [ROOM NUMBER] B on 6/16/2025 at 08:46 A. M., there were three black live insects on the resident's overbed table near the resident's bed. In an immediate interview, the resident stated ants are always in her room, and that they never leave. She states she complains to the staff daily about issues including ants. She states she has seen big bugs in the facility as well. During a tour of room [ROOM NUMBER] on 06/17/2025 at 11:04 A. M., an observation of the bathroom revealed a live brown colored insect crawling on the wall under the sink, in the bottom right corner near where the floor tile meets the wall. In an interview with the resident explained there were insects in the facility and stated a roach was seen earlier crawling across the wardrobe header. The resident stated it went down to the side of the wardrobe cabinet and to the right on the floor. On 06/17/2025 at 11:07 A. M., an interview was conducted with Staff D, Licensed Practical Nurse (LPN)/Unit Manager. She stated that she had not seen any insects, but the residents had complained to her about ants. During an interview on 06/17/2025 at 11:11 A. M., with a random resident, he stated he saw flies on 06/16/2025. He stated that he didn't tell staff because it was a waste of time. During an interview with a random resident on 06/17/2025 at 02:03 P. M., he stated he saw a bug in the 100 hallway near room [ROOM NUMBER]. He stated he sighted it a week prior. The resident stated he notified staff, and the staff proceeded to smash the bug, by stomping on it.An observation of room [ROOM NUMBER] Bed B on 06/18/2025 at 08:07 A. M., revealed the room had a food tray with two small live insects on the table near the resident's bed. The resident confirmed that this was their breakfast tray. Observations of a cubby counter space in between the wardrobe section of the room showed a food tray. The observations revealed ants were on the tray with a tea bag and other items. There was a food plate from the prior day's dinner with no food on it. The plate had approximately forty to fifty live small insects crawling over the plate. An interview was conducted on 06/18/2025 at 08:09 A. M., with Staff C, Registered Nurse (RN)/UM, in 126 B. Staff C UM RN confirmed she saw the live ants on the overbed table and the wardrobe cubby. She stated that she would speak with maintenance. During a tour on 06/18/2025 at 08:22 A. M., observations of room [ROOM NUMBER] B revealed approximately five live small crawling insects, on a counter in a cubby in the wardrobe section connected to the wall near the window. The resident had items on the counter, including a plastic bag that the ants were crawling on. An interview on 06/18/2025 at 08:21 A. M., with Resident #16, he stated that ants are all over the room, on the floor, under the AC, and in the bathroom. He said that it was a waste of time to inform staff. On 06/18/2025 the nursing home administrator (NHA) provided the facility's Service Agreement for Commercial Pest Management, which revealed the facility has a signed service agreement with a pest control maintenance company. The service agreement was signed and dated 04/11/2024. The service agreement details that the service frequency is monthly. The service type was interior. The service for included Fly control. The service agreement shows a three-step process: 1. Inspect to pinpoint pest issues.2. Identify not only the pest, but the true cause of the problem.3. Treat in the most environmentally responsible way to eliminate/prevent any issues.Review of the facility's Pest Sighting Log for April, May, and June of 2025 revealed sightings of roaches, bugs and ants in hallways and resident's rooms.An interview was conducted on 6/18/2025 at 01:12 P. M., with the director of Maintenance (DOM). He stated the facility has a pest control company. He stated he makes sure that the company does what needs to be done and that he requests treatment for specific rooms as necessary. He stated he tries to ensure the company does not miss areas that staff has been alerted of need for treatment. He stated he is alerted about pest issues via staff, logs, and work book/orders. He stated that sometimes the roaches are gone when he checks for them. The DOM stated a specialized visit had been requested on 06/18/2025, but they had not been in yet. He stated the pest control company treats the exterior and the interior twice a month and does not go into resident rooms unless requested. He stated he had not heard reports of ants. Review of the facility's policy dated 11/30/2014, titled Pest Control revealed: The facility will maintain a pest control program, which includes inspection, reporting, and prevention.Procedure:1. A pest control contract will be maintained with a licensed exterminator.2. The contract will include routine quarterly inspections. 3. Treatment will be rendered as required to control the insects and vermin.4. Any unusual occurrence or sightings of insects should be reported immediately to the supervisor (See Policy - Maintenance Repair Request Form). Proper action will be taken.5. A copy of the company's Safety program, including MSDS (material safety data sheet) forms and certification of insurance will be on file in the facility.(Photographic evidence obtained)

Based on observation, record review, and interview, the facility failed to ensure food was labeled and dated, the floor in the walk in freezer was clean, and personal belongings were stored appropriately in one of one kitchen. Findings included: On 06/09/24 at 9:31 a.m., an initial tour of the kitchen was conducted. Two bags of opened pasta were observed with no date. There was a clear container of brown liquid in the walk-in cooler with no date. Pieces of paper and other trash were observed on the floor in the walk-in freezer. The Kitchen Manager confirmed the floor was dirty and stated today was cleaning day. There was an unknown food wrapped in plastic wrap with no label or date in the walk-in freezer. There was a container of cereal observed underneath the prep table in the food prep area with no date. A jacket was observed hanging from a dish rash where clean dishes were stored. On 06/12/24 at 11:59 a.m., the Kitchen Manager stated food should be labeled and dated as soon as items are put in a container or opened. She stated they have hangers for jackets. The Labeling and Dating Inservice undated provided by the facility revealed the following: Importance of Labeling and Dating Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out manner. This will minimize waste and ensure that items that are passed their due dates are discarded. 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.

Based on interview and record review, the facility failed to ensure the grievance policy was followed to include documentation, resolution, and follow-up for 11 of 13 residents attending the resident council meeting and seven (#40, #70, #59, #39, #58, #25, and #97) of 61 total residents sampled. Findings included: Review of the facility's policy and procedures titled Complaint/Grievance with an effective date of 11/30/2014 and a revised date of 10/24/2022, revealed: Policy - The center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Procedure: 1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a complaint/grievance form. * Complaint/grievance forms will be available 24 hours per day seven days a week in an unsecured common area. *Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. 2. Original grievance forms are then submitted to the grievance officer/designee for further action. 3. The grievance officer/designee shall act on the grievance and begin follow up of the concern or submit it to the appropriate department director for follow up. 4. The grievance follow-up should be completed in a reasonable time frame; This should not exceed 14 days. 5. The findings of the grievance shall be recorded on the complaint/grievance form. 6. The results will be forwarded to the executive director for review and filing. 7. The grievance official will log complaints/grievances and monthly grievance log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. 1. During a Resident Council (RC) Meeting on 06/10/24 at 3:15 p.m., residents voiced the following concerns: 11 of 13 residents present stated they had an unresolved grievance about frequently receiving their meals cold for months. The residents stated they were told the facility was going to get tray warmers but the food continued to be cold. Ten of thirteen residents present at the meeting voiced dissatisfaction with the dietary service offered by the facility. Resident #40 stated residents could report a grievance and the facility accepted the grievance, but the breakdown in the process was a resolution. There was never a resolution. Resident #70 stated the facility used to provide the resident with a copy of the grievance when they placed grievances, but we are no longer allowed to have a copy of the grievance we complete. I asked for a copy of a grievance I wrote and was told no. The facility starts to take steps to correct the grievance but generally fall short. Interview on 06/09/24 at 11:34 a.m. with Resident #59 revealed the food was always cold and had informed the facility of this concern. A review of the Admission Record for Resident #59 revealed she had resided in the facility for over 5 years. Review of Resident #59's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 out of 15, indicating intact cognition. Review of the Grievance Log revealed: Resident #39 filed a grievance on 05/24/24 related to cold breakfast. The findings of the investigation showed the hot pellet warmer had not been working for a long period of time. Maintenance had been working to fix it. The plan to resolve the complaint/grievance indicated waiting for the hot pellet warmer to be fixed. The expected results of action taken was to fix the pellet warmer. The post investigation follow up showed the resident understood the pellet warmer was down right now, and staff would try to pass trays out in a timely manner. Resident was understanding and would keep her updated during guardian angel rounds. Resident #58 filed a grievance on 05/24/24 related to cold food. The findings of the investigation showed the hot pellet warmer had not been working for a long period of time. Maintenance had been working to fix it. The post investigation follow up documented explained to the resident the pellet warmer was down and maintenance was fixing it. Resident was understanding and would keep her updated during guardian angel rounds. Resident #25 filed a grievance on 05/29/24 related to cold food. The findings of the investigation showed the hot plates were used with hot food. The plan to resolve the issue was to ensure meals were sent to the floor timely. A review of the Resident Council Meeting Minutes from 01/02/24 to 05/31/24 showed no concerns related to cold food; however, a grievance filed by the Resident Council on 05/24/24 related to cold food. The findings of the investigation showed the hot pellet warmer had not been working properly and maintenance was aware of the situation. A steam table was approved and when it comes, staff will put in place. Residents were thankful that the facility was working on a steam table to ensure meals were hot. Review of the Food Committee Meeting Minutes dated 01/05/24 showed there was a concern about cold food. The pellet warmer was not working. Review of the Food Committee Meeting Minutes dated 05/24/24 showed there were concerns about cold food. On 06/12/24 at 11:53 a.m., the Kitchen Manager reported she reports concerns voiced during the Food Committee Meetings to her boss and the Administrator via email. On 06/12/24 at 11:59 a.m., the Kitchen Manager stated she had not been invited to the Resident Council Meetings. She sets up the meetings for the Food Committee. She reported the facility does not have food delivery carts with warmers. The Kitchen Manager stated the pellet warmer was not working, and this had been an issue prior to her being employed here. Review of the background screening log revealed the Kitchen Manager had a hire date of 4/30/2024. The pellet warmer was leaving the kitchen today stated the Kitchen Manager. She had done audits on food temperatures, and she found that the Certified Nursing Assistants (CNAs) were not delivering the trays timely. There had been some education done. On 06/12/24 at 10:19 a.m., the Social Services Director (SSD) reported anyone can write a grievance. When he receives a grievance related to dietary, he makes a copy of the grievance, put it on the Grievance/Concern Log, and takes the grievance to the Kitchen Manager. The Kitchen Manager conducts the investigation. After the investigation was complete, he would close it out and follow up with the resident and make sure the resident signs the grievance. The SSD reported he had received a lot of dietary grievances related to cold food. Dietary has been a trend, stated the SSD. The SSD stated there had been issues with cold food because they had to order a part for a piece of equipment. On 06/12/24 at 11:05 a.m., the Administrator stated she hadn't heard any concerns regarding cold food since the last grievance was received on 05/24/24. The resolution was more so explaining to the residents what was going on with the pellet warmer in the kitchen. The wire was not functioning properly. It was fixed but went down again, and they had to order another part. She stated right now it does not get super-hot. On 06/12/24 at 11:48 a.m., the Administrator reported the pellet warmer had been fixed before and provided documents related to the work orders. -An invoice dated 01/26/24 showed the plate warmer was not working. Replaced the high limit and thermostat. tested the unit for proper operation and unit was working properly. -An invoice dated 03/22/24 showed 2 or 3 bins on the plate warmer not heating. They took the plates out and checked all wires, adjusted the thermostat, and then tested the unit for proper operation. -An invoice dated 05/15/24 showed the hot food steam table had power issues. The technician arrived onsite and determined parts needed, however the unit was made in 1998 and parts are obsolete, provider was recommending replacement as they cannot locate parts. -An invoice dated 06/06/24 showed pending work was in progress for the pellet warmer to replace 20 dispenser springs, replace thermostat, and replace high limit. The replacements had not been approved. 2. During an interview on 6/12/2024 at 9:09 AM, Resident #40 stated he was having concerns regarding missing clothing and a broken TV since returning from the hospital in April 2024. The resident stated when he returned from his hospitalization his room had been changed and that's when he discovered the missing items and the TV was not working right. Resident #40 stated the concerns were not being followed up on, and Resident #40's responsible party contacted the Ombudsman. Resident #40 reported the Ombudsman came to the facility and spoke with him. Resident #40 stated the Ombudsman would speak with the administration and follow back up. Resident #40 has not had any further follow up. A review of the Grievance Logs from February 2024 to current, revealed one grievance in regard to missing clothing from March, 18, 2024. No other grievances were found related to Resident #40. On 6/12/2024 at 9:43 AM, the Social Service Director (SSD) reviewed the grievance process. The SSD reported once the grievance was received, it was logged in by social services. A decision of who was responsible for investigating the grievance was made. Then the department manager was responsible to investigate, determine resolution and follow up with the resident/responsible party. Once completed, the grievance form was returned to social services. The SSD stated, we like to get them back in three to five days. The SSD stated the Administrator (NHA) and SSD meet weekly to discuss grievances. The SSD was not aware of the Ombudsman visit for Resident #40 and stated a grievance would need to be completed if the visit was related to a concern. The SSD confirmed Residents #40's only grievance on file related to missing clothing in March of 2024. Interview on 6/12/2024 at 11:04 AM with the Nursing Home Administrator (NHA) revealed she was aware of Resident #40's concerns regarding the issues with the TV and the Ombudsman visit. The NHA stated a grievance was completed but never provided any documentation of the grievance. 3. During an interview on 6/12/2024 at 9:28 AM, Resident #97 stated the facility requested he complete a room change in April of 2024. Resident #97 stated he agreed to the move and while he was at dialysis, the facility packed up his belongings and moved them to the new room. The resident reported that his good clothing that were in the closet in the previous room missing upon his return. Resident #97 stated he told the NHA his good clothing was missing. Resident #97 stated he never received any follow up in regards to the missing clothing. During an interview on 6/12/2024 at 9:43 AM with the SSD. The SSD confirmed no grievances were filed for Resident #97. 41015 48223

Based on record review and interviews, the facility failed to notify the resident and/or resident representative in writing of the transfer/discharge and reason and send a copy of the notice to the State Long Term Care Ombudsman's Office for three (#177, #280, and #427) of four residents reviewed for hospitalization . Findings included: 1. A review of the Admission Record showed Resident #177 was admitted to the facility on [DATE]. A review of a change in condition form revealed she was transferred to the hospital on 02/11/24 for altered mental status and did not return to the facility. Review of the medical record revealed no 'Nursing Home Transfer and Discharge Notice could be located and no documentation to indicate the Ombudsman was notified of the transfer/discharge. On 06/11/24 at 5:48 p.m., the Administrator confirmed they could not find any documentation to show the Ombudsman was notified of the discharge, and they did not have the Nursing Home Transfer and Discharge Form. 43453 2. Review of the Admission Record for Resident #280 revealed an original admitted [DATE]. Review of the contact information section revealed the resident was his own Responsible Party. The resident had an emergency contact listed. Review of a document titled, NURSING HOME TRANSFER AND DISCHARGE NOTICE, signed on 05/23/24 showed the resident was transferred to a local medical center. The reason for Discharge or Transfer was not completed. The notice section showed the form was presented by a staff member and dated 05/23/24. The area to list the Resident or Representative's name was blank. The signature line/date for the Resident or Representative to acknowledge the document was received line was blank. The area to date that the notice was provided to the Local Long Term Care Ombudsman Council was blank. Review of a document titled, NURSING HOME TRANSFER AND DISCHARGE NOTICE, signed on 05/18/24 showed the resident was transferred to a local medical center. The notice section showed the form was presented by a staff member and dated 05/18/24. The area to list the Resident or Representative's name was blank. The signature line/date for the Resident or Representative to acknowledge the document was received line was blank. The area to date that the notice was provided to the Local Long Term Care Ombudsman Council was blank. 3. Review of the Admission Record for Resident #427 revealed an original admitted [DATE]. A review of a change in condition form revealed Resident #427 was transferred to the hospital on 03/03/24 and did not return. Review of the contact information section of the Admission Record revealed the resident was his own Responsible Party. A Nursing Home Transfer and Discharge Notice could not be located and no documentation could be found to show the Ombudsman was notified of the transfer/discharge. The record did not show any discharge paperwork was provided to the resident. On 06/11/24 at 11:31 a.m., the Assistant Social Services Director (ASSD) reviewed Resident #427's medical record. The ASSD could not locate the transfer forms in the record. She stated upon discharge all paperwork should be filed in the resident's chart. She stated the expectation was for the nurse who was sending the resident out to initiate the paperwork. She stated if the resident was their own person they would sign, and if the resident was not able to sign, the nurse will write unable to sign and send a copy with the resident to the hospital. If a responsible party was notified of the transfer, it should be documented notification was conducted via phone. An interview was conducted on 06/11/24 at 1:35 p.m. with the Social Services Director (SSD), Regional SSD, and the Nursing Home Administrator (NHA). The Regional SSD confirmed the records she reviewed for Resident #280 and #427 did not show the resident/representative were notified of the transfers. The Regional SSD confirmed the Nursing Home Transfer and Discharge Notices for the two Nursing Home Transfer and Discharge Notices for Resident #280 were incomplete. The SSD confirmed it should be documented if the residents were unable to sign. The SSD stated she faxes the notifications of transfer/discharge to the Ombudsman. She stated if the Ombudsman was notified, it should be documented. The NHA stated they should be keeping a fax as evidence the ombudsman was notified. Review of a facility policy and procedure document titled, Transfer/Discharge Notification and Right to Appeal, Revised 10/14/22, showed transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to federal and/or state regulatory. When the center transfers or discharges a resident under any of the circumstances listed above [emergency transfers to acute care], the facility will ensure that the transfer or discharge is documented in the residents medical record and appropriate information is communicated to the receiving healthcare institution or provider. Review of Notice before transfer showed: Before a center transfers or discharges a resident, the center must: Notify the resident and resident representative of the transfer or discharge and the reasons for the move in writing (in a language and manner they understand). The center must send a copy of the notice to a representative of the office of the state Long-Term Care Ombudsman. Record the reasons for the transfer or discharge in the resident's medical record. Notice must be made as soon as practicable before transfer or discharge.

Based on record review and interview, the facility failed to notify the resident and/or resident representative of the facility policy for bed-hold for three (#177, #280, and #427) of four residents reviewed for hospitalization . Findings included: 1. A review of the Admission Record showed Resident #177 was admitted to the facility on [DATE]. She was discharged to the hospital on 02/13/24. Additional review of the Electronic Medical Record and the Resident's 'Hard Chart' revealed no 'Bed Hold Policy'. On 06/11/24 at 5:48 p.m., the Administrator reported they could not find a bed hold policy for Resident #177. A review of the Admission Record showed Resident #177 was admitted to the facility on [DATE]. A review of a change in condition form revealed she was transferred to the hospital on 02/11/24 for altered mental status and did not return to the facility. Review of the medical record revealed no evidence of a bed-hold notice at the time of transfer. On 06/11/24 at 5:48 p.m., the Administrator confirmed they could not find any documentation to show the resident and the resident representative received written notice of the bed-hold upon transfer. 43453 2. Review of the Admission Record for Resident #280 revealed an original admitted [DATE]. Review of the contact information section revealed the resident was his own Responsible Party. The resident had an emergency contact listed. Review of a Nursing Home Transfer and Discharge Notice revealed the resident was transferred to the hospital on 05/23/24. Review of the bed-hold notice revealed Resident #280's name was filled in and his representative's name was filled in on 05/23/24 to indicate the bed-hold notice was provided; however, below the names of the resident/resident representative was the following statement: By signing below the staff member attest to providing the written bed hold notice to the resident and resident representative if applicable The signature/title line was not completed to attest that the notice was provided. 3. Review of the Admission Record for Resident #427 revealed an original admitted [DATE] and transfer to the hospital on 03/03/24. Review of the contact information section revealed the resident was his own Responsible Party. Review of the medical record revealed no evidence that the resident received the bed-hold notice at the time of transfer. On 06/11/24 at 11:31 a.m., the Assistant Social Services Director (ASSD) reviewed the medical record for Resident #427. She confirmed that no bed hold notification paperwork was present. She stated the expectation was for the nurse who was sending the resident out to initiate the paperwork. She confirmed the staff sending the resident out should sign the bed-hold form confirming they provided the bed hold information. An interview was conducted on 06/11/24 at 1:35 p.m. with the Social Services Director (SSD), Regional SSD, and the Nursing Home Administrator (NHA). The Regional SSD confirmed the records she reviewed for Residents #280 and #427 did not show the resident/representative were notified of the facility's bed hold policy. Review of the August 2018 policy and procedure titled, BED HOLD NOTICE showed in accordance with state and federal law the center provides written notice of its bed hold information to each resident and resident representative, if applicable, regarding the duration of the state bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility and the reserve bed payment policy in state plan.

Based on record review, interview, and review of the facility's policy, the facility failed to ensure residents received an accurate Level I Preadmission Screening and Resident Review (PASARR) for four (Residents #20, #36, #42, and #96) of six residents reviewed for PASARR. Findings included: 1. Review of the Admission Record showed Resident #20 was initially admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, schizophrenia and mixed anxiety disorder. Review of Resident #20's PASARR dated 01/15/24 Section A. MI or suspected MI (check all that apply) showed the check boxes next to Anxiety Disorder and Schizophrenia were not marked. 2. Review of the Admission Record showed Resident #96 was initially admitted to the facility on [DATE] with diagnoses that included schizophrenia unspecified, other seizures and alcohol abuse, uncomplicated. Review of Resident #96's PASARR dated 12/22/23 Section A. MI or suspected MI (check all that apply) showed the check boxes next to Schizophrenia and Substance Abuse were not marked. On 06/11/24 at 3:35 p.m., the Director of Nursing (DON) stated she had been working in the facility for two months. The DON stated when she was first hired there was no one in the facility to review PASARRs. The DON stated that the facility had identified PASARRs that were incorrect and there was a list of PASARRs that need to be corrected, but she was the only person completing this task. The DON stated she would continue to work on them when she could. 39438 3. A review of the Admission Record showed Resident #36 was initially admitted to the facility on [DATE] with a Principle/Primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Section I- Active Diagnoses of the Minimum Data Set (MDS) dated [DATE] showed the resident had diagnoses of non-Alzheimer's Dementia, anxiety disorder, depression, and schizophrenia. Review of Resident #36's PASARR dated 08/28/18 showed the resident was marked no for a primary diagnosis of Dementia. 4. A review of the Admission Record showed Resident #42 was initially admitted to the facility on [DATE] with diagnoses present on admission to include bipolar disorder, major depressive disorder, and post-traumatic stress disorder. An additional diagnosis of anxiety disorder, unspecified with an onset date of 10/12/2023 was also listed. Section I- Active Diagnoses of the MDS dated [DATE] showed diagnoses of anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of the PASARR dated 05/25/23 showed the resident had diagnoses of bipolar disorder and PTSD. The resident's PASARR was not updated to reflect the new anxiety diagnosis that occurred during the resident's stay. On 06/11/24 at 5:27 p.m., the Director of Nursing (DON) stated she would expect to see all the diagnoses listed on the PASARR and if a resident had a primary diagnosis of dementia, a Level II should be completed.

Based on observation, interview, and record review, the facility failed to ensure nine residents (Residents #19, #48, #76, #79, #96 #106, #107, #117 and #279) of twenty three residents reviewed for smoking returned smoking materials to staff after the designated smoking times and when returning back from leave of absence (LOA). Findings included: On 06/09/24 at 1:00 p.m., a total of thirteen residents were observed smoking in the designated smoking area. Staff O, Concierge was observed only providing one resident their cigarettes and lighter. The twelve other residents were observed to have their cigarettes and lighters already in their possession. During an interview on 06/09/24 at approximately 1:00 p.m., Staff O, Concierge stated she only had to assist one resident during this smoke break as the other twelve residents had their cigarettes and lighters already in possession and smoked without assistance. During an interview on 06/09/24 at 1:25 p.m., Resident #117 stated she smokes. Resident #117 stated she kept her cigarettes with her at all times so no one would steal them. During an observation on 06/09/24 at 4:00 p.m., nineteen residents were observed smoking. Nine of Nineteen residents were observed to have either cigarettes, lighters or both in their possession. Observations included: - Resident #76 was observed pulling out a cigarette and in possession of the cigarette. - Resident #96 was observed pulling out a lighter from his pocket. Resident #96 was then observed taking a cigarette from Resident #76. Resident #96 then lit Resident #76's cigarette and his cigarette before Staff M, Certified Nursing Assistant (CNA) even began passing out cigarettes and lighting cigarettes for other residents waiting. - Resident #107 was observed pulling a pack of cigarettes from his pocket and smoking with the assistance of Resident #96 who lit his cigarette. - Resident #19 was observed coming out to the designated smoking area and pulled out a cigarette and lighter. - Resident #117 was observed with 2 cigarettes in hand and giving those cigarettes to Resident #107 to add to his pack of cigarettes. Resident #107 was observed adding those 2 cigarettes to the pack in his possession and put the pack back in his pocket. - Resident #279 received a cigarette from Resident #106. Resident #279 was holding the cigarette in his hand and Resident #106 stated, do you need a light? Resident #279 stated no I am saving it for the 9 p.m. smoke break. Resident #106 said then hide it. Resident #279 was observed putting the cigarette under his shirt and taking the cigarette back into the facility. - Resident #76 was observed throwing cigarettes down into the rocky yard decor. (Photographic evidence obtained.) During an interview on 06/09/24 at 4:30 p.m., Staff M, Certified Nursing Assistant (CNA) stated she had a great relationship with the residents who smoke. She stated she ensured she took all unused cigarettes and lighters before residents entered the facility and placed them in the lock box, per policy. Review of the facility's Resident Council Meeting notes dated 05/31/24 showed, Administration addressed Smoker's not following policy, Leave of Absent Policy Issues and Actions: Administrator addressed concerns about smokers following policy. Making sure they turn in their smoking articles when they go out on LOA to purchase them and when family brings them in to turn into nurse. During an interview on 06/10/24 at 10:00 a.m., Resident #40 stated during the last Resident Council Meeting staff spoke to us regarding the smoking policy. Resident #40 stated that staff told us that they would be cracking down a lot more on residents having their cigarettes and lighters. Resident #40 said the main problem was when the residents who smoke go out on LOA and go smoke to the side of the facility under the trees and throw their cigarette butts on the dry ground. Resident #40 stated the ladies who smoke stated they put their cigarettes and lighters in their bra to keep their smoking materials. Resident #40 stated the guys who smoke put their smoking materials in their pockets or under their shirts. Resident #40 stated most of the smokers have their own stash. Resident #40 stated last night around 10:00 p.m. the nurse had to stop giving me my medications to let a smoker out the side door to smoke. Resident #40 reported the designated smoking time was 9:00-9:30 p.m. During an interview on 06/10/24 at 10:10 a.m., Resident #97 stated at the last resident council meeting the Social Services and the Activity Director stated the non-smokers do not need to worry about the smokers in the facility as staff was going to crack down on the smoking materials in the facility. Resident #97 stated it truly meant nothing because staff had been saying they were going to take control of the smoking materials for awhile now and nothing had been done. Resident #97 stated look out the window. Resident #107 was observed leaving the side of the facility where the trees were and coming back into the facility. Resident #97 stated the smokers smoke under the tree area at the side of the facility all the time. An observation of 06/10/24 at 10:23 a.m., revealed a pathway to the side of the facility with trees and bushes. Further observation showed multiple cigarette butts in this area with no proper safety equipment to dispose of cigarettes to prevent an accident hazard. The observation of the used cigarettes in this area showed multiple cigarette used butts that laid in the dry leaves and around the grass underneath the trees. Photographic evidence obtained. During an interview on 06/10/24 at 10:52 a.m., the Administrator stated a smoking concern had been going on since January 2024 when all the smokers walked out of the resident council meeting and refused to go back due to the smoking policy. The Administrator stated she had to call the Ombudsman to come in and talk with the Resident Council regarding resident rights for the February 2024 Resident Council Meeting. The Administrator stated residents who smoke signed themselves out on LOA and were not supposed to smoke on property. The Administrator stated those residents who go on LOA to smoke were required to go to the city sidewalk to smoke off property. The Administrator stated smokers would be required to obtain their smoking materials from the nurse prior to going on LOA and then return the smoking materials once they returned to the facility from LOA. The Administrator stated that was where the problem was as not all residents returned their smoking materials. During an interview on 06/09/24 at 12:03 p.m., the Ombudsman stated, I was invited to the facility to discuss how to set up a Resident Council Meeting and bylaws. The Ombudsman stated, I know there is a smoking concern there at the facility. The Ombudsman stated she spoke with the Administrator regarding not having control of smoking materials. The Ombudsman stated there was a resident in the facility who was concerned about smoking and his safety regarding fire. The Ombudsman stated that particular resident had a room next to the exit door because of his concern. The Ombudsman stated that resident reported residents were going outside to smoke at 2:00 a.m., and then coming back in to the facility and not turning in their smoking materials. The Ombudsman stated that resident reported there has been no change with these concerns for awhile. The Ombudsman stated she talked with the Administrator about smoking materials. The Administrator's responded, It's LOA, can't do anything about it and stated, my hands are tied. The Ombudsman stated in February 2024 the Administrator was supposed to put out a letter to residents and family that explained they can't have lighters and cigarettes in rooms or in the facility per policy and if they do break the policy then they will be issued a discharge notice. The Ombudsman stated she was unsure if that letter was ever sent out. An observation of smoking on 06/10/24 at 1:00 p.m., revealed eighteen residents smoking with four Residents who supplied their own material. - Resident #48 was observed coming out of the facility to the smoking area past the locked box of resident smoking materials and pulled out a cigarette and lighter in her possession. - Resident #96 was observed coming out of the facility to the smoking area past the locked box and pulled a pack of cigarettes out of his pocket with a lighter and began smoking without assistance. - Resident #106 was observed coming out of the facility to the smoking area and pulled a pack of cigarettes out of his pocket. Resident #106 began distributing cigarettes to Resident #6 and Resident #102. - The Administrator was outside and following around the residents smoking showing them the smoking policy. - After the smoking break, Resident #106 refused to give his pack of cigarettes to the Social Services Director (SSD) at first and re-entered the facility. Resident #106 then turned around and threw his cigarettes at the SSD and stated if even one cigarette comes up missing, he won't give them up again for staff to keep them again. During an observation on 06/10/24 at 1:20 p.m., the Administrator was speaking with Resident #48 with the smoking policy in hand. Resident #48 stated to the Administrator, this is ridiculous, I can't even get my meds and your worried about my cigarettes. The Administrator continued to review the smoking policy with Resident #48. An observation on 06/10/24 at 1:35 p.m. revealed Resident #79 had a pack of cigars and a pack of cigarettes stored in the nightstand beside his bed. (Photographic evidence obtained) During an interview on 06/11/24 at 9:12 a.m., Staff N, Director of Maintenance (DOM) stated the property line ends at the white picket fence in front of the facility. The DOM stated that he came out and informed residents about smoking under the tree and educated the residents that it was a fire safety risk throwing all their cigarettes in the dry leaves and grass area, as there was a burn ban in the county. He stated that when he directed the residents to go further to the city sidewalks the residents pulled up the facility blueprint on the county website and said this land belongs to the county. Staff N, DOM stated he went to the facility's blueprints and discovered the property ends at the white picket fence. Staff N, DOM stated that he did see an accident hazard and even a fire risk with residents throwing their used cigarettes into the dry leaves and on the ground. Staff N, DOM stated it was the facility's responsibility to keep this area of land clean but it was owned by the county not the facility. Staff N, DOM stated that he would call the County Fire Department today as he was sure the county does not know the residents are throwing their used cigarettes out into the dry leaves and ground causing a fire safety risk. During an interview on 06/11/24 at 9:40 a.m., the Administrator stated that all residents are expected to follow the Smoking Policy. The Administrator stated that she gave one resident a 30 day notice yesterday for not following the policy and having smoking materials on her possession. The Administrator reviewed the photographic evidence obtained from the non designated smoking area. The Administrator confirmed residents throwing their used cigarettes down in dry grassy areas and leaves was a safety hazard. The Administrator stated maybe they could look at providing a cigarette receptacle out near that area to try to eliminate the accident hazard. An observation on 06/12/24 at 12:00 p.m., revealed Resident #79 continued to have cigars stored in the nightstand at the bedside. Review of the Smoking Agreement/Notice of Policy dated 01/2020 showed, Smoking is allowed by the Center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All resident who wish to smoke at the center will abide by the center's smoking policy. Resident's electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial action includes but is not limited to to warning, revocation of smoking privilege's, police intervention, and/or discharge. The agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the team set forth in the policy. Review of the facility's policy Smoking-Supervised revised 02/07/2020, revealed The center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by staff during the authorized smoking times. The center will have safety equipment available in designated smoking areas including: smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. The center will retain and store matches, lighters, etc, for all residents. All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. Residents will be advised upon admission that violation of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and served at safe and appetizing temperatures for two (Resident #7 and #73) of six residents sampled for food. Findings included: During an interview on 06/09/24 at 10:38 a.m., Resident #73's family member stated he had filed grievances on her behalf related to food and care. He stated on May 5th, 2024, while he was visiting with Resident #73, the residents were served raw chicken. The family member stated a resident who was sharing the table with Resident #73 ate the whole thing. He stated he had taken a photo which he showed this surveyor, of red meat on the plate that the resident ate. He said, I told the nurse. I said if anyone gets sick, it is their fault. Review of Resident #73's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include dementia. The record showed the family member was the Responsible Party. An interview on 06/12/24 at 11:30 a.m., revealed Resident #7 was frustrated because the food was not served at the right temperatures. Resident #7 showed this surveyor photos with dates and times when he was served raw chicken. He confirmed the dates of 05/05/24 and 06/02/24. The resident stated on 05/10/24, the residents were served grilled cheese sandwiches. He said, it was black and hard as a rock. He stated he had voiced grievances related to food, but they were never resolved. Review of Resident #7's Admission Record revealed he was admitted to the facility on [DATE]. Review of Resident #7's quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of facility menus confirmed the following: On 5/5/24 for lunch the residents were served fried chicken. On 5/10/24 for dinner the residents were served Grilled cheese sandwiches. On 6/2/24 for lunch the residents were served fried chicken. On 06/10/24 at 4:08 p.m. an interview was conducted with the facility's Certified Dietary Manager (CDM) and the Regional Dietary Manager. The CDM stated she had received grievances related to chicken being served raw. She stated a resident had shown her a photo of the raw chicken. She said, We did not serve the chicken at the right temperature. It should not have been served like that. The CDM stated in response to the incident on 05/05/24, she did an in-service. She stated the in-service was to ensure chicken was cooked until internal temperatures reached 165 degrees. During a follow-up interview on 06/12/24 at 1:53 p.m., the CDM stated she became aware there was a second incident of chicken served raw in June. She stated that was not acceptable. She said as a chef, I would know the meat closer to the bottom does not cook all the way. She stated it would be up to nursing staff to stop a vulnerable resident from eating raw meat. She stated nonetheless, it should not have gone out like that. The CDM reviewed a photo of a grilled cheese served to a resident, noted black in color. She said, yes, that is burnt. It should not have been sent out like that. She stated their expectation was to check the food temperatures after cooking, and to confirm it was thoroughly cooked prior to service. She stated the [NAME] should be utilizing a meat thermometer. She stated food should not leave the kitchen if it was not palatable. Review of a facility policy tilted, Food: Preparation, revised 02/2023, showed a policy statement that all foods are prepared with the FDA (Food and Drug Administration) Code. 10. Time/Temperature Control (TCS) hot food items will be cooked to a minimum internal temperature as follows; All poultry and stuffed foods 165 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure dignity was maintained for two (Residents #16 and #32) of 2 residents sampled for dignity out of of 61 total residents sampled. Findings included: 1. An observation was conducted on 6/9/24 at 1:00 p.m. of Resident #16 going to the smoking patio in a wheelchair wearing a hospital gown with one sock on. The resident's skin was visible from the top center of her back to the top of her buttocks. Her hair was also observed to be matted and unkempt. Review of the Admission Record showed Resident #16 was admitted on [DATE] with diagnoses including mechanical loosening of internal left hip prosthetic joint and chronic pain syndrome. Review of Resident #16's Minimum Data Set (MDS) assessment, dated 05/25/2024, Section C - Cognitive Patterns showed her Brief Interview for Mental Status (BIMS) score was 14, indicating she was cognitively intact. An interview was conducted on 6/9/24 at 4:19 p.m. with Resident #16. She stated she had not had clothes in three weeks. She said she had no family to assist her and did not come to the facility with clothes. An observation conducted on 6/10/24 at 4:10 p.m. showed Resident #16 still in a hospital gown, with matted unkempt hair. She was on the smoking patio with 12 other residents and one staff member. A follow-up interview was conducted on 6/11/24 at 10:20 a.m. with Resident #16. She said she had asked for clothes; they gave her a dress that belonged to another resident who wanted it returned. She stated the night gown she was wearing currently; they gave her on 6/10/24. The resident said, It's embarrassing to go into public areas in a hospital gown with my butt hanging out. The resident also said that she had not had a shower and it makes me feel gross. She said the first time they provided her with clothes to wear was yesterday when she was supposed to leave the facility for an appointment. An interview was conducted on 6/11/24 at 2:46 p.m. with Staff U, Social Services Assistant. She said she was aware of three residents that wear gowns regularly throughout the day, that included Resident #16. Staff U said she gave Resident #16 extra clothes from the laundry room on 6/10/24. She also stated Resident #16 had funds that could be used for clothing. An interview was conducted on 6/11/24 at 11:28 a.m. with Staff T, Account Manager, who stated laundry generally had extra or donated clothing available. He stated if there was a situation where they could not help accommodate a resident's needs with laundry, he would notify the Nursing Home Administrator (NHA). During an interview conducted on 6/11/24 at 10:55 a.m. with Staff P, Registered Nurse (RN), Staff P stated they had donated items in laundry to provide clothing to residents when needed. She stated she had access to get resident items from donations or she would notify social services if there was a situation she could not address. During an interview conducted on 6/11/24 at 3:19 p.m., the Director Of Nursing (DON) stated she would expect if a resident had clothing needs it would be brought to her attention. She stated she had not been notified of anyone with clothing needs that the facility could not accommodate. She stated she was not aware of a resident who had been in a hospital gown for 3 weeks, who came in without any personal clothing. 46234 2. An observation was conducted on 6/10/24 at 11:26 a.m. of Resident #32 in her bed. She was noted to have on a hospital style gown and five wrist bands on her right arm and one wrist band on her left arm. The arm bands were from the hospital; there was a band labeled with her name, age, birthday, medical records number, a DNR (Do Not Resuscitate) band, a Fall Risk band, an allergy band, and a band with just her name on it. (Photographic evidence obtained.) An observation and interview was conducted on 6/11/24 at 2:14 p.m. with Resident #32. The resident was observed to still have the five wrist bands on her right arm and one wrist band on her left arm. She also remained in the same hospital style gown. The resident said the arm bands were aggravating on her arm. Review of Admission Record for Resident #32 showed she was admitted on [DATE] with diagnoses including anemia, dementia, and anxiety disorders. Review of Resident #32's Minimum Data Set (MDS) Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) score was not completed. Section C did note Resident #32 was severely impaired cognitively. An interview was conducted on 6/12/24 at 4:30 p.m. with Staff X, Licensed Practical Nurse (LPN)/Unit Manager (UM). She was observed going to Resident #32's room and looking at her arm bands. Staff X said she would have taken the arms bands off if she had seen them. She said she could also see a concern with them being irritating to the resident's skin. An interview was conducted on 6/12/24 at 4:38 p.m. with the DON. When notified Resident #32 had 6 wrist bands from the hospital still on her arms after being in the facility three weeks, she agreed it was a concern and said the bands should have been removed on admission. She said they would be removed immediately. On 6/12/24 at 5:06 p.m. the DON said the facility did not have a policy on Dignity. Review of the [NAME] of Rights for resident of nursing homes posted on the facility wall showed: You, as a long-term care resident, have the right to: -Be treated courteously, fairly, and with the fullest measure of dignity.

Based on observation, interview, and record review, the facility failed to ensure the resident had use of personal belongings for one (Resident #43) of five residents reviewed for personal property. Findings included: During an observation and interview on 06/09/24 at 10:20 a.m., Resident #43 stated she had been readmitted to the facility following a recent hospitalization . The resident stated she had been at the facility for 2 days and did not have her personal belongings. The resident was observed wearing a hospital gown. She stated she did not have her clothes. She stated she had asked staff, and everyone said, Okay, but they did not bring her clothes. The resident stated at her previous room she had all her personal items, stuffed animals and family pictures. She stated she had an air mattress to relief pressure because of wounds. She stated she had fall mats following previous falls. The resident said, most importantly, my glasses are missing. I cannot see without them. I have been asking staff for 2 days. Review of the Admission Record revealed Resident #43 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #43's Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. An interview on 06/09/24 at 10:20 a.m. with Staff I, Licensed Practical Nurse (LPN), revealed she did not know Resident #43 did not have her personal belongings. She stated she had not noticed. She stated Staff F, Registered Nurse went to look for the fall mats. An interview on 06/09/24 at 1:48 p.m. with Staff E, Certified Nursing Assistant (CNA) revealed they were still looking for the resident's glasses. He confirmed the resident did not have an air mattress at this time. He stated these items should be in the resident's old room. He stated he did not know why the resident did not go back to that room. On 06/10/24 at 1:42 p.m., an interview was conducted with Resident #43. She stated her daughter had brought her an old pair of glasses. She stated she still had not heard from the facility regarding her other pair of glasses. She stated an aide brought her clothes this morning. The resident stated the facility had misplaced her glasses and she still did not have her air mattress. An interview on 06/10/24 at 1:58 p.m. with Staff K, Therapy assistant revealed on-going concerns post hospitalization . She stated if a resident returned from the hospital within a short period, they should normally resume the current care plan. She stated fall mats should be replaced. She stated if a resident was using pressure relieving mattress it should be provided upon return. An interview on 06/10/24 at 2:19 p.m. was conducted with the Assistant Social Services Director (ASSD) and Regional SSD. The ASSD stated the process was to box a resident's items and inventory them accordingly when they were transferred out. She stated when a resident is readmitted , they should receive their personal items right away. They should be placed in the room as soon as the resident was admitted , if not prior to their arrival. An interview was conducted on 06/10/24 at 3:52 p.m. with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The NHA stated when a resident was admitted to the hospital, they packed the resident's room up. She stated they inventory the resident's belongings and store them in a locked area. She stated once they knew the resident was coming back or had readmitted , the CNA should go to the storage room and retrieve the belongings. She stated she did not know why Resident #43 did not receive her personal belongings. She stated they had recently hired a concierge to help assist with admissions. The DON stated upon readmission a nurse should assess the resident and if they were still at risk for falls, the fall mats should be placed in the room per orders. She stated for air mattresses, it was tricky because some residents did not own these items. She stated they would contact DME (Durable Medical Equipment) to obtain the equipment as soon as orders were in place An interview on 06/11/24 at 5:01 p.m. with the SSD revealed they were still looking for the resident's glasses. He stated they had called the hospital, and the glasses could not be found. He stated he had added her to the list to be seen the next time the physician was at the facility. Review of a document titled, INVENTORY OF PERSONAL EFFECTS, showed on discharge/move-out, personal items are sent with resident/patient or picked up responsible party. Upon transfer, personal items are to be boxed and placed in designated storage area for safe keeping (or handling per facility/community/center policy). Review of a facility policy and procedure titled, Personal Property - loss or theft, dated 07/24/17 showed the center has a process to minimize the risk of loss or theft of patient's personal property.

Based on interview, record review, and review of the facility's policy Abuse, Neglect, Exploitation & Misappropriation, the facility failed to ensure protection from repeated incidents of verbal abuse by Resident #96 towards one (Resident #34) of three residents reviewed for abuse. Findings included: During an interview on 06/11/24 at 12:50 p.m., Resident #34 stated he was receiving his medications at the nursing station around 7:00 a.m. this morning with Staff A, Licensed Practical Nurse (LPN). Resident #34 stated while taking his medication Resident #96 came to the nurses station and verbally assaulted me calling me a fat ass and using the F word. Resident #34 stated Staff A Licensed Practical Nurse (LPN) heard everything and all she did was apologize to me for his behavior. Resident #34 stated Staff B Licensed Practical Nurse (LPN), Unit Manager (UM) also came to speak with him and apologized for Resident #96's behavior towards him. Resident #34 stated this was not the first time this had occurred and he was getting tired of everyone always apologizing for Resident #96's behavior and not doing anything about it. Resident #34 stated everyone told me to just stay away from him but Resident #96 was the one who seeks me out most of the time and these verbal attacks on me need to stop. Review of the Admission Record showed Resident #34 was admitted to the facility on [DATE] with diagnoses that included but not limited to Unspecified Sequela of unspecified Cerebrovascular disease, recurrent depressive disorder, difficulty walking, weakness, type II diabetes mellitus and osteoarthritis. The quarterly Minimum Data Set (MDS) dated [DATE], Section-C-Cognitive Patterns showed Resident #34 had a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. Review of the Admission Record showed Resident #96 was admitted to the facility on [DATE] with diagnoses that included but not limited to Schizophrenia, Encephalopathy, difficulty walking, pancytopenia, alcohol abuse uncomplicated and muscle weakness. Review of the the quarterly MDS dated [DATE], Section-C-Cognitive Patterns showed Resident #96 had a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. During an interview on 06/11/24 at 12:58 p.m., Staff A Licensed Practical Nurse (LPN) stated there was a verbal altercation between Resident #34 and Resident #96 this morning. Staff A LPN stated Resident #34 was at the medication cart getting his blood pressure taken when Resident #96 approached the nurses station and began cussing at Resident #34. Staff A LPN stated that Resident #34 did not engage in the verbal altercation and Staff B LPN, Unit Manager (UM) heard Resident #96 yelling and came out of her office and took care of the issue. Staff A LPN confirmed this was not the first encounter between Resident #34 and Resident #96 and stated they have a history and did not like each other. During an interview on 06/11/24 at 1:01 p.m., Staff B LPN,UM stated she heard an altercation this morning and came out of her office to see what was going on. Staff B LPN, UM stated she was aware of Resident #96's mental health issues, so she immediately went out the verbal altercation and told Resident #96 to cut it out and told Resident #96 to take a walk. Staff B LPN, UM stated Resident #96 then walked down the hall allowing separation between both Resident #34 and #96. Staff B LPN, UM stated Resident #34 and Resident #96 did not like it each other. During an interview on 06/11/24 at 1:08 p.m., the Administrator stated she was also the Risk Manager. The Administrator stated that nothing had been reported regarding any abuse or resident to resident altercation today. The Administrator stated that she had heard nothing about the verbal altercation between Resident #96 and Resident #34 from this morning, 06/11/2024. The Administrator stated if a Resident to Resident altercation occurred she would have expected Staff B LPN, UM to have reported it to her right away so she could have filed a report within the appropriate timeframe and per policy. The Administrator stated that she would report this altercation immediately and start an investigation now. During an interview on 06/11/24 at 1:12 p.m., Resident #96 stated that he did not like Resident #34 and he did tell him off. Resident #96 stated that Resident #34 was also trying to mess with his life and get him in trouble. Review of the facility's policy Abuse, Neglect, Exploitation & Misappropriation revised date 11/16/22 showed, Verbal Abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written or gestured communication, or sounds, to resident within hearing distance regardless of age ability to comprehend or disability. 7. Reporting/Response: Any employee or contracted service provider who witnessed or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later then 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to the other officials in accordance with State law.

Based on record review, staff interviews, and review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to complete the Level II Preadmission Screening and Resident Review (PASARR) documentation for one (#118) of six residents sampled for PASARRs. Findings included: Review of the admission record for Resident #118 revealed an admitted [DATE] with diagnoses of Alzheimer's disease, primary, depression, and unspecified mood affective disorder. Review of the medical record showed a Level I PASARR was not conducted upon admission. Review showed it was initiated on 05/26/24. Review of Resident #118's Level I PASARR dated 05/26/24 showed diagnoses of Depressive Disorder, other Mood Disorder and Alzheimer's Disease were indicated. The Level I PASARR showed the resident had exhibited behaviors that made them a danger to themselves or others. Level II evaluation section showed Resident #118 had documented behavioral observations, has interpersonal functioning problems, concentration persistence and pace problems, and difficulty adapting to change. On 06/10/24 a level II PASARR was initiated. The requested documents were not submitted. On 06/11/24 at 2:40 p.m., the Regional Social Services Director (SSD) stated she had just submitted the Level II documentation today. She said, I cannot speak of the timing. I don't know why it had not been submitted. She stated nursing should have submitted the paperwork for the Level II recommendation. An interview was conducted with the Director of Nursing (DON) on 06/11/24 at 3:48 p.m. She stated she had initiated the Level I PASARR on 05/26/24. She confirmed Resident #118 did not have a level I PASARR in place upon admission. She said, I have been the only one reviewing PASARRs. Admissions should have initiated a Level I prior to admission or upon admission. She stated upon review of the Level I, she initiated the Level II, but did not submit the required paperwork. She stated she was the only one catching up on PASARRs at that time. She stated the Social Services Department did not have qualified personnel, but they do now. Review of a facility policy titled, Preadmission Screening and Resident Review, dated 11/08/2021, showed The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to the Federal/State guidelines. The purpose is to ensure that the residents with SMI or are [sic] ID receive the care and services they need in the most appropriate setting.

46234 Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were appropriately provided for two (Residents #32, and #68) of five residents sampled for ADLs. Findings included: 1. An observation and interview was conducted on 6/10/24 at 11:27 a.m. with Resident #32. She was observed in a hospital style gown with hospital arm bands on her wrist. The resident said she did not get showers, and no one got her out of bed. Review of the Admission Record for Resident #32 showed she was readmitted on [DATE] with diagnoses including anemia, dementia, morbid obesity, overactive bladder, and anxiety disorders. Review of Resident #32's Minimum Data Set (MDS) Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) score was not completed. Section C did note Resident #32 was severely cognitively impaired. Review of Resident #32's task documentation by the Certified Nursing Assistants (CNAs) showed the resident had two showers (6/3 and 6/10/24) and two bed baths (5/30 and 6/6/24) since her re-admission on 5/22/24. Although documentation showed Resident #32 had a shower on 6/10/24 at 1:28 p.m., the resident was observed to be in the same hospital style gown on 6/10/24 at 3:34 p.m. An interview was conducted on 6/10/24 at 3:34 p.m. with Resident #32. The resident said she had not been out of bed all day and had not showered. An interview and observation was conducted on 6/10/24 at 3:37 p.m. with Staff Y, Registered Nurse (RN). She was observed going to Resident #32's room and looking at the resident. She said the resident had been in the same gown all day. She was observed checking the daily shower sheets and said she had not received one for Resident #32. She said the CNAs should document under tasks and fill out a shower sheet when they gave a resident a shower or bed bath. Staff Y reviewed Resident #32's task documentation and confirmed it showed the resident was scheduled for showers on Monday and Thursday on the 7:00 a.m. to 3:00 p.m. shift and a shower had been documented as done that day. She said additional shower sheets would be in the Unit Manager's office. On 6/12/24 Staff X, Licensed Practical Nurse (LPN)/Unit Manager (UM) provided all the shower sheets she had for Resident #32. The only shower sheet since the resident was readmitted was on 5/28/24. That shower sheet showed the resident had a shower and noted redness to the pubic area. Resident #32 was observed to remain in the same position in bed with the same gown on throughout the days of 6/10 and 6/11/24. An interview was conducted on 6/11/24 at 11:55 a.m. with Staff W, RN. She confirmed she provided wound care to residents. She said Resident #32 did not currently have any wounds but did have redness and irritation on her buttocks and was getting zinc barrier cream applied. 2. An interview was conducted on 6/9/24 at 4:21 p.m. with Resident #68. She said she did not get showers, she said she only got cleaned up. She said it took at least 30 minutes to get cleaned up after she pushed her call light, then staff came in with an attitude. Review of Admission Records showed Resident #68 was readmitted on [DATE] with diagnoses including sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA), fracture of right patella, depression, and anxiety. Review of Resident #68's MDS, Section C, Cognitive Patterns, showed her BIMS score was a 15, which indicated she was cognitively intact. Review of Resident #68's care plan for ADL care showed she required an assist of one staff member for bathing/showering. Review of Resident #68's task documentation by the CNAs showed the resident had five showers (5/30, 6/1, 6/2, 6/9, and 6/11/24) and seven bed baths (6/3, 6/4, 6/5, 6/6, 6/7, 6/8, and 6/9/24) in the past two weeks. On 6/12/24 Staff X, LPN/UM was unable to provide any shower sheets for Resident #68. She said she did not know why there were not any. A follow-up interview was conducted on 6/12/24 at 3:14 p.m. with Resident #68. The resident said she absolutely did not have showers on 6/9 and 6/11/24. She said she had not even had a good bed bath in weeks. She said the only thing that was done was that her private area was cleaned up when her brief was soiled. She said not even her back had been washed. An interview was conducted on 6/12/24 at 3:42 p.m. with the Staffing Coordinator. She said she was also a CNA and worked shifts on the floor. She said resident showers were always documented in tasks and a shower sheet was filled out. She said CNAs should only document what they did. An interview was conducted on 6/12/24 at 3:47 p.m. with Staff X, LPN/UM. She said call lights should be answered and briefs changed immediately if needed. She said showers should be documented by CNAs in tasks and on a shower sheet. She said a shower should absolutely not be documented if it was not done. An interview was conducted on 6/12/24 at 4:38 p.m. with the Director of Nursing (DON). The DON said she would expect a resident to receive a shower if they wanted one. She said it was not up to the CNAs to decide if a resident got a shower or bed bath. The DON said a shower should be documented under tasks in the medical record if and only if a resident received the shower, and a shower sheet should be filled out. On 6/12/24 at 5:06 p.m. the DON said the facility did not have a policy on ADLs or Showers.

Based on observation, interview, and record review, the facility did not ensure residents unable to carry out ADL (Activities of Daily Living) received assistance related to hair care for one (Resident #117) of five residents reviewed for ADLs. Findings included: An observation and interview was conducted on 06/09/24 at 2:14 p.m. with Resident #117. The resident was observed with matted, tangled clumps of hair. She stated she had asked staff for help. She said, I need help with my hair. The staff are not available to help. They are too busy. There is not enough time for me. It will take time to untangle. No one has the time. The resident stated she had been begging staff to help her with her hair since admission. She stated she did not like looking like a bird's nest. She said, it is embarrassing. I would like to brush my hair again. Review of the Admission Record for Resident #117 showed an admitted [DATE], with diagnoses to include partial traumatic metacarpophalangeal amputation of unspecified finger and need for assistance with personal care. Review of Resident #117's Admission Minimum Data Set (MDS), dated [DATE], in Section C-Cognitive and Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. On 06/11/24 at 02:45 p.m., Resident #117 stated a CNA was supposed to help her last night. She never came back this happened all the time. The Resident said, I have not washed my hair since I was admitted because if I wash it, it will be stinky because it will not dry. It is already matted. The resident stated she had been at this facility for almost 2 months. Review of a care plan with a focus ADL-self-care, dated 04/25/24 showed the resident had a self- care deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and trauma to Right hand. Interventions for personal hygiene, bathing/showering showed the resident required assistance by staff for personal care and bathing/showering. An interview on 06/11/24 at 3:05 p.m. with Staff L, Certified Nursing Assistant (CNA) confirmed the resident was admitted with matted hair following a lengthy hospitalization . She stated some CNA's had started helping the resident untangle the hair. She stated, It just takes a while. I know, two months is a long time to wear your hair like that. We have to keep trying. We just don't have the time among the other duties. Staff L stated the resident would not be able to untangle the hair herself. She confirmed the resident needed staff's assistance. An interview was conducted on 06/11/24 at 3:10 p.m. with the Director of Nursing (DON). She stated she just heard about the resident with matted hair. The DON stated residents who were dependent on staff should receive care as needed. She stated they had to prioritize care. She said, We are trying. I understand it's a dignity issue. We hired a concierge two weeks ago. She spent an hour helping her. The DON stated there was only so much they could do because the staff had to attend to higher care needs. She said, I know she is dependent. It is just not a priority for nursing staff. The DON stated the resident refuses to cut her hair. An interview on 06/11/24 at 4:34 p.m. with the Nursing Home Administrator (NHA) revealed they did not have someone to do hair. She stated they had a salon, but it was currently closed. She stated they had recently hired a concierge who would be helping with things like this. On 06/11/24 at 05:22 p.m., the NHA stated they did not have a policy on ADLs.

Based on observation, interview, and record review, the facility failed to ensure the resident received proper treatment to maintain communication abilities for one (Resident #280) of three residents sampled. Findings included: Review of the Admission Record for Resident #280 revealed an original admitted [DATE] and a re-admitted [DATE] with diagnoses to include Deaf non-speaking. During an observation on 06/09/24 at 9:30 a.m., Resident #280 was laying on his bed staring at the Television which was turned off. The resident did not respond to the interview. The resident looked at this surveyor and initiated hand movements, signaling he communicated via sign language. A look around the room revealed there were no personal effects and there were no communication assistive devices, or anything indicating the resident required assistance to communicate with others. Review of an admission Minimum Data Set (MDS) dated [DATE] showed in section B0200 - Hearing, Speech, and Vision, the resident was highly impaired related to absence of useful hearing. B0700 showed the resident is sometimes understood and his ability to make concrete requests was limited. B0800 the resident sometimes understands others. Under B1000 - vision, the resident is highly impaired. Under Health literacy B1300, the resident always needed to have someone help him when he read . written material. Section C - Cognitive Patterns revealed a BIMS (Brief Interview for Mental Status) score of 00, meaning the resident was unable to complete the interview. Review of a care plan initiated on 04/30/24 showed Resident #280 was care planned for a communication problem related to hearing deficit/deaf and partial blindness. Interventions showed to anticipate and meet needs. Be patient with resident as he is deaf and has poor vision. Resident requires assistance with communication. Provide translator as necessary to communicate with the resident. The resident is able to communicate by gesture sign language/translator. Use ASL (American Sign Language) to communicate with patient as deemed appropriate. An interview on 06/09/24 at 9:39 a.m. with Staff D, Certified Nursing Assistant (CNA) revealed the resident was deaf. She stated the resident communicated via sign language and she communicated with him by trying to guess what he needed. She stated the resident was new to this part of the building and she was getting to know him. Staff D, CNA stated the resident stayed in his room most of the time. She stated if he was out, he watched television and did not engage easily with others due to communication disability. On 06/10/24 at 1:54 p.m., an interview was conducted with Staff E, CNA. He stated this resident was deaf. He stated he communicated with him by asking Yes, or NO questions. The CNA stated he tried to guess what the resident was trying to say. He stated he would ask the nurse if he could not figure out what the resident was saying. He stated he did not know any sign language and he was not aware if any of the staff were able to sign. An interview on 06/10/24 at 2:30 p.m. with Staff G, Registered Nurse (RN) revealed she did not know much about this resident. She said, When I walked in earlier, he did not respond to me. I called out to him. His eyes were open. I walked to him and tapped his shoulder. I placed the medication cup in his hand. He knew that meant he should take his medications. Staff G stated she did not know if he was deaf. She stated the resident was new to her and she would review his care plan to know how he communicated. During this interview, this surveyor and nurse walked into the resident's room. He did not have any signs posted to let someone know his preferred method of communication. The room was noted very warm, the temperature on the unit showed it was on heat settings and a reading of 78 degrees was noted. The Nurse stated she did not know if it was the resident's preference to have the heat on during hot summer months. She said, I am not sure if this was his preference. You know there is a language barrier. The nurse attempted to interact with the resident. The resident signed back in response, which the nurse did not understand. Staff G stated she would have to find out what he was trying to say. In an interview on 06/10/24 at 2:45 p.m. with Staff H, RN/ MDS and the Regional MDS, they stated staff should know how to communicate with the resident. The Regional MDS stated the nursing staff could review the [Brand Name of a filing system used in nursing homes] to identify the resident's communication needs. She stated for other people without access, there should be a sign directing them to see nurse posted on the door. She stated they had a care plan with interventions to reach out to the resident's family member for assistance. The Regional MDS stated there should be a number to call for ASL assistance. She stated she would update the care plan to include a communication board or cards with familiar phrases. An observation on 06/11/24 at 9:14 a.m. to 06/11/24 at 12:04 p.m., revealed Resident #280 in a Broda chair positioned in front of the television in the common/dining area in hall 300. This resident was not observed participating in any activities or engaging with staff or residents. During this time period, other residents were observed participating in various activities such as puzzles, cards, making phone calls and engaging with each other and staff in conversations. Resident #280 had his back turned to the other residents the entire time. The resident was unable to initiate any interaction with staff or other residents. Review of a facility policy subject, Reasonable Accommodation of Hearing Impaired, revised 09/05/2017, showed upon admission the charge nurse will determine the level of hearing impairment. If a hearing impairment is noted staff will consult with the resident and if applicable family members to determine what auxiliary aids may be needed to ensure effective communication. If hearing impairment exists, then the following interventions may be implemented as deemed appropriate. Personnel to directly face resident when speaking to him or her. Allow resident to see facial expression to help lip reading. Provide pencil and paper to communicate in writing in cases of totally deaf. Determine residents awareness of hearing loss. Should a qualified interpreter be needed, the family should consult with social services to identify local resources.

Based on observation, interview, and record review, the facility failed to ensure proper care to prevent the worsening of pressure wounds for two (Residents #74 and #12) of four residents sampled for pressure wounds. Findings included: An observation was conducted on 6/11/24 at 11:48 a.m. of Resident #74 lying in bed with his legs exposed crying out for assistance. He said his feet hurt and he needed help moving his leg. The resident was observed to have bandages on both heels and his feet were propped up on a plastic pack of disposable briefs. (Photographic evidence obtained with resident permission.) An observation and interview was conducted on 6/11/24 at 11:50 a.m. of Staff V, Certified Nursing Assistant (CNA) entering Resident #74's room and assisting to reposition his leg. Staff V confirmed the resident's heels were being offloaded with a pack of briefs. She said his pressure relieving boots were in the laundry so someone must have put those there. Staff V said the resident had wound care that morning and maybe they put the briefs under his heels. Review of Admission Records showed Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, muscle weakness and difficulty walking. The resident was listed as his own responsible party. Review of Resident #74's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. Review of Resident #74's physician orders showed: -Encourage offloading bilateral heels while in bed. Every shift for unstageable bilateral heels as tolerated. Date 6/4/24. Review of wound care provider notes showed the resident had right and left heel wounds. On 5/6/24 the wound etiology was noted to be pressure, unstageable, and offloading boots were in place. On 5/15/24 the left and right heel wounds were changed to stage 4. An interview was conducted on 6/11/24 at 11:53 a.m. with Staff W, Registered Nurse (RN). She confirmed Resident #74 had stage 4 pressure wounds on both heels that were in house acquired. She said the resident had boots to offload his heels while he was in bed. Staff W reviewed the photo of Resident #74's heels propped on a pack of briefs. She said that was totally inappropriate. She said she would never put briefs under someone's feet to offload them. She said had she seen that she would have fixed it immediately and educated staff. An interview was conducted on 6/11/24 at 12:31 p.m. with the Director of Nursing (DON). She reviewed the photo of Resident #74's heels offloaded with the pack of briefs. The DON said that was not at all appropriate and she could not believe someone would have used briefs to prop his heels on. She said it should not have happened and she would investigate. Review of the Admission Record showed Resident #12 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to multiple sclerosis, restless leg syndrome, polyneuropathy, and Parkinson's disease with dyskinesia without mention of fluctuations. Review of the quarterly Minimum Data Set (MDS) dated [DATE] Section-C-Cognitive Patterns showed Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 (Cognitively Intact). Review of Resident #12's care plan showed a focus [Resident #12] has a pressure injury to the right heel. The goal showed, The resident's pressure injury will show signs of healing and have minimal risk of infection by/through the review date. The interventions included but not limited to: Administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, and monitor dressing to ensure it is intact and adhering report loose dressing to the nurse An additional focus showed, [Resident #12] has an arterial ulcers to: left dorsal 2nd toe, left lateral malleous, left dorsal 3rd toe, left lateral foot and left dorsal 4th toe. The goal showed, The resident will be free from infection or complications related to arterial ulcer through review date. The interventions included but not limited to Monitor/document wound document progress in wound healing on an ongoing basis, wound medical doctor visit at [local] medical weekly as ordered, WOUND/DRESSING change the dressing and record observations of site. Review of Resident #12's current orders showed wound care orders as followed: - Consultation with wound care provider dated 06/01/24 - Consult with Wound Care [as needed] PRN dated 05/06/24 - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 2nd toe topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 3rd toe topically every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 4th toe topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 4th toe topically every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 2nd toe topically every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left lateral foot topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left lateral malleous every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left lateral malleous topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to right medial calcareous topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to right medial calcareous every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. Review of the Treatment Administration Record dated May 2024 showed Resident #12 missed wound treatments on the following dates: - 05/12/24 -05/14/24 -05/17/24 -05/19/24 -05/21/24 -05/23/24 -05/24/24 -05/27/24 -05/30/24 -05/31/24 Review of the Treatment Administration Record dated June 2024 showed Resident #12 missed wound treatments on the following dates: - 06/08/24 -06/09/24 During an interview on 06/11/24 at 12:32 p.m., the Director of Nursing (DON) stated the TAR did look like the wound treatments were not completed but needed to look into this more because she wondered if it was more of a documentation error than the nurses not providing wound treatment. During an interview on 06/11/24 at 12:40 p.m., Resident #12 stated that no one provided wound treatment to her feet this weekend. Resident #12 stated that she went to the wound care clinic every Wednesday but the nurses at the facility were to provide wound care to her all other days. During an interview on 06/11/24 at 5:50 p.m., The Director of Nursing (DON) stated that she spoke with some of her nurses and they informed her the wound treatment was completed they just forgot to document they completed the treatment. The DON stated that she would have expected the nursing staff to document when they provided the wound treatment for Resident #12 but did not. Review of the facility's policy Non-pressure skin Condition Record revision date 04/01/17 showed, Policy: To document the presence of skin impairments/new skin not related to pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc. One site will be recorded per page. Review of the facility's policy Clinical Guidelines Skin & Wound effective date 04/01/2017 showed, To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Review of the facility's policy Physician Orders revision date 03/03/21 showed, Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Review of the facility's policy Pressure Injury Record revision date 04/01/2017 showed, Policy: To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. Once site will be recorded per page. Review of the facility's Clinical Nurse 1 LPN Job Description showed Duties and Responsibilities that included but not limited to 6. Comply with evaluation, treatment, and documentation of the company guidelines. 7. Complete required documentation in an accurate and timely manner. Review of the facility's Clinical Nurse 1 RN Job Description showed Duties and Responsibilities that included but not limited to 6. Comply with evaluation, treatment, and documentation of the company guidelines. 8. Complete required documentation in an accurate and timely manner. 14. Monitor compliance with resident record documentation, as directed. 46234

Based on medical record review, observations, resident, visitor and staff interviews and review of policy and procedure, the facility failed to provide supervision to prevent an elopement of one resident (#1) of three residents sampled for elopement. Resident #1 was assessed on 4/28/2022 to have severe cognitive impairment after a staff member noticed he was unable to understand discharge planning information. Resident #1 on 6/8/2022 was assessed to be high risk for elopement after exhibiting exit seeking behavior on 6/7/22. He was also assessed to be confused, independent with ambulation and at risk for falls. Staff reported that he frequently walked the halls of the facility. The Care Planned safety interventions were not effective to maintain the resident's safety. Twelve days after he first exhibited exit seeking behaviors he eloped from the building, on 6/19/22, unnoticed by staff. The facility had an employee exit and entrance door used by staff and visitors poorly secured. It is believed Resident #1 exited through this door. Resident #1 was found sitting in front of a gas station approximately one mile from the facility address based on driving distance or 0.5 miles based on walking distance. Resident #1 was located by a staff member (Staff D) and a sheriff's deputy at 9:45 p.m., approximately one and a half hours after he left the facility. Resident #1 was noted by Staff D, Certified Nursing Assistant (CNA), who located him, to be sweating profusely, confused and winded. Resident #1 was at risk for a likelihood of serious harm or death due to his cognitive impairment and fall risk. Resident #1 was at risk for and had the high potential to fall or be hit by a vehicle while traversing the four-lane divided road during the darkening evening time. This resulted in findings of Immediate Jeopardy starting on 6/7/22 and removed on 6/30/22 with the scope and severity reduced to a D. Findings Included: An interview was conducted with Staff D, CNA on 6/28/22 at 3:13 p.m. Staff D was the CNA who found Resident #1 at a gas station at 126th Avenue and [NAME] Road. He stated he had taken care of Resident #1 in the past when Resident #1 was on the rehab (rehabilitation) unit but had not worked with him since he moved to long term care (medical record review revealed Resident #1 moved to the long-term care unit on 5/31/22). He stated when he worked with him, he never mentioned wanting to leave or trying to leave. Staff D stated he was one of the facility staff who drove around the community to try and locate Resident #1. He stated he found him sitting on the sidewalk thing outside the front door of the gas station at 126th Avenue and [NAME] Road. He stated the gas station was closed. Staff D stated he found Resident #1 at 9:45 p.m. He stated he was coming back down [NAME] Road from Ulmerton Road, and out of the corner of his eye, he recognized Resident #1's florescent yellow shirt. He made a U turn to go back to the gas station and, as he pulled in, a sheriff's deputy was pulling in the other entrance. He stated Resident #1 was very calm and recognized him. Staff D helped him stand up because he wanted to make sure he was okay. He stated Resident #1 was sweating profusely and confused, winded and tired. He stated the sheriff was talking on her radio a distance away telling someone the resident was found. He, Staff D, walked over to the deputy and showed her his badge to let her know he was from the facility. He stated the sheriff's deputy asked Resident #1 where he was going, and Resident #1 said he was going home to Biloxi, Mississippi and it was right up the road. Staff D stated he asked the sheriff's deputy what the protocol was now, and she told him, if he knows you and you are okay with it, you can take him back to the facility in your truck. Staff D stated he took him back to the facility. He stated Resident #1 was quiet and staring, spaced out like he normally does, in the truck. He stated when they got back to the entrance, he met the DON (Director of Nursing) and the staff got Resident #1 water and got his vitals. He stated he handed him off to the LTC (Long Term Care) staff and went back to his unit. An interview was conducted with Resident #1 on 6/29/22 at 12:15 p.m. regarding his elopement from the facility on 6/19/22. Resident #1 stated he went out a door but doesn't remember which door, or if the door was open or not. He stated he did not remember where he was going but thinks he was going home. He stated, the black guy found me and brought me back here. An interview was conducted with Staff I, CNA on 6/29/22 at 10:15 a.m. She stated she spoke with Resident #1 after he was returned to the facility from the elopement on 6/19/22. She stated he was okay when he came back, just more scared than anything. She stated he told her the police came and he thought he had done something wrong. Staff I stated she was one of the staff who drove in the community to try and find Resident #1. Regarding where Resident #1 was located, she stated, He crossed [NAME] Road, that's dangerous, I wouldn't want to try that with that traffic on that road. A medical record review revealed a Change in Condition form was completed on 6/19/22 at 22:05 (10:05 p.m.) by the DON. Review of this form revealed : Situation was documented as: resident was able to exit the facility without telling anyone. Things that make the condition or symptom worse are: His repetitive verbalization of him going home. Things that make the condition or symptom better are: direct supervision to provide repetitive redirection. The condition symptom or sign has occurred before: Yes. Treatment for the last episode: 1 on 1 supervision and psych consult and labs ordered by MD. Summarize your observation and evaluation: Upon completing narcotic count with 2 outgoing nurses, resident was noted to be out of his room, nowhere to be found, head count was ordered and completed, search of the entire facility including outside premises completed with no resident in sight, 911 was called re missing resident. The Change in Condition form documented the primary care physician was notified at 21:00 hours (9:00 p.m.) and the physician's recommendation was to call 911 to report missing resident. At 5:11 p.m. on 6/28/22, the DON clarified the statement on the change of condition form regarding, his repetitive verbalization of him going home. He stated after Resident #1 was brought back to the facility he was still saying he wanted to go home. An interview was conducted with the Administrator and DON, on 6/28/22 at 10:45 a.m. The Administrator stated on weekends, the lobby doors lock at 5:00 p.m. and on weekdays, the lobby doors lock at 8:00 p.m., when the receptionist leaves. The Administrator stated there was signage at the lobby door to call a number to be let into the facility. The Administrator stated this number went to the nurses' station and was not always answered promptly as nurses were assisting residents. She stated some families had gotten into the habit of coming in and out of the facility through the employee entrance rather than calling the posted phone number. Both she and the DON stated the visitors would wait for an employee to come in or out. To exit visitors would hold the handle down on the door for 15 seconds to open the door. They stated an alarm would go off and a nurse would come and turn off the alarm without looking outside to see if anyone had gotten out. The Administrator and DON identified Staff X, Licensed Practical Nurse (LPN) as the nurse who re- alarmed the doors without checking outside on 6/19/22. The Administrator reported neither she nor the DON were aware of visitors using the employee exit prior to Resident #1's elopement on 6/19/22. The Administrator and DON stated when visitors entered and exited through the employee entrance, there was no process for them to sign in and out of the facility. The Administrator stated a private duty CNA reported she went out the employee entrance for smoke breaks the evening of 6/19/22 by holding the handle down for 15 seconds until the door opened. The Administrator reported the private duty CNA told her that her last smoke break was around 8:45 p.m. The Administrator and DON reported they believe Resident #1 exited the building on 6/19/22 through this employee entrance and followed the driveway to [NAME] Road. The Administrator stated the Regional Nurse Consultant walked this route and it was 0.47 miles to the gas station by foot. During the survey, the route was measured by car on 6/29/22 and it was 0.5 miles from the facility's side exit onto [NAME] Road to the gas station. Using the facility address and the gas station address the driving distance is 1.0 miles according to Google Maps. They said the Resident had flip flops on his feet. The Administrator and DON reported Resident #1 had not been expressing a desire to leave until a friend he made at the facility went home on 6/7/22. They stated that was when he started voicing that he wanted to go home. An interview was conducted with the facility's Regional Nurse Consultant, on 6/28/22 at 1:00 p.m. She stated she walked from the employee entrance to the gas station at a normal walking pace and it took her 18 minutes. An interview was conducted with Staff G, Staffing Coordinator, at 12:01 p.m. on 6/28/22. She stated she was leaving the facility that day, 6/19/22, and went out into the courtyard after turning the screamer(alarm) on for the lobby door. She reported Resident #1 was sitting by the door leading to the back corridor in the courtyard. She reported she asked him what he was doing, and Resident #1 told her he was looking for a cigarette. She reported Resident #1 had three cigarettes in his pocket and she told him she would bring him cigarettes the next day. Resident #1 told her he could wait. She reported this was right around 8:00 p.m. Staff G stated the door she observed Resident #1 sitting by leads into the back corridor and is across the corridor from the door to the smoking courtyard She stated the smoking courtyard door is kept locked until staff go out for designated smoke breaks with the residents. She stated, I think he likes to sit by the courtyard back door because he can see through to the smoking area door and can see when they are going out on smoke break. (The courtyard utilized for resident smoking and the employee entrance are located in the same corridor) She stated she clocked out about 8:10 p.m. - 8: 15 p.m. and left the building using a keycard to exit through the employee door. Staff G stated she had been waiting for the DON to arrive to work a shift, and the DON arrived in the facility a few minutes after 8:00 p.m. She stated, So far, I am the only one admitting I saw the resident before he eloped. She stated Resident #1 always likes to sit by that courtyard door. An interview was conducted with the DON, on 6/28/22 at 11:53 a.m. He stated he came in about 8:08 p.m. to work the shift on Sunday 6/19/22. He stated he went to the 200 Unit and was doing medication reconciliation and then went to check the residents. He stated Resident #1 was not in his room, he looked all over the building for him and could not find him and he initiated the elopement protocol. He stated this was approximately 8:30 p.m. He stated when he arrived on the 200 Unit around 8:08 p.m., the nurses were at the nursing station doing shift reports, and CNAs were in the hallway. The exit closest to Resident #1's room is alarmed and had a screamer alarm, so he did not go out that way. A phone interview was conducted with Staff F, Registered Nurse (RN) on 6/28/22 at 1:51 p.m. She stated she provided care for Resident #1 on 6/19/22. She stated the last rounds she did with him (Resident # 1) were at 7:15 p.m. and he was in his room. She stated she went in and asked him if he was okay. He told her yes, and said he didn't need anything. A phone interview was conducted, on 6/29/22 at 11:04 a.m. with Staff H, CNA who was assigned to Resident #1 on the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift on 6/19/22. Staff H was very difficult to understand due to limited English communication. She stated she had already given a written statement to the facility. She stated she is an agency CNA, and this was the first time she had worked on this hall. She stated she saw him before dinner in his room. She stated she went to pick up the dinner trays after dinner and (Resident #1) was not in his room. She stated she looked for him and did not find him. She stated she told the female nurse who told her to look around the building as he (Resident #1) walks all over the building and walks fast. She stated she went back to the hall and continued to care for other residents. She stated she did not find him. She said maybe around 8:20 p.m. or 8:30 p.m. she could not find him. She stated she went to find the same nurse but was told she had gone home. She stated a man (DON) said, I am the nurse, what happened. She stated she told this nurse that she could not find the resident. She stated he, the nurse, took over from there. During this phone interview it was difficult to understand Staff H's reported time frame as to when she went to pick up Resident #1's tray the first time. However, review of Resident #1's CNA Task documentation for 6/19/22 revealed at 19:16 (7:16 p.m.) Staff H documented Resident #1 consumed 51-75% of his evening meal. The Administrator, on 6/29/22 at 11:35 a.m., read aloud Staff H's written statement: About 6:30 in the evening, finished giving food to Room 211, went to pick up the tray in Room 202 B (Resident #1's room and bed) and he was not in bed. Went to Room 204 and couldn't find that resident either. She looked for these two residents in other corridors but only found the resident in 204. She told the nurse who told her that Resident #1 could be walking in the corridors. She said she went to the patio to see if she could see him, but he was not there. She then had to assist other patients, when finished with that, she went to Resident #1's room and he was not there, she went to find the nurse again about 8:20 p.m. or 8:30 p.m., to notify about the patient but she had already left. She notified the nurse on duty, and he took care of the patient. The Administrator stated she had to call Staff H several times to obtain clarification of when she last saw him . She stated (Staff H) told her that she did see him sometime between 6:30 p.m. and 8:30 p.m. but she could not find him again at 8:30 p.m. An interview was conducted with Staff I, CNA on 6/29/22 at 10:15 a.m. She stated she arrived at the facility at approximately 2:00 p.m. on 6/19/22 and she saw a female visitor in the lobby who was there to visit a resident on the 100 Hall. She stated she observed that female visitor outside smoking frequently in the staff smoking area (outside of the employee door area). She stated the visitor kept going in and out the employee entrance, she would ring the doorbell to come in but she, the visitor, would go out the employee entrance by pushing on the door. An interview was conducted with Staff P, CNA on 6/29/22 at 1:59 pm. Staff P stated she has worked at the facility for over a year. She stated before the elopement with (Resident #1) on 6/19/22 family members used the employee entrance/exit. She stated the front entrance is locked around 8:00 p.m., so when people came or left after that time, they had to use the employee door. An interview was conducted with Staff C, Registered Nurse (RN) on 6/28/22 at 2:55 p.m. She stated she has been working at the facility for six months. She stated before (Resident #1's) elopement on 6/19/22, the employee entrance was utilized by visitors. She reported that it was a mess for a while, visitors wouldn't even ask, they'd just set the alarm off and go. She stated staff would have to go and turn off the alarm. A confidential interview was conducted, with a family member of a resident, who visited the facility on 6/19/22. She stated she could not confirm the time of her visit on 06/19/22. She stated the facility allowed visitors to enter/exit through a side door, but staff always had to unlock the door for her. She was never able to let herself in or out. Doors were always locked, and she did not particularly like that she had to wait for staff to allow her to enter/exit. She stated she preferred to use the front door instead of walking so far away to the other door. She confirmed she visited her (family member) frequently in the facility but did not use the side door that often, maybe a handful of times. There was a doorbell to press at the outside of the door, then you had to wait for staff to come open the door. (She described the employee entrance.) An interview was conducted with Staff Q, CNA, on 6/29/22 at 2:05 p.m. She stated the employee door was previously used by visitors because the front door of the facility is locked at 8:00 p.m. She worked 06/19/22 on the 7:00 a.m. to 3:00 p.m. shift but did not see Resident #1. An interview was conducted on 6/29/22 at 1:50 p.m. with Staff J, LPN/Unit Manager. He stated (Resident #1) was previously on 1 to 1 for an attempt to go out of the facility. He stated this happened a week or so before he eloped. He stated he was not sure why he was removed from 1 to 1. A review of the medical record for Resident #1 revealed a Change of Condition form, dated 6/7/22 written by Staff C ,RN an indicated exit seeking behavior occurred on 6/7/22. The form documented the following: Situation: On previous shift, wandering and tried to walk out the door. Things that made the condition better: sitter Physician notified: 6/7/22 1800 (6:00 p.m.) Family notified: 6/7/22 1900 (7:30 p.m.) (Name of family member) An interview was conducted with Staff C, RN on 6/28/22 at 2:55 p.m. Staff C stated the nurse before her (on 6/7/2022) told her Resident #1 was trying to get out the door and when she, Staff C, came on shift Resident #1 was still wandering. She reported that she pulled an aide and put Resident #1 on 1: 1 supervision. Staff C stated she did not see this exit seeking firsthand, she stated she thought the nurse who mentioned it was Staff E (RN). She stated that other than June 7, 2022 she had never known Resident #1 to exit seek or say he wanted to leave. A phone interview was conducted with Staff E, RN on 6/28/22 at 3:55 p.m. She stated she did not witness Resident #1 trying to get out the door firsthand. She stated I had heard he (Resident #1) tried to get out the door, I didn't see him try, an aide was staying with him after that. I think it was a CNA in passing who told me. She stated she had no knowledge of Resident #1 trying to leave before or since, or any knowledge of him saying he wanted to go home but, she stated she was relatively new on the assignment and didn't really know him. An interview was conducted with the DON on 6/28/22 at 5:15 p.m. He stated he was the one who saw Resident #1 try to leave on 6/7/22. He stated, I saw him heading out the door (inner door which exits to lobby). He was in the hallway outside my door. He was trying to head out the front door. I stopped him before he hit the first door. I asked him where he was going, and he said home. I asked him how he was going to get there, and he said he was going to hitch [NAME]. The DON stated, That is when he started to question his BIMS (Brief Interview of Mental Status) score as exit seeking was a sign of poor safety awareness. The DON stated he should have done a Change in Condition form and a progress note. He confirmed there was no other documentation of this event except for Staff C's Change in Condition form. He stated he put a 1:1 sitter in place but did not get a physician's order for the 1:1 supervision, and there was no documentation the 1:1 supervision was done. The DON stated he stopped the 1:1 sitter on 6/11/22 as he [Resident #1] was not doing anything. He stated, It was a matter of him not trying to exit seek and a staffing issue. He stated he backed it up with safety checks every 15 minutes after that. He confirmed the only safety checks documented were on 6/11/22 and 6/12/22 as Resident #1 wasn't doing anything so he stopped them. He stated there is no other evidence in the medical record of this event except for the Change in Condition form completed by Staff C and the two safety checks dated 6/11/22 and 6/12/22. Review of the documentation for the 15-minute safety checks for 6/11/22 and 6/12/22 revealed: 6/11/22 documented 15-minute checks from 2:00 p.m. to 10:45 p.m. 6/12/22 documented 15-minute checks from 11:00 p.m. to 7:15 a.m. Review of Resident #1's Admission Record indicated he was admitted to the facility on [DATE] from a local hospital with diagnoses to include cerebral infarction, pneumonia, essential hypertension, unspecified protein malnutrition, muscle weakness, difficulty in walking and cognitive communication deficit. Review of a History and Physical form, from the hospital record for the hospital admission on 3/12/22, revealed, Resident #1 had experienced a ground level fall without head trauma and diagnoses of [CONDITION(S)], [CONDITION(S)], homelessness, mycoplasma pneumonia, hypertension, and protein calorie malnutrition. He was noted to be a poor historian. Review of an Agency for Health Care Administration Form 5000- 3008 Medical Certification for Long-Term Care Services and Patient Transfer Form, completed by a hospital representative and undated. revealed: Decision Making Capacity requires a surrogate, ambulates with assistance, Mental Cognitive Status at transfer: Alert, disoriented but can follow simple instructions. He was not checked as at risk for elopement risk on the Patient Risk Alert section of the 3008. Review of Resident #1's Admission/Readmission Data Collection form, dated 3/15/22, revealed Resident #1 was alert to person, place, time and memory was okay; mood was noted as pleasant and there were no obvious behavior problems. Elopement Risk Evaluations were completed at admission on 3/15/22 and on 3/22/22 and he was determined to not be a risk for elopement. Review of an Admission MDS (Minimum Data Set) assessment, dated 3/20/22, revealed a BIMS score of 14 (cognitively intact). Review of Section G Functional Status revealed the resident needed limited assistance with dressing, toilet use, personal hygiene, and bathing. He was noted to be independent with bed mobility, supervision for transfer, walking in room and locomotion of unit, limited assistance of two persons for walking in corridor, limited assistance of one person for locomotion off unit. Balance during transitions and walking - not steady but able to stabilize without staff assistance, no ROM (Range of Motion) impairment, no mobility devices. No behaviors were noted. A psychiatric services note, dated 4/28/22, and signed by an Advanced Practice Registered Nurse (APRN), revealed: Patient is alert with confusion, BIMS is a 3 today on assessment. Patient is homeless and was previously living in a shelter. When asking the patient what year it is he responded, 2070 and then 1977. Patient denies a history of mental health treatment but does report history of [CONDITION(S)] - per report he used to drink 12 beers daily x many years. Patient is seen today due to staff request for capacity evaluation: Capacity Questionnaire: alert and oriented to self only. The patient is not able to clearly express a treatment preference, nor what communication he has received from the care team or primary care provider. Patient not able to grasp the essential meaning of the information given by the physicians. The patient is not able to recognize his medical condition and the probable consequences of lack of treatment, not the treatment options, the patient is not able to interpret the diagnosis, prognosis or risk and benefits of treatment, nor lack thereof. The Patient is not able to engage in a rational process of manipulating relevant information. Patient is unable to discuss the risk and benefits of choices and the alternative to treatment. In my opinion, this patient lacks the capacity to make decisions related to his need for health care or long-term placement. Due to cognitive impairment, the patient is unable to understand the nature, extent or probable consequences of not receiving medical care. In addition, the patient is unable to make a rational evaluation of the burdens, risks and benefits of treatments. In my opinion, the patient can benefit from a guardian or POA [power of attorney]. Patient's primary care provider to sign off final Capacity Determination Form. An interview was conducted with Staff J, LPN/Unit Manager Rehabilitation Unit on 6/30/22 at 10:53 a.m. He stated the facility was in the process of discharge planning for Resident #1. He stated on 4/28/22, Resident #1 was issued a Notice of Medicare Non-Coverage (NOMNC) and there was some question as to whether he understood it. A BIMS assessment was completed with a score of 4 (severe cognitive impairment). The Primary Care Physician's APRN did not feel he was safe to discharge to a homeless shelter (where he came from) due to his mentation. She, the APRN, requested psychiatric services see him. Staff J LPN/Unit Manager stated both the psychiatric services APRN and the primary care physician's APRN determined Resident #1's mentation was not appropriate for a homeless shelter and that is why he is still here. Review of the progress notes for Resident #1, dated 4/28/22 13:26 (1:26 p.m.), written by Staff A, MDS LPN stated: Message left for resident's (family member) regarding this resident's NOMNC. Last covered day 4/30/22. Resident does not understand what the NOMNC means and is not able to sign. (Family member) needs to be made aware. A subsequent note dated 4/28/22 at 15:53 (3:53 p.m.) revealed: Resident's (family member) called back. She is aware of resident change in cognition, and she is in agreement with resident being long term care. She is aware that his last covered day for Medicare waiver is 4/30/22. MD is to follow up with resident for evaluation. Will continue with current plan of care. An interview was conducted with Staff A. MDS LPN on 6/30/22 at 10:24 a.m. She stated she was the person who gave Resident #1 the Notice of Medicare non coverage on 4/28/22 and she stated she was concerned that he could not understand it. She stated she told the team at the morning meeting about her concern related to his cognition. She stated the team included the previous Administrator and DON and the Unit Managers who are still here. She stated she did a new BIMS assessment on him and it was a 4 (severely impaired cognition). She reported that she was helping out as social services at the time, as there was no social service person. An interview was conducted with the DON and Administrator on 6/28/22 at 4:52 p.m. The DON stated he did not find out about the BIMS score completed on 4/28/22 and Resident #1's poor safety awareness until he was informed by a different psychiatric services APRN this month (June 2022) after the resident left the faciity on [DATE]. He found out that psychiatric services were giving their psychiatric notes to medical records and medical records were uploading them in the computer. The DON stated he was never given the psychiatric notes to review. Both the Administrator and DON stated they are used to looking for BIMS scores in the MDS and this BIMS was done separately from the MDS, so it was not seen by them. The DON stated when he spoke to Resident #1, he was sometimes right on point and sometimes not and he, the DON, was not aware Resident #1 was cognitively impaired. On 6/30/22 at approximately 5:30 p.m., the DON stated after the exit seeking on 6/7/22, he should have done a chart check of Resident #1's record. He stated he was not totally familiar with how things were being done at the facility. For example, the psychiatric notes not being given to him for review and the BIMS assessments done outside of the RAI (Resident Assessment Instrument) process. He stated if he had done this review, he might have made a different decision rather than taking him off 1:1 supervision. Review of a psychiatric services APRN note for Resident #1, dated 6/8/22 indicated: No recent behaviors reported. He is alert and oriented x 1-2 with intermittent confusion and is able to make simple needs known. He will likely be a long-term care patient but wants to go home Staff reports that he has been trying to leave to go home and is more confused and currently has a 1:1 sitter in the room. He states he lives right around the corner, but he was previously homeless and living in a shelter . He had previously reported symptoms of depression but did not wish to take medication. Today he is willing to try an antidepressant to help with his depressive symptoms. His sitter reports he has been more tired and sleepy and more withdrawn. Staff reached out to PCP (Primary Care Physician) for labs to rule out infectious etiology but did not receive a call back. Will obtain labs now and follow up to assess medication effectiveness. [MEDICATION(S)] is a great choice for him to help with brain plasticity related to [CONDITION(S)] (Cerebral Vascular Accident) and to aid in depressive symptoms. Recommend initiate [MEDICATION(S)] 10 mg (milligrams) PO (by mouth) daily for depression an obtain labs (Complete Blood Count, Basic Metabolic Profile, Urinalysis, Culture and Sensitivity) and monitor for behaviors. Review of Resident # 1's Medication Administration Record (MAR) for June 2022 documented the administration of [MEDICATION(S)] 10 mg PO daily. An elopement Risk Evaluation was completed on 6/8/22. The evaluation showed Resident #1 was determined to be at risk for elopement due to yes answers to: cognitively impaired, independently mobile, poor decision making, exit seeking behaviors, wandering, oblivious to safety needs and has ability to exit the facility. A care plan was initiated on 6/8/22 for The resident is at risk for elopement risk. Wanderer, reference to exit seeking. The goal indicated the resident's safety will be maintained through the review date. Interventions initiated on 6/8/22 included: Assess for elopement risk, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book Resident prefers: (This was blank), Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, Provided structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The care plan was updated on 6/20/22 to add 1:1 observation. The care plan was documented as created by the Regional MDS lead who is an RN. There was no documentation in Resident #1's record that interventions from 6/8/22 were implemented or acted upon. An interview was conducted on 6/30/22 at 10:24 a.m. with Staff A, MDS LPN who wrote the 6/8/22 elopement care plan. She stated the interventions for the elopement care plan were discussed at the team morning meeting and We all came up with the interventions. She reviewed the care plan and stated that toileting is not an activity and stated, Did I do that? She stated she has not heard anything about following up on the interventions. She stated she has only been doing MDS since March of last year (2021) and the MDS lead left two weeks after she started. She reported there is a new MDS lead who started recently and she is going to discuss this care plan with her. She stated we need to follow up on the interventions and change them. We need to talk to the patient and talk to the 1:1 staff to have new interventions put in place. An interview was conducted with the DON and Administrator on 6/28/22 at approximately 5:30 p.m., regarding what structured activities were provided to Resident #1. The DON and Administrator stated the facility did not have an activity person at that time and one of the restorative CNAs was helping out with activities, and they did not know what was provided to Resident #1. Review of the CNA Kardex for [TRUNCATED]

Based on interview of staff, attending physician, Advanced Registered Nurse Practitioner, review of clinical record, and facility's policies and procedures the facility failed to develop care plans for symptoms of dizziness, nausea and vomiting for one resident (#49) of 14 sampled residents. On [DATE], [DATE] and [DATE] Resident #49 experienced dizziness, nausea and vomiting and staff did not inform the resident's medical providers in order to give her the benefit of their assessment and interventions. On [DATE] Resident #49 experienced increased weakness, fell out of her wheelchair in her room and later was found unresponsive and pronounced dead after receiving CPR (Cardiopulmonary resuscitation) and the facility failed to ensure the care plan was implemented for three residents (#18, 73, and #36) of 44 residents sampled in regards to care plan implementation. The facility's failure to develop care plans to provide interventions and respond to the resident's symptoms resulted in Immediate Jeopardy beginning on [DATE]. The Immediate Jeopardy was determined to be removed on [DATE], with scope and severity lowered to a D. Findings Included: 1. Review of Resident #49's nursing home admission record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A comprehensive admission data collection form that contained an admission nursing assessment was not present in Resident #49's medical record. Review of Resident #49's Minimum (MDS) data set [DATE] revealed Resident #49's BIMS (Brief Interview for Mental Status) score of 15 (no cognitive impairment), she required limited assistance of one person for bed mobility, extensive assistance of one person for transfers and had a fall in the month prior to admission. Review of Resident #49's base line care plan dated [DATE] at 6:30 p.m. revealed the resident was admitted with focus areas and interventions that included: full liquid diet, nectar thickened liquids, physical and occupational therapy, Oxygen PRN (as needed), self-care deficit for activities of daily living, two persons needed for bed mobility, transfers, eating, toileting, ambulation, grooming/hygiene and one-person assist for dressing. Altered cardiac functions with assessment of vital signs. The care plan for diet was updated on [DATE] to Regular pureed, nectar thick liquids. The comprehensive Care Plan included the focus area of Diabetes Mellitus, required insulin twice a day, initiated [DATE]. Interventions included monitor, document and report as needed, compliance with diet and document any problems. A focus area of pain to left side related to chronic physical disability was initiated on [DATE], interventions included observe and report changes in usual routine, sleep patterns, decrease in functional abilities, and decrease in range of motion withdrawal or resistance to care. Observe and report changes in usual routine sleep patterns, decrease in functional abilities, and decrease range of motion, withdrawal or resistance to care. The focus area of ADL self-care performance deficit related to impaired balance, s/p (status [REDACTED]. Interventions included the resident requires extensive assistance by one person with personal hygiene and oral care, the resident requires extensive assistance by one staff for toileting. A focus area of sedative/hypnotic therapy related to [MEDICAL CONDITION] was initiated on [DATE] with interventions to include monitor for daytime drowsiness, confusion, and loss of appetite in the morning, increased risk of falls and fractures, dizziness. Review of the resident's Care Plan showed that it did not include focus areas of Nausea, Vomiting or Dizziness with goals and interventions. Review of the resident's record from admission until her death showed that there were no orders for PRN (as needed) or scheduled medications for nausea, vomiting or dizziness. Review of the Resident's medical record and staff interviews show that she did experience nausea, vomiting and dizziness. The notes show that the resident's medical providers were not contacted to allow for assessment or treatment of [REDACTED]. During an interview on [DATE] at 10:47 a.m., Staff member H, Physical Therapist, stated that she did not perform the initial evaluation and worked with Resident #49 once or twice. Staff member H stated, on [DATE] the resident stated she was dizzy and she did easy exercises while she sat on the bed. The resident was apprehensive since she was dizzy which would come and go. I told the ,[DATE] nurse how the resident was feeling. During an interview on [DATE] at 10:45 a.m. with Staff member G, PTA (Physical Therapy Assistant), she stated that she worked with Resident #49 on [DATE]. The resident needed to stop and rest at 80 feet due to lightheadedness then walked another 80 feet. Staff member G, PTA stated Resident #49 had improved so much compared to when she arrived, she was walking, talking and speaking clearly. Resident #49 required minimum contact guard with distant supervision from the wheelchair. Staff member G, PTA stated she told nurse on the 3 to 11 shift of the resident's change of condition. I was not familiar with the nurse but let them know that her left eye was closed more than usual and the nurse stated that she also gave her crackers and fluids which made her feel better earlier in the day. During an interview on [DATE], at 2:37 p.m. with Staff member J, LPN, she stated that she checked vital signs twice on Resident #49, after therapy spoke to her about Resident #49 getting dizzy on [DATE]. Staff member J, LPN, stated she checked Resident #49's vital signs twice, the first time was around 11:00 a.m. to 11:30 a.m. and the second time around 12:00 p.m. to 12:30 p.m. Staff member J, LPN, stated she would have documented them in the record under vital signs. Staff member J, LPN confirmed she took the vital signs twice including the pulse ox (oximeter, a non-invasive measure of blood oxygen saturation level, or O2 Sat). Then stated she only took her blood pressure and her pulse twice with temperature taken once since her temperature was good. Review of Resident #49's medical record and progress notes dated [DATE] and [DATE] did not reveal any nursing progress notes for those two days. Review of the Nursing progress note dated [DATE] at 3:49 p.m. showed Late Entry Note for ,[DATE] on [DATE]. Resident stated she didn't feel well at breakfast time. She stated she was nauseous so she didn't eat much of her breakfast. Vitals were good as well as temp was normal. After breakfast she threw up a little bit so for lunch she had Ginger Ale and saltine crackers. Insulin not given at 1130 due to her refusing it because she didn't eat much. At 1400 (2:00 p.m.) her Blood Sugar was 192. She still didn't have a temp and stated she was feeling a little bit better. Signed by Staff member Y, LPN. Staff member Y was interviewed on [DATE] at 9:46 a.m. with the DON as a witness. Staff member Y stated she worked the 7 a.m. to 3 p.m. shift on [DATE]. Resident #49 complained of being nauseous and Staff member Y gave her ginger ale and saltine crackers. Staff member Y, stated, Resident #49 refused her insulin that she gets in the morning. At 2:00 p.m., her blood sugar was 192 and Resident #49 was fine. Staff member Y, stated she did not have a temperature. She checked her temperature around 8:30 a.m. and at 11:30 a.m. or 12:00 p.m. then again and at 2:00 p.m. Temperatures are documented in my note. If they are not there, I may have put them in my record that we have. We have a report sheet and I pass that on during report to the next nurse. In my progress note, I reflected that I checked her temperature and her temperature was between 97 or 98. She was not pale. She transferred from bed to wheel chair by herself while I was giving her medicine. She said she threw up a little in the corner of a basin. Resident #49 said she was nauseated and she did not have anything ordered. I did not speak to the physician but left a message and I did not get an order. She was not nauseated in the afternoon. Around 2:15 p.m. I checked her blood sugar and her temperature because I wanted to make sure was ok. She gets a lot of medication and can vomit when they do not eat much for breakfast. It does not happen often for her but was not un-common for her. She was talking, laughing and thanked me for taking care of her. We got along very well. I would have put a note in the computer, that the physician was called. I do not remember if I put the information in the computer. I reported to Staff member C, LPN. I do not remember what brought her in to the facility. We have such a high influx of residents. Resident #49 did not have special precautions that I am aware of. I had taken care of her about four or five times. I did not notice an eye droop, facial changes, her speech was clear. During an interview with Staff member J, LPN, on [DATE] at 8:54 a.m. she confirmed she took care of Resident #49 daily on the ,[DATE] shift. Staff member J, LPN stated the resident was complaining of a cough the week she died and we were giving her cough syrup. Staff member J, stated she heard the resident had upper respiratory pneumonia. Resident #49 had General weakness but she usually could transfer herself from the bed to the chair and we would stand by so she would feel safe. Resident #49 was weaker during her last week. The day before she died , I was not here. I heard the night before she died , she had a fall with nausea and vomiting earlier in the day. I came in on [DATE] at 7:00 a.m. and read a nurses note that stated the sister was not aware of Resident #49's death. I used Resident #49's phone and called the sister with the resident's phone. Resident #49's sister, wanted to watch as the body was removed from the building and she took her sister's belongings. I told her that her sister had passed away and we had no funeral arrangements on file when I spoke to her on the phone. The sister stated that Resident #49 called the night before she died and stated she was not feeling that great. Staff member J, LPN stated, Resident #49 had some issues with blood pressure and it varied. Staff member J, LPN, stated I didn't know Resident #49's history except she had blood pressure issues, weakness, and diabetic. She did not have an eye droop, just a cough. I believe the physician was contacted for her cough. I did not contact the physician when I had her and she appeared weaker. We just did education on change of condition with a Sign In sheet but no handouts. The last time I saw Resident #49 was on [DATE] after 7 a.m. and she was in bed with the sheet pulled up to her neck. She had dried reddish saliva on her check. We were waiting for funeral home arrangements. During a follow up interview on [DATE] at 2:18 p.m., with Staff member J, LPN she stated she gave Resident #49 regular cough syrup which she had in her drawer, Ultra Tuss DM, 10 cc of cough syrup on [DATE] and would document that she gave it on the Medication administration Record for [DATE]. Staff member J, LPN confirmed Resident #49 complained of nausea sometimes and appeared weaker two days before the weekend. Staff member J, LPN, stated Resident #49 was getting better since admission when she would sleep all day and was progressing to going home. An interview was conducted on [DATE] at 6:56 a.m. with Staff member EE, CNA who said she had worked in the facility almost 4 years. Staff member EE, CNA stated she frequently worked in the high hall in rehab. Resident #49 was independent and needed very limited assistance; she would get dizzy and ask us to take her to the bathroom. She was alert and had dizziness often. If she moved too fast or sat up too fast. She would need to rest. Staff member EE, stated she did not notice too much coughing. She was not using oxygen and was unaware of any vomiting. Resident #49 could transfer fine and could stand and pivot to her wheel chair. When Resident #49 was admitted , she was shaky but got stronger and was able to do for herself. She would say when she did not feel good on the ,[DATE] shift. Staff member EE, stated, on [DATE], Resident #49 stated she did not feel good; she did not look good either. She was pale looking and you could tell when she was sick. I assisted if the light came on. On [DATE], she needed more help than usual. Therapy or someone came in that morning and stated she was not looking good just lying in the bed. Staff member EE, stated she helped to take her to the bathroom and would stand by her for support but this day, Staff member EE had to turn her and assist. I told her CNA, that day that she was not feeling well and asked if she was that way all day. The CNA said she told the nurse and she had been like that all day. During a follow-up phone interview on [DATE] at 11:40 a.m. with Staff member B, CNA she confirmed on [DATE] she told the ADON first then Staff member C, LPN that Resident #49 did not look good. No one else was in the area when this was said near the beginning of the 3p.m. to 11 p.m. shift on [DATE]. Staff member B, CNA confirmed that she saw Staff member A, CNA in the bathroom with Resident #49 and asked Staff member A, CNA what was going on. Staff member A, CNA responded, Resident #49 is weak and normally she was independent. Therefore, they both assisted the resident to the toilet. Staff member B confirmed that prior to this night; Resident #49 was able to transfer herself and confirmed the CNA does not document changes in condition as they tell the nurse which she did since Resident #49 was independent prior to this night. Staff member B, CNA confirmed she did not document the bathroom task at that moment, as she was so busy. Staff member B, CNA stated that she did tell the ADON and Staff member C, LPN that the resident needed to be sent out. Staff member B, CNA confirmed she was in the room with Staff member A and C when the resident stated she wanted to go out and the ADON was coming in the doorway. When Staff member B, CNA was walking out she stated to the ADON, the resident needed to go out and the ADON stated, I am not sending her nowhere! During an interview on [DATE] at 12:20 p.m. with Staff member ADON, he stated that Staff member C, LPN, came and told him, Resident #49 fell and since Staff member B and C could not get the resident up, she came to ask me to assist since I am a man. When entering the room, the resident was between the TV stand and the foot of the bed. Her back was against the wheel chair. Resident #49 stated she was not in pain, she stated she slipped off the wheel chair. She had on regular socks instead of nonskid. Staff member B, CNA, and myself tried to get her up. Resident #49 kept slipping. We lowered her back to the floor and I told Staff member B, CNA, to get the lift while Staff member C, LPN, and I waited in the room with the resident. Staff member C did her neuro-checks on her and I was looking in the hall to see where Staff member B, CNA was with the lift. Staff member A, CNA came down the hall from her break and I told her the resident fell and she asked if we were sending the resident to the hospital and I told her No there is no reason to send her to the hospital. Staff member B, CNA came down the hall with the lift and I left the room with Staff member A, B and C in the room with the resident so I could start the fall documentation. The resident was still on the floor when I left the room. I completed the pain evaluation and fall risk evaluation. I then put a note in the computer. I was not that familiar with Resident #49 but was told that normally she could stand and pivot. I left the building at 11:00 p.m. I was told by Staff member C, LPN she asked the aide to get the resident in bed twice prior to the fall. I did not fill out any other documentation or complete an assessment since I have faith in Staff member C, she is a competent LPN. I did an assessment in the room but did not document anything other than the pain evaluation and fall risk. I have been working in the facility since around Christmas. I am here working Monday through Friday around 14 to 15 hours a day due to us not having a ,[DATE] supervisor. I worked at a sister facility and will be the interim ADON until they find someone. After I left, I received a called from Staff member E, LPN, about 2:54 a.m. to notify me of Resident #49's death. During an interview on [DATE] at 4:20 p.m., with the ADON, he stated he did not hear Resident #49 or the nurse say that the resident wanted to go to the hospital. The ADON stated Resident #49 was on therapy caseload and should have nursing progress notes at a minimum of at least once per day. The ADON confirmed Resident #49 did not have a nursing assessment completed on admission which would have generated an order in the computer for documentation and that would have prompted other assessments to be ordered and get completed such as history of falls which he could not find and stated that adds to his frustration. The ADON stated that after the resident's fall the neurological checks should have been completed every 15 minutes, and documented in the computer, which, he could not locate for Resident #49. The ADON stated he would look in the DON's (Director of Nursing) office. The ADON returned with a paper document labeled neurological assessment flow sheet with a hand written name of Resident #49, dated [DATE] at 10:45 p.m., with a check mark in the alert column, a check mark in the Pupils equal round and reactive column, hand grasps equal, motor functions checked for all extremities, illegible documentation of pain response, vital signs with blood pressure documented as ,[DATE], pulse 89 and respirations of 18 and observations documented as none. The document was not signed, and the physician name was not documented. The document contained only one neuro check at 10:45 pm, and did not contain any further neurological checks. The ADON stated the facility does not have a policy related to neurological checks, they follow the document instructions. Written on the top right corner of the assessment sheet was: to complete checks every 15 minutes for 1 hour, every hour for 4 hours and every 4 hours for 19 hours. The ADON stated, I don't know why it was not completed. During a phone interview on [DATE] at 6:30 p.m., with Resident #49's Primary physician, she stated that she saw the resident last on [DATE] and received a call from the facility regarding Resident #49 on [DATE] after the fall. She was unsure of the exact time but stated the vital signs were stable. She did not have a discussion about the resident going to the hospital at that time. She stated she did not receive a call from the facility on [DATE] prior to the fall. She was unaware of the resident not feeling well and vomiting earlier in the day. During a phone interview on [DATE] at 12:50 p.m., with the Resident's Nurse Practitioner, she stated that she last saw Resident #49 on [DATE] and [DATE]. She stated the resident was stable and did not have any visual changes related to her eyelids drooping. Her vital signs were stable and the resident was observed transferring from the bed to the wheel chair and she was walking with a walker. The resident had been stable and progressing with therapy. She came to us after a stroke and had a similar TIA ([MEDICAL CONDITION]- a brief stroke -like attack wherein symptoms resolve within 24 hours) in (MONTH) (according to record July). When she arrived to us she was on a modified diet and by (MONTH) she transitioned to a regular diet without issues swallowing. She lived alone and we kept her at the facility for therapy. The last time I saw the resident she was stable and had no issues. I did not receive any calls related to her from the facility in (MONTH) after [DATE] that is why I had not seen her again since then. The physician last saw her on (MONTH) 3, (YEAR) and did not see her in (MONTH) prior to her passing. Review of the Nursing progress note dated [DATE] at 3:54 a.m. signed by Staff member F, LPN showed, Resident found unresponsive at 1:45 a.m., Resident full code, CPR (cardiopulmonary resuscitation) started immediately and 911 called. EMS (Emergency Medical Services) worked on Resident #49 over 30 minutes and stated doctor said to stop with resident pronounced at 2:30 a.m. Two calls placed to sister unsuccessful. Medical Director notified. During an interview with Staff member B, CNA on [DATE] at 3:16 p.m. with the Director of Nursing present as a witness, Staff member B, CNA stated, she went into Resident #49's room after she felt something was wrong at approximately 2:00 a.m. on [DATE] and found Resident #49 in bed lying in the same position as she left her after the fall at 10:45 p.m. On [DATE], just three hours earlier. Resident #49 was not responding. Staff member B, CNA notified Staff member F, LPN who called the code and verified the code status. Staff member AA, LPN ran in the room and started Cardiopulmonary Resuscitation while Staff member F, notified 911. Review of emergency medical services report revealed the phone call was received on [DATE] at 1:54 a.m.; emergency services arrived at 2:00 a.m. on scene. Resident #49 was unresponsive, pulseless and apneic (cessation of breathing). Skin cool to the touch but warm at the core, pink and dry. Pupil's non-reactive, no neurological activity noted. During an interview on [DATE] at 12:37 p.m. with Staff member E, LPN, she stated that she notified the ADON on [DATE] at 2:34 a.m. She called the ADON to see if she needed to do anything else and called the sister who did not answer. 2. Resident # 18 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's [DATE] MDS assessment showed the resident had a Stage IV pressure ulcer on admission. physician's orders [REDACTED]. In an interview with the resident's Responsible Party, on [DATE] beginning at 5:15 p.m., it was revealed that the resident was seen by a wound center that had been treating the resident's wound prior to her admission to the facility. The Responsible Party had requested that the resident continue to be treated by this wound center as the wound was almost resolved. A review was conducted of the care plan with the Focus of actual impairment to skin integrity related to immobility, [MEDICAL CONDITION], and requires total care for all ADL(Activities of Daily Living) care and incontinence, initiated on [DATE] with a revision on [DATE]. Interventions per the care plan included: monitor/document location, size, and treatment of [REDACTED]. to MD, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the Medication Administration Record and the Treatment Administration Record from the resident's admission in (MONTH) did not reveal that the physician's orders [REDACTED]. In an interview conducted on [DATE] beginning at 10:17 a.m., the Unit Manager reviewed the (MONTH) MAR and TAR and confirmed that the order to cleanse the wound had not been transcribed to either record to allow for documentation. Review of the Treatment Records for weekly skin checks revealed the ordered once weekly check had been initialed as having been completed, but no documentation of the checks could be located, except for the wound check completed on [DATE] and one report documented on [DATE], which included the measurements of the left trochanter (hip) wound: open area 0.5 cm depth 0.5 cm width - no drainage. The Unit Manager, in an interview that began on [DATE] at 10:17 a.m., reported that there might not have been any weekly skin notes as the resident's wound had resolved. An observation was made of the wound treatment with the Unit Manager, a second nurse, and a RN surveyor. The observation confirmed that the wound was still present. Review of the care plan for the Focus area of nutritional problem or potential nutritional problem related to low BMI (body mass index) and DM (diabetes mellitus). Interventions included: provide, serve diet as ordered, fortified/regular consistency; RD (Registered Dietitian) to evaluate and make diet change recommendations prn. Review of the RD assessment for this resident revealed it had been conducted after the admission on [DATE]. There were no follow up notes as to the resident's nutritional status, the status of the wound, lab values, or acceptance of the protein supplement. 3. Resident #73 was admitted to the facility on [DATE] after surgical repair of her left femur and the [DIAGNOSES REDACTED]. On [DATE] she weighed 154 lbs, a gain of 19 pounds or 12% in two months. She wasn't weighed again until [DATE] when her weight was documented at 176 lbs, a gain of 22 lbs or 12.5% in three months - a significant gain. The resident's [DATE] MDS assessment showed a BIMS score of 14 indicating no cognitive impairment, she required extensive assistance of 2 persons for bed mobility, weighed 176 pounds and was on a mechanically altered diet. Review of a note by the RD, documented after the resident's readmission to the facility after a second fall and left leg fracture, revealed a reference to a weight of 194 lbs as documented on the 3008 admission paperwork. In an interview with the RD on [DATE] beginning at 2:55 p.m., the RD confirmed that weights were missing for this resident and the resident had jumped from the '150's' to the '170's' and then to over 190 lbs. The RD reported that the resident ate a lot of candy and she suggested that habit had caused her to gain the weight. Review of the resident's care plan with the Focus of nutritional problem related to dysphagia with use of thickened liquids. Interventions included, RD to evaluate and make diet change recommendations PRN - as necessary. 4. Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was transferred to the hospital on [DATE] after an observed [MEDICAL CONDITION] and returned on [DATE]. Review of the admitting document requiring the aides to weigh the resident at admission and on the next two days to determine a baseline weight revealed the weights had not been taken. Review of the resident's [DATE] MDS showed that he weighed 147 pounds and was on a mechanically altered diet. Review of the resident's care plan from the initial admission revealed a nutrition problem or potential nutrition problem related to at nutritional risk with a pureed diet with nectar liquids and fortified foods. Interventions included weight per routine and as needed. The baseline care plan developed after the readmission on [DATE] included the intervention under the Problem of Nutrition/hydration: will maintain a stable weight. 5. A review of resident #36's medical chart revealed that she was admitted for long term services with a Health Care Proxy in place. Section C of Resident #36's most current comprehensive assessment from [DATE] revealed the resident is rarely/never understood. Section G revealed the resident is totally dependent for assistance with personal hygiene, Toilet use, Locomotion on /off the unit and dressing. The [DATE] MDS assessment showed that the resident required extensive assistance with bed mobility and had no pressure ulcers. A review of Resident #36's care plan identified interventions related to the following risks - Impaired skin integrity - Heal blisters on her right heel /lateral foot. - Resident Restlessness rubs heels on mattress / refuses to keep heels elevated. The identified interventions included instructions to: - Redirect inappropriate behaviors as needed. - Float Heels - Off load heals when in bed every shift - Posey heel guards while in bed - as ordered A review of Resident #36's physician orders [REDACTED]. On [DATE] at 10:54 a.m. Resident #36 was observed lying in bed without her assistive devices (heel guards) in place. The heel guards were observed lying on resident front dresser/counter. Photo evidence obtained. During an interview regarding the assistive devices with Staff X, LPN on [DATE] at 01:07 PM she stated, I am familiar with Resident #36 but I do not know for certain if there is an order for [REDACTED]. Staff X, LPN then logged onto the facility's Electronic Health Record to research Resident #36's physician orders. Staff X, LPN confirmed and stated, Yes .I see that Resident #36 does have an order for [REDACTED]. I don't know why they weren't on but they should have been. Facility Action to Remove the Immediacy A review of the facility's action plan, dated (MONTH) 25, 2019, revealed the following: 1) Current in house residents were assessed on [DATE] by an RN, to ensure that they were not experiencing any change in condition from their baseline. No changes in condition were identified. 2) Facility wide quality review was initiated to determine if any changes in condition including falls within the last 30 days were missing the appropriate documentation. This will include: Nurse's note reflects MD/Responsible party notification. New orders on Medication Administration Record and Interventions on Care Plan if applicable. Post fall documentation if applicable. SBAR initiated for all changes 24-hour report 3) Licensed staff will be reeducated ensuring: Evaluation/Assessment is done and documented at the time the change is identified. Completion of SBAR/nurses note reflecting the change. Follow up documentation and monitoring to ensure that the resident is stable. 4) IDT team (DCS, ED, ADCS, UM's, MDS, SSD) will review all changes in condition each morning during clinical meeting and afternoon during stand down meeting to ensure all components are in place. 5) Non-licensed staff was re-inserviced on ensuring that they understand the purpose and importance of using the Stop and Watch tool. Education: 1) Licensed staff on duty between ,[DATE], [DATE] and ,[DATE] on [DATE] were educated on the components of the regulations related to Quality of Care and Resident Rights and with an emphasis on: Identifying and reporting a change in condition. Listening to the Resident and honoring their wishes as long as it does not impact them negatively. Completion of SBAR/Nurses note post fall. Neuro-checks if unwitnessed will be completed. Monitoring and documentation to ensure that the resident is stable. 2) All licensed staff will be educated prior to the start of their shift starting on ,[DATE] [DATE]. 3) If necessary, education will be provided via telephone to ensure compliance is attainted. New employees with be in-serviced on the policy to ensure ongoing compliance. Monitoring will be ongoing: 1) The DCS/designee will conduct a weekly quality review of 5 residents who have had a change in condition weekly x 4 weeks, and then every 2 weeks x 2 months to ensure all components of documentation is complete. The findings of these audits will be reported in the next Risk Management/ QA Committee meeting until committee determines substantial compliance has been met and quarterly monitoring is recommended. <b (TRUNCATED)