Every finding on record at Aviata at Central Park

Based on observations and interviews, the facility failed to ensure garbage and refuse were properly contained and disposed of in a manner that prevented accumulation of waste for one of one refuse disposal areas observed. This deficient practice had the potential to create an unsanitary environment and attract insects and rodents.Findings included:During an observation on 08/03/2026 at 6:40 a.m., the dumpster area was observed to have two large commercial dumpsters positioned against a brick wall with the lids open. Loose refuse and debris were visible on the ground immediately adjacent to and behind the dumpsters, including plastic materials and other discarded items. Two large mattress like items were leaning against the wall beside the dumpsters rather than being placed inside the dumpsters. Photographic evidence was obtained.During an interview on 08/05/2026 at 3:50 p.m. with the Kitchen Manager, the Dietary Manager, and the Nursing Home Administrator (NHA), the NHA stated maintenance staff were responsible for the refuse area. The NHA stated that the facility had requested an additional pickup on Monday because the dumpsters were overflowing. The NHA stated that the facility had recently completed a cleaning project and materials from that cleanout needed to be discarded.Record review of the facility's policy titled Solid Waste Management, dated 11/30/2024, showed the policy required solid waste to be handled and disposed of in a manner that ensured a safe and sanitary environment. The procedure required maintaining a contract with a trash hauler for periodic removal of bulk trash containers and scheduling removal in a way that eliminated the possibility of overflowing containers. This confirmed the facility requirement that was not followed.

Based on observation, record review, and interview, the facility failed to ensure a call light was within reach for one resident (#19) out of one resident observed with a call light out of reach. This deficient practice had the potential to affect the resident's ability to request assistance.Findings included:During an observation on 08/03/2026 at 6:11 a.m., Resident #19 was observed lying in bed. Resident #19 stated, I don't have a call light. I just wave staff down from the hall if I need help. The resident's call light was observed under the bed and out of reach.During an observation on 08/04/2026 at 8:24 a.m., Resident #19 was again observed lying in bed. Resident #19's call light was seen on the floor under the bed and out of reach.During an observation on 08/06/2026 at 9:51 a.m., Resident #19's call light was observed tied to an oxygen concentrator. Resident #19 stated they were unsure where the call light was and would just holler if they needed any help from staff.Review of Resident #19's admission record showed an admission date of 06/12/2026. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypoxia, displacement of nephrostomy catheter, muscle weakness, other lack of coordination, and difficulty in walking.Review of Resident #19's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Section GG, Functional Abilities, documented that Resident #19 required substantial/maximal assistance for mobility tasks including rolling left and right, sitting to lying, and lying to sitting on the side of the bed. Substantial/maximal assistance means the helper performs more than half of the effort.During an interview on 08/06/2026 at 10:01 a.m., Staff C, Certified Nursing Assistant (CNA), stated they round on residents every one to two hours and make sure residents are clean and do not need to be changed. Staff C stated they ensure the call light is within the resident's reach.During an interview on 08/06/2026 at 10:05 a.m., Staff E, Licensed Practical Nurse (LPN), stated CNAs complete frequent rounds on residents. Staff E stated the call light should be where the resident can reach it to request assistance, and that if the call light is under the bed it would be out of reach.During an interview on 08/06/2026 at 10:10 a.m., Staff D, LPN Unit Manager, stated call lights should be within reach of residents at all times. Staff D stated that call lights on the floor under the bed would not be within reach, and that a call light may be tied to an oxygen concentrator only if requested by the resident.During an interview on 08/06/2026 at 1:21 p.m., the Director of Nursing (DON) stated that if a resident can move about the bed, the call light could fall to the floor. The DON stated they expected the call light to be within reach and pinned to the bed if needed so the resident could use it.The facility was asked to provide a policy related to ensuring call light accessibility for residents, and one was not provided.

Based on interview and record review, the facility failed to provide written notification and an explanation for a room change for one resident (#128) of two residents reviewed for room changes. This failure had the potential to affect the resident's right to receive advance notice and understand the reason for the room change.Findings included:Record review of Resident #128's progress notes showed no documentation of who requested the room change and there was no written notification provided to the resident or the Resident Representative (RR) explaining why the move was required.Review of the facility census list dated 8/6/26 showed Resident #128's room was changed on 4/9/26. Review of the admission record showed Resident #128 was admitted to the facility on [DATE] with diagnoses to include Dementia.During an interview and record review on 8/4/26 at 4:53 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated that when a resident's room is changed, the staff complete a room change form that documents who was notified of the move. After reviewing Resident #128's record, the DON stated that notification to the resident and the Power of Attorney (POA) was missing and said, there should be a note.Review of a facility policy and procedure titled, Room Changes, effective date 11/30/2014, showed it is the policy of the company to provide safe and necessary room changes.Some considerations for a room change may be: The resident expresses dissatisfaction.The staff or an interested party notices that room mates are incompatible. Medical indications warrant it. Administrative reasons. Other-as determined by the team to provide reasonable accommodation of needs and preferences to all residents.Procedure:1.Team members should consider the pros and cons of the room change with input from the resident and/or interested party whenever feasible.2.Prior to the room change, the team should give the resident/legal representative notice to allow the resident/legal representative time to prepare for the room change. The notice period may be waived by the resident/legal representative. Emergent conditions or safety concerns, as determined by the team, may supersede the notice period.3.Room changes should be documented in the residents' chart. The documentation may include: The reason for the change and notification of resident, legal representative, and their assent.

Based on interviews and record review, the facility failed to notify one resident (#53) out of three sampled residents who required notification of therapy service coverage changes related to benefit exhaustion. This deficient practice resulted in Resident #53 being uninformed about the end of her Medicare coverage, the discontinuation of therapy services, and her options for continuing therapy as a private pay service.Findings included: During a facility tour on 08/03/2026 at 07:00 AM, Resident #53 stated her insurance coverage ran out on 07/16/2026 and she had been private pay since that date. Resident #53 stated therapy had been stopped without warning and confirmed she had not received therapy services since 07/16/2026. Resident #53 stated she had been able to walk before admitting to the facility and wanted to walk again by discharge. Resident #53 stated she cried when she learned her insurance coverage had ended.During an interview on 08/05/2026 at 10:39 AM, the Director of Rehab (DOR) stated he normally requested the Business Office (BO) to ask residents if they wanted to continue therapy after insurance coverage ended. The DOR stated the facility would complete an evaluation and work with the BO to determine next steps. The DOR stated Resident #53 had exhausted 100 days of insurance coverage and was not on the therapy caseload at the time. He stated she was evaluated for physical and occupational therapy on 06/26/2026 and for speech therapy on 07/02/2026, and had previously received therapy for transfer training, bed mobility, exercises, range of motion to the right upper extremity, and lower body dressing. The DOR stated Resident #53 participated in therapy nearly every day, and her last treatment date was 07/15/2026. The DOR stated she was discharged from therapy due to benefit exhaustion and therapy staff did not speak with Resident #53 about continuing services. The DOR stated Resident #53 was making progress, with one of four goals met, and stated she was successful with transfers and could not walk. He stated walking would have been the next step and that Resident #53 could have continued therapy as private pay.During an interview on 08/05/2026 at 12:21 PM, the Business Office Manager (BOM) stated that when a resident exhausted coverage and did not wish to use Medicaid, the resident would either pay privately or discharge. The BOM stated private pay therapy would be based on units and payment would be required upfront. The BOM stated private pay therapy services were not discussed with Resident #53.During an interview on 08/05/2026 at 3:17 PM, the Social Services Director (SSD) stated she had spoken with Resident #53 about post discharge plans but had not discussed therapy.During an interview on 08/06/2026 at 10:13 AM, the SSD stated social services was responsible for issuing a Notice of Medicare Non Coverage (NOMNC) and stated Resident #53 was not provided with one. The SSD stated NOMNCs required a minimum two day notice. She stated Resident #53's benefits were exhausted on 07/12/2026, and staff were aware on 07/10/2026.Record review revealed Resident #53 was admitted on [DATE] with diagnoses including surgical aftercare, morbid obesity, muscle weakness, difficulty in walking, heart failure, obstructive sleep apnea, chronic pain syndrome, and low back pain. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 13, indicating intact cognition. Section GG revealed Resident #53 required full assistance from staff for toileting hygiene, rolling, sitting to lying, lying to sitting, transfers, and sitting to standing.Review of Resident #53's care plan revealed a focus on altered functional performance related to weakness and deconditioning, initiated 06/26/2026, with goals for improving functional performance. Interventions initiated 07/08/2026 included varying ADL participation due to fatigue, weakness, medical conditions, or changes with therapy; substantial/maximal assistance for personal hygiene; and full assistance for putting on or taking off footwear.During an interview on 08/05/2026 at 5:47 PM, the Nursing Home Administrator (NHA) stated Resident #53's last covered day was 07/12/2026 and the facility was aware on 07/10/2026. The NHA stated a NOMNC was not provided when benefits were exhausted. She stated documentation entered on 07/16/2026 did not include notification of benefit exhaustion. During an interview on 08/06/2026 at 2:49 PM, the NHA stated staff reviewed residents receiving skilled therapy to assess coverage, remaining days, discharge plans, and therapy progress. The NHA stated staff should have documented benefit exhaustion discussions and Resident #53 could have continued therapy as private pay if she would have benefited.Review of the facility's Resident Rights policy dated 11/30/2014 revealed residents and representatives were informed of resident rights, but the policy did not address notification of therapy service coverage changes or benefit exhaustion.

Based on record review and interview, the facility failed to notify the Office of the State Long Term Care Ombudsman of the discharge or transfer for two residents (#128 and #129) of two residents reviewed for discharge or transfer. This failure had the potential to affect the residents' right to receive required notice and advocacy protections during discharge or transfer. Findings Included: 1. Record review of Resident #129's admission record showed an admission date of 11/04/2025 and a discharge date of 12/24/2025. Resident #129 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Record review of Resident #129's Assessments dated 12/23/2025 showed documentation of a discharge plan and instructions. Record review of the Nursing Home Transfer and Discharge Notice dated 12/22/2025 showed the section labeled Notice given to Local Long-Term Care Ombudsman Council was left blank, indicating the required notice was not sent. During an interview on 08/04/2026 at 3:10 p.m., the Social Services Director (SSD) stated they completed AHCA (Agency for Health Care Administration) transfer and discharge forms when residents were discharged home. The SSD stated fax cover pages were not kept to verify that the transfer and discharge forms were sent to the ombudsman. During an interview on 08/06/2026 at 10:05 a.m., Staff E, Licensed Practical Nurse (LPN) stated they were not aware of the AHCA Transfer and Discharge Notice or the requirement to notify the ombudsman of resident discharges. 2. Record review showed Resident #128 was admitted on [DATE] with a diagnosis including dementia. Record review of Resident #128's Nursing Home Transfer and Discharge Notice dated 04/30/2026 showed the section labeled Notice given to Local Long-Term Care Ombudsman Council was left blank, indicating the notification was not completed. During an interview on 08/05/2026 at 11:12 a.m. with the SSD and Regional Social Services Director (RSSD), the RSSD stated that when residents were transferred to the hospital, the facility was required to notify the ombudsman. Record review of the facility's policy titled Transfer/Discharge Notification and Right to Appeal, revised 04/28/2025, showed the following requirement under - Notice Before Transfer- Before a center transfers or discharges a resident, the center must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.This confirmed the facility's responsibility to notify the ombudsman prior to transfer or discharge.

Based on observations, record review, and interviews, the facility failed to revise the comprehensive care plan for one resident (#102) of one residents reviewed for care plan revision. This deficient practice had the potential to affect the resident's safety by failing to update interventions related to fall risk when the resident's bed was consistently kept in a high position contrary to the planned intervention.Findings included:Record review of Resident #102's comprehensive care plan dated 11/07/2024 showed a focus area revealing the resident was at risk for falls related to deconditioning, confusion, gait and balance problems, and incontinence. The care plan showed a revision date of 02/11/2026. One of the listed interventions was Bed in low position.During an observation on 08/03/2026 at 6:16 a.m., Resident #102's bed was observed not in a low position. The bed was approximately 3 feet off the floor.During an observation on 08/04/2026 at 8:32 a.m., Resident #102's bed was again observed not in a low position and remained approximately 3 feet off the floor.During an observation on 08/06/2026 at 9:52 a.m., Resident #102's bed continued to be positioned approximately 3 feet off the floor and not in a low position.Record review showed Resident #102 was admitted on [DATE] with diagnoses including senile degeneration of the brain, breakdown of nephrostomy catheter (subsequent encounter), generalized muscle weakness, limitation of activities due to disability, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and neuromuscular dysfunction of the bladder.During an interview on 08/06/2026 at 10:01 a.m., Staff C, Certified Nursing Assistant (CNA) stated they identify fall risk residents through the Kardex (a quick reference nursing tool that summarizes essential information about a resident's current care needs) and shift change reporting. Staff C stated some residents who are fall risks require their bed to be in a low position.During an interview on 08/06/2026 at 10:05 a.m., Staff E, Licensed Practical Nurse ( LPN) stated they review assignment reports and care plans to identify fall risk residents and interventions. Staff E stated when a resident's bed is supposed to be in a low position, the bed would be placed very close to the floor to reduce injury if the resident fell.During an interview on 08/06/2026 at 10:10 a.m., Staff D, LPN/Unit Manager stated Resident #102 kept the bed in a high position and preferred it that way. Staff D stated the resident had been educated about lowering the bed, but the resident continued to keep it higher. Staff D stated that residents with such preferences were typically care-planned for not wanting their bed in a low position.During an interview on 08/06/2026 at 2:20 p.m., the Director of Nursing (DON) stated residents who had past falls, but had not continued to fall, may require care plan revision, especially if they were not following existing interventions. The DON stated the intervention requiring the bed to be in a low position could be modified if it was no longer needed and if the resident preferred the bed higher. The DON stated they would need to be notified about the resident not maintaining the low bed intervention before addressing it through care plan revision.Review of the facility policy dated 11/20/2014 titled Plans of Care showed the facility required an individualized, person centered plan of care established by the interdisciplinary team and updated according to federal regulatory requirements. The policy stated that the comprehensive care plan must be reviewed, updated, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observations, interviews, and record review, the facility failed to ensure essential equipment was maintained in good repair for one resident (#53) out of three residents reviewed for equipment safety. This deficient practice had the potential to affect the resident's comfort, ability to reposition safely, and the overall, well being.Findings included:During a facility tour on 08/03/2026 at 7:00 a.m., Resident #53 was observed lying in bed with the head of the bed elevated and the foot of the bed tilted downward below the flat position. Resident #53 stated the position was uncomfortable and stated the bed had been in that condition since 07/31/2026. Resident #53 also stated, I'm very upset. Record review showed Resident #53 was admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) assessment dated 7//2/2026 revealed a score of 13 out of 15, indicating cognition was intact.During an interview on 08/05/2026 at 3:18 p.m., the Social Services Director (SSD) stated she was informed on 08/04/2026 that Resident #53's bed was broken. She stated she did not know when the bed first malfunctioned. The SSD stated that if the bed malfunction occurred on 07/31/2026, a grievance should have been opened on that date because anybody can have a grievance.During an interview on 08/05/2026 at 4:14 p.m., Staff H, Certified Nursing Assistant (CNA), stated she learned on 07/31/2026 that Resident #53's bed was not working properly. Staff H stated she reported the issue to multiple nurses and entered a work order ticket into the maintenance software on 07/31/2026. Staff H stated Resident #53 said she was uncomfortable.During an interview on 08/06/2026 at 11:11 a.m., Staff I, CNA, stated she believed she spoke with Resident #53 on Tuesday about the resident's bed malfunction. Staff I stated the whole bed did not go up as expected and when the head of the bed went up, the bottom portion did not. Staff I stated she entered a work order request into the maintenance software. Staff I stated the resident reported being uncomfortable.During an interview on 08/06/2026 at 9:36 a.m., the Director of Maintenance (DOM) stated his department received work requests when staff informed him directly or entered a ticket into the maintenance software. The DOM stated if he had the parts needed to repair a bed on hand, he would request nursing staff to remove the resident from the bed so he could fix it immediately. He stated if parts were not available, he would ask nursing staff to remove the resident and he would replace the bed with an available standby bed. The DOM stated he could obtain additional beds from another facility if necessary. The DOM stated a maintenance ticket for Resident #53 was not entered into the software until 08/03/2026 and stated he had no knowledge of the bed malfunction prior to that date.During an interview on 08/06/2026 at 2:49 p.m., the Nursing Home Administrator (NHA) stated staff were instructed to enter work order tickets into the maintenance software for mechanical failures. The NHA stated she was not aware of Resident #53's bed problem until 08/05/2026. She stated if a bed was malfunctioning and not able to raise or lower, it would be considered an emergency and high priority. The NHA stated the maintenance ticket entered for Resident #53 had been marked as medium priority.Review of the facility policy titled Bio Medical Equipment Management, dated 11/30/2014, showed the equipment management program included electric beds and required the facility to manage clinical and physical risks associated with fixed and portable equipment used in resident care. This confirmed the facility requirement that was not met.

Based on record reviews and interviews the facility failed to ensure physician orders were followed by administering medications outside parameters without notifying the physician and the IDT (Interdisciplinary) team for one resident (#1) of three residents reviewed.Findings included: Review of Resident #1's admission record revealed an admission date of 9/15/25 with diagnoses to include but not limited to chronic pain, coronary artery bypass graft, bilateral below the knee amputations (BKA), cardiogenic shock, acute respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes type 2, hypertension and dyspnea. Review of Resident #1's care plan focus: Resident #1 has alteration in acute/chronic pain. Goal: Resident #1 will have minimal interruption in normal activities due to pain. Interventions included to administer analgesia as per orders. Review of Resident #1's order summary report showed Percocet 5-325 mg 1 tablet every 6 hours as needed for moderate pain 4-7 [pain level] ordered on 9/16/25 and discontinued on 9/22/25. Review of Resident #1's medication administration report (MAR) schedule for September 2025 showed:-On 9/16/25 at 9:00 p.m. Percocet 5-325 one tablet was administered for a pain level of 10.-On 9/22/25 at 6:16 a.m. Percocet 5-325 one tablet was administered for a pain level of 8.-On 9/22/25 at 1:14 p.m. Percocet 5-325 one tablet was administered for a pain level of 8. Resident #1's progress notes did not show follow-up documentation to indicate the medical team was notified when ordered parameters for administering medications were not followed. On 11/5/2025 at 9:52 a.m. during an interview, Staff C, Registered Nurse (RN) said she notified the doctor if orders are not followed. On 11/5/25 at 1:50 p.m. during an interview and review of Resident #1's medical record with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), Staff A said on 9/16/25 at 9:00 p.m. Resident #1 received Percocet for pain level of 10 and it does not appear the doctor was notified. During an interview with the Director of Nursing (DON) on 11/5/25 at 3:30 p.m., the DON said when medications are given outside of the ordered parameters, nurses are expected to notify the doctor. Review of the facility's policy and procedure titled Pain Management Guideline revised 8/28/2017 revealed: Policy: The center strives to improve patient/resident comfort and minimize pain in order to help a resident attain or maintain his or her highest practicable level of well-being. Purpose: To ensure residents receive the treatment and care in accordance with professionals standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Process: Identification: Evaluate patient/residents upon admission/re-admission, quarterly, with a change in condition or with a new onset of pain. Pain Evaluation: Identify if a resident is experiencing pain using either the resident's self-report of pain (utilizing a 0-10 scale) or for those patient/residents who cannot self-report, use the non-verbal clinical indicators. The Pain Flow Record or electronic equivalent to be maintained in the Medication Administration Record (MAR). Treatment: Develop patient centered interventions (pharmacologic and nonpharmacologic) to manage pain. Document the interventions on the care plan. Monitoring: Monitor and document the patient/resident's response to the interventions. Evaluate the effectiveness of the interventions and progress towards goals. Discuss new interventions and goals with the resident and/or family/resident representative. Update the care plan as indicated. Review of the facility's policy and procedure titled Plans of Care revised 9/25/2017 revealed: Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Note: The resident's plan of care encompasses many documents that are part of the resident's clinical record including, but not limited to, structured care plan documents, MARS, TARS, physician orders, flow records, and/or legal documents that would drive the plan of care for the individual resident. Review of the facility's policy and procedure titled Medication Oral Administration revised 8/15/2019 revealed: .Review physician's orders .Review the MAR or EMAR should there be any uncertainties verify the MAR or EMAR with the Physician's Order Sheet (POS) and seek clarification as indicated.

Based on interviews and record review the facility failed to ensure baseline care plans for code status were in place for three residents (#1, #2, and #3) of three residents sampled. Resident #1 was readmitted on [DATE] with diagnoses to include but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, altered mental status, generalized muscle weakness, dysphagia, obstructive sleep apnea, stage III chronic kidney disease, hypertension, anemia, sepsis, pneumonia, metabolic encephalopathy, congestive heart failure (CHF), and dependence on supplemental oxygen.Review of Resident #1's physician order dated 9/8/25 showed resident was a full code. Review of Resident #1's Care Plan revealed no care plan for a code status. Resident #2 was admitted on [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, COPD, CHF, atrial fibrillation, and pulmonary embolism. Review of Resident #2's physician order dated 9/11/25 showed resident was a full code. Review of Resident #2's Care Plan revealed no care plan for a code status until 10/3/25.Resident #3 was admitted on [DATE] with diagnoses to include but not limited to COPD, atrial fibrillation, CHF, pulmonary hypertension, non-ST elevation myocardial infarction, and stage 3 chronic kidney disease. Review of Resident #3's admitting physician order dated 9/13/25 showed resident was a do not resuscitate (DNR). Review of Resident #3's Care Plan revealed no care plan for a code status until 9/17/25.During an interview on 10/8/25 at 1:31 PM the Social Service Director (SSD) stated upon admission code status is reviewed with each resident and resident representative (RR). The SSD stated the nurse goes over this with the resident at the time of admission and social services reviews again within 72 hours. The SSD stated the code status is important and it should be on the care plan. The SSD confirmed Resident #1, #2, and #3 did not have baseline care plans in place. During an interview on 10/8/25 at 2:02 PM the Assistant Director of Nursing (ADON) stated the admitting nurse reviews resident and RR preference for code status and should then place the code status on the baseline care plan. Once the comprehensive care plan is started the minimum data set (MDS) nurse would place the code status in the comprehensive care plan. The code status is important due to ensuring resident's wishes are followed. During an interview on 10/8/25 at 2:25 PM the Nursing Home Administrator (NHA) stated the expectation was for baseline care plans to be put in place within 48 hours for code status.Review of facility's policy titled Plans of Care, dated 9/25/2017 revealed Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representatives(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: . develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed.

Based on interviews and record reviews, the facility failed to ensure nursing staff had the skills, knowledge and certification necessary to provide cardiopulmonary resuscitation (CPR) services for one resident (#1) of three residents sampled.Review of Resident #1's admission record revealed a readmission date of [DATE] with diagnoses to include but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, altered mental status, generalized muscle weakness, dysphagia, obstructive sleep apnea, stage III chronic kidney disease, hypertension, anemia, sepsis, pneumonia, metabolic encephalopathy, congestive heart failure (CHF), and dependence on supplemental oxygen. Review of Resident #1's physician order dated [DATE] showed the resident was a full code. Review of Resident #1's Care Plan revealed no care plan for a code status. Review of Resident #1's medical record revealed a note dated [DATE] at 8:25 a.m. authored by Staff A, Licensed Practical Nurse (LPN) titled: SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers: Unresponsiveness . Full Code; . At 2026 EST [eastern standard time] I was called to room [ROOM NUMBER]A. Upon arrival the pt [patient] was found unresponsive, pulse-less, and apneic. Code blue activated immediately. CPR [cardiopulmonary resuscitation] was initiated per ACLS [advanced cardiac life support] protocol. Code team arrived at bedside and resuscitation measures began. During code, pt achieved return of spontaneous circulation (ROSC) with thready pulse at 133 BPM [beats per minute] and blood pressure of 151/54 mmHg [millimeters of mercury] at 2033. At 2043 EMS [emergency medical service] arrived at bedside shortly thereafter. Repeat blood pressure 150/51 pulse 152. Pt stabilized for transport. During an interview on [DATE] at 2:03 p.m. Staff B, CNA stated during normal rounds finding Resident #1 unresponsive. Staff B, CNA stated immediately calling for Staff A, LPN. Staff A, LPN came into Resident #1's room. Staff A, LPN checked Resident #1's pulse and said it was low and told me to get another nurse. When returning Staff C, LPN, Staff F, CNA and Staff H, CNA were performing CPR. Staff A, LPN was standing between the dressers in the room. I was not needed in the room, so I went to open the door for EMS when they arrived. Staff B, CNA stated not being certified in CPR. During an interview on [DATE] at 9:31 a.m. Staff C, LPN stated hearing assistance was needed downstairs in Resident #1's room. Staff C, LPN explained being familiar with Resident #1 as having cared for the resident, the prior evening and knew resident was a full code. Staff C, LPN explained no other staff members were in the room upon entering. Staff F, CNA and Staff H, CNA entered at almost the same time as me. Staff C, LPN stated immediately checking Resident #1's pulse, resident did not have one. Resident #1 had oxygen on via nasal canal. Staff C said, Immediately, I dropped the head of the bed and started CPR. I became tired and requested to switch. Staff F, CNA took over compressions. I then placed Resident #1's CPAP (Continuous Positive Airway Pressure) on Resident #1. Staff E, RN (Registered Nurse) brought the backboard in, we checked resident #1's pulse and placed the backboard. Staff D, LPN entered, and I asked her to call 911. Staff F, CNA requested to switch at this time. Staff H, CNA jumped in and took over compressions. Staff H, CNA requested to switch and Staff F, CNA continued with the compressions. EMS arrived and took over. Staff C, LPN confirmed being certified in CPR. During an interview on [DATE] at 10:25 a.m. Staff F, CNA stated a code blue was called and headed to Resident #1's room. Staff H, CNA and I were just steps behind Staff C, LPN and entered the room. No other staff members were in the room when we all entered. Staff C, LPN immediately checked Resident #1's pulse and said there was not one. Staff C, LPN dropped the head of the bed, and decided resident was too heavy to move to the floor, then Staff C, LPN started CPR. Staff C, LPN got tired at about the same time the back board arrived, Staff H, CNA and I placed the board. Staff C, LPN checked for a pulse and then I jumped in and continued started compressions. Staff F said, I requested to switch. Staff C, LPN checked for a pulse, then Staff H, CNA started compressions. Another female was in the room and was going to switch with Staff H, CNA but just froze up (stood there). I therefore jumped back in and continued with compressions. Staff F, CNA stated not remembering who the female who froze up was as being new to the facility. EMS arrived and took over care of the resident. Staff F, CNA confirmed being certified in CPR. During an interview on [DATE] at 10:37 a.m. Staff A, LPN stated Staff B, CNA, yelled to come to Resident #1's room. Staff A said, I immediately went to the room, noted Resident #1 not responding. I ran out of the room to get the blood pressure machine, called a rapid response, and verified code status. Staff A, LPN stated taking the crash cart back to Resident #1's room. Staff H, CNA was providing compressions when I arrived back to Resident 1's room. Staff C, LPN was directing everyone and Staff F, CNA took over from Staff H, CNA. Staff A, LPN confirmed being certified in CPR. During an interview on [DATE] at 11:55 a.m. Staff D, LPN stated Staff A, LPN came to the nurse station and stated Resident #1 was unresponsive. Staff D said, I immediately checked Resident #1's code status. Resident #1 was a Full Code. Staff A, LPN and I grabbed the crash cart and headed to Resident #1's room. Staff C, LPN was already performing compressions on Resident #1 when we arrived at the room. Staff F, CNA and Staff H, CNA were standing next to the bed. I ran back to the nurse station and contacted 911 and began preparing the paperwork. Staff D, LPN confirmed being certified in CPR. During an interview on [DATE] at 2:18 p.m. Staff E, RN stated they called code blue over the speakers. Staff E, RN stated headed to Resident #1's room and upon arrival noted Staff C, LPN was working with Resident #1. The staff were not yet performing CPR; they determined Resident #1 was too heavy to move to the floor. Staff C, LPN asked me to get the crash cart and back board. Upon returning with the backboard and cart, Staff C, LPN was performing chest compressions. Staff C, LPN stopped and checked Resident #1 while Staff F, CNA and Staff H, CNA placed the backboard under Resident #1. Staff E, RN stated leaving the room since Staff C, LPN and Staff A, LPN were in the room. Staff E, RN confirmed being certified in CPR. Multiple attempts were made to reach Staff H, CNA via phone on [DATE] and [DATE] with no response. Staff H, CNA did not have a CPR certification located in the facility employee record. During an interview on [DATE] at 10:53 a.m. the Nursing Home Administrator stated during the review of Resident #1's code it was determined Staff H, CNA admitted to performing chest compressions on Resident #1 although not being certified in CPR. The NHA stated licensed nurses certified in CPR are the expected staff members to perform CPR in the facility. The NHA stated CPR is not in the CNA's job description and Staff H, CNA should not have performed chest compressions on Resident #1. Review of the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR) dated [DATE] revealed: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: * Resident identification * Fully executed Florida Do Not Resuscitate order (DHI 896), located in the advanced directive section of the medical record 3. Use the paging system and call Code Blue to Room Number or location of the event three times. 4. In the absence of a fully executed Florida Do Not Resuscitate order (DHI 896) the facility will immediately begin CPR. 5. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: The resident responds. 6. Notify the physician and resident representative/ legal representative 7. Document in the medical record.

Based on observations, record review, and interviews, the facility failed to ensure four residents (Resident #5, Resident #6, Resident #7, and Resident #8) of five residents observed requiring assistance with eating, were provided a dignified dining experience. Findings included: On 1/7/25 at 12:50 p.m., an observation showed a staff member standing next to the bed of Resident #5 with utensil in hand. The staff member identified themselves as a speech therapist. On 1/7/25 at 1:02 p.m., an observation showed a covered meal tray sitting on the over-bed table of Resident #8. On 1/7/25 at 1:03 p.m., an observation revealed Staff E, Certified Nursing Assistant (CNA) entered Resident #7's room and stood between the privacy curtain and Resident #7's bed. The observation showed the resident's face was level with the mid-torso of the staff member as Staff E, CNA held a cup with a straw and encouraged the resident to eat. On 1/7/25 at 1:06 p.m., Staff E, CNA left Resident #7's room and was interviewed. Staff E, CNA reported feeding Resident #8 and the resident's roommate at same time. The staff member re-entered the room and sat down on Resident #7's bed, uncovered the meal, and spooned a helping of food into the resident's mouth. On 1/7/25 at 1:11 p.m., an observation revealed a staff member, later identified as Staff F, CNA, standing up between the bed of Resident #6 and the privacy curtain. The staff member placed a spoon with a large amount of food into the resident's mouth. An interview and observation was conducted on 1/7/25 at 1:13 p.m. with Staff G, Registered Nurse (RN). Staff G, RN watched the CNA assisting Resident #6 with eating and stated staff were supposed to stand up while assisting the residents with eating as the previous Director of Nursing said staff were not supposed to sit down. Staff G, RN identified on 1/7/25 at 1:55 p.m. the staff member standing next to Resident #6 was Staff F, CNA. An interview was conducted on 1/7/25 at 1:15 p.m. with Staff G, RN and Staff H, CNA. After speaking with Staff H, CNA, Staff G, RN stated staff were supposed to sit down while assisting residents with meals. Staff H, CNA confirmed staff were to sit down while assisting residents with eating. An interview was conducted on 1/7/25 at 4:25 p.m. with the Nursing Home Administrator (NHA). The NHA reported staff were not supposed to stand up while assisting the resident's with eating. The NHA also stated the facility did not have a policy regarding Activities of Daily Living (ADLs) for dependent residents. Review of the policy titled Resident Rights, effective 11/30/2014, revealed under Policy, it is the policy of the company to 1. Make residents and their legal representative aware of residents' rights (and) 2. Ensure that residents' rights are known to staff. The policy also showed under Procedure, ongoing training on resident rights will be given to staff members as required by state and/or federal regulations.

Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three residents (Resident #2, Resident #3, Resident #4) of three residents sampled for care plans. Findings included: 1. Review of the Admission Record showed Resident #2 was originally admitted to the facility on [DATE]. Resident #2 was readmitted on [DATE] from the hospital and was discharged from the facility to the hospital on 12/31/24. The Admission Record also showed Resident #2 had diagnoses including but not limited to displaced comminuted fracture of shaft of right femur on 12/12/24, Parkinsonism, generalized muscle weakness, Chronic Obstructive Pulmonary Disease, anemia, hypertension, and disorders of bone density. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #2 was cognitively intact. The Assessment also showed under Section GG - Functional Abilities, Resident #2 was dependent for chair/bed-to-chair transfers. Review of Resident #2's December 2024 physician orders showed the following orders: - Stat x-rays for bilateral knees, hips, and pelvis related to acute pain after fall on 12/8/24. - Send to ER (emergency room ) for stat CT (Computed Tomography) of right knee and pelvis related to ground level fall on 12/10/24. - Cleanse buttocks with soap and water, pat dry, apply zinc every shift as of 12/18/24 to 12/20/24. - Cleanse right buttock with wound cleanser, pat dry, apply collagen and dry dressing daily and as needed for soiled or dislodged as of 12/20/24 to 12/27/24. - Wound consult for right calf blister on 12/19/24. - Skin prep to right calf blister every shift for right calf blister as of 12/19/24 to 12/27/24. - Send toER on [DATE]. Review of the Treatment Administration Record (TAR) for December 2024 showed the following: - Cleanse buttocks with soap and water, pat dry, apply zinc every shift as of 12/18/24 to 12/20/24 was performed on 12/18/24 and 12/19/24. - Cleanse right buttock with wound cleanser, pat dry, apply collagen and dry dressing daily and as needed for soiled or dislodged as of 12/20/24 to 12/27/2024 was performed on 12/20/24, 12/21/24, twice on 1/22/24, 12/23/24, 12/24/24, 12/25/24. - Skin prep to right calf blister every shift for right calf blister as of 12/19/2024 to 12/27/2024 was performed on 12/20/24, 12/21, 12/22, 12/23, 12/24, 12/25/24. Review of Resident #2's care plan showed the following: - Resident had an ADL self-care performance deficit related to confusion, dementia, impaired balance, limited mobility and shortness of breath initiated on 06/1/22 and revised on 06/1/22. Interventions included but not limited to skin inspection: required skin inspection daily during care to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse as of 06/1/22, transfer: required extensive assistance by 2 staff to move between surfaces and as necessary initiated on 06/01/22 and canceled on 12/19/24, and the resident required mechanical lift [brand name] with 2 staff assistance for transfers initiated on 02/16/23 and revised on 12/17/24. - Resident had a displaced comminuted fracture of shaft of right femur related to fall as of 12/20/24. Interventions included but not limited to monitor limb for swelling and skin changes, take pedal pulses (specify frequency) as of 12/20/24, and right knee immobilizer at all times as of 12/20/24. - Resident had potential for impairment of skin integrity related to fragile skin, incontinent, limited mobility; blister right arm resolved, right great ingrown toe nail resolved, red left heel resolved, red heels resolved; initiated 6/1/22 and revised on 8/20/24. Interventions included but not limited to monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD (Medical Doctor) as of 6/1/22, and treatment as ordered resolved 2/16/23. Review of Resident #2's Weekly Skin Integrity Review showed the following: - On 12/04/24, skin intact - On 12/18/24, right buttock with two lesions in superior and lower site, clean, no drainage, Unit Manager aware. - On 12/25/24, right lower leg rear with blister; sacrum open area. Review of Resident #2's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) dated 12/22/24 showed skin intact and knee immobilizer on at all times. Review of Resident #2's physician, wound care physician, and nursing progress notes revealed the following: - On 12/8/24 at 11:47 a.m., review of the Situation, Background, Assessment, Recommendation (SBAR) showed right and left knee pain, stat x-ray of both knees and pelvis. - On 12/8/24 at 3:59 p.m., a nursing progress note showed, reported by a CNA, while transferring resident from the bed to the chair her legs became weak, and resident was lowered to the floor. Resident complained of knee pain, prn (as needed) pain medication was administered. Attending Physician notified, orders noted for stat x-ray of both knees and pelvis. Family member notified of Plan of Care. - On 12/9/24 at 1:32 a.m., a nursing progress note showed the writer called the attending physician to report results for bilateral knee and hip x-ray. Left voice mail requesting a return call to facility. Writer called family, notified of x-ray results, family verbalized understanding. - On 12/9/24 at 6:07 a.m., a nursing progress note showed x-ray results received and reported to APRN (Advanced Practice Registered Nurse). New order received to apply Voltaren gel 1% to bilateral knees 4 times a day for 30 days. - On 12/9/24 at 9:28 a.m., an Interdisciplinary Team (IDT) meeting note showed the IDT met to review a fall that occurred on 12/8/24 at 11:20 a.m. Resident was being transferred and CNA lowered resident to the floor due to knees buckling. Resident has no injury. IDT recommends therapy referral and staff education on transfers. - On 12/10/24 at 1:20 p.m., a physician progress note showed the resident had a non-syncopal ground level fall and was complaining of bilateral knee pain. Ordered x-rays for both knees. No fracture. Came to see her today. She was complaining of right knee pain, and she was unable to move or weight bearing with the right leg. The right knee was very swollen and tender. Will order a stat CT of the knee and pelvis, fracture could be missed in regular x-ray. - On 12/13/24 at 2:26 p.m., a late entry second skin check revealed an open area to the right upper buttock, open area to right lower buttock, and discolorations right lower extremity. - On 12/16/24 at 9:34 a.m., a physician progress note showed resident assumption of care following readmission, right femur fracture. On 12/10/24 the resident presented to the hospital due to a fall at the facility. The resident was found to have bilateral lower extremity deep vein thrombosis and right femur fracture. The resident was evaluated by orthopedics in the hospital and was deemed non-surgical with conservative management. The resident was stabilized and readmitted to the facility. The resident was seen sitting up in bed. The resident appears stable and in no apparent distress. The resident stated she was having 4/10 pain to right lower leg, but the pain was doing much better. - On 12/17/24 at 12:36 p.m., a physician note showed: nurse called due to Resident #2 ground level fall. The resident was complaining of pain. Ordered stat x-ray right knee and pelvis. Visited resident and she was complaining of right knee pain and the knee was very swollen and tender with specific tender point at the level of the post lateral condyle. Considering the possibility of fracture missing in regular x-ray. Resident was sent to the hospital for stat CT of the right femur and pelvis. CT was positive of fracture, acute mildly displaced left posterior condyle. Ultrasound positive for bilateral lower extremities deep vein thrombosis. Resident was evaluated by orthopedic, not a good candidate for surgery considering all her co-morbidities and age. The resident will be sent back to facility after discharge. She was seen today, and she was doing fine. Pain was under control. Family was at bedside. - On 12/18/24 at 3:41 p.m., a nursing progress note showed resident was noted with a skin lesion on the lower and superior buttock, measure was 1 cm (centimeter.) Clean. No drainage. Unit Manager was notified, and family was aware. - On 12/19/24, a Wound Assessment Physician progress note showed stage II buttock pressure ulcer, 2.0 x 1.0 x 0.1, present on admission, scant serous drainage. - On 12/19/24, a Physician note showed new blister to the right leg. The nurse called today that resident had blister right leg related to the brace in the leg. Will do wound care and decrease pressure in the area. Resident had right leg brace, skin was normal color and no open area, new blister on right leg, resident status post a fall, right femur fracture and bilateral deep venous thrombosis. - On 12/19/24 at 11:00 a.m., a review of the SBAR showed skin prep every shift to right calf blister. - On 12/19/24 at 4:32 p.m., a nursing progress note showed attending physician ordered wound care for right calf blister and skin prep every shift. - On 12/20/24 at 1:23 p.m., the IDT met to review the skin impairment observed on 12/19/24. Resident had a fluid filled blister to right calf due to right knee immobilizer. IDT recommends to continue current treatment and wrap Right Lower Extremity in ace wrap under immobilizer. - On 12/24/24, a Physician note showed Resident #2 was feeling fine. Pain was in control. Resident stated she was weaker after the fall. Blister on right leg, being followed by wound care in the facility. Resident had right leg brace, skin was normal color and no open area, new blister on right leg, resident status post a fall, right femur fracture and bilateral deep venous thrombosis. - On 12/26/24, a Wound Assessment Physician progress note showed: stage II right anterior buttock pressure injury, 1.0 x 1.0 x 0.1; present on admission, 100% dermis, scant serous drainage. - On 12/26/24, a Physician note showed Resident #2 was complaining of right leg pain, about 7 on the pain scale. Resident family at bedside. Had a long conversation with family, and she stated the resident was in pain. Family thinks brace was hurting her, not helping her. Family wanted resident to be evaluated by orthopedic today. Called the nurse to do orthopedic evaluation today. Resident had right leg brace, skin was normal color and no open area, new blister on right leg, resident status post fall, right femur fracture and bilateral deep venous thrombosis. - On 12/26/24 at 11:15 a.m., a review of the SBAR showed worsening pain, at fracture site, front of right knee; Send to ER. During an interview on 1/7/25 at 2:21 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Nurse Consultant (RNC), the NHA stated on 12/8/24 at 11:20 a.m., Staff A, CNA did an improper transfer and subsequently had to lower Resident #2 to the floor. The resident was care planned for a sit-to-stand transfer. The NHA stated Staff A, CNA stated she tried to pivot the resident alone and the resident went to the floor on her knees. Staff A, CNA called for help. The NHA stated Staff B, Licensed Practical Nurse (LPN) came in and did an assessment, including vital signs, and skin changes. The resident was complaining of pain in her knees. The attending physician was called and received an order for stat x-rays. The x-rays were negative and the APRN ordered Voltaren 1% and Tylenol. The NHA stated they performed an IDT meeting on 12/9/24 regarding the fall. Staff A, CNA, was educated on transfers on 12/9/24. The NHA read Staff A, CNA's statement, which showed she was transferring her alone and could not hold her weight and lowered the resident to the floor. Staff A, CNA wrote she called for help. The NHA stated Staff A, CNA did not specify why she did the transfer alone. Review of the statement by Staff B, LPN with the NHA showed Staff A, CNA reported while transferring Resident #2 from bed to chair, the residents legs became weak. Lowered to the floor on her knees. Upon examination no visible signs of injury noted. Moving all extremities. Complained of knee pain and medicated with pain meds as needed. Doctor was notified. Order for stat bilateral knee x-ray and pelvis. Family notified of change in condition and Plan of Care. Review of statement by Staff C, LPN with the NHA showed resident on the floor. Observed resident sitting on her knees with legs tucked underneath her. She was sitting on the floor by the bed. Wheelchair was locked between resident and bed. The NHA stated on 12/9/24 at 1:32 a.m., the facility received Resident #2's x-ray results, which were negative and reported them to the physician. The NHA stated on 12/10/24, the attending physician came in and saw the resident. The resident was complaining of pain and received an order for a CT scan and the resident was sent to the hospital for a CT scan on 12/10/24. The NHA stated on 12/12/24, at 12:43 p.m., the hospital sent over a record indicating the resident had a right femoral fracture. The NHA also stated on 12/12/24 at 7:57 p.m., they submitted the report and suspended the CNA during the investigation. The NHA stated on 12/12/24 at 10:10 p.m., the resident returned from the hospital with a soft brace. The NHA also stated on 12/13/24 they started an investigation. The NHA verified a re-admission assessment was not performed when the resident returned to the facility on [DATE]. The NHA verified due to a readmission assessment not being performed, there was not a skin assessment performed. The DON stated a resident in the hospital over 24 hours needed a re-admission assessment. They verified the resident was in the hospital for 48 hours and required a re-admission to the facility. The NHA verified Resident #2's Form 3008 showed the resident's skin was intact. The NHA verified a late entry in the nursing progress notes showing on 12/13/24 at 2:26 p.m., second skin check: open area right upper buttock, open area to right lower buttock, discolorations right lower extremity. The NHA verified A Weekly Skin Integrity Review on 12/18/24, showed right buttock with two lesions in superior and lower site, clean, no drainage, Unit Manager aware. The NHA verified this Weekly Skin Integrity Review was documented six days after Resident #2's re-admission. The NHA verified the resident was seen by the wound care physician on 12/18/24 and wound care was put into place, six days post re-admission. The NHA verified the wound physician note dated 12/19/24 showed the wound was on admission, even though the skin was not assessed upon Resident #2's re-admission. The resident was readmitted on [DATE] with a soft brace in place on the right leg. The DON stated the protocol for the brace was to monitor capillary refill and monitor skin integrity daily. The NHA verified no documentation in the clinical record regarding monitoring the right lower leg and brace fitting was present. The NHA verified the lack of pressure ulcer and/or blister interventions on Resident #2's care plans. The NHA stated she would expect both the buttock pressure ulcer and right lower leg blister to be addressed on the care plans. The NHA verified the care plan related to brace care was not being followed. 2. A review of Resident #3's Admission Record showed Resident #3 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record also showed diagnoses including but not limited to cerebral infarction with hemiparesis on the left side, diabetes, spinal stenosis in lumbar region, generalized muscle weakness, and chronic pain syndrome. Review of Resident #3's January 2025 physician orders and Treatment Administration Record (TAR) showed the following: - Cleanse sacrum with soap and water, pat dry and apply zinc daily and as needed as of 10/25/24 to 11/21/24. - Cleanse sacrum with wound cleanser and pat dry, apply collagen and cover with dry dressing daily and as needed as of 11/21/24 to 12/26/24. - Cleanse sacrum with normal saline, pat dry, apply Santyl, and cover with dry dressing as of 12/26/24 to 01/02/25. Review of Resident #3's Wound Physician progress notes showed the following: - On 11/07/24, sacrum wound was resolved. - On 11/21/24, stage III, sacrum wound, 1.5 x 1.0 x 0.2, 100% granulation, light serous drainage. - On 12/5/24, stage III, sacrum wound, 1 x 0.80 x 0.20, 100% granulation, light serous drainage. - On 12/12/24, stage III, sacrum wound, 0.80 x 0.50 x 0.20, 70% granulation, 30% slough, light serous drainage, improving. - On 12/18/24, stage III, sacrum wound, 0.50 x 0.50 x 0.20, 100% granulation, light serous drainage, improving. - On 12/26/24, stage III, sacrum wound, 0.50 x 0.50 x 0.20, 100% slough, light serous drainage, improving. Change in wound care to include Santyl. - On 1/2/25, stage III, sacrum wound, 0.50 x 0.30 x 0.20, 60% granulation, 40% slough, light serous drainage, improving. Change in wound care to include collagen. Review of Resident #3's care plans showed the following: - Resident #3 had a pressure injury, left heel, initiated on 9/25/24 and revised 10/18/24. Interventions included but not limited to require pressure relieving/reducing device on bed-chair as of 9/25/24 and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate as of 9/25/24. During an observation on 1/7/25 at 1:55 p.m., Resident #3 was sitting with the head of the bed elevated. No air mattress was observed. During an interview on 1/7/24 at 2:11 p.m., Staff D, CNA entered the room and confirmed by pushing on the bed the resident did not have an air mattress. During an interview on 1/7/25 at 2:21 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Nurse Consultant (RNC), the NHA verified the sacrum pressure ulcer was not addressed on Resident #3's care plans and the expectation was for the sacrum pressure ulcer to be on the care plan, including interventions. The NHA and DON stated once a pressure wound has reached stage III or higher or if the wound care physician requested, an air mattress would be ordered. The NHA stated Resident #3 should be on an air mattress. 3. A review of Resident #4's Admission Record showed Resident #4 was admitted on [DATE]. Review of the Admission Record also showed diagnoses including but not limited to cutaneous abscess of buttock, Cerebral infarction, generalized muscle weakness, metabolic encephalopathy, traumatic subdural hemorrhage, dementia, underweight, Altered Mental Status, pleural effusion, anemia, and hypertension. Review of Resident #4's Baseline Care Plan and Summary dated 1/2/25 showed the following: - Altered Skin Integrity/Potential for showed goals as prevent any skin breakdown or injury and heal/improve current skin issue. Interventions: follow facility skin protocol, turn every 2 hours and as needed, immediately report any skin redness to nurse; report an y skin breakdown to charge nurse, provide incontinent care as needed. - Self-Care Deficit - ADL - Function Rehab Potential was blank for interventions. - Infection: blank. Review of Resident #4's care plans showed the following: - On IV antibiotic medications related to gluteal abscess as of 1/2/25. Interventions related to IV site only. Review of Resident #4's January 2025 physician orders and TAR for January 2025 showed the following: - Cleanse sacrum with wound cleanser, pat dry, apply collagen and dry dressing every day as of 1/2/25. - Cleanse sacrum wounds with normal saline and pat dry, apply Santyl and cover with super absorbent dressing daily and as needed as of 1/3/25. - Isolation type, enhanced barriers for wounds, Foley and midline as of 1/7/25. - Cefepime HCl (hydrochloride) IV (Intravenous) 1 gm (gram) every 12 hours for abscess of buttocks as of 1/1/25 to 1/10/25. - Micafungin Sodium IV 100 mg (milligrams) in the a.m. for abscess of buttocks as of 1/1/25 to 1/10/25. Review of a Wound Physician note dated 1/2/25 showed Resident #4 had a stage IV pressure injury of the sacrum back, 5 cm x 4 cm x 0.1 cm, 40% granulation and 60% slough, macerated peri-wound, moderate serous drainage. Review of a physician progress note dated 1/3/25 showed Resident #4 primary diagnosis of dementia. The resident presented to the hospital due to Altered Mental Status. Resident found to have right buttock abscess. Resident had an incision and drainage of wound and was placed on antibiotics. An observation on 1/7/25 at 1:59 p.m. showed Resident #4 was lying on an air mattress with an air pump in place. During an interview on 1/7/25 at 2:21 p.m. with the NHA, DON, and RNC, the NHA verified Resident #4's Baseline Care Plan lacked documentation related to the stage IV sacrum pressure wound, IV antibiotics for infected sacrum pressure wound, and did not have interventions for transfers. The NHA stated the expectation was for the Baseline Care Plan to be completed on admission. The DON stated she was not sure if the Infection Control Preventionist had revised the resident for appropriate antibiotics and isolation precautions. Review of the facility's policy titled Plans of Care, revised 9/25/17 showed an individualized person-centered plan of care will be established by the IDT with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of Care is to be maintained as part of the final medical record. The policy also revealed the following Procedure: - Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. - Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR (Preadmission Screening and Resident Review) recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. - Review, update and / or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA (Omnibus Budget Reconciliation Act) MDS assessment, and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. - The individualized Person-Centered plan of care may include but is not limited to the following: services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements.

Based on observation, interviews, and record review, the facility failed to ensure residents received necessary treatment and services consistent with profession standards of practice related to pressure wounds/ ulcers for two residents (Resident #2 and Resident #3) of three residents sampled for pressure wounds/ ulcers. Findings included: 1. Review of the Admission Record showed Resident #2 was originally admitted to the facility on [DATE]. Resident #2 was readmitted on [DATE] from the hospital and was discharged from the facility to the hospital on 12/31/24. The Admission Record also showed Resident #2 had diagnoses including but not limited to displaced comminuted fracture of shaft of right femur on 12/12/24, Parkinsonism, generalized muscle weakness, Chronic Obstructive Pulmonary Disease, anemia, hypertension, and disorders of bone density. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #2 was cognitively intact. The Assessment also showed under Section GG - Functional Abilities, Resident #2 was dependent for chair/bed-to-chair transfers. Review of Resident #2's December 2024 physician orders showed the following orders: - Stat x-rays for bilateral knees, hips, and pelvis related to acute pain after fall on 12/8/24. - Send to ER (emergency room ) for stat CT (Computed Tomography) of right knee and pelvis related to ground level fall on 12/10/24. - Cleanse buttocks with soap and water, pat dry, apply zinc every shift as of 12/18/24 to 12/20/24. - Cleanse right buttock with wound cleanser, pat dry, apply collagen and dry dressing daily and as needed for soiled or dislodged as of 12/20/24 to 12/27/24. - Wound consult for right calf blister on 12/19/24. - Skin prep to right calf blister every shift for right calf blister as of 12/19/24 to 12/27/24. - Send toER on [DATE]. Review of the Treatment Administration Record (TAR) for December 2024 showed the following: - Cleanse buttocks with soap and water, pat dry, apply zinc every shift as of 12/18/24 to 12/20/24 was performed on 12/18/24 and 12/19/24. - Cleanse right buttock with wound cleanser, pat dry, apply collagen and dry dressing daily and as needed for soiled or dislodged as of 12/20/24 to 12/27/2024 was performed on 12/20/24, 12/21/24, twice on 1/22/24, 12/23/24, 12/24/24, 12/25/24. - Skin prep to right calf blister every shift for right calf blister as of 12/19/2024 to 12/27/2024 was performed on 12/20/24, 12/21, 12/22, 12/23, 12/24, 12/25/24. Review of Resident #2's Weekly Skin Integrity Review showed the following: - On 12/04/24, skin intact - On 12/18/24, right buttock with two lesions in superior and lower site, clean, no drainage, Unit Manager aware. - On 12/25/24, right lower leg rear with blister; sacrum open area. Review of Resident #2's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) dated 12/22/24 showed skin intact and knee immobilizer on at all times. Review of Resident #2's physician, wound care physician, and nursing progress notes revealed the following: - On 12/8/24 at 11:47 a.m., review of the Situation, Background, Assessment, Recommendation (SBAR) showed right and left knee pain, stat x-ray of both knees and pelvis. - On 12/8/24 at 3:59 p.m., a nursing progress note showed, reported by a CNA, while transferring resident from the bed to the chair her legs became weak, and resident was lowered to the floor. Resident complained of knee pain, prn (as needed) pain medication was administered. Attending Physician notified, orders noted for stat x-ray of both knees and pelvis. Family member notified of Plan of Care. - On 12/9/24 at 1:32 a.m., a nursing progress note showed the writer called the attending physician to report results for bilateral knee and hip x-ray. Left voice mail requesting a return call to facility. Writer called family, notified of x-ray results, family verbalized understanding. - On 12/9/24 at 6:07 a.m., a nursing progress note showed x-ray results received and reported to APRN (Advanced Practice Registered Nurse). New order received to apply Voltaren gel 1% to bilateral knees 4 times a day for 30 days. - On 12/9/24 at 9:28 a.m., an Interdisciplinary Team (IDT) meeting note showed the IDT met to review a fall that occurred on 12/8/24 at 11:20 a.m. Resident was being transferred and CNA lowered resident to the floor due to knees buckling. Resident has no injury. IDT recommends therapy referral and staff education on transfers. - On 12/10/24 at 1:20 p.m., a physician progress note showed the resident had a non-syncopal ground level fall and was complaining of bilateral knee pain. Ordered x-rays for both knees. No fracture. Came to see her today. She was complaining of right knee pain, and she was unable to move or weight bearing with the right leg. The right knee was very swollen and tender. Will order a stat CT of the knee and pelvis, fracture could be missed in regular x-ray. - On 12/13/24 at 2:26 p.m., a late entry second skin check revealed an open area to the right upper buttock, open area to right lower buttock, and discolorations right lower extremity. - On 12/16/24 at 9:34 a.m., a physician progress note showed resident assumption of care following readmission, right femur fracture. On 12/10/24 the resident presented to the hospital due to a fall at the facility. The resident was found to have bilateral lower extremity deep vein thrombosis and right femur fracture. The resident was evaluated by orthopedics in the hospital and was deemed non-surgical with conservative management. The resident was stabilized and readmitted to the facility. The resident was seen sitting up in bed. The resident appears stable and in no apparent distress. The resident stated she was having 4/10 pain to right lower leg, but the pain was doing much better. - On 12/17/24 at 12:36 p.m., a physician note showed: nurse called due to Resident #2 ground level fall. The resident was complaining of pain. Ordered stat x-ray right knee and pelvis. Visited resident and she was complaining of right knee pain and the knee was very swollen and tender with specific tender point at the level of the post lateral condyle. Considering the possibility of fracture missing in regular x-ray. Resident was sent to the hospital for stat CT of the right femur and pelvis. CT was positive of fracture, acute mildly displaced left posterior condyle. Ultrasound positive for bilateral lower extremities deep vein thrombosis. Resident was evaluated by orthopedic, not a good candidate for surgery considering all her co-morbidities and age. The resident will be sent back to facility after discharge. She was seen today, and she was doing fine. Pain was under control. Family was at bedside. - On 12/18/24 at 3:41 p.m., a nursing progress note showed resident was noted with a skin lesion on the lower and superior buttock, measure was 1 cm (centimeter.) Clean. No drainage. Unit Manager was notified, and family was aware. - On 12/19/24, a Wound Assessment Physician progress note showed stage II buttock pressure ulcer, 2.0 x 1.0 x 0.1, present on admission, scant serous drainage. - On 12/19/24, a Physician note showed new blister to the right leg. The nurse called today that resident had blister right leg related to the brace in the leg. Will do wound care and decrease pressure in the area. Resident had right leg brace, skin was normal color and no open area, new blister on right leg, resident status post a fall, right femur fracture and bilateral deep venous thrombosis. - On 12/19/24 at 11:00 a.m., a review of the SBAR showed skin prep every shift to right calf blister. - On 12/19/24 at 4:32 p.m., a nursing progress note showed attending physician ordered wound care for right calf blister and skin prep every shift. - On 12/20/24 at 1:23 p.m., the IDT met to review the skin impairment observed on 12/19/24. Resident had a fluid filled blister to right calf due to right knee immobilizer. IDT recommends to continue current treatment and wrap Right Lower Extremity in ace wrap under immobilizer. - On 12/24/24, a Physician note showed Resident #2 was feeling fine. Pain was in control. Resident stated she was weaker after the fall. Blister on right leg, being followed by wound care in the facility. Resident had right leg brace, skin was normal color and no open area, new blister on right leg, resident status post a fall, right femur fracture and bilateral deep venous thrombosis. - On 12/26/24, a Wound Assessment Physician progress note showed: stage II right anterior buttock pressure injury, 1.0 x 1.0 x 0.1; present on admission, 100% dermis, scant serous drainage. - On 12/26/24, a Physician note showed Resident #2 was complaining of right leg pain, about 7 on the pain scale. Resident family at bedside. Had a long conversation with family, and she stated the resident was in pain. Family thinks brace was hurting her, not helping her. Family wanted resident to be evaluated by orthopedic today. Called the nurse to do orthopedic evaluation today. Resident had right leg brace, skin was normal color and no open area, new blister on right leg, resident status post fall, right femur fracture and bilateral deep venous thrombosis. - On 12/26/24 at 11:15 a.m., a review of the SBAR showed worsening pain, at fracture site, front of right knee; Send to ER. Review of Resident #2's care plan showed the following: - Resident had an ADL self-care performance deficit related to confusion, dementia, impaired balance, limited mobility and shortness of breath initiated on 06/1/22 and revised on 06/1/22. Interventions included but not limited to skin inspection: required skin inspection daily during care to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse as of 06/1/22, transfer: required extensive assistance by 2 staff to move between surfaces and as necessary initiated on 06/01/22 and canceled on 12/19/24, and the resident required mechanical lift [brand name] with 2 staff assistance for transfers initiated on 02/16/23 and revised on 12/17/24. - Resident had a displaced comminuted fracture of shaft of right femur related to fall as of 12/20/24. Interventions included but not limited to monitor limb for swelling and skin changes, take pedal pulses (specify frequency) as of 12/20/24, and right knee immobilizer at all times as of 12/20/24. - Resident had potential for impairment of skin integrity related to fragile skin, incontinent, limited mobility; blister right arm resolved, right great ingrown toe nail resolved, red left heel resolved, red heels resolved; initiated 6/1/22 and revised on 8/20/24. Interventions included but not limited to monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD (Medical Doctor) as of 6/1/22, and treatment as ordered resolved 2/16/23. During an interview on 1/7/25 at 2:21 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Nurse Consultant (RNC), the NHA stated on 12/8/24 at 11:20 a.m., Staff A, CNA did an improper transfer and subsequently had to lower Resident #2 to the floor. The resident was care planned for a sit-to-stand transfer. The NHA stated Staff A, CNA stated she tried to pivot the resident alone and the resident went to the floor on her knees. Staff A, CNA called for help. The NHA stated Staff B, Licensed Practical Nurse (LPN) came in and did an assessment, including vital signs, and skin changes. The resident was complaining of pain in her knees. The attending physician was called and received an order for stat x-rays. The x-rays were negative and the APRN ordered Voltaren 1% and Tylenol. The NHA stated they performed an IDT meeting on 12/9/24 regarding the fall. Staff A, CNA, was educated on transfers on 12/9/24. The NHA read Staff A, CNA's statement, which showed she was transferring her alone and could not hold her weight and lowered the resident to the floor. Staff A, CNA wrote she called for help. The NHA stated Staff A, CNA did not specify why she did the transfer alone. Review of the statement by Staff B, LPN with the NHA showed Staff A, CNA reported while transferring Resident #2 from bed to chair, the residents legs became weak. Lowered to the floor on her knees. Upon examination no visible signs of injury noted. Moving all extremities. Complained of knee pain and medicated with pain meds as needed. Doctor was notified. Order for stat bilateral knee x-ray and pelvis. Family notified of change in condition and Plan of Care. Review of statement by Staff C, LPN with the NHA showed resident on the floor. Observed resident sitting on her knees with legs tucked underneath her. She was sitting on the floor by the bed. Wheelchair was locked between resident and bed. The NHA stated on 12/9/24 at 1:32 a.m., the facility received Resident #2's x-ray results, which were negative and reported them to the physician. The NHA stated on 12/10/24, the attending physician came in and saw the resident. The resident was complaining of pain and received an order for a CT scan and the resident was sent to the hospital for a CT scan on 12/10/24. The NHA stated on 12/12/24, at 12:43 p.m., the hospital sent over a record indicating the resident had a right femoral fracture. The NHA also stated on 12/12/24 at 7:57 p.m., they submitted the report and suspended the CNA during the investigation. The NHA stated on 12/12/24 at 10:10 p.m., the resident returned from the hospital with a soft brace. The NHA also stated on 12/13/24 they started an investigation. The NHA verified a re-admission assessment was not performed when the resident returned to the facility on [DATE]. The NHA verified due to a readmission assessment not being performed, there was not a skin assessment performed. The DON stated a resident in the hospital over 24 hours needed a re-admission assessment. They verified the resident was in the hospital for 48 hours and required a re-admission to the facility. The NHA verified Resident #2's Form 3008 showed the resident's skin was intact. The NHA verified a late entry in the nursing progress notes showing on 12/13/24 at 2:26 p.m., second skin check: open area right upper buttock, open area to right lower buttock, discolorations right lower extremity. The NHA verified A Weekly Skin Integrity Review on 12/18/24, showed right buttock with two lesions in superior and lower site, clean, no drainage, Unit Manager aware. The NHA verified this Weekly Skin Integrity Review was documented six days after Resident #2's re-admission. The NHA verified the resident was seen by the wound care physician on 12/18/24 and wound care was put into place, six days post re-admission. The NHA verified the wound physician note dated 12/19/24 showed the wound was on admission, even though the skin was not assessed upon Resident #2's re-admission. The resident was readmitted on [DATE] with a soft brace in place on the right leg. The DON stated the protocol for the brace was to monitor capillary refill and monitor skin integrity daily. The NHA verified no documentation in the clinical record regarding monitoring the right lower leg and brace fitting was present. The NHA verified the lack of pressure ulcer and/or blister interventions on Resident #2's care plans. The NHA stated she would expect both the buttock pressure ulcer and right lower leg blister to be addressed on the care plans. The NHA verified the care plan related to brace care was not being followed. 2. A review of Resident #3's Admission Record showed Resident #3 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record also showed diagnoses including but not limited to cerebral infarction with hemiparesis on the left side, diabetes, spinal stenosis in lumbar region, generalized muscle weakness, and chronic pain syndrome. Review of Resident #3's January 2025 physician orders and Treatment Administration Record (TAR) showed the following: - Cleanse sacrum with soap and water, pat dry and apply zinc daily and as needed as of 10/25/24 to 11/21/24. - Cleanse sacrum with wound cleanser and pat dry, apply collagen and cover with dry dressing daily and as needed as of 11/21/24 to 12/26/24. - Cleanse sacrum with normal saline, pat dry, apply Santyl, and cover with dry dressing as of 12/26/24 to 01/02/25. Review of Resident #3's Wound Physician progress notes showed the following: - On 11/07/24, sacrum wound was resolved. - On 11/21/24, stage III, sacrum wound, 1.5 x 1.0 x 0.2, 100% granulation, light serous drainage. - On 12/5/24, stage III, sacrum wound, 1 x 0.80 x 0.20, 100% granulation, light serous drainage. - On 12/12/24, stage III, sacrum wound, 0.80 x 0.50 x 0.20, 70% granulation, 30% slough, light serous drainage, improving. - On 12/18/24, stage III, sacrum wound, 0.50 x 0.50 x 0.20, 100% granulation, light serous drainage, improving. - On 12/26/24, stage III, sacrum wound, 0.50 x 0.50 x 0.20, 100% slough, light serous drainage, improving. Change in wound care to include Santyl. - On 1/2/25, stage III, sacrum wound, 0.50 x 0.30 x 0.20, 60% granulation, 40% slough, light serous drainage, improving. Change in wound care to include collagen. Review of Resident #3's care plans showed the following: - Resident #3 had a pressure injury, left heel, initiated on 9/25/24 and revised 10/18/24. Interventions included but not limited to require pressure relieving/reducing device on bed-chair as of 9/25/24 and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate as of 9/25/24. During an observation on 1/7/25 at 1:55 p.m., Resident #3 was sitting with the head of the bed elevated. No air mattress was observed. During an interview on 1/7/24 at 2:11 p.m., Staff D, CNA entered the room and confirmed by pushing on the bed the resident did not have an air mattress. During an interview on 1/7/25 at 2:21 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Nurse Consultant (RNC), the NHA verified the sacrum pressure ulcer was not addressed on Resident #3's care plans and the expectation was for the sacrum pressure ulcer to be on the care plan, including interventions. The NHA and DON stated once a pressure wound has reached stage III or higher or if the wound care physician requested, an air mattress would be ordered. The NHA stated Resident #3 should be on an air mattress. Review of the facility's policy titled Clinical Guideline Skin and Wound dated 4/1/17 showed an Overview 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. The policy also revealed the following Process: - On admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record - Licensed Nurse to complete skin evaluation weekly and prior to transfer / discharge and document in the medical record - CNA to complete skin observations and report changes to Licensed Nurse - Licensed Nurse to document presence of skin impairment/new skin impairment when observed and weekly until resolved - Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident / responsible party and document in the medical record - Develop individualized goals and interventions and document on the care plan and the CNA Kardex - Monitor residents' response to treatment and modify treatment as indicated - Evaluate the effectiveness of interventions, and progress towards goals during the care management meeting and as needed.

Based on observation, interview, and policy and procedure review the facility failed to label and store all medications in accordance with professional standards of practice for 3 of 4 medication carts, and failed to ensure all medications were stored to permit only authorized personnel access. Findings include: 1. During an observation on 1/22/24 at 8:46 AM with Staff A, Licensed Practical Nurse (LPN) of medication cart #1, there was one unopened Lantus insulin pen with pharmacy instructions to refrigerate until opened, one opened insulin glargine pen with no resident identifier, not in original pharmacy packaging, with no date opened, or expiration date, one opened bottle of Lispro insulin with no date opened or expiration date, one unopened bottle of Aspart insulin with pharmacy instructions to refrigerate until opened, and two opened bottles of tobramycin ophthalmic solution with no date opened or expiration dates. During an interview on 1/22/2024 at 8:50 AM Staff A, LPN stated, I don't know why they [the insulins] are not refrigerated, and all medications should be in the original pharmacy package for the resident and should have when they were opened or expire. Eye drops should be labeled. 2. During an observation on 1/22/2024 at 8:54 AM of medication cart #2 showed there was no staff present at the medication cart. Staff B, LPN returned to the medication cart after three minutes, unlocked the cart, and opened the top drawer. In the top drawer there was a medication cup containing ten medications, the cup was not labeled with a resident identifier, the medications, or who prepared the medications. There was one unopened Levemir insulin pen with pharmacy instructions to refrigerate until opened, one unopened Lantus insulin pen with pharmacy instructions to refrigerate until opened, and one opened bottle of Levemir insulin with no date opened or expiration date. During an interview on 1/22/2024 at 9:00 AM Staff B, LPN stated, I should not have pre poured the medication, but I just had to walk away from the cart. They should be labeled if I walk away. All insulins should be labeled when opened and kept in the refrigerator until its opened. 3. During an observation on 1/22/24 at 9:15 AM with Staff C, Registered Nurse (RN) of medication cart #4, there was one opened bottle of Latanoprost ophthalmic solution with no date opened or expiration date, one opened bottle of Timolol ophthalmic solution with a date opened of 12/9/2023, one opened bottle of Prednisolone ophthalmic solution with no date opened or expiration date, one opened bottle of Timolol ophthalmic solution with no date opened or expiration date, one opened bottle of Timolol ophthalmic solution with an expiration date of 12/31/2023, one opened bottle of Lumigan ophthalmic solution with an expiration date of 12/23/23, one opened Lispro insulin pen with an expiration date of 12/12/23 and labeled with pharmacy instruction to store using direction provided: Throw away any medication that remains 28 days after first use; one opened Novolin insulin pen with an expiration date of 1/6/2024, one opened Novolog pen with an expiration date of 12/28/2023, one opened Humalog pen with an expiration date of 1/13/2024, one opened Humalog pen with an expiration date of 1/13/2024, one opened Lantus pen with no date opened or expiration date, and one opened bottle of Levemir with no date opened or expiration date. During an interview on 1/22/2024 at 9:25 AM Staff C, RN stated, What can I say, all expired meds [medications] should not be on the cart they should have been thrown out. Everything the insulin and eye drops should be labeled when they are opened or when they are expiring. During an interview on 1/22/2024 at 1:55 PM the Director of Nursing stated, All expired medications should not be on the cart. All insulin and eye drops should have the date opened or expiration date on them. No meds should be pre-poured. Review of the Policy and Procedure titled, Medication Storage last revied on 10/4/2023 read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with the FL [Florida] Department of Health guidelines. Procedure: E. Medications will be stored in the original, labeled containers received from pharmacy. F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. G. Medications will be stored at appropriate temperature in accordance with the pharmacy and/or manufacturer labeling. Appropriate temperature will be determined as per the following: 3. Cold Place: 2-8 degrees Celsius (36-46 degrees F [Fahrenheit]. H. Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2-8 degrees Celsius (36-46 degrees F). If a medication label indicates to store in a cool place, the medication will be stored in the refrigerator unless specifically noted otherwise. 47275 4. During an observation on 1/22/24 at 09:30 AM of Resident #86 it showed she was sitting in bed and there was a bottle of Voltaren gel on her over the bed table. During an observation on 1/23/24 at 08:30 AM of Resident #86 it showed she was laying in her bed and a bottle of Voltaren Gel was on her over the bed table. During an interview on 1/23/24 at 8:30 AM Resident #86 stated, I bought that online, and the staff are supposed to help me put it on my knees every 6 hours. Review of the physician's orders dated 12/28/23 read, Voltaren External Gel 1% (diclofenac sodium topical) Apply to knees topically every day shift for mild pain. During an interview on 1/24/24 at 10:00 AM the Regional Director of Clinical Services stated the residents must be assessed for self-administration to be able to have medications at their bedside. During an interview on 1/24/24 at 10:05 AM the Director of Nursing stated, Resident #86 has not had an assessment for self-medication, and there should be no medications left at her bedside. If she is capable of self-medication, we will get her a lock box where she can keep the Volteran gel. The Director of Nursing, stated resident #86 is not care planned for self-administration of medications.

Based on interview and record review the facility failed to promptly notify the ordering physician of urine culture results requiring a change in treatment for 2 of 3 residents, Residents #31 and #84, in a total sample of 39 residents. Findings include: Review of the admission record for Resident #31 documented diagnosis to include paroxysmal atrial fibrillation (an irregular heartbeat), urinary tract infection, hypertensive heart disease without heart failure and gastroesophageal reflux disease. Review of the nursing progress note for Resident #31 dated 1/15/2024 read, Resident went to infectious disease appointment today, new order received from ID [infectious disease] doctor for CBC [complete blood count], CMP [complete metabolic profile], lipase, procalcitonin, U/A [urinalysis], C&S [urine culture and sensitivity] daughter aware. Review of the physician orders for Resident #31 dated 1/16/2024 read, U/A with micro C&S [culture and sensitivity] one time. Review of the lab results completed by [name of the laboratory group] for Resident #31 read, 1/17/2024 13:57 [1:57 PM] Comprehensive Panel/Lipase/CBC w/o Diff [differential]/Procalcitonin. Procalcitonin Result 0.670 ng/mL, Ref. [Reference] Range <0.100, Flag H [high]. Interpretation Guidelines >= 0.5 to <2.00 ng/mL [nanograms per millilitre]: Sepsis is possible; other conditions possible. WBC [white blood cell] Result 12.5, Flag HIGH, Referent Range/Cutoff 3.8 - 10/8. Review of the lab results completed by [name of the laboratory group] for Resident #31 read, Collection date 1/18/2024 3:39 AM, received date 1/18/2024 at 8:52 AM, originally reported on: 1/20/2024 11:30 AM, Urine culture: Organism Escherichia coli, Colony count: >100,00 cfu [colony forming units]/ml [milliliter]. Review of the physician orders for Resident #31 dated 1/22/2024 at 8:43 AM read, Cipro oral tablet 500 mg (Ciprofloxacin HCL) Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 5 days. During an interview conducted on 1/24/2024 at 9:58 AM the Director of Nursing (DON) verified the urine culture results were provided to the facility on [DATE], there was no physician notification documented in the medical record, and no orders documented to treat Resident #31 for a UTI until 1/22/2024. The DON stated, This should have been called on 1/20 when we received the results. We should have notified the physician or ARNP [Advance Registered Nurse Practitioner] and gotten orders for the antibiotic then. It is my expectation that staff call culture results immediately. During an interview conducted on 1/24/2024 at 1:15 PM Staff C, Registered Nurse (RN) stated, I saw her [Resident #31] culture results on Monday morning. When I came on Monday, I looked for the results, but we should have called before Monday to get it [the UTI] treated. When it came in is when we should call [the physician]. During a telephone interview on 1/25/2024 at 9:00 AM the Medical Director (MD) stated, I fully expect staff to call immediately with any urine culture reports so that we may begin treatment. I was not notified in a proper amount of time. I should have been notified when the lab report was provided to the facility on ,d+[DATE]. Given her elevated WBC, and elevated PCT [procalcitonin], she could have developed sepsis from the UTI. But ultimately she did not have any harm. During a telephone interview on 1/25/2024 at 1:35 PM Staff J, Registered Nurse stated, I really can't remember if I was aware of the C&S results for her [Resident #31]. They will come across the fax machine when they are completed. I should have checked the culture results and called them to the doctor for treatment. I can't tell you why I didn't. Review of the policy and procedure titled, Notification of Change in Condition revision date of 12/16/2020, last approval date of 10/4/2023 read, Policy: The Center to promptly notify the patient/resident, the attending physician, and the resident representative when there is a change in the condition or status. Procedure: The nurse to notify the attending physician and resident representative when there is a (n): Need to alter treatment significantly, new treatment. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. 2. Review of the admission record for Resident #84 documented diagnosis that include cerebral Infarction (a stroke), secondary neoplasm of brain (brain cancer), malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer), non-ST elevation myocardial infarction (a heart attack), anemia, and unspecified dementia. Review of the physician orders for Resident #84 dated 1/3/2023 read, UA, C&S one time only for 1 day. Review of the laboratory results report for Resident #84 dated 1/3/2024 read, Collection date 1/3/2024, received date 1/3/2024 08:42 reported date 1/5/2024 at 11:16 AM. Urine Culture: Organism: Klebsiella oxytoca 50,000-100,000 CFU/ml. Review of the physician orders for Resident #84 dated 1/8/2024 read, Ciprofloxacin HCL [hydrochloride] oral tablet 500 mg give 1 tablet by mouth two times a day for UTI for 5 days. During an interview on 1/25/2024 at 2:10 PM the DON stated, All culture results should be called when they are received. Her results were not called, and her UTI was not treated until 1/8/2024 and they should have been called when they came in on the 5th.

Based on observation, interview and record review, the facility failed to ensure residents were provided a clean and homelike environment (Photographic evidence obtained). Findings include: 1. During an observation on 1/22/2023 at 9:03 AM, a previously repaired portion of the ceiling was split opened and was detaching from the rest of the ceiling in the hallway in front the nursing station near room [ROOM NUMBER]. During an observation on 1/23/2023 at 10:00 AM a previously repaired portion of the ceiling was split opened and was detaching from the rest of the ceiling in the hallway in front the nursing station near room [ROOM NUMBER]. 2. During an observation on 1/23/2023 at 9:54 AM, in Resident #23's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. During an observation on 12/24/2024 at 11:35 AM, in Resident #23's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. 3. During an observation on 1/23/2023 at 9:58 AM, in Resident #16's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. During an observation on 1/24/2024 at 11:35 AM, in Resident #16's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. During an interview on 1/24/2024 at 11:35 AM, while conducting a tour with the Administrator, she confirmed the observed physical environment concerns and stated that they need to be taken care of. Review of the facility policy and procedure titled Cleaning and Disinfecting Resident's Rooms last review on 10/04/2023revised in August 2013, reads, Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. General Guidelines: 1. Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled.

Based on observation and interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary care and services related to nail care, for 3 (Resident #48, #66, #88) of 8 residents out of a total sample of 39 residents. Findings include: 1. During an observation on 1/22/2024 at 9:50 AM, Resident #48's toenails of both feet were long and untrimmed. During an interview on 1/22/2024 at 9:50 AM, Resident #48's stated, I asked about cutting my toenails about a month ago and nobody has taken care of it. During an observation on 1/23/2024 at 2:30 PM, Resident #48's toenails of both feet were long and untrimmed. During an interview on 1/23/2024 at 2:30 PM, the resident stated, The toenails are the same. Somebody special needs to come and nobody has come. During an observation on 1/24/2024 at 8:09 AM, Resident #48 had long and untrimmed toenails. Review of the admission record for Resident #48 showed the resident was admitted on [DATE] with the diagnoses including nontraumatic intracerebral hemorrhage in cerebellum, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, other cerebral infarction due to occlusion or stenosis of small artery, benign neoplasm of meninges, and type 2 diabetes mellitus with hyperglycemia. Review of Resident #48's Minimum Data Set (MDS) Medicare 5-Day assessment dated [DATE] under Section GG - Functional Abilities and Goals documented the resident needed partial/moderate assistance for self-care related to showering/bathing. Review of care plan dated 12/11/2023 reads, Focus: [Resident #48's name] has an ADL self-care performance deficit r/t [related to] impaired balance. Date Initiated: 12/08/2023. Goal: [Resident #48's name] will improve current level of function in ADLs through the review date. Interventions: - Bathing/ Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. 2. During an observation on 1/23/24 at 8:53 AM, Resident #88 had long and untrimmed toenails. During an interview on 1/23/24 at 8:53 AM, Resident #88 stated, My toenails are long and need to be cut. I can't reach them. I don't know who does that here. During on observation on 1/24/2024 at 8:15 AM, Resident #88 had long and untrimmed toenails. During an observation on 1/24/2024 at 10:51 AM with Staff E, Registered Nurse (RN), it was confirmed Resident #88's toenails were long and untrimmed. Review of Resident #88's MDS Medicare 5-Day assessment dated [DATE] Section GG - Functional Abilities and Goals documented the resident required substantial maximal assistance for self-care related to showering/ bathing. Review of Resident #88's care plan dated 12/22/2023, reads, Focus: [Resident #88's name] has an ADL self-care performance deficit r/t impaired balance, musculoskeletal impairment, and s/p [status post] surgery. Date Initiated: 01/02/2024. Goal: [Resident #88's name] will improve current level of function in ADLs through the review date. Date Initiated: 01/02/2024. Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During an Interview on 1/24/2024 at 11:33 PM, the Director of Nursing (DON) stated that her expectation from the staff was to provide care according to the care plan. During an interview on 1/24/2024 at 1:30 PM, the Social Services Director stated that the podiatry company comes twice a month. [Resident #48's name] and [Resident #88's name] were not on podiatry services and he was not aware why the residents were not on podiatry services. 3. During an observation 1/23/2024 at 9:26 AM, Resident #66 had long untrimmed fingernails. The fingernail beds had a yellow substance underneath. During an observation on 1/24/2024 at 8:11 AM, Resident #66 had long untrimmed fingernails with a yellow substance under the fingernail beds. Review of the admission record for Resident #66 showed the resident was admitted on [DATE] with the diagnoses included severe dementia without behavioral disturbance. Review of Resident #66's MDS Medicare 5-Day assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 3 of 15 [indicating severe cognitive impairment] under Section C. Cognitive Patterns. Section GG. Functional Abilities and Goals documented the resident requires partial/moderate assistance for self-care related to showering/bathing. Review of Resident #66's care plan dated 1/23/2024, reads, Focus: [Resident #66's name] has an ADL self-care performance deficit r/t Activity Intolerance, Dementia, Fatigue, Limited Mobility. Date Initiated: 10/24/2023. Goal: Will improve current level of function in ADLs through the review date. Date Initiated: 10/24/2023. Interventions . - Bathing/ Showering: requires (mod. [moderate] assistance by 1) staff for bathing and grooming daily and showers per weekly schedule and as necessary. During an interview on 1/24/2024 at 10:25 AM, Staff E, Licensed Practical Nurse (LPN), confirmed that the resident had long, untrimmed, fingernail, and there was a yellow substance underneath the nail beds. During an interview on 1/24/2024 at 1:30 PM, the Social Services Director stated that the Podiatry company twice a month and the resident was not on podiatry services, and he was not aware why the resident was not on podiatry services.

Based on observation, interview, record review and policy and procedure review the facility failed to provide care for peripherally inserted central catheters in accordance with professional standards of practice for 1 out of 2 residents, Resident #88, out of a total sample of 39 residents. Findings include: During an observation on 1/25/2024 at 12:45 PM of medication administration for Resident #88 Staff E, Registered Nurse (RN) did not perform hand hygiene, donned gloves, locked the medication cart with one of her gloved hands, knocked on Resident #88's room door with one of her gloved hands and entered Resident #88's room. Resident #88 was observed in bed with a right upper arm double lumen PICC line (peripherally inserted central catheter). Staff E touched items on Resident #88's overbed table and placed supplies on the resident's dresser with her gloved hands. Staff E did not remove the gloves, did not perform hand hygiene, and opened an intravenous (IV) tubing package and connected the IV tubing to an IV bag of antibiotics. Staff E removed the end cap from the tubing and primed the tubing leaving the end of the tubing uncapped and hung the tubing on the IV pole. The uncapped end of the IV tubing was observed touching the IV pole. Staff E then scrubbed the needleless connector for less than three seconds, did not check for blood return and flushed the needleless connector with 5 milliliters of normal saline. Staff E scrubbed the second needleless connector for less than two seconds and without verifying for blood return flushed the remaining 5 milliliters into the second needleless connector. Staff E doffed the gloves and donned a new set of gloves without performing hand hygiene and attached the IV tubing to the needleless connector. During an interview on 1/25/2024 at 12:58 PM Staff E, RN stated, I did not wash my hands when I changed my gloves, I should have. I shouldn't have put my gloves on before I went into the room. I should not have uncapped the IV tubing when I primed the tubing. I didn't realize that it was touching the IV pole. I didn't realize that I couldn't use the same normal saline flush for both of them. I don't know if the order is for 5 or 10 milliliters. I didn't verify the placement before I flushed it. I did not verify, and I should have done that. I should have taken more time cleaning the connectors. During an interview on 1/25/2024 at 1:30 PM the Director of Nursing stated, I expect staff to complete hand hygiene and flush PICCs according to doctor orders. She should have verified placement of the PICC line before giving the saline. She should not have used the same syringe for both sides. The orders are for 10 ml (milliliter) flushes. Review of the admission record for Resident #88 documented diagnosis which include psoas muscle abscess [a collection of pus in the psoas muscle of the spine], discitis [an inflammation or infection in the cushion spaces between each part of the spine], paroxysmal atrial fibrillation [an irregular heart beat], anemia, acute embolism and thrombosis of deep vein of left upper extremity [blood clot], idiopathic peripheral autonomic neuropathy [nerve damage], unspecified glaucoma, major depressive disorder, and vertebral osteomyelitis [severe bone infection in the spine]. Review of the physician order for Resident #88 dated 12/21/2023 reads, Normal s Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 10 ml (milliliters) intravenously every shift for iv (intravenous) abt (antibiotic). Review of the physician order for Resident #88 dated 12/21/2023 reads, Cefazolin Sodium Intravenous Solution Reconstituted 2 GM (grams) (Cefazolin Sodium) Use 2 gram intravenously every 6 hours for sepsis/abscess until 01/31/2024. Review of the policy and procedure titled Flushing and Locking Central Vascular Access Device ( CVAD) last review 10/04/2023, reads, Policy: 4. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. 5. Needleless connectors require vigorous cleaning with alcohol prior to accessing to reduce the risk of catheter related bloodstream infections. 6. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures. General Guidelines. 5. Catheter patency must be verified prior to each access. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood. 8. Single use flushing/locking systems must be used. Procedure. 4. Perform hand hygiene. 6. Don gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry. 9. Attach syringe filled with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency.

Based on observations, interviews, and record reviews the facility failed to administer oxygen per physician's orders and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care (Resident #5 and #27) out of a total sample of 39 residents. Findings include: During an observation on 1/22/2024 at 10:26 AM, Resident #5 was observed resting in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at 4 liters. During an observation on 1/23/2024 at 7:27 AM, Resident #5 was sitting in bed with the head of bed elevated receiving oxygen via nasal cannula. The oxygen concentrator was running at 4 liters per minute. The oxygen concentrator was on her right side of the bed pushed against the wall out of the resident's reach. During an interview on 1/23/2024 at 7:27 AM Resident #5 stated, I can't reach the oxygen machine to change it. I don't have the strength to reach that far. During an observation on 1/24/24 at 7:15 AM, Resident #5 was resting in bed with the head of the bed elevated, receiving oxygen via nasal cannula. The oxygen concentrator was set at 4 liters per minute. The oxygen concentrator was on the right side of the resident's bed, against the wall at the head of her bed, out of residents reach. During an observation on 1/24/2024 at 7:16 AM with Staff I, Registered Nurse (RN) verified that oxygen was running at 4 liters nasal cannula and that oxygen concentrator was not within the resident's reach. During an interview on 1/24/2024 at 7:16 AM Staff I, RN, stated, This resident [Resident #5] doesn't play with her oxygen, she can't reach the oxygen tank to change it. It [the oxygen concentrator] is too far from her for her to reach it. I did not verify what the oxygen was running at, and we should do that every day. During an interview on 1/24/2024 at 8:10 AM the Director of Nursing (DON) stated, The staff should check the amount of oxygen a resident is getting at least when they are passing medications. Oxygen is considered a medication, and they should verify this. Review of the admission record for Resident #5 documented diagnosis which included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, unspecified combined systolic (congestive) and diastolic (congestive) heart failure (CHF), personal history of pulmonary embolism [a blood clot in the lungs], and unspecified atrial fibrillation [an irregular heartbeat]. Review of the physician's orders dated 12/8/2023 read, Respiratory: Oxygen 2 liters continuous every shift related to COPD. Review of the comprehensive resident centered care plan for Resident #5 revised on 1/4/2019 reads [Resident #5's Name] is at risk for ineffective gas exchange r/t (related to) COPD, O2 (Oxygen) therapy. Goal. Will have no s/sx (signs and symptoms) of poor oxygen absorption. Interventions. Oxygen settings: O2 as ordered. [Resident #5's Name] has potential for altered respiratory status/difficulty breathing r/t COPD, CHF. Goal. [Resident #5's Name] will maintain normal breathing pattern as evidenced y normal respirations, normal skin color, and regular respiratory rate/pattern. Interventions. Administer medications/puffers as ordered. Review of the policy and procedure titled, Oxygen Therapy last reviewed 10/4/2023, reads, Policy: Oxygen therapy is the administration of a FiO2 [Fraction of Inspired Oxygen; it is the amount of oxygen a patient is inhaling produced by an oxygen device] greater than 21% by means of various administration devices to: raise the residents PaO2 [partial pressure of oxygen; the oxygen pressure in arterial blood] to an acceptable baseline, to treat arterial hypoxemia, to decrease the work of breathing, to reverse and prevent tissue hypoxia and/or to decrease myocardial workload. Procedure: Review physicians order, , start O 2 flowrate at prescribed liter flow or appropriate liter flow for administration device. Review of the policy and procedure titled, Medication preparation for administering, last review on 10/4/2023, reads, Policy: All medications will be prepared and administered in a manner consistent with the general requirements outlined in this policy. Procedure: D. Medication Inspection: 1. Confirm the medication name and dose are correct. G. Prior to medication administration: 1. Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. 2. During an observation on 1/22/2024 at 3:34 PM, Resident #27 was observed sitting in bed with the head of bed elevated with oxygen infusing via nasal cannula. The oxygen concentrator was set a 3 liters per minute. During an observation on 1/23/2024 at 9:19 AM, Resident #27 was observed in bed with the head of the bed elevated with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters. During an observation on 1/24/2024 at 7:12 AM Resident #27 was observed in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters. During an interview on 1/24/24 at 7:12 AM, Staff I, RN verified that Resident #27's oxygen was running at 3.5 liters. During an interview on 1/24/2024 at 7:12 AM Staff I, RN stated, Her [Resident #27's oxygen] orders are for 2 liters. I did not have any change in condition last night. I did not verify what her oxygen was running at last night. We should complete this [verify oxygen administration] when we are administering meds [medications] and doing our checks. Review of the admission record for Resident #27 documented diagnosis which included acute respiratory failure with hypercapnia, pneumonia unspecified organism, chronic obstructive pulmonary disease, type 2 diabetes mellitus, unspecified combined systolic and diastolic heart failure, chronic ischemic heart disease, hypertensive heart and chronic kidney disease with heart failure, and chronic kidney disease stage 2. Review of the physician's orders for Resident #27 dated 12/7/2023 reads, Respiratory: Oxygen-continuous 2 LPM (liters per minute) every shift. Review of the nursing progress notes from 1/18/2024 through 1/22/2024, there were no progress notes or change of condition notes within the medical record. Review of the comprehensive resident centered care plan for Resident #27 initiated 5/08/2023 reads [Resident #27's Name] has oxygen therapy r/t ineffective gas exchange Goal. [Resident #27's Name] will have no s/sx of poor oxygen absorption. Interventions. Oxygen settings: O2 via nasal cannula as ordered. [Resident #27's Name] has potential for altered respiratory status/difficulty breathing r/t Sleep Apnea, COPD, CHF, and c/o (complaints of) SOB (shortness of breath) and wheezing at times. Goal. [Resident #27's Name] will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern. Interventions. Administer medications/puffers as ordered.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection during medication administration for 2 of 6 observations. Findings include: 1. During an observation on 1/22/2024 at approximately 2:02 PM of medication cart #3, Staff, C, Registered Nurse (RN) did not perform hand hygiene and began preparing medications for Resident #84. Staff C opened the medication cart drawer, pulled the medication blister packs up but did not remove the medication blister packs out of the drawer and began to pop the medications into her bare hand, then placed them into the medication cup for a total of six medications. Staff C went to Resident #84's room and without performing hand hygiene administered the medications and returned to the medication cart. Staff C did not perform hand hygiene and began to prepare medications for another resident. During an interview on 1/22/2024 at 2:05 PM Staff C, RN stated, Oh, I didn't realize that I did that. I should not have put the medicine into my hand, they need [the medications] to go directly into the medicine cup. I should have used the hand sanitizer. Review of the policy and procedure titled Medication Preparation for Administering last reviewed 10/4/2023 read, Policy: All medications will be prepared (blister card, vials, Artromick box [mobil medical storage]) and administered in a manner consistent with the general requirements outlined in this policy. Procedure: A. Prior to preparing or administering medications, follow the facility's infection control policies (e.g. hand washing). B. Medication Dose Preparation: 4. Do not touch the medication when opening a bottle or unit dose package. 2. During an observation on 1/25/2024 at 12:45 PM of medication administration for Resident #88 Staff E, RN did not perform hand hygiene, donned gloves, locked the medication cart with one of her gloved hands, knocked on Resident #88's room door with one of her gloved hands and entered Resident #88's room. Resident #88 was observed in bed with a right upper arm double lumen PICC line (peripherally inserted central catheter). Staff E touched items on Resident #88's overbed table and placed supplies on the resident's dresser with her gloved hands. Staff E did not remove the gloves, did not perform hand hygiene, and opened an intravenous (IV) tubing package and connected the IV tubing to an IV bag of antibiotics. Staff E removed the end cap from the tubing and primed the tubing leaving the end of the tubing uncapped and hung the tubing on the IV pole. The uncapped end of the IV tubing was observed touching the IV pole. Staff E then scrubbed the needleless connector for less than three seconds, did not check for blood return and flushed the needleless connector with 5 milliliters of normal saline. Staff E scrubbed the second needleless connector for less than two seconds and without verifying for blood return flushed the remaining 5 milliliters into the second needleless connector. Staff E doffed the gloves and donned a new set of gloves without performing hand hygiene and attached the IV tubing to the needleless connector. During an interview on 1/25/2024 at 12:58 PM Staff E, RN stated, I did not wash my hands when I changed my gloves, I should have. I shouldn't have put my gloves on before I went into the room. I should not have uncapped the IV tubing when I primed the tubing. I didn't realize that it was touching the IV pole. I should have taken more time cleaning the connectors. During an interview on 1/25/2024 at 1:30 PM the Director of Nursing stated, I expect staff to complete hand hygiene. Review of the policy and procedure titled Flushing and Locking Central Vascular Access Device (CVAD) last reviewed 10/4/2023 read, Policy: 5. Needleless connectors require vigorous cleaning with alcohol prior to accessing to reduce the risk of catheter related bloodstream infections. 6. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures. Procedure: 4. Perform hand hygiene. 6. Don gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry.

Based on observation, interview with the facility ' s nursing staff and administration staff, the Durable Power of Attorney (DPOA), the Medical Director, Primary Care Physician, and review of clinical records and facility policies, it was determined that the facility failed to protect the rights of the resident ' s right to refuse Cardio-Pulmonary Resuscitation (CPR) consistent with their end of life wishes for one (#94) of 15 sampled residents and one of 48 residents identified as having do not resuscitate orders (DNR), according to a [DATE] facility audit of all current resident records and review of Resident #94 ' s clinical record on [DATE]. The facility initiated CPR on Resident #94, who was a [AGE] years old and was admitted to the facility for rehabilitation care and services. Resident # 94 had a Do Not Resuscitate Order (DNR), completed by her appointed Durable Power of Attorney (DPOA), who was also her Health Care Surrogate (HCS), on [DATE]. The Do Not Resuscitate order, which was on goldenrod paper, was signed by the Durable Power of Attorney and her Physician on [DATE]. The facility failed to honor Resident #94 ' s advanced directives and denied the resident and her guardian the opportunity to refuse treatment. The facility initiated CPR for Resident #94 by checking her face sheet (not updated) and not using the facility systems in place. The facility provided unwanted treatment of [REDACTED]. The facility violated this resident/guardian ' s wishes to have a peaceful and dignified death and failed to protect the resident from unwanted interventions at their last moments of life. Failure of the facility staff to ensure the right to formulate an advanced directive of DNR was honored in accordance with resident /guardian ' s wishes to withhold treatment and service of CPR, resulted in findings of immediate jeopardy which was removed on [DATE] at 11:54 a.m. and the severity and scope was reduced to a D. Findings included: 1. A review of the facility ' s admission agreement, undated, revealed the following pertinent information related to Advanced Directives: 1. Nursing and Personal Care: The facility will provide the Resident with 24 hour nursing and personal care. Your care will be that needed for your health, safety and well-being as required by the facility license. 6. Right Leave/ Refuse Treatment: The resident has the right to refuse any medical treatment, as defined by law, and to be informed of the consequences of refusing treatment. The appropriate notification and documentation will be provided if the Resident communicates this wish. 36. Advanced directives: The resident acknowledges receipt of information concerning advanced directives and your right to make decisions about medical care. 2. A review of the Advanced Directives-Administration policy and procedure, dated [DATE] ' revealed: The resident has the right to refuse treatment and to formulate an Advanced Directive. The facility will abide by the resident ' s advanced directives if known. The following are definitions of terminology contained within the facility ' s policies and procedures: Life Support System: Life support systems may include among other things: Devices such as respiratory and [MEDICAL TREATMENT]. Cardiopulmonary resuscitation (CPR). Health Agent/Proxy: A healthcare agent/proxy is a person who is authorized by the resident in writing to convey their wishes concerning with holding or withdrawing life support systems. A healthcare agent does not act unless the resident is unable to make or communicate their decisions. Durable Power of Attorney: A Durable Power of Attorney for health care decisions is a document in which you name another person to make medical decisions, other than withdrawal of life support systems, on your behalf should you become unable to make or communicate such decisions yourself. The Executive Director must make certain the Admission staff, Social Services, Medical staff, Nursing staff, and Interdisciplinary team are informed, aware and trained to follow the company ' s policies and the residents wishes regarding advanced directives. Health care personnel are not obligated to participate actively in decision to withhold treatment, which they consider repugnant to their code. Anyone who does not wish to participate actively in any such decision should see the Executive Director. 3. Review of the facility ' s policies and procedures, effective date: [DATE], Code Blue Policy: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident had a DNR order written by a physician on their medical records. Procedure: When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. Confirm DNR status with the physician ' s written order. The Nurse Manager/ Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: Summon emergency equipment to the room. Activate the EMS system. Assign a person to document the ongoing code. 4. Review of the facility ' s policy and procedure Resident Abuse, dated on [DATE] with a revision date of [DATE], revealed the following pertinent information: Policy: It is inherent in the nature and dignity of each resident at the Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, 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 [REDACTED]. Procedure: Definition of Resident abuse: An abusive act is any act or omission, which may cause or causes actual physical, psychological or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein. 5. Medical record review, conducted for Resident #94, revealed a face sheet indicating the resident was [AGE] years old and was admitted to the facility on [DATE]. The face sheet also indicated that Resident #94 was admitted for short term therapy and the resident ' s advanced directives were full code. 6. A review of the advanced directives section of the clinical record revealed the following pertinent documents: a. A Durable Power of Attorney which was signed and dated by Resident #94, her appointee and a Notary Public of the state of Florida on [DATE]. b. A Certificate of Incapacity was signed and dated by the primary physician on [DATE]. c. A Behavioral Health Consultation note also dated on [DATE]. Listed next to the number 3 PCP -present- states PT is now a DNR, + incapacitated to make any verbal decisions. d. A Florida Department of Health State of Florida Do Not Resuscitate order. This form contained Resident ' s #94 ' s name and a written date of [DATE]. The order/form was signed by the spouse and a second signature of Resident #94 ' s primary physician. e. Mini-Mental State Examination (MMSE) test was located on Resident #94 ' s medical record. The test was dated on [DATE] with a total score of 0. (The test is a 30-point questionnaire (1) It is commonly used in medicine and allied health to screen for dementia). Test interpretations: a score greater than or equal to 27 points (out of 30) indicates a normal cognition. Below this, scores can indicate severe cognition (=9 points). 7. The resident had the following [DIAGNOSES REDACTED]. 8. Nursing notes were reviewed including: [DATE] at 12:11 a.m.: PO (pulse-ox) 85% on room air, increased to 94% with 02 (oxygen) on. [DATE] at 12:26 a.m.: PO (pulse-ox) 89% RA (room air) increased to 95% with 02 (oxygen). [DATE] at 1:31 a.m.: PO 88% on room air, PRN administration was: effective PO 96%. [DATE] 15:00 (3:00 p.m.): expired. 9. Resident #94 was included in the sample of the stage one QIS survey. On [DATE] at 12:39 p.m., the surveyor was outside of the resident ' s bedroom and heard an audible tracheal congestion. The door was open to the bedroom and the resident was observed sitting up in her Geri chair. She was noted with her bed table positioned on her right side with her meal tray on top. She was observed in the bedroom alone. Resident #94 was covered with a blanket that was positioned up to her chin. The resident ' s eyes were closed and she did not respond to verbal stimuli when approached. At 12:41 p.m., Staff O, Certified Nursing Assistant (CNA), entered the bedroom and was asked if she was going to assist Resident #94 with her lunch meal. Resident #94 began coughing with audible tracheal congestion. Her skin tone appeared pale and ashen in color. The CNA stated she was going to get the nurse and added the congestion is new. The CNA left the room, was observed approaching Staff I, LPN. She was heard telling the nurse that Resident #94 was having congestion and she wanted the nurse to look at her. Staff I was overheard telling the CNA, ok. Staff I entered Resident# 94 ' s bedroom at 12:44 p.m. and looked at the resident momentarily. She said why isn ' t her oxygen on? She went to the bathroom and washed her hands. She walked out of the bathroom and asked the surveyor if she could get her gloves. The surveyor indicated that she could not give supplies during that situation. Staff I then left the bedroom. The resident was observed for 5 seconds without breathing. On the count of six the resident inhaled deeply. The resident ' s skin, after inhalation, was observed as turning a darker gray (ashen) color at 12:46 p.m. On [DATE] at 12:47 p.m., Staff I returned to the bedroom followed by Staff Q, LPN, and the DON. Staff Q started calling the resident out by her name. The resident did not respond. Staff Q next performed a sternal rub to the resident. The resident was observed inhaling deeply. Staff Q stated we need to get her in bed. DON, Staff Q, Staff I, and Staff O were observed transferring the resident from her Geri-chair into her bed. Her oxygen was now in place and her head of bed was flat. Staff member O, who was still in the bedroom, stated out loud she has a pulse. At 12:48 p.m. while repositioning Resident #94 ' s head in the bed, Staff Q said, she ' s not breathing, she is a Full Code. Staff Q began chest compressions. While Staff Q was performing the chest compressions she asked, where ' s the ambu-bag (resuscitator bag)? Staff I had just returned to the bedroom with the crash cart and handed the ambu-bag to the DON. Staff Q was observed administering and counting out loud for a total of thirty chest compressions. The DON gave two breaths to the resident per the ambu- bag. One of the nurses stated, Go and call the code blue. At 12:49 p.m., a code blue was overheard on the facility ' s loud speaker. Staff Q was observed continuing with chest compressions followed by two breaths by the ambu-bag. At 12:50 p.m., Staff I entered the resident ' s bedroom. She said, She is a DNR . Staff Q, while continuing to perform the chest compressions stated, She is a full code I read it in her chart. Staff I turned around and left the bedroom. At 12:52 p.m., Staff P, LPN, took over for Staff Q and continued with chest compressions to the resident. On [DATE] at 12:53 p.m., Staff L, LPN, entered the bedroom and stood in front of the surveyor. Staff L was observed taking her right hand and making a motion across her throat to indicate stop. She then stated, She is a DNR; she has a yellow DNR sheet on her chart. The DON stated, Bring her chart in the room. At that time, Staff P stopped performing chest compressions. 10. Listed on Resident #94 ' s medical record face sheet, under the title, other information, was a box titled Advanced Directives. The Advanced Directive was listed as Full Code. She said she was unaware of her code status changing. She also confirmed she had only looked at Resident #94 ' s face sheet in her (paper) medical record. 11. On [DATE] at 4:12 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She said she had been a licensed nurse for fourteen years now and had worked at the facility for three and half years. She said her normal shift was on days and she always worked the first floor B-hallway. When asked if she knew Resident # 94, she said no. The nurse said she was told by the staff member O that the resident had needed help and was having breathing problems. I went to the room and realized that was the wrong room number. She said, When staff member O came to me I didn ' t know what I needed until I got there. She said when I got there (bedroom) I seen her oxygen tubing was on the floor. I then left the room to find Staff Member Q. LPN I was asked where would find a resident ' s code status in the medical record. She said, You would look for the yellow sheet in the advanced directives section on the medical record. When asked if the code status was listed on the face sheet, she said you ' re not supposed to use the face sheet for their code status, it ' s not always updated. 12. 0n [DATE] at 4:44 p.m., an interview was conducted the facility ' s Director of Social Services (DSS). She said Resident #94 ' s spouse was in her office during the code blue incident on [DATE]. The DSS said that Resident #94 ' s spouse had asked her what was going on in his wife ' s bedroom. The DSS said she looked up from her desk and observed staff members taking a crash cart into her bedroom. She said at that time I told Resident #94 ' s spouse that I was going to see what was going on in her bedroom. She confirmed she had observed staff members performing CPR to her. The DSS said, I remembered seeing you in there and asking for gloves. The DSS was asked if she knew that Resident #94 ' s advanced directives had been changed. The DSS stated, Yes, I had put the paper work together the week before. The Physician and Resident #94 ' s spouse signed the paper work on Saturday. The DSS was asked when she had first seen the signed golden rod. She said she had seen it on the next Monday ([DATE]) when she came into work that morning. When asked if she had told anyone that Resident #94 ' s code status had changed she said, I told everyone in the Monday morning stand up meeting. She was asked who was in the meeting. She said she remembered the Director of Nursing (DON), Nursing Home Administrator (NHA), the unit manager, and said she and couldn ' t remember everyone. The DSS was asked who told Resident #94 ' s spouse that she had expired at the facility. The DSS stated Resident #94 ' s spouse came back to her office after he had spoken with the DON. He told me that the DON said his wife had passed away peacefully. He said he was going to sit in his wife ' s bedroom for a while. 13. On [DATE] at 2:00 p.m. a telephone interview was conducted with Resident #94 ' s spouse. He confirmed he was the spouse of Resident #94 and said that the facility had problems getting her medication. He stated that, after her last surgery his wife was having memory problems. They say the memory problems were a direct side effect from loss of oxygen during her operation. Her muscles wouldn ' t do what her mind was telling them to do. They thought she had Alzheimer ' s but she didn ' t. Resident #94 ' s spouse confirmed that his wife was a DNR. He said he was at the facility and was aware that the staff members were performing CPR on her. He said, I had to remind the staff that she was a DNR so they would quit. I guess they didn ' t realize it. As soon as I told them they stopped the CPR. I sat in the room with Resident #94 for a while after they stopped the CPR. When asked if it was his expectation that the staff members honor Resident #94 ' s wishes when she stopped breathing and no longer had a pulse, he said, They just didn ' t know she was a DNR. 14. On [DATE] at 11:08 a.m., a phone interview was conducted with Resident #94 ' s Primary Care Physician (PCP). The PCP said he had just seen Resident #94 at the facility on Saturday ([DATE]). The PCP said her husband was also there and in agreement with her advanced directives changing. The PCP said he had signed her Do Not Resuscitate Certificate (DNR) on [DATE]. The PCP was asked when the last time he had heard from the facility. He said they had called him on Tuesday and told him that Resident #94 ' s vital signs had ceased. He said he had given orders. The PCP was asked, Once Resident #94 ' s code status changed to a DNR, what would he have expected when the facility ' s licensed staff members found her not breathing. He said, I would expect them not to perform CPR. The PCP was then informed that the licensed staff members performed CPR to Resident #94 for five minutes. PCP said he was not aware that the facility had performed CPR to Resident #94. He said, That was not right. 15. On [DATE] at 11:30 p.m., an interview was conducted with the facility ' s Medical Director. The Medical Director confirmed that she was notified by the facility that Resident #94 expired on [DATE]. She confirmed that she was aware that CPR had been performed on Resident #94. She said that she was also was informed that there had been a DNR on her medical record. She stated, Education on where to find the Advanced Directives (in the chart) in the medical record is our main goal. 16. On [DATE] at 5:45 p.m., the Nursing Home Administrator (NHA), DON and the Corporate Nurse provided a copy of The Situation, Background, Assessment and Recommendation (SBAR) report. The SBAR report was reviewed and listed under the nursing notes, dated on [DATE], Primary nurse reported that she checked face sheet and resident was a full code. Reports that she did not know that code status had changed. The SBAR indicated, on [DATE], the physician was notified at 2:15 p.m. 17. On [DATE] at 6:10 p.m., the NHA informed the survey team We have immediately in-serviced Licensed Practical Nurse Q on the facility ' s Code blue policy. We also verified her CPR certification. She is a Basic Life Support (BLS) Instructor for the American Heart Association. The NHA said, We have suspended her during our investigation and pending the determination of the outcome. It ' s part of our facility policy. Licensed Practical Nurse Q received a Corrective Action Form on [DATE]. Listed under Description of violation: 1. Abuse of resident -Violation of Resident/patient Bill of Rights. Supervisor ' s Corrective Plan of Action, Employee educated in viewing DNR before initiating CPR-cannot use Face sheet information. Employee suspended pending investigation. Employee comments: I do not agree with this. The Face sheet stated Full Code when time is of the essence. It is NOT realistic search for information that needed to be clear. I am not agreeing with this. I am signing under duress. 18. On [DATE] at 1:22 p.m. an interview was conducted with the Nursing Home Administrator. The NHA stated the facility ' s investigation that had involved Resident #94 was found as substantiated. She said she would be calling Staff member Q today and asking her to come into the facility. Staff member Q will be terminated at that time. The NHA confirmed the root cause of the incident was that the nurse looked at the face sheet and not the golden rod in the medical record. Our policy does not reflect that. The NHA said the nurse ' s job is to try and save a life. The nurses that were helping during the Code Blue didn ' t ask for her code status, they saw Staff member Q performing compressions and it was a natural response to help them out. 19. On [DATE] at 11:00 a.m. an interview was conducted with the DON. The DON said that she has been at the facility for over a month now and was the interim DON. She was asked about the facility ' s policy on resident ' s code status. She said you have to look for the physician orders. She confirmed that it is her expectation that the staff review the medical record for the Physician order [REDACTED]. The DON said we are continuing with education on codes and responding appropriately. We are now bringing the resident ' s chart to the room and we have started a two person verification of the code status. 20. On [DATE] at 6:10 p.m., the NHA and the Regional Corporate nurses were asked if there was a system in place to prevent further occurrences. The NHA stated, Education, auditing on all new admissions. The nurses will be obtaining code status on admission. The root cause was the nurse looked at the face sheet and not the golden rod. We have educated the business office and the Social Services on the status. The Business office was entering the code status on the resident ' s face sheet and they were instructed not to enter this any longer. The NHA and the Regional Corporate Nurse revealed the following actions were taken to remove the Immediate Jeopardy: a. A 100% audit was conducted on all current residents ' code status, face sheets and care plans to ensure accuracy. On [DATE] at 6:10 p.m., the NHA identified the facility census of 113 residents. She said there were 48 residents currently residing in the facility with a DNR status. This was verified as survey team reviewed face sheets, physician orders [REDACTED]. b. The NHA said the Quality Assurance (QA) team had meet on [DATE]. She said the following actions were CPR/DNR policy and procedures and they were working on a 4 point plan. The NHA provided a copy of the QA and A that they had conducted. She stated everyone in the QA team had been notified of the incident and the only signature we did not have at this time was the Medical Director. She said she will be in to sign it. 20. On [DATE] at 2:50 p.m., a Code Blue mock drill was conducted and observed on the lower level of the facility. A staff member was overheard announcing Code Blue room [ROOM NUMBER] on the overhead intercom system. Staff members were observed immediately responding to room [ROOM NUMBER] totaling seven altogether. A CPR instructor, from the sister facility, was present in the bedroom. She was heard asking the staff members what they were going to do and what they were doing. On [DATE] at 5:00 p.m. the facility provided a copy of the observed Code Blue mock drill titled: Code Blue Quality Assurance Drill. Comments from the Instructor included: 1. Staff answered appropriately, utilized critical thinking skills, prompt response. 2. Identified record keeper and delegator for the drill and actual code. 3. Staff needs to work as a team vs, o2, accu, compression are all done simultaneously to complete all tasks during drill. This will ensure the response time is as quick as possible and will increase chances of survival. 21. On [DATE] at 4:10 p.m., the Regional Nurse stated we are at 100% compliance with educating our staff on the facility policy and procedure on code blue and had them sign the CPR/DNR -Zero Tolerance. The Regional Nurse said we will continue with our mock drills every shift. 22. On [DATE] at 1:19 p.m., the NHA stated they are at 100% compliance with their Cardiopulmonary Resuscitation for licensed staff members. The facility provided copies of their in house audit on CPR certificates. The facility identified a total of 30 active licensed nurses. 23. Verification interviews were conducted between [DATE] and [DATE] that included nurses across all three shifts. All of the nurses verbalized they had attended the CPR/DNR in-service that the facility had conducted. The nurses verbalized knowledge of the training by looking in the medical record under the Advanced Directives section and having a second nurse verify the resident ' s code status. On [DATE] at 11:54 a.m. the facility ' s Regional Corporate Nurse provided a copy of their updated, Four Point Action Plan , dated [DATE] at 1:15 p.m. The Action steps now contain: Code status was removed from face sheets. The Regional Nurse said our corporate office has initiated a corporate wide removal of a ' cell ' that was on face sheet. The face sheet no longer contains the box (cell) that was titled: Advanced Directives. As a result of the measures, the Immediate Jeopardy was removed on [DATE], at 11:54 a.m., and the severity and scope reduced to D.

Based on observation, facility policy review, review of advanced directives, clinical record review, interview with nursing, administration staff, Medical Director, Primary Care Provider, and Power of Attorney, it was determined that the facility failed to ensure staff were knowledgeable of facility policies and procedures for advanced directives and could identity end of life wishes regarding resuscitation for one (#94), out of 15 sampled residents of 48 identified as having a do not resuscitate order (DNR), according to a [DATE] audit of all current resident records and review of Resident #94 ' s clinical record on [DATE]. The facility failed to implement their own policies for Code Arrest and the execution of Advanced Directives in accordance with their policies and procedures as the facility initiated CPR on Resident #94, a [AGE] year old. This resident had a signed DO NO RESUSCIATE (DNR) order completed by her Power of Attorney (POA) on [DATE]. The facility failed to honor Resident #94 ' s advanced directives and denied the resident/guardian the right to refuse treatment. The facility initiated CPR for Resident #94 without checking her code status using the systems in place. The resident was at the mercy of the staff and provided with unwanted treatments of cardiac compressions and artificial ventilation to prolong life. The facility violated this resident ' s rights by failing to honor the resident ' s wishes to have a peaceful and dignified death and failed to protect the resident from unwanted interventions at their last moments of life. Failure to protect the rights of residents to ensure facility staff correctly implemented advanced directives resulted in findings of Immediate Jeopardy, which were removed on [DATE], and the severity and scope was reduced to a D. Findings included: 1. A review of the Advanced Directives-Administration policy and procedure, dated [DATE], revealed: The resident had the right to refuse treatment and to formulate an Advanced Directive. The facility will abide by the resident ' s advanced directives if known. The following are definitions of terminology contained within the facility ' s policies and procedures: Life Support System: Life support systems may include among other things: Devices such as respiratory and [MEDICAL TREATMENT]. Cardiopulmonary resuscitation (CPR). Health Agent/Proxy: A healthcare agent/proxy is a person who is authorized by the resident in writing to convey their wishes concerning with holding or withdrawing life support systems. A healthcare agent does not act unless the resident is unable to make or communicate their decisions. Durable Power of Attorney: A Durable Power of Attorney for health care decisions is a document in which you name another person to make medical decisions, other than withdrawal of life support systems, on your behalf should you become unable to make or communicate such decisions yourself. The Executive Director must make certain the Admissions staff; Social Services, Medical staff, Nursing staff, and Interdisciplinary team are informed, aware and trained to follow the company ' s policies and the resident ' s wishes regarding advanced directives. Health care personnel are not obligated to participate actively in a decision to withhold treatment, which they consider repugnant to their code. Anyone who does not wish to participate actively in any such decision should see the Executive Director. 2. Review of the facility ' s policies and procedures, effective date: [DATE], Code Blue Policy identified the following: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by a physician on their medical records. Procedure: When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. Confirm DNR status with the physician ' s written order. The Nurse Manager/ Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: Summon emergency equipment to the room. Activate the EMS system. Assign a person to document the ongoing code. 3. Review of the facility ' s policy and procedure Resident Abuse, dated on [DATE] with a revision date of [DATE], revealed the following pertinent information: Policy: It is inherent in the nature and dignity of each resident at the Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, 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 [REDACTED]. Procedure: Definition of Resident abuse: An abusive act is any act or omission, which may cause or causes actual physical, psychological or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein. 3. Medical record review, conducted for Resident #94, revealed a face sheet indicating the resident was [AGE] years old and was admitted to the facility on [DATE]. The face sheet also indicated that Resident #94 was admitted for short term therapy and the resident ' s advanced directives were full code. A review of the advanced directives section for Resident #94 revealed the following pertinent documents: a. A document that was bright yellow in color (golden rod) with capitalized words that stated DO NOT RESUSCUTATE ORDER. The first section of the golden rod document had Resident #94 s name on with a written date of [DATE]. The second section of the document included: PATIENT ' S STATEMENT: Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): Resident #94 ' s spouse had put an X in the box indicating he was the health care proxy (both as defined in Chapter 765, F.S.) and signed the documents. The final section of the document included: PHYSICIAN ' S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient ' s cardiac or respiratory arrest. Resident #94 ' s Primary Care Physician had signed the golden rod on [DATE]. b. A Durable Power of Attorney which was signed and dated by Resident #94, her appointee and a Notary Public of the State of Florida on [DATE]. c. Certificate of Incapacity. The certificate was signed and dated by the primary physician on [DATE]. The clinical record included a Behavioral Health Consultation note, which was reviewed and revealed, PCP -present- states PT is now a DNR, + incapacitated to make any verbal decisions, dated: [DATE]. A review of the resident ' s individualized plan of care revealed the following pertinent information, dated [DATE], with a revision on [DATE]. Focus: Resident #94 has no advanced directives. The resident had the following [DIAGNOSES REDACTED]. 4. Resident #94 was included in the sample of the stage one QIS survey. On [DATE] at 12:39 p.m., the surveyor was outside of her bedroom and heard an audible tracheal congestion. The door was open to the bedroom and the resident was observed sitting up in her Geri-chair. She was noted with her bed table positioned on her right side with her meal tray on top. She was observed in the bedroom alone. Resident #94 was covered with a blanket that was positioned up to her chin. The resident ' s eyes were closed and she did not respond to verbal stimuli when approached. At 12:41 p.m., Staff O, Certified Nursing Assistant, entered the bedroom and was asked if she was going to assist Resident #94 with her lunch meal. Resident #94 began coughing with audible tracheal congestion. Her skin tone appeared pale and ashen in color. The CNA stated she was going to get the nurse and added the congestion is new. The CNA left the room, was observed approaching Staff I, LPN. She was heard telling the nurse that Resident #94 was having congestion and she wanted the nurse to look at her. Staff I was overheard telling the CNA, ok. Staff I entered Resident# 94 ' s bedroom at 12:44 p.m. and looked at the resident momentarily. She said, Why isn ' t her oxygen on? She went to the bathroom and washed her hands. She walked out of the bathroom and asked the surveyor if she could get her gloves. The surveyor indicated that she could not give supplies during that situation. Staff I then left the bedroom. The resident was observed for 5 seconds without breathing. On the count of six, the resident inhaled deeply. The resident ' s skin after inhalation was observed as turning a darker gray (ashen) color at 12:46 p.m. On [DATE] at 12:47 p.m., Staff I returned to the bedroom followed by Staff Q, LPN, and the DON. Staff Q started calling the resident by her name. The resident did not respond. Staff Q next performed a sternal rub to the resident. The resident was observed inhaling deeply. Staff Q stated, We need to get her in bed. The DON, Staff Q, Staff I, and Staff O were observed transferring the resident from her Geri-chair into her bed. Her oxygen was now in place and the head of the bed was flat. The CNA, who was in the bedroom, stated out loud, she has a pulse. At 12:48 p.m. while repositioning Resident #94 ' s head in the bed, Staff Q said, she ' s not breathing, she is a Full Code. Staff Q began chest compressions. While Staff Q was performing the chest compressions she asked, Where ' s the ambu-bag (resuscitator bag)? Staff I had just returned to the bedroom with the crash cart and handed the ambu-bag to the DON. Staff Q was observed administering and counting out loud for a total of thirty chest compressions. The DON gave two breaths to the resident per the ambu- bag. One of the nurses stated, Go and call the code blue. At 12:49 p.m., a code blue was overheard on the facility ' s loud speaker. Staff Q was observed continuing with chest compressions followed by two breaths by the ambu-bag. At 12:50 p.m., Staff I entered the resident ' s bedroom. She said, She is a DNR . Staff Q, while continuing to perform the chest compressions, stated, She is a full code I read it in her chart. Staff I turned around and left the bedroom. At 12:52 p.m., Staff P, LPN, took over for Staff Q and continued with chest compressions to the resident. On [DATE] at 12:53 p.m., Staff L, LPN, entered the bedroom and stood in front of the surveyor. Staff L was observed taking her right hand and making a motion across her throat to indicate stop. She then stated, She is a DNR; she has a yellow DNR sheet on her chart. The DON stated, Bring her chart in the room. At that time, Staff P stopped performing chest compressions. 5. 0n [DATE] at 4:44 p.m. an interview was conducted the facility ' s Director of Social Services (DSS). She said Resident #94 ' s spouse was in her office during the code blue incident on [DATE]. The DSS said that Resident #94 ' s spouse had asked her what was going on in his wife ' s bedroom. The DSS said she looked up from her desk and observed staff members taking a crash cart into her bedroom. She said at that time I told Resident #94 ' s spouse that I was going to see what was going on in her bedroom. She confirmed she had observed staff members performing CPR to her. The DSS said, I remembered seeing you in there and asking for gloves. The DSS was asked if she knew that Resident #94 ' s advanced directives had been changed. The DSS stated, Yes, I had put the paper work together the week before. The Physician and Resident #94 ' s spouse signed the paper work on Saturday . The DSS was asked when she had first seen the signed golden rod. She said she had seen it on the next Monday ([DATE]) when she came into work that morning. When asked if she had told anyone that Resident #94 ' s code status had changed she said, I told everyone in the Monday morning stand up meeting. She was asked who was in the meeting. She said she remembered the Director of Nursing (DON), Nursing Home Administer (NHA), the unit manager and said she and couldn ' t remember everyone. The DSS was asked who had told Resident #94 ' s spouse that she had expired at the facility. DSS stated Resident #94 ' s spouse came back to her office after he had spoken with the DON. He told me that the DON said his wife had passed away peacefully. He said he was going to sit in his wife ' s bedroom for a while. 6. On [DATE] at 2:00 p.m., a telephone interview was conducted with Resident #94 ' s spouse. He confirmed he was the spouse of Resident #94 and said that the facility had problems getting her medication. He stated that after her last surgery his wife was having memory problems. They say the memory problems were a direct side effect from lost oxygen during her operation. Her muscles wouldn ' t do what her mind was telling them to do. They thought she had Alzheimer ' s but she didn ' t. Resident #94 ' s spouse confirmed that his wife was a DNR. He said he was at the facility and was aware that the staff members were performing CPR on her. He said, I had to remind the staff that she was a DNR so they would quit, I guess they didn ' t realize it. As soon as I told them they stopped the CPR. I sat in the room with Resident #94 for a while after they stopped the CPR. When asked if it was his expectation that the staff members honor Resident #94 ' s wishes when she stops breathing and no longer has a pulse, he said, They just didn ' t know she was a DNR. 7. On [DATE] at 12:58 p.m., an interview was conducted with Staff Q. Staff Q was asked where she had looked in the medical record for Resident#94 ' s code status. Staff Q pointed to Resident #94 ' s face sheet. Listed on the face sheet under the title, other information, was a box titled Advanced Directives. The Advanced Directive was listed as Full Code. She said she was unaware of her code status changing. She also confirmed she had only looked at Resident #94 ' s face sheet in her (paper) medical record. 8. On [DATE] at 11:00 a.m. an interview was conducted with the DON. The DON said that she had been at the facility for over a month and was the interim DON. She was asked about the facility ' s policy on resident ' s code status. She said, You have to look for the physician orders. She confirmed that it was her expectation that the staff review the medical record for the Physician order [REDACTED]. The DON said we are continuing with education on codes and responding appropriately. We are now bringing the resident ' s chart to the room and we have started a two person verification of the code status. 9. On [DATE] at 4:12 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She said she had been a licensed nurse for fourteen years now and had worked at the facility for three and half years. She said her normal shift was on days and she always worked the first floor B-hallway. When asked if she knew Resident # 94, she said no. The nurse said she was told by the staff member O that the resident had needed help and was having breathing problems. I went to the room and realized that was the wrong room number. She said, When staff member O came to me I didn ' t know what I needed until I got there. She said, when I got there (bedroom) I saw her oxygen tubing was on the floor. I then left the room to find Staff Member Q. LPN I was asked where would find a resident ' s code status in the medical record. She said, You would look for the yellow sheet in the advanced directives section on the medical record. When asked if the code status was listed on the face sheet, she said you ' re not supposed to use the face sheet for their code status, it ' s not always updated. 10. On [DATE] at 11:30 p.m., an interview was conducted with the facility ' s Medical Director. The Medical Director confirmed that she was notified by the facility that Resident #94 expired on [DATE]. She confirmed that she was aware that CPR had been performed on Resident #94. She said that she was also informed that there had been a DNR on her medical record. She stated, Education on where to find the Advanced Directives (in the chart) in the medical record is our main goal. 11. On [DATE] at 11:08 a.m., a phone interview was conducted with Resident #94 ' s Primary Care Physician (PCP). The PCP said he had just seen Resident #94 at the facility on Saturday ([DATE]). She said her husband was also there and in agreement with her advanced directives changing. The PCP said he had signed her Do Not Resuscitation Certificate (DNR) on [DATE]. The PCP was asked when the last time he had heard from the facility was. He said they had called him on Tuesday and told him that Resident #94 ' s vital signs had ceased. He said he had given orders to release the resident. The PCP was asked, once Resident #94 ' s code status changed to a DNR, what would you have expected when the facility ' s licensed staff members found her not breathing. He said I would expect them not to perform CPR. The PCP was then informed that the licensed staff members performed CPR to Resident #94 for five minutes. PCP said he was not aware that the facility had performed CPR to Resident #94. He said That was not right. 12. On [DATE] at 1:22 p.m. an interview was conducted with the Nursing Home Administrator. The NHA stated the facility ' s investigation that had involved Resident #94 was found as substantiated. She said she would be calling Staff member Q today and asking her to come into the facility. Staff member Q will be terminated at that time. The NHA confirmed the root cause of the incident was that the nurse looked at the face sheet and not the golden rod in the medical record. Our policy does not reflect that. The NHA said the nurse ' s job is to try and save a life. The nurses that were helping during the Code Blue didn ' t ask for her code status, they saw Staff member Q performing compressions and it was a natural response to help them out. 13. On [DATE] at 6:10 p.m., the NHA informed the survey team, We have immediately in-serviced Licensed Practical Nurse Q on the facility ' s Code blue policy. We also verified her CPR certification. She is a Basic Life Support (BLS) Instructor for the American Heart Association. The NHA said, We have suspended her during our investigation and pending the determination of the outcome. It ' s part of our facility policy. Licensed Practical Nurse Q received a Corrective Action Form on [DATE]. Listed under Description of violation: 1. Abuse of resident -Violation of Resident/patient Bill of Rights. Supervisor ' s Corrective Plan of Action, Employee educated in viewing DNR before initiating CPR-cannot use Face sheet information. Employee suspended pending investigation. Employee comments: I do not agree with this. The Face sheet stated Full Code when time is of the essence. It is NOT realistic search for information that needed to be clear. I am not agreeing with this. I am signing under duress. 14. On [DATE] at 2:50 p.m., a Code Blue mock drill was conducted and observed on the lower level of the facility. A staff member was overheard announcing Code Blue room [ROOM NUMBER] on the overhead intercom system. Staff members were observed immediately responding to room [ROOM NUMBER] totaling seven altogether. A CPR instructor, from the sister facility, was present in the bedroom. She was heard asking the staff members what they were going to do and what they were doing. On [DATE] at 5:00 p.m. the facility provided a copy of the observed Code Blue mock drill titled: Code Blue Quality Assurance Drill. Comments from the Instructor included: 1. Staff answered appropriately, utilized critical thinking skills, prompt response. 2. Identified record keeper and delegator for the drill and actual code. 3. Staff needs to work as a team vs, o2, accu, compression are all done simultaneously to complete all tasks during drill. This will ensure the response time is as quick as possible and will increase chances of survival. 15. On [DATE] at 6:10 p.m., the NHA and the Regional Corporate nurses were asked if there was system in place to prevent further occurrences. The NHA stated, Education, auditing on all new admissions. The nurses will be obtaining code status on admission. The root cause was the nurses looked at the face sheet and not the golden rod. We have educated the business office and the Social Services on the status. The Business office is entering the code status on the resident ' s face sheet and they were instructed not to enter this any longer. The NHA and the Regional Corporate Nurse revealed the following actions were taken to remove the Immediate Jeopardy: a. A 100% audit was conducted on all current residents ' code status, face sheets and care plans to ensure accuracy. On [DATE] at 6:10 p.m., the NHA identified the facility census of 113 residents. She said there are 48 residents currently residing in the facility with a DNR status. This was verified as survey team reviewed face sheets, physician orders [REDACTED]. b. The NHA said the Quality Assurance (QA) team had meet on [DATE]. She said the following actions were CPR/DNR policy and procedures and they were working on a 4 point plan. The NHA provided a copy of the QA and A that they had conducted. She stated everyone in the QA team had been notified of the incident and the only signature we did not have at this time was the Medical Director. She said she will be in to sign it. c. On [DATE] at 4:10 p.m., the Regional Nurse stated we are at 100% compliance with educating our staff on the facility policy and procedure on code blue and had them sign the CPR/DNR -Zero Tolerance. The Regional Nurse said we will continue with our mock drills every shift. 16. On [DATE], at 11:54 a.m., the facility ' s Regional Corporate Nurse provided a copy of their updated, Four Point Action Plan , dated [DATE] at 1:15 p.m. The Action steps now contain: Code status was removed from face sheets. The Regional Nurse said our corporate office has initiated a corporate wide removal of a ' cell ' that was on face sheet. The face sheet no longer contains the box (cell) that was titled: Advanced Directives. 17. Verification interviews were conducted between [DATE] and [DATE] that included nurses across all three shifts. All of the nurses verbalized they had attended the CPR/DNR in-service that the facility had conducted. The nurses verbalized knowledge of the training by looking in the medical record under the Advanced Directives section and having a second nurse verify the resident ' s code status. As a result of the measures, the Immediate Jeopardy was removed on [DATE] and the severity and scope reduced to D.

Based on observation, interview with facility staff, review of resident ' s medical records and policy and procedures, it was determined the facility failed to fulfill a care taking obligation to provide goods or services necessary to avoid physical harm and mental anguish for one (#94) out of 15 sampled residents of 48 identified as having Do Not Resuscitate orders (DNR), according to the [DATE] facility audit of all current resident records and review of Resident ' s #94 clinical record on [DATE]. The facility initiated Cardio-Pulmonary Resuscitation (CPR) when the resident ' s breathing ceased and her pulse stopped. The facility initiated CPR on a [AGE] year old without verifying the resident ' s advanced directives with the physician ' s written order. The facility staff did not properly implement their corporate policy and procedure for Code Blue, dated [DATE], and the Resident Abuse policies and procedures, dated [DATE]. The facility did not honor the expressed wishes of the legally appointed guardian of an incapacitated resident. Failure of the facility staff to correctly implement the Code Blue policy/guidelines resulted in findings of Immediate Jeopardy which was removed on [DATE], at 11:54 a.m., and the severity and scope was reduced to a D. Findings included: 1. Resident #94 was included in the sample of the stage one Quality Indicator Survey. On [DATE], at 12:39 p.m., the surveyor was outside of Resident #94 ' s bedroom and heard an audible tracheal congestion. The door was open to the bedroom and the resident was observed sitting up in her Geri chair. She was noted with her bed table positioned on her right side with her meal tray on top. She was observed in the bedroom alone. Resident #94 was covered with a blanket that was positioned up to her chin. The resident ' s eyes were closed and she did not respond to verbal stimuli when approached. At 12:41 p.m. Staff O, Certified Nursing Assistant ,entered the bedroom and was asked if she was going to assist Resident #94 with her lunch meal. Resident #94 began coughing with audible tracheal congestion. Her skin tone appeared pale and ashen in color. The CNA stated she was going to get the nurse and added the congestion is new. The CNA left the room, was observed approaching Staff I, LPN. She was heard telling the nurse that Resident #94 was having congestion and she wanted the nurse to look at her. Staff I was overheard telling the CNA, ok. Staff I entered Resident # 94 ' s bedroom at 12:44 p.m. and looked at the resident momentarily. She said why isn ' t her oxygen on? She went to the bathroom and washed her hands. She walked out of the bathroom and asked the surveyor if she could get her gloves. The surveyor indicated that she could not give supplies during that situation. Staff I then left the bedroom. The resident was observed for five seconds without breathing. On the count of six, the resident inhaled deeply. The resident ' s skin after inhalation was observed as turning a darker gray (ashen) color at 12:46 p.m. On [DATE] at 12:47 p.m., Staff I returned to the bedroom followed by Staff Q, LPN, and the DON. Staff Q started calling the resident out by her name. The resident did not respond. Staff Q next performed a sternal rub to the resident. The resident was observed inhaling deeply. Staff Q stated we need to get her in bed. DON, Staff Q, Staff I and Staff O were observed transferring the resident from her Geri-chair into her bed. Her oxygen was now in place and her head of bed was flat. The CNA who was in the bedroom, stated out loud, she has a pulse. At 12:48 p.m., while repositioning Resident #94 ' s head in the bed, Staff Q said, she ' s not breathing, she is a Full Code. Staff Q began chest compressions. While Staff Q was performing the chest compressions she asked, Where ' s the ambu-bag (resuscitator bag)? Staff I had just returned to the bedroom with the crash cart and handed the ambu-bag to the DON. Staff Q was observed administering and counting out loud for a total of thirty chest compressions. The DON gave two breaths to the resident per the ambu-bag. One of the nurses stated, Go and call the code blue. At 12:49 p.m., a code blue was overheard on the facility ' s loud speaker. Staff Q was observed continuing with chest compressions followed by two breaths by the ambu-bag. At 12:50 p.m., Staff I entered the resident ' s bedroom. She said, She is a DNR. Staff Q, while continuing to perform the chest compressions stated, She is a full code I read it in her chart. Staff I turned around and left the bedroom. At 12:52 p.m., Staff P, LPN, took over for Staff Q and continued with chest compressions to the resident. On [DATE] at 12:53 p.m., Staff L, LPN, entered the bedroom and stood in front of the surveyor. Staff L was observed taking her right hand and making a motion across her throat to indicate stop. She then stated, She is a DNR; she has a yellow DNR sheet on her chart. The DON stated, Bring her chart in the room. At that time, Staff P stopped performing chest compressions. 2. On [DATE] at 12:58 p.m., Resident #94 ' s medical record was at the nursing station along with Staff member Q. Staff member Q was asked if the medical record was Resident #94 ' s and she confirmed it was. The medical record contained a sectioned off tab labeled Advanced Directives. The Advanced Directives section contained a document that was bright yellow in color (golden rod) with capitalized words that stated DO NOT RESUSCUTATE ORDER. The first section of the golden rod document had Resident #94 s name on with a written date of [DATE]. The second section of the document included: PATIENT ' S STATEMENT: Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): Resident #94 ' s spouse had put an X in the box indicating he was the health care proxy (both as defined in Chapter 765, F.S.) and signed the documents. The final section of the document included: PHYSICIAN ' S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient ' s cardiac or respiratory arrest. Resident #94 ' s Primary Care Physician signed the golden rod on [DATE]. 3. Staff Q was still at the nursing station and was asked where she had looked in the medical record for Resident #94 ' s code status. Staff Q walked toward the surveyor and pointed to Resident #94 ' s face sheet. She put her finger on a boxed section titled Advanced Directives. The advanced directives indicated Resident #94 was Full Code. She said she did not know Resident #94 ' s code status had changed. She also confirmed she had only looked at Resident #94 ' s face sheet in her medical record and not her advanced section. On Resident #94 ' s face sheet, on the top right hand corner, revealed the day it had been printed as [DATE] at 3:07:30 ET. The face sheet, then, had not been updated with current and pertinent advanced directives. 4. The facility provided a copy of their policy and procedure titled Code Blue with an effective date of [DATE]. Policy: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by a physician on their medical records. Procedure: When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. Confirm DNR status with the physician ' s written order. The Nurse Manager/Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: Summon emergency equipment to the room. Activate the EMS system. Assign a person to document the ongoing code. 5. Review of the facility ' s policy and procedure Advanced Directives/DNR , dated [DATE], revealed the following pertinent information: Policy: All residents and /or their family member ' s must provide the residence with a copy of his or her Advanced Directives to include the DNR. All residents shall receive care appropriate to their condition and needs, including measures essential to comfort and wellbeing. 6. On [DATE] at 5:45 p.m., the Nursing Home Administrator (NHA), DON and the Corporate Nurse provided a copy of The Situation, Background, Assessment and Recommendation (SBAR) report . The SBAR report was reviewed and listed under the nursing notes, dated on [DATE], Primary nurse reported that she checked face sheet and resident was a full code. Reports that she did not know that code status had changed. The SBAR indicated, on [DATE], the physician was notified at 2:15 p.m. The NHA confirmed the Code Blue policy was their current policy. She also confirmed that the advanced directive section should have been looked at. She said a face sheet was not a Physician ' s written order. Our policy indicates a DNR status is confirmed with a physician's order [REDACTED].>7. Review of the facility ' s policy and procedure, Resident Abuse, dated on [DATE] with a revision date of [DATE], revealed the following pertinent information: Policy: It is inherent in the nature and dignity of each resident at the Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, polices, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED]. 8. On [DATE] at 4:12 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She said she had been a licensed nurse for fourteen years now and had worked at the facility for three and half years. She said her normal shift was on days and she always worked the first floor B-hallway. When asked if she knew Resident # 94, she said no. The nurse said she was told by the staff member O that the resident had needed help and was having breathing problems. I went to the room and realized that was the wrong room number. She said, When staff member O came to me I didn ' t know what I needed until I got there. She said, when I got there (bedroom) I saw her oxygen tubing was on the floor. I then left the room to find Staff Member Q. LPN I was asked where would find a resident ' s code status in the medical record. She said, You would look for the yellow sheet in the advanced directives section on the medical record. When asked if the code status was listed on the face sheet, she said you ' re not supposed to use the face sheet for their code status, it ' s not always updated. 9. On [DATE] at 6:10 p.m., the NHA informed the survey team We have immediately in-serviced Licensed Practical Nurse Q on the facility ' s Code blue policy . We also verified her CPR certification. She is a Basic Life Support (BLS) Instructor for the American Heart Association. The NHA said, We have suspended her during our investigation and pending the determination of the outcome. It ' s part of our facility policy. Licensed Practical Nurse Q received a Corrective Action Form on [DATE]. Listed under Description of violation: 1. Abuse of resident -Violation of Resident/patient Bill of Rights. Supervisor ' s Corrective Plan of Action, Employee educated in viewing DNR before initiating CPR-cannot use Face sheet information. Employee suspended pending investigation. Employee comments: I do not agree with this. The Face sheet stated Full Code when time is of the essence. It is NOT realistic search for information that needed to be clear. I am not agreeing with this. I am signing under duress. Further interview with the NHA on [DATE] at 12:30 p.m. indicated that they were going to terminate employee Q as a result from their investigation . 10. On [DATE] at 11:08 a.m., a phone interview was conducted with Resident #94 ' s Primary Care Physician (PCP). The PCP said he had just seen Resident #94 at the facility on Saturday ([DATE]). She said her husband was also there and in agreement with her advanced directives changing. The PCP said he had signed her Do Not Resuscitation Certificate (DNR) on [DATE]. The PCP was asked when the last time he had heard from the facility was. He said they had called him on Tuesday and told him that Resident #94 ' s vital signs had ceased. He said he had given orders to release the resident. The PCP was asked once Resident #94 ' s code status changed to a DNR, what would you have expected when the facility ' s licensed staff members found her not breathing. He said I would expect them not to perform CPR. The PCP was then informed that the licensed staff members performed CPR to Resident #94 for five minutes. PCP said he was not aware that the facility had performed CPR to Resident #94. He said That was not right. 11. On [DATE] at 6:10 p.m., the NHA and the Regional Corporate nurses were asked if there was system in place to prevent further occurrences. The NHA stated, Education, auditing on all new admissions. The nurses will be obtaining code status on admission. The root cause was the nurses looked at the face sheet and not the golden rod. We have educated the business office and the Social Services on the status. The Business office is entering the code status on the resident ' s face sheet and they were instructed not to enter this any longer. 12. Medical record review was conducted for Resident #94 which revealed a face sheet indicating the resident was [AGE] years old and was admitted to the facility on [DATE]. The face sheet also contained the resident ' s [DIAGNOSES REDACTED]. 13. Further review of the Advanced Directives section contained a document titled, Durable Power of Attorney. The document indicated that Resident #94 ' s spouse had been appointed as her agent for health care on [DATE] indicting he was able to make changes on her advanced directives. A sectioned off portion in the medical revealed a Behavioral Health Consultation note, also dated on [DATE]. Listed next to the number 3 PCP -present- states PT is now a DNR, + incapacitated to make any verbal decisions. 14. 0n [DATE] at 4:44 p.m. an interview was conducted the facility ' s Director of Social Services (DSS). She said Resident #94 ' s spouse was in her office during the code blue incident on [DATE]. The DSS said that Resident #94 spouse had asked her what was going on in his wife ' s bedroom. The DSS said she looked up from her desk and observed staff members taking a crash cart into her bedroom. She said at that time I told Resident #94 ' s spouse that I was going to see what was going on in her bedroom. She confirmed she had observed staff members performing CPR to her. The DSS said I remembered seeing you in there and asking for gloves. The DSS was asked if she knew that Resident #94 advanced directives had been changed. The DSS stated, Yes, I had put the paper work together the week before. The Physician and Resident #94 ' s spouse signed the paper work on Saturday. The DSS was asked when she had first seen the signed golden rod. She said she had seen in on the next Monday ([DATE]) when she came into work that morning. When asked if she had told anyone that Resident #94 ' s code status had changed she said, I told everyone in the Monday morning stand up meeting. She was asked who was in the meeting she said she remembered the Director of Nursing (DON), Nursing Home Administer (NHA), the unit manager and said she and couldn ' t remember everyone. The DSS was asked who had told Resident #94 ' s spouse that she had expired at the facility. DSS stated Resident #94 ' s spouse came back to her office after he had spoken with the DON. He told me that the DON said his wife had passed away peacefully. He said he was going to sit in his wife ' s bedroom for a while. 15. On [DATE] at 11:00 a.m., an interview was conducted with the DON. The DON said that she has been at the facility for over a month now and is the interim DON. She was asked about the facility ' s policy on resident ' s code status. She said you have to look for the physician orders. She confirmed that it is her expectation that the staff review the medical record for the Physician order [REDACTED]. The DON said we are continuing with education on codes and responding appropriately. We are now bringing the residents chart to the room and we have started a two person verification of the code status. 16. On [DATE] at 11:30 p.m., an interview was conducted with the facility ' s Medical Director. The Medical Director confirmed she did not remember Resident #94 and she had been notified by the facility that she expired on [DATE]. She confirmed that she was aware that CPR had been performed on Resident #94. She said that she was also was informed that there had been a DNR on her medical record. She stated, Education on where to find the Advanced Directives (in the chart) in the medical record is our main goal. 17. On [DATE] at 1:22 p.m. an interview was conducted with the Nursing Home Administrator. The NHA stated the facility ' s investigation that had involved Resident #94 was found as substantiated. She said she would be calling Staff member Q today and asking her to come into the facility. Staff member Q will be terminated at that time . The NHA confirmed the root cause of the incident was that the nurse looked at the face sheet and not the golden rod in the medical record. Our policy does not reflect that. The NHA said the nurse ' s job is to try and save a life. The nurses that were helping during the Code Blue didn ' t ask for her code status, they saw Staff member Q performing compressions and it was a natural response to help them out. 18. On [DATE] at 2:00 p.m., a telephone interview was conducted with Resident #94 ' s spouse. He confirmed he was the spouse of Resident #94 and said he that the facility had problems getting her medication. He stated that after her last surgery his wife was having memory problems. They say the memory problems were a direct side effect from lost oxygen during her operation. Her muscles wouldn ' t do what her mind was telling them to do. They thought she had Alzheimer ' s but she didn ' t. Resident #94 ' s spouse confirmed that his wife was a DNR. He said he was at the facility and was aware that the staff members were performing CPR on her. He said I had to remind the staff that she was a DNR so they would quit, I guess they didn ' t realize it. As soon as I told them they stopped the CPR. I sat in the room with Resident #94 for a while after they stopped the CPR. When asked if it was his expectation that the staff members honor Resident #94 ' s wishes when she stops breathing and no longer has a pulse. He said they just didn ' t know she was a DNR. 19. On [DATE] at 6:10 p.m. the NHA and the Regional Corporate Nurse revealed the following actions were taken to remove the Immediate Jeopardy: a. A 100% audit was conducted on all current residents ' code status, face sheets and care plans to ensure accuracy. On [DATE] at 6:10 p.m., the NHA identified the facility census of 113 residents. She said there are 48 residents currently residing in the facility with a DNR status. This was verified as survey team reviewed face sheets, physician orders [REDACTED]. b. The NHA said the Quality Assurance (QA) team had meet on [DATE]. She said the following actions were CPR/DNR policy and procedures and they were working on a 4 point plan. The NHA provided a copy of the QA and A that they had conducted. She stated everyone in the QA team had been notified of the incident and the only signature we did not have at this time was the Medical Director. She said she will be in to sign it. d. On [DATE] at 4:10 p.m., the Regional Nurse stated we are at 100% compliance with educating our staff on the facility policy and procedure on code blue and had them sign the CPR/DNR -Zero Tolerance. The Regional Nurse said we will continue with our mock drills every shift. e. On [DATE] at 1:19 p.m., the NHA stated they are at 100% compliance with their Cardiopulmonary Resuscitation for licensed staff members. The facility provided copies of their in house audit on CPR certificates. The facility identified a total of 30 active licensed nurses. 20. On [DATE] at 2:50 p.m., a Code Blue mock drill was conducted and observed on the lower level of the facility. A staff member was overheard announcing Code Blue room [ROOM NUMBER] on the overhead intercom system. Staff members were observed immediately responding to room [ROOM NUMBER] totaling seven altogether. A CPR instructor, from the sister facility, was present in the bedroom. She was heard asking the staff members what they were going to do and what they were doing. On [DATE] at 5:00 p.m. the facility provided a copy of the observed Code Blue mock drill titled: Code Blue Quality Assurance Drill. Comments from the Instructor included: 1. Staff answered appropriately, utilized critical thinking skills, prompt response. 2. Identified record keeper and delegator for the drill and actual code. 21. On [DATE], at 11:54 a.m., the facility ' s Regional Corporate Nurse provided a copy of their updated, Four Point Action Plan , dated [DATE] at 1:15 p.m. The Action steps now contain: Code status was removed from face sheets. The Regional Nurse said our corporate office has initiated a corporate wide removal of a ' cell ' that was on face sheet. The face sheet no longer contains the box (cell) that was titled: Advanced Directives. 22. Verification interviews were conducted between [DATE] and [DATE] that included nurses across all three shifts. All of the nurses verbalized they had attended the CPR/DNR in-service that the facility had conducted. The nurses verbalized knowledge of the training by looking in the medical record under the Advanced Directives section and having a second nurse verify the resident ' s code status. As a result of the measures, the Immediate Jeopardy was removed on [DATE] and the severity and scope reduced to D.

Based on observation, the review of the Florida Nurse Practice Act, clinical record review, staff interviews, facility policy review and job description review for the Director of Clinical Services I, Director of Nursing (DON), Clinical Nurse I, & Licensed Practical Nurse (LPN) it was determined that the facility did not ensure physician orders [REDACTED].#94) out of 15 sampled residents of 48 identified as having a Do No Resuscitate order (DNR), according to the facility audit on [DATE] of all current residents records and review of Resident # 94 ' s clinical record on [DATE]. The Licensed Practical Nurse did not withhold Cardio-Pulmonary Resuscitation for a DNR resident after identifying the resident without a pulse or respirations. In addition, the Director of Nursing participated in the Cardio-Pulmonary Resuscitation and failed to provide supervision and direction in accordance with her job description and the facility ' s policy and procedures when she was informed that Resident #94 was absent of vital signs. Failure of the facility to ensure nurses met professional standards and acted in accordance with the Nurse Practice Act, as defined in the Florida Statues, Chapter 464, resulted in the findings of Immediate Jeopardy which was removed on [DATE], at 11:54 a.m., and the severity and scope was reduced to a D. Findings include: 1. The Florida Nurse Practice Act includes: 3) (a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 2. Review of the Clinical Nurse I Licensed Practical Nurse (LPN) job description, undated, revealed this position reported to the Director of Clinical Services or Assistant Director of Clinical Services. The job description contained: The Purpose of Your Job Position: The primary purpose of your job is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the director of Clinical Services to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Function: As a Clinical Nurse I-LPN, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for providing direct resident care in accordance with the established care plans. Resident Rights: Ensure that all nursing service personnel are knowledgeable of the resident ' s responsibilities and rights including the right to refuse treatment. Ensure that nursing staff personnel honor the residents ' refusal of treatment request. Ensure that such requests are in accordance with the facility ' s policies governing advance directives. Specific Requirements: Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Must possess the ability to make independent decisions when circumstances warrant such action. Must be knowledgeable of nursing and medical practices and procedures, as well as lows, regulations, and guidelines that pertain to nursing care facilities. 3. Review of the Director of Clinical Services 1 (DON) job description, undated, revealed: Purpose of Your Job Position: The primary purpose of your job is to plan, organize, develop, and direct the overall operation of our nursing services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality of care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions: As Director of Clinical Services I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care. Supervises Nurse Practitioner, Assistant Director of Clinical Services, Clinical Nurses, and Nurse Techs. Duties and Responsibilities: Assure compliance with resident rights policies and work to resolve resident grievances. Establish and monitor compliance with an effective medical record documentation system. Resident Rights: Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect. Ensure that all nursing service personnel are knowledgeable of the resident ' s ' responsibilities and rights, including the right to refuse treatment. Report and investigate all allegations of resident abuse and /or misappropriation of resident property. Ensure that nursing staff personnel honor the resident ' s refusal of treatment request. Ensure that such requests are in accordance with the facility ' s policies governing advance directives. Ensure that the facility ' s policies and procedures governing advanced directives are reviewed with the resident and/or representative. 4. Medical record review, conducted for Resident #94, revealed a face sheet indicating the resident was [AGE] years old and was admitted to the facility on [DATE]. The face sheet also contained the resident ' s [DIAGNOSES REDACTED]. 5. Resident #94 was included in the sample of the stage one QIS survey. On [DATE] at 12:39 p.m. the surveyor was outside of her bedroom and heard an audible tracheal congestion. The door was open to the bedroom and the resident was observed sitting up in her Geri-chair. She was noted with her bed table positioned on her right side with her meal tray on top. She was observed in the bedroom alone. Resident #94 was covered with a blanket that was positioned up to her chin. The resident ' s eyes were closed and she did not respond to verbal stimuli when approached. At 12:41 p.m., Staff O, Certified Nursing Assistant, entered the bedroom and was asked if she was going to assist Resident #94 with her lunch meal. Resident #94 began coughing with audible tracheal congestion. Her skin tone appeared pale and ashen in color. The CNA stated she was going to get the nurse and added the congestion is new. The CNA left the room, was observed approaching Staff I, LPN. She was heard telling the nurse that Resident #94 was having congestion and she wanted the nurse to look at her. Staff I was overheard telling the CNA, ok. Staff I entered Resident# 94 ' s bedroom at 12:44 p.m. and looked at the resident momentarily. She said why isn ' t her oxygen on? She went to the bathroom and washed her hands. She walked out of the bathroom and asked the surveyor if she could get her gloves. The surveyor indicated that she could not give supplies during that situation. Staff I then left the bedroom. The resident was observed for 5 seconds without breathing. On the count of six the resident inhaled deeply. The resident ' s skin after inhalation was observed as turning a darker gray (ashen) color at 12:46 p.m. On [DATE] at 12:47 p.m., Staff I returned to the bedroom followed by Staff Q, LPN, and the DON. Staff Q started calling the resident by her name. The resident did not respond. Staff Q next performed a sternal rub to the resident. The resident was observed inhaling deeply. Staff Q stated, We need to get her in bed. The DON, Staff Q, Staff I and Staff O were observed transferring the resident from her Geri-chair into her bed. Her oxygen was now in place and her head of bed was flat. The C.N.A., who was in the bedroom, stated out loud, She has a pulse. At 12:48 p.m. while repositioning Resident #94 ' s head in the bed, Staff Q said, She ' s not breathing, she is a Full Code. Staff Q began chest compressions. While Staff Q was performing the chest compressions she asked, Where ' s the ambu-bag (resuscitator bag)? Staff I had just returned to the bedroom with the crash cart and handed the ambu-bag to the DON. Staff Q was observed administering and counting out loud for a total of thirty chest compressions. The DON gave two breaths to the resident per the ambu- bag. One of the nurses stated, Go and call the code blue. At 12:49 p.m., a code blue was overheard on the facility ' s loud speaker. Staff Q was observed continuing with chest compressions followed by two breaths by the ambu-bag. At 12:50 p.m., Staff I entered the resident ' s bedroom. She said, She is a DNR. Staff Q, while continuing to perform the chest compressions stated, She is a full code I read it in her chart. Staff I turned around and left the bedroom. At 12:52 p.m., Staff P, LPN, took over for Staff Q and continued with chest compressions to the resident. On [DATE] at 12:53 p.m., Staff L, LPN, entered the bedroom and stood in front of the surveyor. Staff L was observed taking her right hand and making a motion across her throat to indicate stop. She then stated, She is a DNR; she has a yellow DNR sheet on her chart. The DON stated, Bring her chart in the room. At that time, Staff P stopped performing chest compressions. 6. Nursing Progress notes were reviewed and revealed: [DATE] at 12:11 a.m.: PO (pulse-ox) 85% on room air, increased to 94% with 02 (oxygen) on. [DATE] at 12:26 a.m.: PO (pulse-ox) 89% RA (room air) increased to 95% with 02 (oxygen). [DATE] at 1:31 a.m.: PO 88% on room air, PRN administration was: effective PO 96%. [DATE] 15:00 (3:00 p.m.): expired. 7. On [DATE] at 12:58 p.m., an interview was conducted with Staff Q. Staff Q was asked where she had looked in the medical record for Resident#94 ' s code status. Staff Q pointed to Resident #94 ' s face sheet. Listed on the face sheet under the title, other information, was a box titled Advanced Directives. The Advanced Directive was listed as Full Code. She said she was unaware of her code status changing. She also confirmed she had only looked at Resident #94 ' s face sheet in her (paper) medical record. 8. On [DATE] at 11:08 a.m., a phone interview was conducted with Resident #94 ' s Primary Care Physician (PCP). The PCP said he had just seen Resident #94 at the facility on Saturday ([DATE]). The PCP said the resident ' s husband was also there and in agreement with her advanced directives changing. The PCP said he had signed her Do Not Resuscitation Certificate (DNR) on [DATE]. The PCP was asked when the last time he had heard from the facility was. He said they had called him on Tuesday and told him that Resident #94 ' s vital signs had ceased. He said he had given orders to release the resident. The PCP was asked, once Resident #94 ' s code status changed to a DNR, what would you have expected when the facility ' s licensed staff members found her not breathing. He said I would expect them not to perform CPR. The PCP was then informed that the licensed staff members performed CPR to Resident #94 for five minutes. The PCP said he was not aware that the facility had performed CPR to Resident #94. He said, That was not right. 9. The medical record section titled, Advanced Directives, was reviewed and contained a document titled, Durable Power of Attorney. The document indicated that Resident #94 ' s spouse had been appointed as her agent for health care on [DATE]. A second document was reviewed that was titled, Certificate of Incapacity. The certificate was signed and dated by the primary physician on [DATE]. A sectioned off portion in the medical record revealed a Behavioral Health Consultation note, also dated on [DATE]. Listed next to the number 3 PCP -present- states PT is now a DNR, + incapacitated to make any verbal decisions. Further review of the medical record revealed a section titled, Advanced Directives. This section contained a yellow form titled: Florida Department of Health State of Florida Do Not Resuscitate order. This form contained Resident #94 ' s name and a written date of [DATE]. The order/form was signed by the spouse and included a second signature of Resident #94 ' s primary physician. 10. On [DATE] at 4:12 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She said she had been a licensed nurse for fourteen years now and had worked at the facility for three and half years. She said her normal shift was on days and she always worked the first floor B-hallway. When asked if she knew Resident # 94, she said no. The nurse said she was told by the staff member O that the resident had needed help and was having breathing problems. I went to the room and realized that was the wrong room number. She said, When staff member O came to me I didn ' t know what I needed until I got there. She said when I got there (bedroom) I saw her oxygen tubing was on the floor. I then left the room to find Staff Member Q. LPN I was asked where would find a resident ' s code status in the medical record. She said, You would look for the yellow sheet in the advanced directives section on the medical record. When asked if the code status was listed on the face sheet, she said you ' re not supposed to use the face sheet for their code status, it ' s not always updated. 11. On [DATE] at 5:45 p.m., the Nursing Home Administrator (NHA), DON and the Corporate Nurse provided a copy of The Situation, Background, Assessment and Recommendation (SBAR) report. The SBAR report was reviewed and listed under the nursing notes, dated on [DATE], Primary nurse reported that she checked face sheet and resident was a full code. Reports that she did not know that code status had changed. The SBAR indicated, on [DATE], the physician was notified at 2:15 p.m. 12. On [DATE] at 1:22 p.m. an interview was conducted with the Nursing Home Administrator. The NHA stated the facility ' s investigation that had involved Resident #94 was found as substantiated. She said she would be calling Staff member Q today and asking her to come into the facility. Staff member Q will be terminated at that time. The NHA confirmed the root cause of the incident was that the nurse looked at the face sheet and not the golden rod in the medical record. Our policy does not reflect that. The NHA said the nurse ' s job is to try and save a life. The nurses that were helping during the Code Blue didn ' t ask for her code status, they saw Staff member Q performing compressions and it was a natural response to help them out. 13. On [DATE] at 11:30 p.m., an interview was conducted with the facility ' s Medical Director. The Medical Director confirmed that she was notified by the facility that Resident #94 expired on [DATE]. She confirmed that she was aware that CPR had been performed on Resident #94. She said that she was also informed that there had been a DNR on her medical record. She stated, Education on where to find the Advanced Directives (in the chart) in the medical record is our main goal. 14. On [DATE] at 2:00 p.m. a telephone interview was conducted with Resident #94 ' s spouse. He confirmed he was the spouse of Resident #94 and said that the facility had problems getting her medication. He stated that after her last surgery his wife was having memory problems. They say the memory problems were a direct side effect from lost oxygen during her operation. Her muscles wouldn ' t do what her mind was telling them to do. They thought she had Alzheimer ' s but she didn ' t. Resident #94 ' s spouse confirmed that his wife was a DNR. He said he was at the facility and was aware that the staff members were performing CPR on her. He said I had to remind the staff that she was a DNR so they would quit, I guess they didn ' t realize it. As soon as I told them they stopped the CPR. I sat in the room with Resident #94 for a while after they stopped the CPR. When asked if it was his expectation that the staff members honor Resident #94 ' s wishes when she stops breathing and no longer has a pulse, he said, They just didn ' t know she was a DNR. 15. Review of the facility ' s policies and procedures, effective date [DATE], Code Blue Policy: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by a physician on their medical records. Procedure: When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. Confirm DNR status with the physician ' s written order. The Nurse Manager/ Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: Summon emergency equipment to the room. Activate the EMS system. Assign a person to document the ongoing code. 16. Review of the facility ' s policy and procedure Resident Abuse , dated [DATE], with a revision date of [DATE], revealed the following pertinent information: Policy: It is inherent in the nature and dignity of each resident at the Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, 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 [REDACTED]. Procedure: Definition of Resident abuse: An abusive act is any act or omission, which may cause or causes actual physical, psychological or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein. Employee Obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Investigation of Abuse: The Abuse Coordinator or her/his designee shall investigate all reports or allegations of abuse. Investigations will be accomplished in the following manner. Preliminary investigation: Immediately upon an allegation of abuse or neglect, the suspect (s) shall be segregated from the residents pending the investigation of the allegation. The Clinical Nurse in charge of Director of Clinical Services shall perform and document a thorough nursing assessment and notify the attending physician. An incident report shall be filed by the individual in charge who received the report in injunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator. Investigation: Any suspect(s), who is an employee, once he/she has (have) been identified, will be suspended pending the investigation. 17. On [DATE] at 6:10 p.m., the NHA informed the survey team We have immediately in-serviced Licensed Practical Nurse Q on the facility ' s Code blue policy. We also verified her CPR certification. She is a Basic Life Support (BLS) Instructor for the American Heart Association. The NHA said, We have suspended her during our investigation and pending the determination of the outcome. It ' s part of our facility policy. Licensed Practical Nurse Q received a Corrective Action Form on [DATE]. Listed under Description of violation: 1. Abuse of resident -Violation of Resident/patient Bill of Rights. Supervisor ' s Corrective Plan of Action, Employee educated in viewing DNR before initiating CPR-cannot use Face sheet information. Employee suspended pending investigation. Employee comments: I do not agree with this. The Face sheet stated Full Code when time is of the essence. It is NOT realistic search for information that needed to be clear. I am not agreeing with this. I am signing under duress. 18. On [DATE] at 6:10 p.m., the NHA and the Regional Corporate nurses were asked if there was system in place to prevent further occurrences. The NHA stated, Education, auditing on all new admissions. The nurses will be obtaining code status on admission. The root cause was the nurses looked at the face sheet and not the golden rod. We have educated the business office and the Social Services on the status. The Business office is entering the code status on the resident ' s face sheet and they were instructed not to enter this any longer. The NHA and the Regional Corporate Nurse revealed the following actions were taken to remove the Immediate Jeopardy: a. A 100% audit was conducted on all current residents ' code status, face sheets and care plans to ensure accuracy. On [DATE] at 6:10 p.m., the NHA identified the facility census of 113 residents. She said there are 48 residents currently residing in the facility with a DNR status. This was verified as survey team reviewed face sheets, physician orders [REDACTED]. b. The NHA said the Quality Assurance (QA) team had meet on [DATE]. She said the following actions were CPR/DNR policy and procedures and they were working on a 4 point plan. The NHA provided a copy of the QA and A that they had conducted. She stated everyone in the QA team had been notified of the incident and the only signature we did not have at this time was the Medical Director. She said she will be in to sign it. c. On [DATE] at 4:10 p.m., the Regional Nurse stated we are at 100% compliance with educating our staff on the facility policy and procedure on code blue and had them sign the CPR/DNR -Zero Tolerance. The Regional Nurse said we will continue with our mock drills every shift. 19. On [DATE] at 1:19 p.m., the NHA stated they are at 100% compliance with their Cardiopulmonary Resuscitation for licensed staff members. The facility provided copies of their in house audit on CPR certificates. The facility identified a total of 30 active licensed nurses. On [DATE] at 2:50 p.m., a Code Blue mock drill was conducted and observed on the lower level of the facility. A staff member was overheard announcing Code Blue room [ROOM NUMBER] on the overhead intercom system. Staff members were observed immediately responding to room [ROOM NUMBER] totaling seven altogether. A CPR instructor, from the sister facility, was present in the bedroom. She was heard asking the staff members what they were going to do and what they were doing. On [DATE] at 5:00 p.m. the facility provided a copy of the observed Code Blue mock drill titled: Code Blue Quality Assurance Drill. Comments from the Instructor included: 1. Staff answered appropriately, utilized critical thinking skills, prompt response. 2. Identified record keeper and delegator for the drill and actual code. 3. Staff needs to work as a team vs, o2, accu, compression are all done simultaneously to complete all tasks during drill. This will ensure the response time is as quick as possible and will increase chances of survival. 20. On [DATE], at 11:54 a.m., the facility ' s Regional Corporate Nurse provided a copy of their updated, Four Point Action Plan, dated [DATE] at 1:15 p.m. The Action steps now contain: Code status was removed from face sheets. The Regional Nurse said our corporate office has initiated a corporate wide removal of a ' cell ' that was on face sheet. The face sheet no longer contains the box (cell) that was titled: Advanced Directives. Verification interviews were conducted between [DATE] and [DATE] that included nurses across all three shifts. All of the nurses verbalized they had attended the CPR/DNR in-service that the facility had conducted. The nurses verbalized knowledge of the training by looking in the medical record under the Advanced Directives section and having a second nurse verify the resident ' s code status. As a result of the measures, the Immediate Jeopardy was removed on [DATE] and the severity and scope reduced to D.

Based on observation, resident medical record review, interviews with staff members, the resident ' s primary physician and the resident ' s spouse/Durable Power of Attorney, facility ' s policy and procedures, it was determined that the facility failed to ensure advanced directives, which were in effect for DNR, were carried out in accordance with the resident's current physician's order [REDACTED].#94) of 15 sampled residents of 48 identified as having a do not resuscitate order (DNR), according to the [DATE] facility audit of all current resident records and review of resident #94's clinical record on [DATE]. Facility personnel performed Cardio-Pulmonary Resuscitation (CPR) when the resident was found absent of respirations and pulse. The facility staff did not follow advanced directives, which were in effect for DNR. The facility personnel did not ensure that, in the event the resident ' s heart stopped or breath ceased, the CPR would not be initiated to honor the residents advanced directives. In addition, the facility did not ensure that the legally appointed agent for healthcare ' s wishes for DNR was honored. Failure of the facility staff to execute the revision of the plan of care for advanced directives per the physician's order [REDACTED]. Findings included: 1. Medical record review, conducted for Resident #94, revealed a face sheet indicating the resident was [AGE] years old and was admitted to the facility on [DATE]. The face sheet also contained the resident ' s [DIAGNOSES REDACTED]. 2. Resident #94 ' s medical record section, titled Advanced Directives, was reviewed and contained a yellow form titled: Florida Department of Health State of Florida Do Not Resuscitate order. This form contained Resident #94 ' s name and a written date of [DATE]. The order/form was signed by the spouse and included a second signature of Resident #94 ' s primary physician. The Advanced Directives section also contained a document titled, Durable Power of Attorney. The document indicated that Resident #94 ' s spouse had been appointed as her agent for health care on [DATE]. A second document was reviewed that was titled, Certificate of Incapacity. The certificate was signed and dated by the primary physician on [DATE]. A sectioned off portion in the medical record revealed a Behavioral Health Consultation note also dated on [DATE]. Listed next to the number 3 PCP -present- states PT is now a DNR, + incapacitated to make any verbal decisions. 3. Review of Resident #94 ' s original care plan with date initiated of [DATE] revealed, however, a Focus area of no advanced directives. The care plan contained a revision date of [DATE] by the facility ' s Social Worker, which preceded the changes in the Advanced Directives, dated [DATE]. The Goal of Resident 94 ' s care plan was that she will have advanced directives followed and indicated that Resident #94 had not executed any advanced directives and had a FULL CODE STATUS with target date of [DATE]. The care planned interventions stated, Discuss advanced directives with resident and/or family. 4. On [DATE] at 11:08 a.m., a phone interview was conducted with Resident #94 ' s Primary Care Physician (PCP). The PCP said he had just seen Resident #94 at the facility on Saturday ([DATE]). The PCP said the resident ' s husband was also there and in agreement with her advanced directives changing. The PCP said he had signed her Do Not Resuscitation Certificate (DNR) on [DATE]. The PCP was asked when the last time was he had heard from the facility. He said they had called him on Tuesday and told him that Resident #94 ' s vital signs had ceased. He said he had given orders to release the resident. The PCP was asked, once Resident #94 ' s code status changed to a DNR, what would you have expected when the facility ' s licensed staff members found her not breathing. He said I would expect them not to perform CPR. The PCP was then informed that the licensed staff members performed CPR to Resident #94 for five minutes. The PCP said he was not aware that the facility had performed CPR to Resident #94. He said, That was not right. 5. On [DATE] at 2:00 p.m. a telephone interview was conducted with Resident #94 ' s spouse. He confirmed he was the spouse of Resident #94. He stated that after her last surgery his wife was having memory problems. They say the memory problems were a direct side effect from loss of oxygen during her operation. Her muscles wouldn ' t do what her mind was telling them to do. They thought she had Alzheimer ' s but she didn ' t. Resident #94 ' s spouse confirmed that his wife was a DNR. He said he was at the facility and was aware that the staff members were performing CPR on her. He said I had to remind the staff that she was a DNR so they would quit, I guess they didn ' t realize it. As soon as I told them they stopped the CPR. I sat in the room with Resident #94 for a while after they stopped the CPR. When asked if it was his expectation that the staff members honor Resident #94 ' s wishes when she stops breathing and no longer has a pulse, he said, They just didn ' t know she was a DNR. 6. On [DATE] at 11:30 p.m., an interview was conducted with the facility ' s Medical Director. The Medical Director confirmed that she was notified by the facility that Resident #94 expired on [DATE]. She confirmed that she was aware that CPR had been performed on Resident #94. She said that she was also informed that there had been a DNR on her medical record. She stated, Education on where to find the Advanced Directives (in the chart) in the medical record is our main goal. 7. Resident #94 was included in the sample of the stage one QIS survey. On [DATE] at 12:39 p.m. the surveyor was outside of her bedroom and heard an audible tracheal congestion. The door was open to the bedroom and the resident was observed sitting up in her Geri-chair. She was noted with her bed table positioned on her right side with her meal tray on top. She was observed in the bedroom alone. Resident #94 was covered with a blanket that was positioned up to her chin. The resident ' s eyes were closed and she did not respond to verbal stimuli when approached. At 12:41 p.m., Staff O, Certified Nursing Assistant, entered the bedroom and was asked if she was going to assist Resident #94 with her lunch meal. Resident #94 began coughing with audible tracheal congestion. Her skin tone appeared pale and ashen in color. The CNA stated she was going to get the nurse and added the congestion is new. The CNA left the room, was observed approaching Staff I, LPN. She was heard telling the nurse that Resident #94 was having congestion and she wanted the nurse to look at her. Staff I was overheard telling the CNA, ok. Staff I entered Resident# 94 ' s bedroom at 12:44 p.m. and looked at the resident momentarily. She said why isn ' t her oxygen on? She went to the bathroom and washed her hands. She walked out of the bathroom and asked the surveyor if she could get her gloves. The surveyor indicated that she could not give supplies during that situation. Staff I then left the bedroom. The resident was observed for 5 seconds without breathing. On the count of six the resident inhaled deeply. The resident ' s skin after inhalation was observed as turning a darker gray (ashen) color at 12:46 p.m. On [DATE] at 12:47 p.m., Staff I returned to the bedroom followed by Staff Q, LPN, and the DON. Staff Q started calling the resident by her name. The resident did not respond. Staff Q next performed a sternal rub to the resident. The resident was observed inhaling deeply. Staff Q stated, We need to get her in bed. The DON, Staff Q, Staff I and Staff O were observed transferring the resident from her Geri-chair into her bed. Her oxygen was now in place and her head of bed was flat. The C.N.A., who was in the bedroom, stated out loud, She has a pulse. At 12:48 p.m. while repositioning Resident #94 ' s head in the bed, Staff Q said, She ' s not breathing, she is a Full Code. Staff Q began chest compressions. While Staff Q was performing the chest compressions she asked, Where ' s the ambu-bag (resuscitator bag)? Staff I had just returned to the bedroom with the crash cart and handed the ambu-bag to the DON. Staff Q was observed administering and counting out loud for a total of thirty chest compressions. The DON gave two breaths to the resident per the ambu- bag. One of the nurses stated, Go and call the code blue. At 12:49 p.m., a code blue was overheard on the facility ' s loud speaker. Staff Q was observed continuing with chest compressions followed by two breaths by the ambu-bag. At 12:50 p.m., Staff I entered the resident ' s bedroom. She said, She is a DNR. Staff Q, while continuing to perform the chest compressions stated, She is a full code I read it in her chart. Staff I turned around and left the bedroom. At 12:52 p.m., Staff P, LPN, took over for Staff Q and continued with chest compressions to the resident. On [DATE] at 12:53 p.m., Staff L, LPN, entered the bedroom and stood in front of the surveyor. Staff L was observed taking her right hand and making a motion across her throat to indicate stop. She then stated, She is a DNR; she has a yellow DNR sheet on her chart. The DON stated, Bring her chart in the room. At that time, Staff P stopped performing chest compressions. 8. On [DATE] at 12:58 p.m., Resident #94 ' s medical record was at the nursing station along with Staff member Q. Staff member Q was asked if the medical record was Resident #94 ' s and she confirmed it was. The medical record contained a sectioned off tab labeled Advanced Directives. The Advanced Directives section contained a document that was bright yellow in color (golden rod) with capitalized words that stated DO NOT RESUSCUTATE ORDER. The first section of the golden rod document had Resident #94 s name on with a written date of [DATE]. The second section of the document included: PATIENT ' S STATEMENT: Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): Resident #94 ' s spouse had put an X in the box indicating he was the health care proxy (both as defined in Chapter 765, F.S.) and signed the documents. The final section of the document included: PHYSICIAN ' S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient ' s cardiac or respiratory arrest. Resident #94 ' s Primary Care Physician signed the golden rod on [DATE]. Staff Q was asked where she had looked in the medical record for Resident#94 ' s code status. Staff Q pointed to Resident #94 ' s face sheet. Listed on the face sheet under the title, other information was a box titled Advanced Directives. The Advanced Directive was listed as Full Code. She said she was unaware of her code status changing. She also confirmed she had only looked at Resident #94 ' s face sheet in her (paper) medical record. 9. Review of the facility ' s policies and procedures, effective date [DATE], Code Blue Policy: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by a physician on their medical records. Procedure: When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. Confirm DNR status with the physician ' s written order. The Nurse Manager/ Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: Summon emergency equipment to the room. Activate the EMS system. Assign a person to document the ongoing code. 10. On [DATE] at 4:12 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She said she had been a licensed nurse for fourteen years now and had worked at the facility for three and half years. She said her normal shift was on days and she always worked the first floor B-hallway. When asked if she knew Resident # 94, she said no. The nurse said she was told by the staff member O that the resident had needed help and was having breathing problems. I went to the room and realized that was the wrong room number. She said, When staff member O came to me I didn ' t know what I needed until I got there. She said when I got there (bedroom) I saw her oxygen tubing was on the floor. I then left the room to find Staff Member Q. LPN I was asked where would find a resident ' s code status in the medical record. She said, You would look for the yellow sheet in the advanced directives section on the medical record. When asked if the code status was listed on the face sheet, she said you ' re not supposed to use the face sheet for their code status, it ' s not always updated. 11. A review of the Advanced Directives-Administration policy and procedure, dated [DATE] ' revealed: The resident has the right to refuse treatment and to formulate an Advanced Directive. The facility will abide by the resident ' s advanced directives if known. The following are definitions of terminology contained within the facility ' s policies and procedures: Life Support System: Life support systems may include among other things: Devices such as respiratory and [MEDICAL TREATMENT]. Cardiopulmonary resuscitation (CPR). Health Agent/Proxy: A healthcare agent/proxy is a person who is authorized by the resident in writing to convey their wishes concerning with holding or withdrawing life support systems. A healthcare agent does not act unless the resident is unable to make or communicate their decisions. Durable Power of Attorney: A Durable Power of Attorney for health care decisions is a document in which you name another person to make medical decisions, other than withdrawal of life support systems, on your behalf should you become unable to make or communicate such decisions yourself. The Executive Director must make certain the Admission staff, Social Services, Medical staff, Nursing staff, and Interdisciplinary team are informed, aware and trained to follow the company ' s policies and the residents wishes regarding advanced directives. Health care personnel are not obligated to participate actively in decision to withhold treatment, which they consider repugnant to their code. Anyone who does not wish to participate actively in any such decision should see the Executive Director. 12. On [DATE] at 5:45 p.m., the Nursing Home Administrator (NHA), DON and the Corporate Nurse provided a copy of The Situation, Background, Assessment and Recommendation (SBAR) report. The SBAR report was reviewed and listed under the nursing notes, dated on [DATE], Primary nurse reported that she checked face sheet and resident was a full code. Reports that she did not know that code status had changed. The SBAR indicated, on [DATE], the physician was notified at 2:15 p.m. 13. On [DATE] at 6:10 p.m., the NHA informed the survey team, We have immediately in-serviced Licensed Practical Nurse Q on the facility ' s Code blue policy. We also verified her CPR certification. She is a Basic Life Support (BLS) Instructor for the American Heart Association. The NHA said, We have suspended her during our investigation and pending the determination of the outcome. It ' s part of our facility policy. Licensed Practical Nurse Q received a Corrective Action Form on [DATE]. Listed under Description of violation: 1. Abuse of resident -Violation of Resident/patient Bill of Rights. Supervisor ' s Corrective Plan of Action, Employee educated in viewing DNR before initiating CPR-cannot use Face sheet information. Employee suspended pending investigation. Employee comments: I do not agree with this. The Face sheet stated Full Code when time is of the essence. It is NOT realistic search for information that needed to be clear. I am not agreeing with this. I am signing under duress. 14. Review of the facility ' s policy and procedure, Resident Abuse, dated on [DATE] with a revision date of [DATE], revealed the following pertinent information: Policy: It is inherent in the nature and dignity of each resident at the Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, polices, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED]. 15. On [DATE] at 1:22 p.m. an interview was conducted with the Nursing Home Administrator. The NHA stated the facility ' s investigation that had involved Resident #94 was found as substantiated. She said she would be calling Staff member Q today and asking her to come into the facility. Staff member Q will be terminated at that time. The NHA confirmed the root cause of the incident was that the nurse looked at the face sheet and not the golden rod in the medical record. Our policy does not reflect that. The NHA said the nurse ' s job is to try and save a life. The nurses that were helping during the Code Blue didn ' t ask for her code status, they saw Staff member Q performing compressions and it was a natural response to help them out. 16. On [DATE] at 6:10 p.m., the NHA and the Regional Corporate nurses were asked if there was system in place to prevent further occurrences. The NHA stated, Education, auditing on all new admissions. The nurses will be obtaining code status on admission. The root cause was the nurses looked at the face sheet and not the golden rod. We have educated the business office and the Social Services on the status. The Business office is entering the code status on the resident ' s face sheet and they were instructed not to enter this any longer. The NHA and the Regional Corporate Nurse revealed the following actions were taken to remove the Immediate Jeopardy: a. A 100% audit was conducted on all current residents ' code status face sheets and care plans to ensure accuracy. On [DATE] at 6:10 p.m., the NHA identified the facility census of 113 residents. She said there are 48 residents currently residing in the facility with a DNR status. This was verified as survey team reviewed face sheets, physician orders [REDACTED]. b. The NHA said the Quality Assurance (QA) team had meet on [DATE]. She said the following actions were CPR/DNR policy and procedures and they were working on a 4 point plan. The NHA provided a copy of the QA and A that they had conducted. She stated everyone in the QA team had been notified of the incident and the only signature we did not have at this time was the Medical Director. She said she will be in to sign it. c. On [DATE] at 4:10 p.m., the Regional Nurse stated we are at 100% compliance with educating our staff on the facility policy and procedure on code blue and had them sign the CPR/DNR -Zero Tolerance. The Regional Nurse said we will continue with our mock drills every shift. 17. On [DATE] at 1:19 p.m., the NHA stated they are at 100% compliance with their Cardiopulmonary Resuscitation for licensed staff members. The facility provided copies of their in house audit on CPR certificates. The facility identified a total of 30 active licensed nurses. 18. On [DATE] at 2:50 p.m., a Code Blue mock drill was conducted and observed on the lower level of the facility. A staff member was overheard announcing Code Blue room [ROOM NUMBER] on the overhead intercom system. Staff members were observed immediately responding to room [ROOM NUMBER] totaling seven altogether. A CPR instructor, from the sister facility, was present in the bedroom. She was heard asking the staff members what they were going to do and what they were doing. On [DATE] at 5:00 p.m. the facility provided a copy of the observed Code Blue mock drill titled: Code Blue Quality Assurance Drill. Comments from the Instructor included: 1. Staff answered appropriately, utilized critical thinking skills, prompt response. 2. Identified record keeper and delegator for the drill and actual code. 3. Staff needs to work as a team vs, o2, acc, compression are all done simultaneously to complete all tasks during drill. This will ensure the response time is as quick as possible and will increase chances of survival. 19. On [DATE], at 11:54 a.m., the facility ' s Regional Corporate Nurse provided a copy of their updated, Four Point Action Plan, dated [DATE] at 1:15 p.m. The Action steps now contain: Code status was removed from face sheets. The Regional Nurse said our corporate office has initiated a corporate wide removal of a cell that was on the face sheet. The face sheet no longer contains the box (cell) that was titled: Advanced Directives. 20. Verification interviews were conducted between [DATE] and [DATE] that included nurses across all three shifts. All of the nurses verbalized they had attended the CPR/DNR in-service that the facility had conducted. The nurses verbalized knowledge of the training by looking in the medical record under the Advanced Directives section and having a second nurse verify the resident's code status. As a result of the measures, the Immediate Jeopardy was removed on [DATE] and the severity and scope reduced to D.

Based on observation, clinical record review, policy and procedure review for Advanced Directives, Code Blue, and Abuse Prevention Policy and Procedure, Nursing Home Administrator (NHA) job description review, and interviews with staff, Primary Care Provider and the Medical Director, it was determined that administration failed to provide resource management to ensure that the right to refuse treatment and exercise of advanced directives for end of life decisions were protected for one (#94) of 15 sampled residents of 48 identified as having a Do Not Resuscitate order (DNR), according to the [DATE] facility audit of all current resident records and review of Resident #94 ' s clinical record on [DATE]. Administration did not ensure the direct functions and continued operations of the facility, including the right to be free from neglect, were in accordance with current regulations governing long term care facilities related to implementing policies and procedures for code arrest and abuse prevention. The facility failed to ensure that Resident #94 ' s Advanced Directive of DNR was properly carried out as facility personnel administered Cardio-Pulmonary Resuscitation (CPR) after identifying the resident without a pulse or respirations. The administration ' s failure to ensure, that the resident ' s expressed wishes related to advanced directives and right to refuse treatment were honored and protected, led to findings of Immediate Jeopardy which was removed on [DATE] at 11:54 a.m. and the severity and scope was reduced to a D. Finding included: 1. Review of the job description for the Executive Director I (Nursing Home Administrator), undated, revealed the following relevant information: Purpose of Your Job Position: The primary purpose of the Executive Director is to direct the day-to-day functions in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure the highest degree of quality care can be provide to our resident ' s at all times. Job Functions: Responsible for day-today clinical and administrative activities of the facility, including profit and loss responsibility and ensure compliance with all state and federal regulation. Duties and Responsibilities: 6. Interpret and ensure implementation of governing board policies and procedures. 7. Schedule regular meetings with direct staff to provided supervision, ensure communication and to monitor facility operations. 9. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. 11. Support and guide the facility ' s quality improvement process. 2. Resident #94 was included in the sample of the stage one QIS survey. On [DATE] at 12:39 p.m., the surveyor was outside of Resident #94 ' s bedroom and heard an audible tracheal congestion. The door was open to the bedroom and the resident was observed sitting up in her Geri-chair. She was noted with her bed table positioned on her right side with her meal tray on top. She was observed in the bedroom alone. Resident #94 was covered with a blanket that was positioned up to her chin. The resident ' s eyes were closed and she did not respond to verbal stimuli when approached. At 12:41 p.m., Staff O, Certified Nursing Assistant, entered the bedroom and was asked if she was going to assist Resident #94 with her lunch meal. Resident #94 began coughing with audible tracheal congestion. Her skin tone appeared pale and ashen in color. The CNA stated she was going to get the nurse and added the congestion was new. The CNA left the room, was observed approaching Staff I, LPN. She was heard telling the nurse that Resident #94 was having congestion and she wanted the nurse to look at her. Staff I was overheard telling the C.A.N., ok. Staff I entered Resident# 94 ' s bedroom at 12:44 p.m. and looked at the resident momentarily. She said why isn ' t her oxygen on? She went to the bathroom and washed her hands. She walked out of the bathroom and asked the surveyor if she could get her gloves. The surveyor indicated that she could not give supplies during that situation. Staff I then left the bedroom. The resident was observed for 5 seconds without breathing. On the count of six the resident inhaled deeply. The resident ' s skin after inhalation was observed as turning a darker gray (ashen) color at 12:46 p.m. On [DATE] at 12:47 p.m., Staff I returned to the bedroom followed by Staff Q, LPN, and the DON. Staff Q started calling the resident by her name. The resident did not respond. Staff Q next performed a sternal rub to the resident. The resident was observed inhaling deeply. Staff Q stated, We need to get her in bed. The DON, Staff Q, Staff I and Staff O were observed transferring the resident from her Geri-chair into her bed. Her oxygen was now in place and her head of bed was flat. The C.N.A., who was in the bedroom, stated out loud, she has a pulse. At 12:48 p.m. while repositioning Resident #94 ' s head in the bed, Staff Q said, she ' s not breathing, she is a Full Code. Staff Q began chest compressions. While Staff Q was performing the chest compressions she asked, Where ' s the ambu-bag (resuscitator bag)? Staff I had just returned to the bedroom with the crash cart and handed the ambu-bag to the DON. Staff Q was observed administering and counting out loud for a total of thirty chest compressions. The DON gave two breaths to the resident per the ambu- bag. One of the nurses stated, Go and call the code blue. At 12:49 p.m., a code blue was overheard on the facility ' s loud speaker. Staff Q was observed continuing with chest compressions followed by two breaths by the ambu-bag. At 12:50 p.m., Staff I entered the resident ' s bedroom. She said, She is a DNR . Staff Q, while continuing to perform the chest compressions stated, She is a full code, I read it in her chart. Staff I turned around and left the bedroom. At 12:52 p.m., Staff P, LPN, took over for Staff Q and continued with chest compressions to the resident. On [DATE] at 12:53 p.m., Staff L, LPN, entered the bedroom and stood in front of the surveyor. Staff L was observed taking her right hand and making a motion across her throat to indicate stop. She then stated, She is a DNR; she has a yellow DNR sheet on her chart. The DON stated, Bring her chart in the room. At that time, Staff P stopped performing chest compressions. 2. Medical record review conducted for Resident #94 revealed a face sheet indicating the resident was [AGE] years old and was admitted to the facility on [DATE]. The face sheet also indicated that Resident #94 was admitted for short term therapy and her advanced directives were full code. Her [DIAGNOSES REDACTED]. 3. The medical record contained a sectioned off tab labeled advanced directives. The section contained a document that was bright yellow in color (golden rod) with capitalized words that stated DO NOT RESUSCUTATE ORDER. The first section of the golden rod document had Resident #94 s name on with a written date of [DATE]. The second section of the document included: PATIENT ' S STATEMENT: Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): Resident #94 ' s spouse had put an X in the box indicating he was the health care proxy (as defined in Chapter 765, F.S.) and signed the documents. The final section of the document included: PHYSICIAN ' S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient ' s cardiac or respiratory arrest. Resident #94 ' s Primary Care Physician signed the golden rod on [DATE]. 4. Upon further review of the Advanced Directives section in the medical record, a document titled, Durable Power of Attorney was noted. The document indicated that Resident #94 ' s spouse had been appointed as her agent for health care on [DATE]. A second document was reviewed that was titled, Certificate of Incapacity. The certificate was signed and dated by the primary physician on [DATE]. A sectioned off portion in the medical revealed a Behavioral Health Consultation note, also dated on [DATE]. Listed next to the number 3 PCP -present- states PT is now a DNR, + incapacitated to make any verbal decisions. 5. On [DATE] at 5:45 p.m., the NHA confirmed the facility ' s Code Blue policy was their current policy for residents who are found in Cardio-Pulmonary arrest. She also confirmed that the advanced directive section should have been looked at. She said a face sheet was not a Physician ' s written order. Our policy indicates a DNR status is confirmed with a physician's order [REDACTED]. 6. Review of the facility ' s policies and procedures, effective date: [DATE], Code Blue Policy: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by a physician on their medical records. Procedure: When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. Confirm DNR status with the physician ' s written order. The Nurse Manager/ Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: Summon emergency equipment to the room. Activate the EMS system. Assign a person to document the ongoing code. 7. Review of the facility provided policy on Advanced Directives-Administration, with an effective date of [DATE], relevant findings included: Policy: The resident has the right to refuse treatment and to formulate an Advanced Directive. The facility will abide by the resident ' s advanced directives if known. Procedure: The Executive Director must make certain the Admissions staff, Social Services, Medical staff, nursing staff and Interdisciplinary team, are informed, aware and trained to follow the company ' s policies and regarding resident ' s wishes regarding advance directives. Social services and/or Medical staff must inform the Executive Director whenever a resident, family member, etc. expresses doubts about existing advanced directives, treatments, or expresses a desire to revoke or change advance directives. The Executive Director will keep informed of all current regulations concerning advanced directives and will inform all departments of any changes or current and future laws and regulations through updated policies and procedures. 8. Review of the facility ' s policy and procedure Resident Abuse , dated on [DATE] with a revision date of [DATE], revealed the following pertinent information: Policy: It is inherent in the nature and dignity of each resident at the Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, 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 [REDACTED]. Procedure: Definition of Resident abuse: An abusive act is any act or omission, which may cause or causes actual physical, psychological or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein. Employee Obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. 9. On [DATE] at 12:58 p.m., an interview was conducted with Staff Q. Staff Q was asked where she had looked in the medical record for Resident#94 ' s code status. Staff Q pointed to Resident #94 ' s face sheet. Listed on the face sheet under the title, other information, was a box titled Advanced Directives. The Advanced Directive was listed as Full Code. She said she was unaware of her code status changing. She also confirmed she had only looked at Resident #94 ' s face sheet in her (paper) medical record. 10. On [DATE] at 5:45 p.m., the Nursing Home Administrator (NHA), DON and the Corporate Nurse provided a copy of The Situation, Background, Assessment and Recommendation (SBAR) report. The SBAR report was reviewed and listed under the nursing notes, dated on [DATE], Primary nurse reported that she checked face sheet and resident was a full code. Reports that she did not know that code status had changed. The SBAR indicated, on [DATE], the physician was notified at 2:15 p.m. 11. On [DATE] at 6:10 p.m., the NHA informed the survey team, We have immediately in-serviced Licensed Practical Nurse Q on the facility ' s Code blue policy. We also verified her CPR certification. She is a Basic Life Support (BLS) Instructor for the American Heart Association. The NHA said, We have suspended her during our investigation and pending the determination of the outcome. It ' s part of our facility policy. Licensed Practical Nurse Q received a Corrective Action Form on [DATE]. Listed under Description of violation: 1. Abuse of resident -Violation of Resident/patient Bill of Rights. Supervisor ' s Corrective Plan of Action, Employee educated in viewing DNR before initiating CPR-cannot use Face sheet information. Employee suspended pending investigation. Employee comments: I do not agree with this. The Face sheet stated Full Code when time is of the essence. It is NOT realistic search for information that needed to be clear. I am not agreeing with this. I am signing under duress. Further interview with the NHA on [DATE] at 12:30 p.m. indicated that they were going to terminate employee Q as a result of their investigation. 12. On [DATE] at 4:12 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She said she had been a licensed nurse for fourteen years now and had worked at the facility for three and half years. She said her normal shift was on days and she always worked the first floor B-hallway. When asked if she knew Resident # 94, she said no. The nurse said she was told by the staff member O that the resident had needed help and was having breathing problems. I went to the room and realized that was the wrong room number. She said, When staff member O came to me, I didn ' t know what I needed until I got there. She said, When I got there (bedroom) I saw her oxygen tubing was on the floor. I then left the room to find Staff Member Q. LPN I was asked where would find a resident ' s code status in the medical record. She said, You would look for the yellow sheet in the advanced directives section on the medical record. When asked if the code status was listed on the face sheet, she said you ' re not supposed to use the face sheet for their code status, it ' s not always updated. 13. 0n [DATE] at 4:44 p.m. an interview was conducted the facility ' s Director of Social Services (DSS). She said Resident #94 ' s spouse was in her office during the code blue incident on [DATE]. The DSS said that Resident #94 spouse had asked her what was going on in his wife ' s bedroom. The DSS said she looked up from her desk and observed staff members taking a crash cart into her bedroom. She said, at that time, I told Resident #94 ' s spouse that I was going to see what was going on in her bedroom. She confirmed she had observed staff members performing CPR to her. The DSS said, I remembered seeing you in there and asking for gloves. The DSS was asked if she knew that Resident #94 ' s advanced directives had been changed. The DSS stated, Yes, I had put the paper work together the week before. The Physician and Resident #94 ' s spouse signed the paper work on Saturday. The DSS was asked when she had first seen the signed golden rod form. She said she had seen it on the next Monday ([DATE]) when she came into work that morning. When asked if she had told anyone that Resident #94 ' s code status had changed she said, I told everyone in the Monday morning stand up meeting. She was asked who was in the meeting. She said she remembered the Director of Nursing (DON), Nursing Home Administer (NHA), the unit manager and said she and couldn ' t remember everyone. The DSS was asked who had told Resident #94 ' s spouse that she had expired at the facility. DSS stated Resident #94 ' s spouse came back to her office after he had spoken with the DON. He told me that the DON said his wife had passed away peacefully. He said he was going to sit in his wife ' s bedroom for a while. 14. On [DATE] at 2:00 p.m. a telephone interview was conducted with Resident #94 ' s spouse. He confirmed he was the spouse of Resident #94 and said he that the facility had problems getting her medication. He stated that after her last surgery his wife was having memory problems. They say the memory problems were a direct side effect from lost oxygen during her operation. Her muscles wouldn ' t do what her mind was telling them to do. They thought she had Alzheimer ' s but she didn ' t . Resident #94 ' s spouse confirmed that his wife was a DNR. He said he was at the facility and was aware that the staff members were performing CPR on her. He said I had to remind the staff that she was a DNR so they would quit, I guess they didn ' t realize it. As soon as I told them they stopped the CPR. I sat in the room with Resident #94 for a while after they stopped the CPR. She had taken a couple of breaths . When asked if it was his expectation that the staff members honor Resident #94 ' s wishes when she stops breathing and no longer has a pulse. He said they just didn ' t know she was a DNR. 15. On [DATE] at 11:30 p.m., an interview was conducted with the facility ' s Medical Director. The Medical Director confirmed that she was notified by the facility that Resident #94 expired on [DATE]. She confirmed that she was aware that CPR had been performed on Resident #94. She said that she was also was informed that there had been a DNR on her medical record. She stated, Education on where to find the Advanced Directives (in the chart) in the medical record is our main goal. 16. On [DATE] at 11:08 a.m., a phone interview was conducted with Resident #94 ' s Primary Care Physician (PCP). The PCP said he had just seen Resident #94 at the facility on Saturday ([DATE]). She said her husband was also there and in agreement with her advanced directives changing. The PCP said he had signed her Do Not Resuscitate Certificate (DNR) on [DATE]. The PCP was asked when was the last time he heard from the facility. He said they had called him on Tuesday and told him that Resident #94 ' s vital signs had ceased. He said he had given orders to release the resident. The PCP was asked once Resident #94 ' s code status changed to a DNR, what would you have expected when the facility ' s licensed staff members found her not breathing. He said, I would expect them not to perform CPR. The PCP was then informed that the licensed staff members performed CPR to Resident #94 for five minutes. PCP said he was not aware that the facility had performed CPR to Resident #94. He said, That was not right. 17. On [DATE] at 11:00 a.m. an interview was conducted with the DON. The DON said that she had been at the facility for over a month and was the interim DON. She was asked about the facility ' s policy on resident ' s code status. She said, You have to look for the physician orders. She confirmed that it was her expectation that the staff review the medical record for the Physician order [REDACTED]. The DON said we are continuing with education on codes and responding appropriately. We are now bringing the resident ' s chart to the room and we have started a two person verification of the code status. 18. On [DATE] at 1:22 p.m. an interview was conducted with the Nursing Home Administrator. The NHA stated the facility ' s investigation that had involved Resident #94 was found as substantiated. She said she would be calling Staff member Q today and asking her to come into the facility. Staff member Q will be terminated at that time. The NHA confirmed the root cause of the incident was that the nurse looked at the face sheet and not the golden rod in the medical record. Our policy does not reflect that. The NHA said the nurse ' s job is to try and save a life. The nurses that were helping during the Code Blue didn ' t ask for her code status, they saw Staff member Q performing compressions and it was a natural response to help them out. 19. On [DATE] at 6:10 p.m., the NHA and the Regional Corporate nurses were asked if there was system in place to prevent further occurrences. The NHA stated, Education, auditing on all new admissions. The nurses will be obtaining code status on admission. The root cause was the nurses looked at the face sheet and not the golden rod. We have educated the business office and the Social Services on the status. The Business office was entering the code status on the resident ' s face sheet and they were instructed not to enter this any longer. The NHA and the Regional Corporate Nurse revealed the following actions were taken to remove the Immediate Jeopardy: a. A 100% audit was conducted on all current residents ' code status, face sheets and care plans to ensure accuracy. On [DATE] at 6:10 p.m., the NHA identified the facility census of 113 residents. She said there are 48 residents currently residing in the facility with a DNR status. This was verified as survey team reviewed face sheets, physician orders [REDACTED]. b. The NHA said the Quality Assurance (QA) team had meet on [DATE]. She said the following actions were CPR/DNR policy and procedures and they were working on a 4 point plan. The NHA provided a copy of the QA and A that they had conducted. She stated everyone in the QA team had been notified of the incident and the only signature we did not have at this time was the Medical Director. She said she will be in to sign it. c. On [DATE] at 4:10 p.m., the Regional Nurse stated we are at 100% compliance with educating our staff on the facility policy and procedure on code blue and had them sign the CPR/DNR -Zero Tolerance. The Regional Nurse said we will continue with our mock drills every shift. d. On [DATE] at 1:19 p.m., the NHA stated they are at 100% compliance with their Cardiopulmonary Resuscitation for licensed staff members. The facility provided copies of their in house audit on CPR certificates. The facility identified a total of 30 active licensed nurses. 20. On [DATE] at 2:50 p.m., a Code Blue mock drill was conducted and observed on the lower level of the facility. A staff member was overheard announcing Code Blue room [ROOM NUMBER] on the overhead intercom system. Staff members were observed immediately responding to room [ROOM NUMBER] totaling seven altogether. A CPR instructor, from the sister facility, was present in the bedroom. She was heard asking the staff members what they were going to do and what they were doing. On [DATE] at 5:00 p.m. the facility provided a copy of the observed Code Blue mock drill titled: Code Blue Quality Assurance Drill. Comments from the Instructor included: 1. Staff answered appropriately, utilized critical thinking skills, prompt response. 2. Identified record keeper and delegator for the drill and actual code. 21. On [DATE] at 11:54 a.m. the facility ' s Regional Corporate Nurse provided a copy of their updated, Four Point Action Plan, dated [DATE] at 1:15 p.m. The Action steps now contain: Code status was removed from face sheets. The Regional Nurse said our corporate office has initiated a corporate wide removal of a ' cell ' that was on face sheet. The face sheet no longer contains the box (cell) that was titled: Advanced Directives. 22. Verification interviews were conducted between [DATE] and [DATE] that included nurses across all three shifts. All of the nurses verbalized they had attended the CPR/DNR in-service that the facility had conducted. The nurses verbalized knowledge of the training by looking in the medical record under the Advanced Directives section and having a second nurse verify the resident ' s code status. As a result of the measures, the Immediate Jeopardy was removed on [DATE] and the severity and scope reduced to D.

Based on observations, record review, interview and review of the facility's policy on Infection Control and hand washing, facility staff failed to adhere to the acceptable standards of practice related to hand washing and infection control practices for five (#3, #4, #7, #8 and #9) of five treatments observed. The facility census was 117 at the time of the survey. Resident #3, #4, #7, #8 and #9 during wound care treatments, facility staff failed to appropriately wash their hands before, during and/or after the treatments. The findings included: Per the Florida Statutes, Regulation of Professions and Occupations, Chapter 464 Nursing: "Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments." 1) The facility admitted Resident #3 on 8/28/13 with [DIAGNOSES REDACTED]. During an observation of wound care on 9/25/13 at 2:40 PM, Employee A completed the pressure ulcer treatment in accordance with acceptable standards of practice. Upon completion of the treatment Employee A removed her gloves and washed her hands and then gathered her dirty supplies and tied the biohazard bag. She then went to the treatment cart and the red biohazard bag was observed to touch the treatment cart, the floor, the front of the nurse's clothes and the treatment book. She then initialed the treatment. The nurse then went to one soiled utility room and opened the door, she exited that room and went across the hallway to another soiled utility room and deposited the biohazard bag in that room. She exited the soiled utility room and then returned to the nurse's station without washing her hands. 2) The facility admitted Resident #4 on 8/29/2013 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations of wound care conducted with staff member B on 9/26/2013. Employee B washed her hands at 9:05 a.m. and returned to treatment cart to gather supplies. A barrier was placed on top of the treatment cart and supplies. The nurse pulled out skin prep, normal saline, [MEDICATION NAME] and calcium alginate and placed on top of the barrier. Employee B then used an ungloved hand to remove and cut the calcium alginate. With her ungloved hands, she cut a 2 inch x 2 inch piece of calcium alginate and replaced the remaining medication back into the package. Employee B then applied a clean glove to one of her hands to remove gauze. She then removed and discarded the glove from her hand and entered Resident's room. The nurse placed the supplies on the bedside table and pulled the curtain for privacy. At 9:11 a.m. Employee B washed her hands. She then left room to open the treatment cart outside the door. Employee B unlocked and opened the bottom drawer and removed a red bag from the cart. She locked the cart and returned to the room without washing her hands. The nurse applied clean gloves to her soiled hands to begin wound care. The nurse removed the resident's old soiled dressing and removed her old gloves. Without washing her hands Employee B applied new gloves to soiled hands then applied new gauze next to wound area and rinsed wound bed with normal saline three times. Employee B removed soiled gloves and washed her hands. She donned clean gloves applied skin prep to surrounding area. The nurse applied the prescribed [MEDICATION NAME] with a clean gauze and calcium alginate to wound bed. Employee B applied a border edge dressing to the site. The nurse then fastened Resident #4's brief, pulled down her clothes and pulled up the bed linen with soiled gloves. She then removed her gloves tossed them into a red bag and tied the bag. Without washing her hands she carried the bag into the hallway to the soiled utility room for disposal. She returned to treatment cart without washing her hands and touching the treatment cart. The surveyor asked her if there was anything else she planned to do. She replied "are there anymore more wound care observations you want to see? " At that point she opened treatment book and started documenting. The surveyor asked her "do you have anything else to do?" She then looked at book and pointed to resident's treatment order and started to read off the wound care orders to surveyor. She was never observed to wash her hands. 3) The facility admitted Resident #7 on 7/9/13 with [DIAGNOSES REDACTED]. During an observation of wound care on 9/26/13 at 10:35 AM Employee C (LPN) was observed to place several items directly on the resident's bedside table next to the resident's water cup. The Santyl ointment remained in the bag sitting on the napkin by the cup. Skin prep, normal saline vials and alcohol pads were observed touching the resident's remote control and other items. During an observation of wound care on 9/26/13 at 10:35 AM Employee C (LPN) knocked on the door and informed the resident of the dressing change. The nurse sanitized her hands and set up her supplies on a sterile drape on the resident's bedside table. She placed several items directly on the table next to the resident's water cup. The Santyl ointment remained in the bag sitting on the napkin by the cup. Skin prep, normal saline vials and alcohol pads were observed touching the resident's remote control and other items. The nurse then changed her gloves without washing her hands and cleansed her scissors with alcohol pads; she then washed her hands and donned clean gloves. She then removed the resident's socks, and changed her gloves without washing her hands. She donned new gloves and placed a drape under the resident's legs. The nurse then removed her gloves, washed her hands and donned new gloves. She cleaned her scissors again and proceeded to cut the old dressing off. The nurse then changed her gloves without washing her hands. She then cleaned the resident's left second toe with normal saline. She picked up another piece of gauze and cleansed the lateral calf with normal saline. The nurse did not wash her hands or change her gloves in between the two wounds. The nurse then applied Santyl to the wound bed of the toe wound and covered the wound with gauze. She changed her gloves without washing her hands and applied Santyl to the left lateral wound bed. She covered the wound with clean gauze. The nurse changed her gloves without washing her hands. She then cleaned the heel wound, applied Santyl to the wound bed and covered the wound with gauze. She then wrapped the wounds with Kerlix. (The nurse contaminated the clean wound when she did wash her hands between clean and dirty). The nurse washed her hands and donned new gloves. She then realized she was not able to perform the treatment on the left posterior calf. She removed her gloves, washed her hands and exited the room to obtain new supplies. She re-entered the room and placed the soiled scissors directly on the resident's table and touched several other items with her bare hands. The nurse then donned gloves and opened the new Kerlix wrap. She changed her gloves without washing her hands. The nurse removed the previously wrapped Kerlix and changed her gloves again without washing her hands. She then cleansed the posterior wound with normal saline, applied skin prep to the wound margins and Santyl to the wound bed. The nurse then covered the wound with a dry dressing and proceeded to re-wrap the resident's leg with Kerlix. The nurse secured the dressing with paper tape. The red biohazard bag was noted to be sitting on the resident's bed overflowing with the contents (soiled bandages, rolled gauze and soiled gloves) touching the resident's bare leg and bed linens. She then gathered the trash and tied the red bag. The nurse removed her gloves, washed her hands and initialed the resident's dressing and donned gloves. The nurse picked up the trash and removed her gloves. The nurse then exited the room and deposited the trash in the soiled utility room. The nurse then returned to the resident's room and washed her hands. The treatment ended at 11:34 AM. Employee C was not observed to clean the bedside table at any point during or after the treatment. 4) The facility admitted Resident #8 on 5/16/2013 and readmitted on [DATE] with [DIAGNOSES REDACTED]. During a wound care observation on 9/26/13 at 2:25 PM Employee A was observed to exit another resident's room and then go to the treatment cart to retrieve her supplies without washing her hands first. The nurse was observed to place the supplies directly on the treatment cart. She was unable to find the prescribed Santyl ointment. The nurse entered the resident's room and began rummaging through his dresser drawers; the nurse found a tube of Santyl ointment in the right second drawer of the dresser. She exited the room with the ointment and stated to the surveyors that the tube of Santyl was from the hospital. She stated that medications should be kept locked up in the treatment cart and the CNAs were responsible for inventorying the resident's belongings and removing medications. The nurse then continued to set up her supplies. She entered the room, washed her hands and washed the bedside table and then placed a barrier on the table and set up her supplies. The nurse washed her hands and donned gloves and then pushed the bedside table to the resident's bedside. The nurse repositioned the resident to his right side. She changed her gloves without washing her hands. The nurse removed the old dressing and cleaned the wound with normal saline and applied skin prep to the wound margins. The nurse removed her gloves and washed her hands and donned new gloves. The nurse squeezed a small amount of Santyl onto an applicator and placed the uncapped ointment on the resident's bedside table. She then applied the ointment to the wound and covered with a bordered dressing. The nurse then re-capped the Santyl ointment with her soiled gloves. She then removed her gloves and washed her hands. She gathered the trash and then held the Santyl ointment and the red biohazard bag in one hand and exited the room. She placed the red bag on top of the treatment cart and then picked it back up and deposited the red bag into soiled utility room. Without washing her hands she returned to the nurse's station to retrieve the wound care book. The nurse was not observed to wash her hands. 5) During an interview on 9/27/13 at 10:00 AM, Employee A (RN) stated that she was the infection control preventionist for the facility and she stated that it was policy and an expectation for staff to wash hands between glove changes. She also stated that the wound should not be contaminated and they should have been treated separately. She also confirmed that staff's hands should be washed before and after the treatments and in between clean and dirty sections of the treatment. Review of the Infection Control Log revealed the sampled residents did not have wound infections. Review of the facility's policy entitled Hand Washing Technique effective 1/1/2007 and revised 9/1/2011 revealed: "All personnel will wash hands to remove dirt, organic material, and transient microorganisms to prevent the spread on infections. Hands must be washed: after contact with blood/body fluids, in between resident contacts, before clean procedure, after contact with contaminated items or surfaces, after removal of gloves..." 6) During an interview on 9/27/13 at 9:50 AM Employee A, B and C, the Nurse Consultant and the Director of Nurses were informed of the wound care observations on 9/25 and 9/26. Employee A confirmed that the soiled red bag touched the counter, cart, her clothes and the treatment book. She also confirmed that she did not wash her hands immediately after disposing of the soiled items. Employee B confirmed that she did not wash her hands between changing gloves and confirmed that she did not wash her hands after disposing of the soiled items after the treatment for [REDACTED]. Employee A also confirmed the medication left at the resident's bedside and acknowledged she did not wash her hands between glove changes. Employee A confirmed that she did not wash her hands after the treatment for [REDACTED]. During an interview on 9/27/13 at 10:05 AM Director of Nurses and Nurse Consultant were informed that Employee A obtained Santyl from the resident's drawer and squeezed a small amount onto the applicator stick then left the ointment uncapped on the resident's bedside table until after the treatment was completed. She then used her soiled gloved hand to replace the cap and put the ointment back into the box which was then placed in the treatment cart. Both the DON and the Nurse Consultant stated that this was not acceptable practice and the nurse should not have left the tube uncapped and should not have stored in the cart. During an interview on 9/27/13 at 9:50 AM Employee C, the Nurse Consultant and the Director of Nurses were informed of the wound care observation 9/26. Employee C confirmed that she did not wash her hands in between the multiple glove changes and confirmed that she contaminated the toe wound and the left lateral shin wound on Resident #7. Employee C also confirmed that she placed treatment items on the resident's bedside table next to the resident's water cup and other personal items. She confirmed that the soiled scissors were also placed directly on the resident's bedside table. During an interview on 9/27/13 at 10:05 AM DON and Nurse Consultant confirmed the staff member should have washed her hands between glove changes and before and after the treatments. The DON stated that her expectation for the staff was to wash their hands and to not sanitize. However, the nurse did neither. 7) Review of the facility's policy entitled Dressing Changes effective 1/1/2007 and revised on 1/1/2009 revealed the procedure was as follows: 1. Identify resident. 2. Explain procedure, provide privacy. 3. Assemble the following: a. disposable gloves. B. dressing needed to apply to wound. C. gauze to clean the wound. D. applicators. E. bag for dressing disposal per universal precautions. F. tape. 4. Put on disposable gloves. 5. Untie tape or loosen disposable tape. 6. Remove soiled dressings and dispose of per Exposure policy. 7. Remove gloves. 8. Wash hands. 9. Apply new disposable gloves. 10. Assess wound for type, color, amount of drainage. Obtain wound culture if indicated. 11. Cleanse wound as ordered, using gauze cleanse the wound. 12. Dry the wound with gauze. 13. Apply clean dressing and secure. 14. Discard gloves and wash hands. 15. Document in medical record." 8) Review of the facility's policy entitled Hand Washing Technique effective 1/1/2007 and revised 9/1/2011 revealed: "All personnel will wash hands to remove dirt, organic material, and transient microorganisms to prevent the spread on infections. Hands must be washed: after contact with blood/body fluids, in between resident contacts, before clean procedure, after contact with contaminated items or surfaces, after removal of gloves..."

Based on observations, record review, interview and review of the facility's One on One In-Service Treatment Administration Checklist, the facility failed to assure licensed personnel followed acceptable standards of practice for four of five residents observed for wound care. The facility identified 10 residents with wounds. Resident's #7, 8, 9, and 10 had inappropriate wound care and infection control breaches during and after the wound care. Resident #8 had actual harm observed during the wound care. The findings included: Per the Florida Statutes, Regulation of Professions and Occupations, Chapter 464 Nursing: "Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments." 1) The facility admitted Resident #8 on 5/2/13 and readmitted on [DATE] with [DIAGNOSES REDACTED]. During an observation of wound care on 11/13/13 at 2:14 PM Employee C gathered his supplies, applied a towel barrier on an over the bed table retrieved from the clean supply room. The Santyl was capped and labeled; an open bag of multi-ply 4x4 gauze was then placed into a zip lock bag with room number and named placed on the bag. The nurse knocked on the door, provided for privacy and washed his hands and donned gloves. He assisted the resident to roll to his right side. The nurse then removed the old dressing. The dressing was noted to be an adhesive gauze dressing. The nurse removed the dressing without adhesive remover of saline to assist in the removal of the dressing. The resident stated "Ow." The removal of the dressing caused 4 additional wounds that were actively bleeding. The nurse did not stop the wound care and proceeded to cleanse the wound. He washed his hands and donned new gloves. The resident's pressure ulcer was noted to have a yellow wound bed with red wound margins. The newly acquired wounds were still noted to be bleeding. The nurse then used his gloved finger to scoop Santyl from a medicine cup and apply directly to the resident's right buttock wound. He then used the same finger to obtain more Santyl from the medicine cup and apply to the Left Buttock wound. The nurse washed his hands and donned clean gloves. He applied Skin Prep to the wound margins, applying directly to the bleeding wounds, the resident, again, said "Ow." The surveyor asked where the resident was hurting and the resident stated, "everywhere he just put that." The nurse was then noted to begin to apply an adhesive dressing over the newly acquired wounds. The surveyor stopped the process and stated he had bleeding wounds. The nurse then put the adhesive dressing with the sticky side up on the overbed table and cleansed the new wounds and applied Santyl ointment with his finger, again. The adhesive dressing was noted to stick to the gauze Ziploc bag and a Skin Prep applicator. The nurse removed these two items and applied the adhesive dressing onto the resident's skin. The Santyl ointment was observed to remain open with the cap laying on the bedside table. The nurse recapped the Santyl with soiled gloves and placed into the bag and back into the treatment cart. After the treatment was completed, the resident requested pain medications. He was given 7.5/325 mg of [MEDICATION NAME] with effective results 45 minutes later. On 11/13/13 at 2:52 PM, the surveyor immediately informed the Director of Clinical Services and the Regional Consultant for Clinical Services of the wound care observation. The DCS and Consultant assessed the resident, educated the nurse and contacted the resident's physician for new orders for the new wound. 2) The facility admitted Resident #9 on 3/29/07 with [DIAGNOSES REDACTED]. During an observation of wound care on 11/13/13 at 1:16 PM, Employee D gathered supplies from the clean utility, medicine room and treatment cart. Hydrogel was not in any of the locations and she contacted the Central Supply Clerk to obtain Hydrogel. The Hydrogel was given to the nurse who then squeezed a small amount into two medicine cups. At 1:30 PM, the nurse entered the room, washed her hands and donned gloves. The resident was observed in bed, no wounds were noted on her arms or hands. The resident was assisted to her right side. The nurse stated that the old dressing was removed by Employee A. The wound was observed to have denuded skin with an open area noted to the lower lateral portion of the wound. The nurse completed the wound care. She returned to the treatment cart at 2:10 PM, where the hydrogel remained. The surveyor asked where the Hydrogel came from. Employee D stated that it was from another cart. She stated that she did not open the gel and confirmed the ointment was not dated. She also confirmed that there was no cap or sealant on the applicator tip. The nurse then placed the Hydrogel into the cart for future use. The nurse also had removed the package of gauze from the resident's bedside table and placed the package back into the med cart for use on additional residents. The Director of Clinical Services was immediately informed of the infection control risk. She instructed Employee D to discard the Hydrogel and she also confirmed there was no cap or date on the vial. The DCS also informed Employee D that, if supplies are brought into a resident's room, they could not be used for other residents. She instructed the nurse to only bring in what was needed for the treatment. The remaining gauze was placed in a Ziploc bag with the resident's name on bag. 3) The facility admitted Resident #7 on 11/1/2013 with [DIAGNOSES REDACTED]. During an observation of would care on 11/13/2013 at 12:06 PM, Employee E provided wound care to Resident #7. The nurse washed her hands, donned gloves, pulled back the bedside curtain, and used the hand control to lower the head of bed. She then waited at the side of the bed while the CNA positioned the patient. Still wearing the gloves that she had used to reposition the curtain and the head of the bed, the RN cleaned the two wounds on the patient's buttocks. (Deviation from the facility Treatment Administration Guideline, steps 6 and 7 done before step 4.) She removed her gloves, washed her hands, and donned new gloves. She then removed the paper from the tongue blade, dipped the tongue blade into the hydrogel and applied it to the wound on the left side. Using the same portion of the same tongue blade, she again, dipped into the hydrogel and then applied it to the wound on the right side. (Potential for cross-contaminating wounds.) The RN applied the dressing, put her gloves into the red bag, and washed her hands. She completed the treatment and washed her hands. She then donned one glove on her right hand and picked up the red bag with her gloved right hand. She exited the room and deposited the bag in the soiled utility room while wearing one glove. (Deviation from the Facility Treatment Administration Guideline #15.) After observing wound care to the patient's buttocks, the surveyor asked if the resident had any other wounds. Employee E stated that "There was a wound to the elbow but it is healed. She only has the buttocks wound." On 11/14/2013 at 10:50 AM, a skin inspection was requested by the surveyor and was performed by Regional Director of Clinical Services, and was observed by the surveyor. An open wound on the right elbow was observed and verified by the Regional Director of Clinical Services. Review of the treatment Record for November 2013 revealed the resident was receiving the ordered treatment to the right elbow until 11/8/13 when it was marked through as discontinued. No other treatment was performed on the elbow. During an interview on 11/14/2013 at 9:25 am, the Regional Director of Clinical services stated that the nursing leadership had performed skin sweeps on all the residents on the wound care list and had staged and measured the wounds. She stated that Resident #7 did have a wound on her right elbow that was not being treated. 4) The facility admitted Resident #10 on 11/5/13. During an observation of wound care on 11/14/13 at 12:10 PM Employee A and Employee B completed wound care for Resident #10. Employee A exited the room. Employee B then washed her hands and donned new gloves, she gathered the bathroom and treatment trash and placed the bag of trash directly on the floor. She washed her hands and donned new gloves. She exited the room still wearing gloves and opened the soiled utility room with her gloved hand and disposed of the trash. She then removed her gloves and washed her hands. 5) Review of the facility's One-on-One In-service - Treatment Administration documents revealed that Employees A, B, C, D and E reviewed and signed the document in 10/2013. A review of the facility's Nurse Educational Checklist revealed that the employees were checked off on both Dressing Change Education and Dressing Change Return Demonstration and the document was signed by the Director of Clinical Services. 6) Review of the One-on-One In-service - Treatment Administration revealed the steps were as listed: "1. Knock on the door, introduce self ...set up table with barrier. 2. Wash hands. 3. Prepare supplies from treatment cart: can of cleaning solution, strips of tape, treatment medications/ointments with a plastic medication cup, alcohol wipes scissors, etc. Date and initial a piece of tape or outer dressing. Take 2 plastic bags into room. 4. Knock on door, place equipment on barrier. Close door, pull privacy curtain and window curtain. Place plastic bag on bed within reach for soiled dressings- use other plastic bag for linen. 5. Wipe scissors with alcohol swab and leave open, placed on the barrier for at least one minute to dry. 6. Assist patient to comfortable position. Place overbed table with equipment where it is comfortable. 7. Wash hands. Take at least three pairs of gloves and place two sets by equipment on barrier. Put on one set of gloves. 8. Remove old dressing and place in plastic bag. 9. Remove gloves, wash hands. Put on clean gloves. 10. Cleanse area as ordered, place towel under area to prevent patient/bed from becoming wet. Pat wound bed dry. 11. Remove gloves and wash hands. Put on clean gloves and proceed with treatment as ordered. 12. Remove gloves, wipe scissors with alcohol wipe and leave open to dry. Wipe cleaning solution can with alcohol and allow to dry. 13. Throw away barrier and extra treatment supplies, wash hands. 14. Don't put tape, scissors, etc. in uniform pocket. 15. Don't touch curtains, door knobs etc. with soiled gloves. Never wear gloves down hall. 16. Take plastic bags with soiled treatment supplies to soiled utility room. Discard and wash hands. 17. Document treatment. 18. Do not leave any medications involving treatments in resident room." 7) During an interview on 11/14/13 at 7 PM, the Regional Consultant for Clinical Services and the Vice President for Clinical Services was informed of the treatment observations. The Vice President of Clinical Services confirmed the observations did not adhere to the facility policy and they facility expected the nurses to follow policy and the standards of practice.

Based on observations, record review, interview and review of the facility's policies entitled Dressing Changes and Handwashing, the facility failed to assure three (#4, 8, 9)of four residents observed for pressure ulcer treatment received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility had a total of 12 residents with pressure ulcers. Resident #'s 4, 8, 9 did not receive the necessary treatments that adhered to acceptable standards of practice in regards to infection control and handwashing. The findings included: 1) The facility admitted Resident #4 on 8/29/2013 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations of wound care conducted with staff member B on 9/26/2013. Employee B washed her hands at 9:05 a.m. and returned to treatment cart to gather supplies. A barrier was placed on top of the treatment cart and supplies. The nurse pulled out skin prep, normal saline, [MEDICATION NAME] and calcium alginate and placed on top of the barrier. Employee B then used an ungloved hand to remove and cut the calcium alginate. With her ungloved hands, she cut a 2 inch x 2 inch piece of calcium alginate and replaced the remaining medication back into the package. Employee B then applied a clean glove to one of her hands to remove gauze. She then removed and discarded the glove from her hand and entered the resident's room. The nurse placed the supplies on the bedside table and pulled the curtain for privacy. At 9:11 a.m. Employee B washed her hands. She then left room to open the treatment cart outside the door. Employee B unlocked and opened the bottom drawer and removed a red bag from the cart. She locked the cart and returned to the room without washing her hands. The nurse applied clean gloves to her soiled hands to begin wound care. The nurse removed the resident's old soiled dressing and removed her old gloves. Without washing her hands Employee B applied new gloves to soiled hands then applied new gauze next to wound area and rinsed wound bed with normal saline three times. Employee B removed soiled gloves and washed her hands. She donned clean gloves applied skin prep to surrounding area. The nurse applied the prescribed [MEDICATION NAME] with a clean gauze and calcium alginate to wound bed. Employee B applied a border edge dressing to the site. The nurse then completed the treatment. Cross Refer to F 441 as it related to infection control and handwashing. Record review Nutritional Review dated 9/19/13 revealed the resident's weight was 107.6 pounds and under Section Weight Trend reads; losses during hospital stay. Under Section Additional comments reads; recommend 75 gram protein, prostat AWC twice a day. On 8/29/13 the resident's weight was listed as 115.2 ponds. Under Section Summary and Prognosis reads; Note sacral wound increasing nutrient needs, which is contraindicated by CKD with elevated BUN/[MEDICATION NAME]. However wound healing is a priority. Recommended 60 ml med pass twice a day is appropriate. Interdisciplinary Progress Notes dated 9/26/13 reads; Wound care continues at Stage IV to sacrum improving. Specialty mattress and wheelchair cushion measures in place. Physician Telephone Order's dated 9/19/13. The order clarification Skin preparation to bilateral heels every shift. On 9/19/13 order reads; Sacral wound; cleanse wound with normal saline, pat dry and apply skin preparation to peri-wound. Apply [MEDICATION NAME] to wound bed, cover with calcium alginate then apply a dry protective dressing. Change daily and as needed for soiling and dislodgement. Prostate AWC 30 ml (milliliters) po (by mouth) two times a day every day. Order for 9/19/13 reads; Low airloss mattress, skin preparation to bilateral heels. The order on 9/16/13 reads: Offload buttocks wound and bilateral heel per facility protocol, discontinue [MEDICATION NAME] cream to sacrum. The order on 9/14/13 reads skin prep to periwound , apply [MEDICATION NAME] cream to wound bed and cover with DCD change twice a day and as needed. MDS dated [DATE]- skin condition lists a pressure ulcer (PU) as stage IV present upon admission. Review of the wound data notes from the Pressure Ulcer Record. Stages the pressure ulcer at a Stage IV with wound measurements on the following dates; 8/29/13 D 4.2 cm x W 3.7 cm x L 1.0 cm 9/5/13 D 4.5 cm x W 3.1 cm x L 0.1 cm 9/19/13 W 3.2 cm x L 2.6 cm x D 0.8 cm 9/26/13 W 3.0 cm x D 2.5 cm x L 0.8 cm. 2) The facility admitted Resident #8 on 5/16/2013 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Wound care observation on 9/26/13 at 2:25 PM Employee A was observed to exit another resident's room and then go to the treatment cart to retrieve her supplies without washing her hands first. The nurse was observed to place the supplies directly on the treatment cart. She was unable to find the prescribed Santyl ointment. The nurse entered the resident's room and began rummaging through his dresser drawers; the nurse found a tube of Santyl ointment in the right second drawer of the dresser. She exited the room with the ointment and stated to the surveyors that the tube of Santyl was from the hospital. She stated that medications should be kept locked up in the treatment cart and the CNAs were responsible for inventorying the resident's belongings and removing medications. The nurse then continued to set up her supplies. She entered the room, washed her hands and washed the bedside table and then placed a barrier on the table and set up her supplies. The nurse washed her hands and donned gloves and then pushed the bedside table to the resident's bedside. The nurse repositioned the resident to his right side. She changed her gloves without washing her hands. The nurse removed the old dressing and cleaned the wound with normal saline and applied skin prep to the wound margins. The nurse removed her gloves and washed her hands and donned new gloves. The nurse squeezed a small amount of Santyl onto an applicator and placed the uncapped ointment on the resident's bedside table. She then applied the ointment to the wound and covered with a bordered dressing. The nurse then re-capped the Santyl ointment with her soiled gloves. She then removed her gloves and washed her hands. Physicians Order's dated 9/5/2013 an order for [REDACTED]. Change daily and as needed for soiling and dislodgement. Skin prep to periwound. Pressure Ulcer Record to Right outer ankle stage III. Wound measurements on dates; 8/10/13 L 1cm x W 1cm x D 0.1, 8/15/13 L 1.2 cm x W 1.3 cm x D 0.2 cm 8/22/13 L 2.5 cm x W 1.0 cm x D 0.2 cm Note reads Re-ADM ( readmission) 8/31/13 W 2.4 cm x D 1.4 cm x D 0.3 cm 9/5/13 D 2.2 cm x W 1.4 cm x D 0.3 cm 9/12/13 D 1.8 cm x W 1.0 cm x L 0.3 cm 9/19/13 L 1.7 cm x W 0.8 cm x D ? Placed 9/26/13 L 2.0 x W 1.0 cm x D ? Placed. Due to multi-organ system failure worsening of wounds was unavoidable. MDS dated [DATE] admission. The resident had short and long term memory problems and was severely impaired with decision making abilities. Total dependence for ADLs. Pressure ulcers stage II, III and IV present upon admission. 3) The facility admitted Resident #9 on 5/18/10 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Cover with a dry dressing and change daily. Further review revealed the resident was receiving supplements and multivitamins to promote wound healing. The resident was followed by the wound care team. The resident's family requested no surgical consults due to her debilitated stated and advanced age (92). During an interview on 9/26/13 at 2:20 PM Employee C (LPN) stated that the wound was healing and was looking much better. She stated that the wound was as stage IV with tendon exposure and has since healed to the point of very little wound depth and granulating tissue. Review of the Wound Notes revealed on 9/19 the wound measured 1 x 0.3 x 0.1 cm with pink [MEDICATION NAME] tissue, no signs or symptoms of infection and a scant amount of drainage. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had short term and long term memory problems and was moderately impaired with daily decision making abilities. The resident was coded as having a pressure ulcer present upon admission that was a Stage IV. During an observation of wound care on 9/26/13 at 2:10 PM Employee C washed her hands and retrieved her supplies from the med cart. The nurse entered the room and washed her hands and donned gloves. She provided for privacy. She then placed a barrier on the bedside table and set her supplies on the table. She changed her gloves without washing her hands and donned new gloves. The nurse removed the old dressing and changed her gloves without washing her hands. She then cleansed the wound with normal saline. The nurse did not change her gloves and she applied Santyl ointment to the wound bed and Skin Prep to the wound margins. She covered the wound with a 2 x 2 piece of gauze and secured with a bordered gauze dressing. The nurse removed her gloves, signed and dated the dressing and applied new gloves without washing her hands. She covered the resident, tied up the red biohazard bag, placed the bag on the bathroom counter and then washed her hands. The nurse deposited the soiled bag in the soiled utility room and washed her hands. 4) During an interview on 9/27/13 at 9:50 AM Employee A, B and C, the Nurse Consultant and the Director of Nurses were informed of the wound care observations on 9/25 and 9/26. Employee A confirmed that the soiled red bag touched the counter, cart, her clothes and the treatment book. She also confirmed that she did not wash her hands immediately after disposing of the soiled items. Employee B confirmed that she did not wash her hands between changing gloves and confirmed that she did not wash her hands after disposing of the soiled items after the treatment for [REDACTED]. Employee A also confirmed the medication left at the resident's bedside and acknowledged she did not wash her hands between glove changes. Employee A confirmed that she did not wash her hands after the treatment for [REDACTED]. During an interview on 9/27/13 at 10:05 AM the DON and the Nurse Consultant confirmed the staff should have washed their hands between glove changes and before and after the treatments. The DON stated that her expectation for the staff was to wash their hands and to not sanitize. However, the nurses did neither. Review of the facility's policy entitled Dressing Changes effective 1/1/2007 and revised on 1/1/2009 revealed the procedure was as follows: 1. Identify resident. 2. Explain procedure, provide privacy. 3. Assemble the following: a. disposable gloves. B. dressing needed to apply to wound. C. gauze to clean the wound. D. applicators. E. bag for dressing disposal per universal precautions. F. tape. 4. Put on disposable gloves. 5. Untie tape or loosen disposable tape. 6. Remove soiled dressings and dispose of per Exposure policy. 7. Remove gloves. 8. Wash hands. 9. Apply new disposable gloves. 10. Assess wound for type, color, amount of drainage. Obtain wound culture if indicated. 11. Cleanse wound as ordered, using gauze cleanse the wound. 12. Dry the wound with gauze. 13. Apply clean dressing and secure. 14. Discard gloves and wash hands. 15. Document in medical record." 4) Review of the facility's policy entitled Hand Washing Technique effective 1/1/2007 and revised 9/1/2011 revealed: "All personnel will wash hands to remove dirt, organic material, and transient microorganisms to prevent the spread on infections. Hands must be washed: after contact with blood/body fluids, in between resident contacts, before clean procedure, after contact with contaminated items or surfaces, after removal of gloves..."

Based on observations, record review, interviews and review of the facility's "One on One In-Services-Treatment Observation Checklist" the facility failed to provide wound care to promote healing for three of five observed residents (#7, 8, & 9). The facility identified 10 residents with wounds. Resident #8 had actual harm observed during the wound care and was noted to have developed a wound infection on 11/1/13. The findings included: 1)The facility admitted Resident #8 on 5/2/13 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 30 Day Minimum Data Set, dated dated [DATE], revealed the resident scored a 15/15 on the Brief Interview for Mental Status indicating no cognitive impairment. The resident was coded as requiring total two person dependence for activities of daily living. The resident was coded as having a Stage II and Stage III pressure ulcer present on admission. During an observation of wound care on 11/13/13 at 2:14 PM Employee C gathered his supplies, applied a towel barrier on an over the bed table retrieved from the clean supply room. The Santyl was capped and labeled; an open bag of multi-ply 4x4 gauze was then placed into a zip lock bag with room number and named placed on the bag. The nurse knocked on the door, provided for privacy and washed his hands and donned gloves. He assisted the resident to roll to his right side. The nurse then removed the old dressing. The dressing was noted to be an adhesive gauze dressing. The nurse removed the dressing without adhesive remover of saline to assist in the removal of the dressing. The resident stated "Ow." The removal of the dressing caused 4 additional wounds that were actively bleeding. The nurse did not stop the wound care and proceeded to cleanse the wound. He washed his hands and donned new gloves. The resident's pressure ulcer was noted to have a yellow wound bed with red wound margins. The newly acquired wounds were still noted to be bleeding. The nurse then used his gloved finger to scoop Santyl from a medicine cup and apply directly to the resident's right buttock wound. He then used the same finger to obtain more Santyl from the medicine cup and apply to the Left Buttock wound. The nurse washed his hands and donned clean gloves. He applied Skin Prep to the wound margins, applying directly to the bleeding wounds. The resident, again, said "Ow." The surveyor asked where the resident was hurting and the resident stated, "everywhere he just put that." The nurse was then noted begin to apply an adhesive dressing over the newly acquired wounds. The surveyor stopped the process and stated he had bleeding wounds. The nurse then put the adhesive dressing with the sticky side up on the overbed table and cleansed the new wounds and applied Santyl ointment with his finger again. The adhesive dressing was noted to stick to the gauze Ziploc bag and a Skin Prep applicator. The nurse removed these two items and applied the adhesive dressing onto the resident's skin. The Santyl ointment was observed to remain open with the cap laying on the bedside table. The nurse recapped the Santyl with soiled gloves and placed into the bag and back into the treatment cart. After the treatment was completed, the resident requested pain medications. He was given 7.5/325 mg of [MEDICATION NAME] with effective results 45 minutes later. On 11/13/13 at 2:52 PM, the surveyor immediately informed the Director of Clinical Services and the Regional Consultant for Clinical Services of the wound care observation. The DCS and Consultant assessed the resident, educated the nurse and contacted the resident's physician for new orders for the new wound. Review of the Physician Notes revealed on 10/8/13 the resident complained of pain to his bilateral gluteal fold decubitus. The physician documented, "Stage II Decub ulcer-improving, off load, wound care consult." Review of the physician's orders [REDACTED]." (The order was obtained after the treatment observation). On 11/1, an order was obtained for a wound care consult. On 11/4/13, the resident was prescribed [MEDICATION NAME] 7.5/325 mg every 6 hours as needed for pain. Review of the POS [REDACTED]. Skin prep to the peri-wound area; Santyl to the wound bed and cover with a dry dressing twice daily and as needed. The original order was obtained on 9/30/13. On 11/3/13, the resident was diagnosed with [REDACTED]. daily for 7 days. Review of the Lab Data revealed a Sacral Wound Culture was collected on 11/1/13 the wound grew 3+ Gram Negative Rods of Proteus Mirabilis. Review of the Weekly Skin Notes revealed the wound was measured weekly, except between 10/24/13 and 11/7/13, when the wound infection occurred. The notes did not indicate the presence of infection, however, slough was noted in the wound bed. 2) The facility admitted Resident #9 on 3/29/07 with [DIAGNOSES REDACTED]. During an observation of wound care on 11/13/13 at 1:16 PM, Employee D gathered supplies from the clean utility, medicine room and treatment cart. Hydrogel was not in any of the locations and she contacted the Central Supply Clerk to obtain Hydrogel. The Hydrogel was given to the nurse who then squeezed a small amount into two medicine cups. At 1:30 PM, the nurse entered the room, washed her hands and donned gloves. The resident was observed in bed. No wounds were noted on her arms or hands. The resident was assisted to her right side. The nurse stated that the old dressing was removed by Employee A. The wound was observed to have denuded skin with an open area noted to the lower lateral portion of the wound. The nurse completed the wound care. She returned to the treatment cart at 2:10 PM, where the hydrogel remained. The surveyor asked where the Hydrogel came from, Employee D stated that it was from another cart. She stated that she did not open the gel and confirmed the ointment was not dated. She also confirmed that there was no cap or sealant on the applicator tip. The nurse then placed the Hydrogel into the cart for future use. The nurse also had removed the package of gauze from the resident's bedside table and placed the package back into the med cart for use on additional residents. The Director of Clinical Services was immediately informed of the infection control risk. She instructed Employee D to discard the Hydrogel and she also confirmed there was no cap or date on the vial. The DCS also informed Employee D that, if supplies are brought into a resident's room, they could not be used for other residents. She instructed the nurse to only bring in what was needed for the treatment. The remaining gauze was placed in a Ziploc bag with the resident's name on bag. Review of the physician's orders [REDACTED]. The coccyx wound was to be cleansed with normal saline and have Hydrogel to the wound bed, covered with a dry dressing daily and as needed. On 11/9, a wound consult was ordered. Review of the Nurses Notes revealed an SBAR, dated 11/9/13, that documented a new raised open area to the left leg. The physician and responsible party were notified and a wound consult was obtained. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the resident had short and long term memory problems and was moderately impaired for daily decision making abilities. Review of the Care Plan (November, 2013) revealed a problem area related to Pressure Ulcers Stage II with interventions. The care plan was updated to include the left lower extremity mole. 3) The facility admitted Resident #7 on 11/1/2013 with [DIAGNOSES REDACTED]. During an observation of would care on 11/13/2013 at 12:06 PM, Employee E provided wound care to Resident #7. The nurse washed her hands, donned gloves, pulled back the bedside curtain, and used the hand control to lower the head of bed. She then waited at the side of the bed while the CNA positioned the patient. Still wearing the gloves that she had used to reposition the curtain and the head of the bed, the RN cleaned the two wounds on the patient's buttocks. (Deviation from the facility Treatment Administration Guideline, steps 6 and 7 done before step 4.) She removed her gloves, washed her hands, and donned new gloves. She then removed the paper from the tongue blade, dipped the tongue blade into the hydrogel and applied it to the wound on the left side. Using the same portion of the same tongue blade, she, again, dipped into the hydrogel and then applied it to the wound on the right side. (Potential for cross-contaminating wounds.) The RN applied the dressing, put her gloves into the red bag, and washed her hands. After observing wound care to the patient's buttocks, the surveyor asked if the resident had any other wounds. Employee E stated that, "There was a wound to the elbow but it is healed. She only has the buttocks wound." On 11/14/2013 at 10:50 AM, a skin inspection was requested by the surveyor and was performed by Regional Director of Clinical Services, and was observed by the surveyor. An open wound on the right elbow was observed and verified by the Regional Director of Clinical Services. A review of the Interdisciplinary Progress Notes revealed an entry on 11/2/2013 "Admit with R elbow, R upper arm and L buttock wounds." A review of the Admission Data Collection form revealed an "open area approximately dime sized, beige in color, abrasion on area 4" (right elbow). A review of the Treatment Record revealed an order, dated 11/2/2013, to "Cleanse R elbow with Normal Saline then apply Santyl on CDD every day." The order was marked through as "Resolved" on 11/8/2013. A review of the Pressure Ulcer Record of the R elbow revealed: 11/2/2013 - Stage 3. 2.6 x 2.4 x 2. Granulation and slough. Yellow, firm, small serous drainage. 11/7/2013 - Stage 3. 2.0 x 2.0 x 2. Granulation. Yellow, firm, small serous drainage. 11/13/2013 - Unstageable. 1 x 0.8 x _. (Blank) Slough. Yellow, firm, small purulent drainage. A review of the Weekly Skin Integrity Review reveals an entry from 11/7/2013 "Abrasion R elbow." Review of the treatment Record for November 2013 revealed the resident was receiving the ordered treatment to the right elbow until 11/8/13 when it was marked through as discontinued. No other treatment was performed on the elbow. During an interview on 11/14/2013 at 9:25 am, the Regional Director of Clinical services stated that the nursing leadership had performed skin sweeps on all the residents on the wound care list and had staged and measured the wounds. She stated that Resident #7 did have a wound on her right elbow that was not being treated. 4) Review of the facility's One-on-One In-service - Treatment Administration documents revealed that Employee A, B, C, D and E reviewed and signed the document in 10//2013. A review of the facility's Nurse Educational Checklist reveals that the employees were checked off on both Dressing Change Education and Dressing Change Return Demonstration and the document was signed by the Director of Clinical Services. 5) Review of the One-on-One In-service - Treatment Administration revealed the steps were as listed: "1. Knock on the door, introduce self ...set up table with barrier. 2. Wash hands. 3. Prepare supplies from treatment cart: can of cleaning solution, strips of tape, treatment medications/ointments with a plastic medication cup, alcohol wipes scissors, etc. Date and initial a piece of tape or outer dressing. Take 2 plastic bags into room. 4. Knock on door, place equipment on barrier. Close door, pull privacy curtain and window curtain. Place plastic bag on bed within reach for soiled dressings- use other plastic bag for linen. 5. Wipe scissors with alcohol swab and leave open, placed on the barrier for at least one minute to dry. 6. Assist patient to comfortable position. Place overbed table with equipment where it is comfortable. 7. Wash hands. Take at least three pairs of gloves and place two sets by equipment on barrier. Put on one set of gloves. 8. Remove old dressing and place in plastic bag. 9. Remove gloves, wash hands. Put on clean gloves. 10. Cleanse area as ordered, place towel under area to prevent patient/bed from becoming wet. Pat wound bed dry. 11. Remove gloves and wash hands. Put on clean gloves and proceed with treatment as ordered. 12. Remove gloves, wipe scissors with alcohol wipe and leave open to dry. Wipe cleaning solution can with alcohol and allow to dry. 13. Throw away barrier and extra treatment supplies, wash hands. 14. Don't put tape, scissors, etc. in uniform pocket. 15. Don't touch curtains, door knobs etc. with soiled gloves. Never wear gloves down hall. 16. Take plastic bags with soiled treatment supplies to soiled utility room. Discard and wash hands. 17. Document treatment. 18. Do not leave any medications involving treatments in resident room." 6) During an interview on 11/14/13 at 7 PM the Regional Consultant for Clinical Services and the Vice President for Clinical Services was informed of the treatment observations. The Vice President of Clinical Services confirmed the observations did not adhere to the facility policy and they facility expected the nurses to follow policy and the standards of practice.