Every finding on record at Aviata at Colonial Lakes

Based on observations interviews and record review, the facility failed to administer medication as ordered by the physician for 1 out of 3 residents sampled for pain management of a total sample of 52 (#104). Findings:Resident #104 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, muscle weakness, muscle spasm chronic pain due to trauma and unspecified injury at unspecified level of cervical spinal cord.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #104 was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. The MDS also revealed the resident had pain that interfered with sleep occasionally.On 3/30/26 at 12:13 PM resident #104 was lying in bed and stated that his pain was not controlled. He said that the medication he received doesn't seem to relieve his pain and he had told facility staff of his concern.A review of the March 2026 Medication Administration Record (MAR) revealed orders for Dantrium oral capsule 25 mg (Dantrolene Sodium) 1 capsule to be given by mouth at 6 AM, 2 PM and 10 PM for muscle spasms. This medication was discontinued on 3/31/26. The MAR revealed the resident received Dantrium on the following dates and times:3/2/26 at 2 PM (missed 2 doses 6 AM and 10 PM)3/23/26 at 2 PM (missed 2 doses 6 AM and 10 PM)3/24/26 at 2 PM (missed 2 doses 6 AM and 10 PM)3/26/26 at 2 PM (missed 2 doses 6 AM and 10 PM)3/27/26 at 6 AM and 10 PM (missed 2PM dose)3/28/26 at 6 AM and 2 PM (missed 10 PM dose)3/29/26 at 2 PM (missed 2 doses 6 AM and 10 PM)3/30/26 at 2 PM (missed 2 doses 6 AM and 10 PM)3/31 at 6 AMReview of nurse's progress notes regarding the missed doses of Dantrium read; on 3/23/26, 3/26/26 and 3/27/26 medication on order, on 3/28/30, 3/30/26 and 3/31/26 progress notes read medication not available until next week per pharmacy.On 4/01/26 at 3:56 PM, the Pharmacy Technician stated that the medication was last delivered on 3/13/26 and 3/7/16. The Pharmacy Technician said that there was a scheduled delivery today for a 5-day supply of the medication and at no time should a medication run out before reorder dates.A review of the MAR showed Licensed Practical Nurse (LPN) E signed that she administered the medication on 3/25/26 at 2 PM but did not administer it on 3/28/26 at 2 PM.On 4/02/26 at 10:55 AM, LPN E opened the medication cart and retrieved two blister packs of the medication with a label that showed 90 capsules were delivered on 3/5/26 with a reorder date of 3/31/26. There were at least 13 capsules remaining. There was also a brand-new blister pack of the medication with a total of 15 capsules delivered on 4/01/26. LPN E explained that she was removing the medication from the cart because she believed it was discontinued. LPN E said that she was familiar with resident #104 and did not have any issues with reordering medications. LPN E explained that she administered the medication as ordered and if she signed that it was not administered, then it was not on the cart. She continued to explain that she would have followed up with the pharmacy and called the physician.On 4/02/26 at 12:05 PM, the Director of Nursing (DON) reviewed the MAR with corresponding progress notes for March 2026 and could not explain why some nurses documented that the medication was on order from pharmacy whereas, other nurses were able to administer the medication on the same day. She said she would follow up with the nurses to find out what happened.A review of the MAR showed LPN D signed that Dantrium was not administered 5 out of the 8 doses not administered at 2 PM.On 4/02/26 at 1:20 PM, LPN D explained that she would never sign that a medication was administered if she did not have it. She acknowledged all the times she documented the medication was not administered. She also acknowledged her progress note written on 3/26/ 26 that the medication was on order because it was not on the cart. LPN D remembered that she called the pharmacy last week and was told that it was too early to be refilled and that she should have had enough coverage. LPN D explained that she did not find any in the medication cart nor accessed the pyxis and she did not follow up with pharmacy nor anyone else after.On 4/02/26 at 1:45 PM, the DON did not give any additional explanation for the missed doses and said she only spoke with LPN D and could not reach the other nurses who signed that the medication was not available. The DON said, clearly the medication was in the cart and maybe they did not look for it. She explained that her expectation is that nurses follow the physician's orders and look for the med.The facility's policy on Administering Medications revised April 2019 stated medications are administered in a safe and timely manner and as prescribed and the Director of Nursing Services supervises and directs all personnel who administer medications.

Based on interview and record review, the facility failed to ensure residents' right to privacy for 2 of 2 residents reviewed for privacy, out of a total sample of 52, (#90 and #159).Findings: 1. Resident #90 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, weakness, anxiety and diabetes. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 2/9/26 revealed resident #90 had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated she was cognitively intact. Resident #90 had impairment to one side of her upper extremities and required substantial/maximal assistance for personal hygiene. On 3/31/26 at 9:18 AM, resident #90 was observed in her bed with the head of bed elevated. She stated the middle curtain which divides the space between the A and B beds in the room was too narrow and did not provide privacy during care. The curtain was noted to be fully extended with spaces on either side which exposed the head and foot of the bed. On 4/01/26 at 11:30 AM, the curtain between A and B beds in resident #90's room was noted to be extended with spaces on either side which exposed the head and the foot of the bed. On 4/02/26 at 9:45 AM, the Certified Nursing Assistant (CNA) C stated she was assigned to resident #90. She observed the middle curtain in the room and confirmed the curtain was too narrow to provide privacy during care. She stated she tried to provide as much privacy as she could given the size of the curtain. CNA C explained that housekeeping was responsible for changing the curtains in the resident rooms. 2. Resident #159 was admitted to the facility on [DATE] with diagnoses including dementia, spinal cord injury, anxiety, hypertension, kidney failure and depression. Review of the MDS quarterly assessment with ARD of 2/02/26 revealed resident #159 had a BIMS score of 3/15 which indicated he had severe cognitive impairment. The assessment indicated he had impairments on the upper and lower extremities on both sides of his body and was dependent on staff for care including personal hygiene. On 3/30/26 at 12:40 PM, resident #159 was observed in the bed closest to the window, lying on his back. The curtain between the two beds consisted of two curtains which were opened in the middle exposing resident #159 to people outside the room. On 4/01/26 at 9:30 AM, resident #159 was in bed on his left side facing the door. The air conditioner next to the bed was on and the divider curtains were noted to be moving and had separated exposing resident #159's mid-section to anyone passing by the open door. On 4/02/26 at 10:03 AM, the Environmental Services Manager stated he is responsible for changing the curtains in residents' rooms. He observed the privacy curtain in resident #90's room and confirmed there was only one curtain. The Environmental Services Manager measured the curtain and reported it was 64 inches in width. He acknowledged the privacy curtain was not wide enough to provide complete privacy as the bed was 96 inches long. He explained the additional curtain had been taken to laundry. The Environmental Services Manager acknowledged a replacement curtain should have been hung when the other curtain was removed. He walked across the hall to resident #159's room and noted the curtains were separated in the middle. He examined the curtains and explained they were not hung appropriately to ensure enough of an overlap to provide privacy to the residents when extended. On 4/02/26 at 10:21 AM, the Nursing Home Administrator (NHA) expressed his expectation was for each residents' privacy to be respected. He stated he was informed of the issues related to the width of the privacy curtains and acknowledged they should be wide enough to provide privacy during care. Review of the facility's policy and procedure for privacy effective 11/30/14 indicated the company's policy was to give all residents the opportunity for privacy and each resident's privacy would always be respected.

Based on observation, interview, and record review the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services per standards of care for a medication administration for 1 of 6 resident reviewed during observation of medication administration, out of a total sample of 52 residents (186). Findings:Resident #186 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus. Severe dementia, major depressive disorder, brief psychotic disorder, seizures, hypertension, dysphagia, and adult failure to thrive.On 3/31/26 at 8:37 AM, Licensed Practical Nurse (LPN) B, prepared resident #186's scheduled medications at her medication cart. She poured Colace 100 milligrams (mg), Lamotrigine 25mg, Losartan 100mg, Multi-vitamin 1 tablet, Tradjenta 5mg, Zinc 50mg and 2 tablets of Metformin 500mg. LPN B then placed the medicine into a clear sleeve and crushed the medication. LPN B then stated that she will ask 'if she wants it in her food or fluids'. LPN B took the sleeve of medications and walked down to the resident's room. When LPN B exited the resident #186's room she no longer had the medication in her hand. LPN B stated that she poured the medication over the resident's breakfast. Upon entering the resident's room, resident #186 was noted to be sitting up in bed being assisted with feeding by a Certified Nursing Assistant (CNA). The CNA was noted to be sitting to the left of the resident feeding the resident spoonful's of her breakfast. LPN B stated that she poured the medication into the resident's breakfast because the resident was a 'feeder' and it is the only way she will take her medication. Resident noted to grimace and grunt after CNA fed her a spoonful of her breakfast. LPN B stated that the resident must have received a spoonful her breakfast with some of the crushed medication and asked the CNA to give the resident a sip of her drink in order to wash down. LPN B then proceeded to leave the resident's room and return to her medication cart.On 3/31/2026 at 11:30 AM LPN B acknowledged that she poured the medication into the resident's breakfast and then left the resident's room for the CNA to administer. LPN B acknowledged that it is out of a CNA's scope of practice to administer medication. LPN B stated that she should have placed the medication in a small medicine cup with a small amount of applesauce and administered that herself. LPN B acknowledged that procedure for medication administration requires a nurse to remain with the resident while medication is being administered to ensure that the resident took the medication safely and completely. LPN B did not respond when asked what she would have done if the resident did not finish her breakfast.On 4/1/26 at 11:21 AM, the Director of Nursing (DON) verified that the facilities procedure for medication administration is for the nurse who prepared the medication to be the one who administers it. She acknowledged that in this instance the CNA was the person administering the medication which is out of scope of practice. She confirmed the CNAs at the facility are not qualified to administer medications and have received no training for medication administration. The facility does not employ Qualified Medication Aides (QMA) currently. She stated that the expectation is for nurses to stay with the resident during the entire medication administration in order to ensure the medication was administered safely and completely. The DON acknowledged that pouring medication into a resident's meal can lead to many issues including some of the medication not being administered if the resident does not complete their meal.Review of Florida Administrative Code on medication administration revealed a CNA cannot administer medication without receiving medication administration training and obtaining a validation for the route the medication is being administered. Further review of Florida Administrative Code revealed a LPN shall not delegate an activity for which the CNA has not demonstrated competence. (retrieved from https://flrules.org/gateway/ChapterHome.asp?Chapter=64B9-16 on 4/10/26)Review of the Job Description for Clinical Nurse I (LPN) revealed a LPN must act in accordance with company and regulatory and professional standards and guidelines.Review of facility policy titled Administering Medications revised April 2019 revealed that only a license or permitted by this state is to prepare administer and document the administration of medications may do so.

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 2 residents reviewed for mood and behavior, of a total sample 52 residents, (#31).Findings:Resident #31 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis following a cerebral infarction, autistic disorder, pseudobulbar affect, gender identity disorder, major depressive disorder, mild cognitive impairment, mild neurocognitive disorder due to know physiological condition with behavioral disturbance, mood disorder, anxiety disorder and noncompliance with medical treatment and regimen due to unspecified reason. A review of the resident's care plan revealed resident #31 identified as transgender and prefers she/her pronouns. Resident #31 had a care plan for behaviors related to refusing medications, refusing care, crawling on the floor, cursing out staff, accusatory behaviors such as claiming staff stealing her items and attention seeking behaviors. The resident was noted to have another behavior care plan which noted resident #31 had a behavior of physical aggression such as throwing things on the floor and at her television. She was also noted to at times be verbally abusive toward staff. Resident #31 had a care plan with the focus for a communication problem related to the resident rarely speaking and communicating by typing on phone at times. A psychology consult from 3/26/26 revealed that resident #31 was having ongoing mood lability with increasing agitation and behavioral dysregulation. The resident recently had medication adjustments which were in progress and required time to reach therapeutic effect. The plan of care included to continue current psychotropic medication regimen as well as allow time for medications to reach therapeutic effect before further adjustments. The staff were to report any worsening behaviors, safety concerns, or need for as needed or emergency interventions.A review of the resident's physician orders revealed an order for haloperidol lactate injection 5 milligrams per milligrams (mg/ml) for 5mg to be injected intramuscularly (IM) one time for agitation with a start date of 3/23/26. Review of the electronic medication administration record (EMAR) revealed the medication was administered on 3/23/26 at 12:13 PM.Resident #31's progress note on 3/23/26 at 10:43 AM, revealed that the resident had been exhibiting increased agitation since the previous night. The resident had demonstrated aggressive behaviors, including hitting staff members and throwing objects. Verbal redirection and de-escalation techniques were attempted but were ineffective in managing the behavior. The provider was notified of the patient's condition. Following assessment and consultation, a one-time order for haloperidol lactate 5 mg intramuscular injection was received and carried out as prescribed.Haloperidol is classified as an atypical antipsychotic which can be used to treat a variety of symptoms in autism and mood disorders. It can be used to treat irritability and associated behaviors including aggression and self injury (retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC2171144/#:~:text=Subjects%20were%20assigned%20to%20cycles,the%20most%20treatment-refractory%20patients on 4/2/26).A review of the resident's physician orders revealed an order for haloperidol oral tablet 2mg to be injected intramuscularly one time for agitation with a start date of 3/25/26. Review of the electronic medication administration record (EMAR) revealed the medication was administered on 3/25/26 at 1:17 AM.Review of the resident's progress notes revealed no documentation at the time the haloperidol was administered as to the rationale for the need of the medication.A review of the resident's physician orders revealed an order for haloperidol lactate Injection for 2mg to be injected intramuscularly one time for agitation with a start date of 3/26/26. Review of the electronic medication administration record (EMAR) revealed the medication was administered on 3/29/26 at 11:05 PM.Review of the resident's progress notes revealed no documentation of the behaviors that required the haloperidol as the intervention.Review of the resident's progress notes revealed no documentation at the time the haloperidol was administered as to the rationale for the need of the medication.On 4/2/26 at 8:31 AM, the Pharmacy Technician revealed in the month of March only two doses of haloperidol injection were filled by the pharmacy. One dose was sent on 3/23/26 and one dose was sent on 3/26/26. No dose was sent from the pharmacy on 3/25/26. On 4/2/26 at 11:13 AM, phone interview with RN F revealed that on 3/25/26 resident #31 had become aggressive and yelling. The resident had punched her. She stated she had called the physician for an order for IM haloperidol. She stated that she did not pull the medication for the emergency medication kit. She replied that the resident had a box of haloperidol IM in the medication cart and that is what she used. She could not remember the dose but confirmed she did not give the medication orally.On 4/2/26 at 11:40 AM, the Director of Nursing (DON) stated that an order written for a 2mg tablet of haloperidol to be given intramuscularly would need clarification before administration. She was unable to answer how the medication was given if the pharmacy did not supply it and the emergency medication kit did not stock 2mg haloperidol. She stated that the expectation for nurses is to document any changes with the residents which includes behaviors and new orders from the physician. Her expectation was for nurses to document behaviors that led up to the administration of haloperidol as well as all interventions that were used prior to the administration.Review of facility policy titled Administering Medications revised April 2019 revealed that the individual administering the medication should document any complaints or symptoms for which the drug was administered in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure a Midline Intravenous (IV) dressing care was completed as per professional standards for 1 of 1 resident of a total sample of 4 residents, (#1).Resident #1, an [AGE] year-old female was readmitted to the facility on [DATE]. Her diagnoses included abscess left great toe, cerebral infarction (stroke), type 2 diabetes, heart failure, peripheral vascular disease, elevated white blood cell count and lymphedema. A Midline Catheter is a thin, flexible tube placed into a vein in the arm. The catheter is 8-10 centimeters long and can stay in the arm for up to 29 days. This allows patients to get IV (intravenous) medicines and have blood samples drawn. The catheter is placed by a trained nurse. (retrieved on 10/4/25 at 3:57 PM from https://patient.uwhealth.org/healthfacts).On 9/30/25 at 12:30 PM, resident #1 was observed lying in recliner type chair in her room. The 200 Unit Manager was observed doing wound care to the resident #1's left great toe which was swollen and red. The Unit Manager acknowledged that resident #1 had transparent dressing on her right upper arm midline IV site dated 9/26/25. She acknowledged the IV dressing was dirty, half off and gauze was covering the insertion site. The nurse explained the resident had been getting antibiotics in her IV for foot wound infection and the physician wanted to keep the IV in place should she need more IV antibiotics. The Unit Manager said because there was gauze present covering the IV the dressing should have been changed on 9/28/25. The nurse added that even if there are no orders it is standard of nursing practice to change IV dressing every 7 days when clear dressing present and every 2 days when gauze is used. Current nursing orders for resident #1's midline IV were dated 9/22/25: flush with normal saline every shift, measure right arm circumference and external catheter length on admission and with each dressing change, evaluate right forearm IV site for leakage/bleeding /signs of infection every shift. Resident #1 received IV Zosyn every 6 hours for 7 days starting on 9/18/25. The resident had care plan in effect last updated on 9/22/25 for IV medication related to left great toe abscess with goal that she will not have any complications related to her IV therapy. Review of the medication administration record revealed that although the nurses were flushing the midline IV twice daily with saline, they failed to notice the dressing needed to be changed 5 times between 9/28/25 to 9/30/25. On 9/30/25 at 12:57 PM, the Regional Registered Nurse (RN) said they teach the nurses who take the IV course that when gauze is present to change the IV dressing every 48 hours and it is preferred, they place a clear transparent dressing instead to allow for visualization of the IV insertion site. Review of the facility Catheter Insertion and Care policy revised 1/17/19 read, Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter -site dressings. General Guidelines 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in anyway. The facility workbook provided to the nurses for IV training on page 60 gave instructions Change dressing weekly or per facility policy or every 2 days if gauze is used.

Based on interview, and record review, the facility failed to ensure prescribed therapeutic diet of dysphagia mechanical soft consistency was followed for 1 of 8 sampled residents, (#1). This failure resulted in resident #1 consuming the wrong consistency snack, causing her to choke, and turn blue until she was transferred and admitted to the hospital Intensive Care Unit (ICU) and treated for acute respiratory failure with hypoxia. On 12/20/24 at 11:00 AM, resident #1, who was on a mechanical soft consistency diet, was allowed to consume a peanut butter and jelly (PB&J) sandwich from a tray of snacks left on a table in the dayroom by Certified Nursing Assistant (CNA) A. The CNA was aware resident #1 was on a mechanical soft diet but allowed the resident to eat the sandwich because she had seen her eat bread in the past. The CNA recalled she was called back into the dayroom by CNA B who told her resident #1 did not look good. She said resident #1 was sitting up in a chair with her mouth open and tongue sticking out. Licensed Practical Nurse (LPN) C and LPN D immediately responded, and LPN C attempted to administer the Heimlich maneuver but the resident was unresponsive. The resident was lowered to the floor and suctioned with some food removed from her airway. The resident remained unconscious with a pulse when the paramedics arrived and removed food from the back of the resident's airway. The resident was transported to the hospital and admitted to the Intensive Care Unit with admitting diagnoses of acute respiratory failure with hypoxia. The facility's failure to follow the prescribed therapeutic diet resulted in substandard quality of care at the Immediate Jeopardy level, starting on 12/20/24. The facility implemented actions to remove the immediacy as of 1/14/25. Findings: Cross reference F726 Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Parkinson's disease, unspecified psychosis, dysphagia oropharyngeal phase, history of cerebral infarction (stroke), unspecified dementia, generalized anxiety disorder, and major depressive disorder. Review of resident #1's physician orders for December 2024 revealed an order for a dysphagia mechanical soft texture diet since 8/29/23. Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. The assessment indicated resident #1 had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs). The assessment did not document any symptoms of a swallowing disorder but showed she was on a mechanically altered diet which required a change in food texture or liquids. Dysphagia is defined as difficulty swallowing that could, in some cases, make it almost impossible to swallow. Oropharyngeal phase dysphagia can be caused by neurological conditions such as Parkinson's disease. Not being able to swallow correctly can lead to complications such as aspiration pneumonia due to food entering the lungs and choking due to food getting stuck in the throat. When food gets stuck in the throat it can block the airway and lead to death if not attended to promptly (retrieved on 01/21/25 from the mayoclinic.org). The National Foundation of Swallowing Disorders, following the recommendations of The American Dietetic Association, described dysphagia mechanical soft texture diet included foods such as pureed breads but advised all other bread textures should be avoided. The recommendations included other foods to be avoided included sandwiches and peanut butter, (retrieved on 1/23/25 from swallowingdisorderfoundation.com). A progress note written by the Director of Nursing (DON) on 12/20/24 at 11:28 AM, revealed that at 11:10 AM, a hospice CNA and floor CNA were in the dining room of the memory care unit passing snacks. The floor CNA was called to assist on the floor and within seconds the hospice CNA alerted the floor CNA that the resident didn't look like she felt well. The note described the floor CNA stated that the resident had her mouth open and tongue sticking out, so she called the nurse immediately. The DON documented the LPN started the Heimlich maneuver and soggy bread material came out, then she was laid on the floor on her side and suctioned. The APRN, Physician Assistant (PA), and another LPN also responded. She detailed the resident's oxygen saturation was 71% on room air so oxygen was applied, and the oxygen saturations came up to 92%. The DON detailed that Emergency Medical Service (EMS) arrived and used a laryngoscope (a small tool to look in your throat) to remove the remaining object from blocking the airway. Resident #1 was transferred to the hospital for possible aspiration and the family was notified. Normal oxygen saturation levels should be between 95% and 100% for most people. Oxygen is essential to all body functions so low oxygen levels are concerning and may lead to many serious conditions and damage to individual organ systems, especially your heart and brain. If your level is lower than 88% you should get emergency treatment, (retrieved on 1/27/25 from www.myclevelandclinic.org). Review of a nursing progress note revealed a change in condition note entered on 12/20/24 at 1:30 PM, that indicated resident #1 had respiratory arrest. The note revealed resident #1's vital signs at that time were, blood pressure 85/56, pulse 44, no respirations, oxygen saturation 71% on room air, and mental status was unresponsive. The LPN documented that she responded immediately and noticed the resident had something in her mouth and her face was discolored. She started the Heimlich maneuver and soggy bread material was expelled from her mouth, so they lowered her to the floor on her side and suctioned. EMS was called, oxygen was applied on the resident, and the APRN gave the order to transfer the resident to the hospital. At 2:34 PM, the LPN documented she spoke with the resident's son who said he was at the hospital with the resident. A nursing progress note dated 12/24/24 at 11:02 PM, indicated resident #1 returned to the facility from the hospital with orders for a diet change. On 12/25/24 at 10:25 AM, the Respiratory Therapist (RT) assessed the resident and documented she was awaiting orders from the APRN. The Registered Dietician (RD) evaluated the resident on 12/26/24 and noted resident #1's diet order was changed to a regular diet with pureed texture and thin liquids. She also documented the resident required supervision with meals due to her history of attempting to take food from others. On 12/26/24 a change in condition note was documented by a nurse that the resident had abnormal lung sounds (rales, rhonchi, wheezing) and the doctor ordered a chest X-ray due to chest congestion. Review of a physician progress note dated 12/29/24, revealed resident #1 was evaluated for resumption of care after a hospitalization from [DATE] to 12/24/24 due to choking resulting in intubation (a tube in her throat to breath) as per hospital records with administration of multiple Intravenous antibiotics in the ICU setting. She returned to the facility on antibiotic therapy for five days. Review of resident #1's hospital records with admitted [DATE], revealed she was seen due to a choking incident where she was unresponsive. The admission summary indicated the resident choked on her meal and became unresponsive, so EMS were called. Upon arrival to the hospital emergency room (ER), she remained unresponsive, so they intubated her for hypoxic (low oxygen) respiratory failure and admitted her to the ICU. The discharge summary on 12/24/24 showed the discharge diagnosis of acute hypoxic respiratory failure and noted that speech and swallow tests had been done, and her diet was adjusted. On 1/13/25 at 1:56 PM, the DON stated she served as the facility's Risk Manager. She confirmed that on 12/20/24 around 11:00 AM, CNA A alerted staff that resident #1 was choking on a snack in the memory care unit day room. The DON stated the facility found the root cause of the event was staff were not familiar with the approved snacks per diet texture orders and snacks being placed unsecured in the dementia unit. In a joint interview on 1/13/25 at 4:15 PM, with the Director of Rehabilitation (DOR) and the Speech Therapist (ST), the DOR stated resident #1's most recent Speech evaluation was completed on 8/27/24 and showed a decline in cognitive and swallowing function which required a mechanical soft/chopped textured diet. The DOR explained resident #1 also required supervision during meals and cues for swallowing. The ST stated their goal was for resident #1 to implement compensatory strategies to increase safety during meals. She explained that a mechanical soft diet consisted of foods like pudding, applesauce, Jello, and pureed bread but would not include peanut butter and jelly sandwiches. On 1/14/25 at 9:24 AM, in a telephone interview CNA A said she had worked at the facility since July 2024 and had no prior experience as a CNA. She recounted that on 12/20/24 she was assigned to work the secure memory care unit and had worked with resident #1 before. CNA A stated she was aware resident #1 required a dysphagia mechanical soft texture diet and said around 11:00 AM she went to the nourishment room, outside of the secured unit, to get snacks for the residents. She recalled she grabbed a tray that contained labeled snacks with resident's names and other unlabeled snacks such as peanut butter sandwiches and cookies. She returned to the memory care unit's dayroom and saw resident #1 sitting at a table by herself, next to the door. CNA A said she placed the tray of snacks on a table across from resident #1 and saw her grab the peanut butter and jelly sandwich from the tray. She confirmed she allowed resident #1 to have the sandwich because she had seen her eating bread before, thought the sandwich was soft, and ok for her to eat. CNA A explained she was then called away by another CNA that needed help and left the dayroom. She recalled there was a hospice CNA in the dayroom that was attending to another resident who called her back into the dayroom a few moments later to say that resident #1, didn't look good. CNA A explained she returned to the dayroom and saw resident #1, who was turning blue, had her mouth open and tongue sticking out. She said she immediately called for help and LPN C and LPN D arrived to provide emergency care for resident #1. CNA A remembered resident #1 was unresponsive and they gave her supplemental oxygen until EMS arrived and transferred her to the hospital. CNA A explained she had not been educated about which foods were appropriate for a dysphagia mechanical soft diet and had not asked anyone if a peanut butter and jelly sandwich was appropriate for resident #1. On 1/14/25 at 9:35 AM, LPN C stated that she was assigned to the memory care unit on 12/20/24 and around the time of the incident she was out of the secured unit making copies at the nurse's station. She recalled at approximately 11:00 AM, CNA A came out of the secured unit saying she needed help right away. When she entered the dayroom, she saw resident #1 sitting up in a chair with her mouth open, tongue sticking out, and a creamy substance in her mouth. LPN C said she immediately started the Heimlich maneuver, and some food came out, but the resident was unresponsive. She recounted that LPN D came to the room with portable suction and assisted her to lower resident #1 to the floor, place her on her side and suction her mouth. LPN C explained some food came out of resident #1's moth, but she was still unresponsive, and her oxygen saturation was low at 71%. She said at that time that they gave her supplemental oxygen and waited for EMS to arrive. LPN C said when EMS arrived they used the laryngoscope to get more food out of her mouth and then transported her to the hospital. She confirmed that resident #1 had known behaviors of grabbing food from others and ate very fast. LPN C stated resident #1 required a mechanical soft texture diet and therefore a peanut butter and jelly sandwich would not be appropriate for her because it was very sticky and hard to swallow. On 1/14/25 at 9:40 AM, the Certified Dietary Manager (CDM) confirmed that resident #1 was prescribed a dysphagia mechanical soft texture diet on 12/20/24. He stated that prescribed snacks were served around 10:00 AM and 2:00 PM daily but resident #1 did not get a prescribed snack. The CDM explained resident #1 was offered a daily snack because she liked them so extra snacks were always added to the tray. He related that the dietary aides were directed to place the snack trays in the 400-hall nourishment room and not in the memory care unit's dayroom, to prevent memory care residents from grabbing foods not prescribed for their diet. He explained some of the snacks offered were peanut butter sandwiches, applesauce, pudding, and cookies. He confirmed that resident #1 had behaviors of grabbing foods from others, so trays should not be left unattended. The CDM said pureed bread was okay, but peanut butter and jelly sandwiches were not acceptable or safe for a resident who needed a dysphagia mechanical soft texture diet. On 1/14/25 at 1:46 PM, LPN D explained he had not worked on the secured memory care unit, but on 12/20/24 he was at the nurses' station outside the secured unit when he heard CNA A calling for help. He recounted that when he entered the dayroom, resident #1 was sitting in a chair making gasping sounds and appeared to be having trouble breathing. He explained LPN C was administering the Heimlich maneuver to resident #1 when she went unconscious but had a pulse. He said they lowered her to the floor on her side and suctioned her mouth with some food coming out. On 1/14/25 at 2:24 PM, in a telephone interview CNA B confirmed she worked for an outside hospice and was at the facility on 12/20/24 to provide care to hospice residents in the building. She explained that on that day at approximately 11:00 AM, she was visiting a resident in memory care unit and was working with a resident in the dayroom when she noticed that resident #1 did not look good. Hospice CNA B said she did not see CNA A bringing the snack tray in to the room and had not seen resident #1 take the peanut butter and jelly sandwich. She explained that CNA A had left the room and CNA B ran out to get her back when she saw resident #1 looking ill. Hospice CNA B said CNA A arrived immediately and went to call for help. She reported that because she was not directly observing resident #1 when CNA A left the room, she could not say how long she had been choking before she noticed. On 1/15/25 at 2:05 PM, the APRN said that around lunch time on 12/20/24, she was called to the memory care unit by a nurse who told her a resident was choking. She recounted when she arrived in the dayroom she saw resident #1 sitting up in a chair and a nurse was behind her performing the Heimlich maneuver. The APRN described the resident as looking ashen and not responding but having a pulse. She said during the Heimlich some food came out, but the resident was still unresponsive. The APRN directed the staff to lower the resident to the floor on her side and a male nurse started suctioning. She recalled that oxygen was applied until EMS arrived and proceeded with additional life saving measures. The APRN said the resident's color started improving and EMS transported her to the ER. She explained that prior to the incident she had not worked with resident #1 and was unaware of her dysphagia diagnosis or food texture order. but was told by staff that the resident had ingested some type of bread, and which caused her to choke. The APRN indicated she did not believe bread was part of a mechanical soft texture diet and it was her expectation for staff to be knowledgeable on the types of textures and foods appropriate for each diet. She said that a resident with swallowing difficulties could potentially choke, aspirate, or become unresponsive if they ingested food not suitable for their diet texture. The Immediate Jeopardy was determined to be removed on 1/14/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The resident sample was expanded to include seven additional residents who required dysphagia diets. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *CNA A received a teachable moment regarding appropriate snacks according to diet texture with the DON on 12/20/24. * On 12/20/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the action plan. The Medical Director reviewed and approved the plan. * On 12/20/24 the RD completed a quality review on residents diet orders and validated with the CDM against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed. * On 12/20/24 resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were posted to dining rooms, nursing stations, and med carts. The CDM validated that snacks were delivered to the secured pantry. * Education for staff started on 12/20/24 and continued through 1/3/25. They educated staff on appropriate snacks based on resident diet texture order and the procedure to validate the resident's diet order if needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders. * On 12/23/24 the CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedures for snacks. New diet orders would be reviewed during morning clinical meeting. *On 12/23/24 Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done 12/23/24, 12/30/24, and 1/06/25 with no discrepancies noted. *On 12/24/24 a facility wide quality review was begun by Speech Language Pathologist to verify that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed on 1/14/25 with no discrepancies noted. *Resident #1 returned to the facility on [DATE] from the hospital with diet texture downgraded to puree. Orders and care plans were updated accordingly to reflect the texture change. The RD followed up with resident #1 on 12/26/24 with no new recommendations. * On 12/24/24 NHA and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective. *On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker. There were no issues noted. Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks. Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

Based on interview, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had the knowledge, skill sets, and competencies to provide foods/snacks to residents in accordance with their plan of care and physician orders for 1 of 8 sampled residents, (#1). This failure resulted in the resident being allowed to consume the wrong consistency snack which resulted in the resident choking and being transferred to a higher level of care where she was admitted to the Intensive Care Unit (ICU) and treated for acute respiratory failure with hypoxia. On 12/20/24 at 11:00 AM, resident #1, who was on a mechanical soft consistency diet, was allowed to consume a peanut butter and jelly (PB&J) sandwich from a tray of snacks left on a table in the dayroom by CNA A. The CNA was aware resident #1 was on a mechanical soft diet but allowed the resident to eat the sandwich because she had seen her eat bread in the past. The CNA recalled she was called back into the dayroom by CNA B who told her resident #1 did not look good. CNA A said resident #1 was sitting up in a chair with her mouth open and tongue sticking out. Licensed Practical Nurse (LPN) C and LPN D immediately responded, and LPN C attempted to administer the Heimlich maneuver but the resident was unresponsive. The resident was lowered to the floor and suctioned with some food removed from her airway. The resident remained unconscious with a pulse when the paramedics arrived and removed food from the back of the resident's airway. The resident was transported to the hospital and admitted to the Intensive Care Unit with admitting diagnoses of acute respiratory failure with hypoxia. The facility's failure to follow the prescribed therapeutic diet resulted Immediate Jeopardy starting on 12/20/24. The facility implemented actions to remove the Immediate Jeopardy as of 1/14/25. Findings: Cross reference F692 Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Parkinson's disease, dysphagia oropharyngeal phase (trouble swallowing in the mouth or throat), history of cerebral infarction (stroke), and unspecified dementia. Review of resident #1's physician orders for December 2024 revealed orders for a dysphagia mechanical soft texture diet since 8/29/23. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. She had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs). She was not identified as having any symptoms of a swallowing disorder but was on a mechanically altered diet which required a change in food texture or liquids. Review of resident #1's care plan, with revision date 11/20/24, identified she had a potential nutritional problem related to the need for mechanically altered diet texture and past medical history of Parkinson's disease, dysphagia, dementia, and Gastro Esophageal Reflux Disease. The interventions included staff to monitor/document/report as needed any signs or symptoms of dysphagia but failed to include interventions for staff to serve diet as ordered. According to the National Foundation of Swallowing Disorders, which followed the recommendations from the American Dietetic Association, a dysphagia mechanical soft texture included foods such as soft pancakes, and pureed breads but all other bread textures should be avoided. Other foods that should be avoided included sandwiches and peanut butter, (retrieved on 1/23/25 from Swallowingdisorderfoundation.com). On 1/13/25 at 1:56 PM, the facility's Reportable and Adverse incident log from December 2024 was reviewed with the Director of Nursing (DON) who was also the Risk Manager. She said that on 12/20/24 at around 11:00 AM, CNA A alerted staff that resident #1, who at the time was in the day room of the memory care unit, was choking on a snack. The Heimlich maneuver was performed, and the resident was suctioned but ultimately, was transferred via Emergency Medical Services (EMS) to the hospital. The DON recalled she responded to the scene along with two nurses, the Advance Practice Registered Nurse (APRN), and the Physician Assistant (PA). According to the DON, the root cause was staff not being familiar with the approved snack list based on diet texture orders and snacks being placed unsecured on a dementia unit. On 1/14/25 at 9:24 AM, during a telephone interview, CNA A stated she had worked at the facility since July 2024 and had no prior CNA experience. She reported on 12/20/24 she was assigned to work on the secure memory care unit. She noted she had worked with resident #1 before and was aware she was on a dysphagia mechanical soft texture diet. She recalled at about 11:00 AM, she went to the nourishment room, located outside of the secured unit, to get snacks for the residents. She said she picked up a tray with labeled snacks with resident names and other snacks such as peanut butter sandwich and cookies, that had no resident names. She stated she went back to the memory care unit's dayroom where resident #1 was seated at a table by herself next to the door. She said she placed the tray of snacks on a table across from resident #1 and then saw the resident grab a peanut butter and jelly sandwich. She said she allowed the resident to have the sandwich because she had seen her eating bread before, and the sandwich was soft. She remembered she was called away by another CNA that needed help and left the dayroom. She noted she was called back to the dayroom by a hospice CNA a few seconds later as resident #1 didn't look good. She said the resident was turning blue, had her mouth open and tongue sticking out. She recalled she immediately called for help and LPN C administered the Heimlich maneuver and LPN D assisted with suctioning the resident's airway. She reported resident #1 was unresponsive and was given supplemental oxygen until paramedics arrived and transferred the resident to the hospital. She said she was not trained on what foods were appropriate for a dysphagia mechanical soft diet and did not ask anyone if a peanut butter and jelly sandwich was appropriate for the resident. Review of the nursing progress notes revealed a change in condition note entered on 12/20/24 at 1:30 PM, by an LPN that noted the resident went into respiratory arrest. The note revealed resident #1's vital signs at the time of the incident were, blood pressure 85/56, pulse 44, respirations 0, oxygen saturation 71% on room air, and mental status was unresponsive. The LPN documented that she responded immediately and noticed the resident had something in her mouth and her face was discolored. She started the Heimlich maneuver and soggy bread material was expelled from her mouth. The note showed they lowered the resident on to the floor on her side and suctioned. The note read that EMS arrived, applied oxygen and the APRN gave the order to transfer the resident to the hospital. At 2:34 PM the LPN noted she spoke with the resident's son who said he was at the hospital with the resident. According to resident #1's hospital records with admitted [DATE], noted she was seen due to the choking incident and resident being unresponsive. The admission summary showed the resident was having her meal, started to choke and became unresponsive. On arrival to the emergency room (ER), she remained unresponsive, was intubated for hypoxic respiratory failure and admitted to the ICU. The discharge summary dated 12/24/24 showed the discharge diagnosis of acute hypoxic respiratory failure and noted that speech and swallow tests were done, and diet was adjusted. Review of resident #1's modified Quarterly MDS completed on 12/27/24, post readmission from an acute care hospital, revealed she required setup assistance for eating, had a new behavior of rejecting care, had difficulty swallowing due to coughing or choking during meals, and continued on mechanically altered diet. Review of a physician progress note dated 12/29/24, noted resident #1 was evaluated for resumption of care after hospitalization from [DATE] to 12/24/24 due to choking resulting in intubation as per hospital record with administration of multiple intravenous antibiotics in the ICU setting. She returned to the facility on antibiotic therapy for five days. Review of CNA A's personnel file revealed she was hired on 7/09/24 and had received her CNA certification in 2024. The facility's Job Description for CNAs noted CNAs were entrusted to provide responsible healthcare and were responsible to provide each of their assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan. Other duties and responsibilities included providing direct care in accordance with treatment plans and attending scheduled facility in-services, orientations, and educational classes. According to the job requirements, CNAs must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. On 1/14/25 at 4:34 PM, the Assistant Director of Nursing (ADON) was interviewed with the Regional Nurse Consultant (RNC) and DON present. The ADON confirmed she was the Staff Educator and stated staff received orientation with general nursing topics that included nutrition but not specific to diet types and appropriate food textures. Review of CNA A's education file revealed she completed the new hire orientation packet and skills competency assessment for eating support on 7/10/24. There were no documented competencies or in-services related to caring for dysphagia residents, food textures, or appropriate foods/snacks for each diet type. On 1/15/25 at 12:43, CNA E said that prior to the choking incident she had not been educated on diet types or food textures. She worked with resident #1 regularly and said she preferred not giving resident #1 a snack because she was at risk for choking. On 1/15/25 at 1:10 PM, CNA A stated she had not received training related to diet types or food textures when she was hired, and she did not remember attending any in-services prior to the choking incident. On 1/15/25 at 1:46 PM, LPN D reported he had worked at the facility for a total of two years. He said he had never received education during orientation related to diet types and food textures but had received education at a prior facility. On 1/15/25 at 3:21 PM, interviews were conducted with five CNAs from the first and second shift, who said they did not receive education regarding diet types or food textures prior to the choking incident. They confirmed they were responsible for passing out meal trays, handing out snacks, assisting with feeding residents, and monitoring residents during meals. A review of the Facility Assessment revised 8/01/24, noted the facility provided resident services such as eating assistance and nutritional services including individualized dietary plans and specialized diets. The assessment lacked an explanation of how the facility would educate their staff to ensure these services were provided safely and appropriately. According to section 3.4, Staff training/education and competencies, in-service trainings for nursing aides must address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff. According to the Consistency Census Report printed on 1/14/25 at 2:51 PM, 31 out of 175 residents in the facility required a mechanically altered texture diet (mechanical soft, pureed, thickened liquids) related to a dysphagia diagnosis. In the memory care unit six residents required a mechanically altered texture diet. The resident sample was expanded to include seven additional residents who required dysphagia diets. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *CNA A received a teachable moment regarding appropriate snacks according to diet texture with DON on 12/20/24. * On 12/20/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the action plan. The Medical Director reviewed and approved the plan. * On 12/20/24 the RD completed a quality review on resident diet orders and validated with the Certified Dietary Manager (CDM) against the kitchen's meal ticket identifiers to ensure that diets were being served as prescribed. Orders were clarified as needed. * On 12/20/24 resident diet orders were posted in pantry rooms and dining rooms. Print outs listing approved snacks for regular texture, dysphagia advanced, dysphagia mechanical soft, and dysphagia pureed were posted to dining rooms, nursing stations, and med carts. CDM validated that snacks were delivered to the secured pantry. * Education for staff started on 12/20/24 and continued through 1/3/25 with 98% trained. Education included recognizing the different diet types and food textures, appropriate snacks for each diet type, and procedure to validate the resident's diet order as needed. Training also included Abuse/Neglect training and supervision during snack pass. Newly hired staff would receive education during orientation regarding appropriate snacks to be offered based on diet texture orders. * On 12/23/24 CDM completed 100% training with dietary staff regarding meal ticket accuracy and procedure for snacks. New diet orders would be reviewed during morning clinical meeting. *On 12/23/24 Unit Managers began weekly audits to ensure appropriate snacks were being passed, meal tickets matched what was being served, and staff was able to verbalize where to find correct diet information. Audits were done 12/23/24, 12/30/24, and 1/6/25 with no discrepancies noted. *On 12/24/24 a facility wide quality review began by Speech Language Pathologist verifying that residents with dysphagia diagnosis were on the correct texture diets. The audit was completed on 1/14/25 with no discrepancies noted. *Resident #1 returned to the facility on [DATE] from the hospital with diet texture downgraded to puree. Orders and care plan were updated accordingly to reflect the texture change. Registered Diet (RD) followed up with resident on 12/26/24 with no new recommendations. * On 12/24/24 the Administrator and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made. They determined that all plans that had been put in place were effective. *On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker. There were no issues noted. Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks. Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

Based on interview, and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable goals and interventions for a vulnerable resident with behaviors that posed a risk to their safety, (#1). Findings: Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Parkinson's disease, unspecified psychosis, need for assistance with personal care, dysphagia oropharyngeal phase, history of stroke, and unspecified dementia. Dysphagia oropharyngeal phase is a term to describe swallowing problems that occur in the mouth or throat, usually from impaired muscle function or sensory changes, (retrieved on 1/27/25 from www.uclahealth.org). Resident #1's Quarterly Minimum Data Set (MDS) assessment with reference date 9/30/24 revealed she had a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. She had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs). The assessment noted resident #1 required a mechanically altered diet due to her dysphagia diagnosis. A modified Quarterly MDS was completed on 12/27/24, post readmission from an acute care hospital which indicated she now required setup assistance for eating, had new behavior of rejecting care, and had difficulty swallowing due to coughing or choking during meals. The assessment noted resident #1 continued to require a mechanically altered diet. Review of resident #1's medical record revealed her diet orders were changed from a regular texture to a dysphagia mechanical soft texture on 8/29/23 which was continued until 12/25/24 after the choking incident. After 12/25/24 when resident #1 returned from the hospital her diet was changed to dysphagia with pureed texture. On 1/13/25 at 1:56 PM, the facility's Reportable and Adverse incident log from December 2024 was reviewed with the Risk Manager. She said that on 12/20/24 at around 11:00 AM, Certified Nursing Assistant (CNA) A alerted staff that resident #1, who at the time was in the day room of the memory care unit, was choking on a snack that had been provided to her. The Risk Manager continued to explain, the Heimlich maneuver was performed, and the resident was suctioned and subsequently transferred via Emergency Medical Service (EMS) to the hospital and admitted to the Intensive Care Unit (ICU) for acute respiratory failure with hypoxia. She recounted the facility's investigation of the event revealed that on 12/20/24 at around 10:50 AM, CNA A entered the memory care unit with a tray of snacks that included peanut butter and jelly (PB&J) sandwiches and placed the tray on a table across from resident #1. Resident #1 was not prevented from grabbing a sandwich by CNA A because she said that although the resident required a mechanical soft diet she had previously seen her eating bread and assumed the PB&J sandwich was okay. On 1/14/25 at 9:24 AM, in a telephone interview CNA A corroborated the Risk Manager's statements of the incident that involved resident #1 on 12/20/24. She recalled she had worked with resident #1 regularly and knew her well. CNA A explained that resident #1 had behaviors where she grabbed food from other resident's plates and staff tried to keep her safe by doing things like sitting her at a table by herself and ensuring the snack tray was not left unattended. She stated the snack trays were delivered to the nourishment room outside the secure memory care unit to prevent residents from grabbing food not prescribed for their diet. CNA A said she had never observed resident #1 grabbing food from the tray or from other residents during her shift, but other CNAs had previously reported the behavior to her. On 1/14/25 at 9:35 AM, Licensed Practical Nurse (LPN) C confirmed that on 12/20/24 she responded to the choking incident with resident #1 and assisted with first aid including the Heimlich maneuver. She recounted that she worked with resident #1 before and had observed her grabbing food from other residents during mealtimes. She stated resident #1 loved to eat and often ate very fast. On 1/14/25 at 9:40 AM, the Certified Dietary Manager (CDM) confirmed resident #1 was on a mechanical soft diet and did not have prescribed snacks but was offered a snack daily. He said he was aware resident #1 had behaviors of grabbing food from trays and from other residents. He confirmed dietary aids delivered the snack trays to the nourishment rooms. Review of resident #1's medical record revealed she had a care plan with revision date of 11/20/24 for potential nutritional problem related to need for mechanically altered diet, texture and past medical history of stroke, dysphagia, and history of significant weight gain. The interventions included monitor/document/report as needed any signs or symptoms of dysphagia. Review of the care plan revealed goals and interventions did not address the resident's known behaviors to ensure the resident's safety during meals. On 1/02/25, two weeks after the choking incident and nine days after readmission from the hospital, the Registered Dietician (RD) added to the care plan that resident #1 attempted to eat foods not on her prescribed food consistency. On 1/15/25 from 12:43 PM to 3:21 PM, interviews were conducted with CNAs E, F, G, H, I, J and K who had worked with resident #1 previously or had knowledge of her behaviors. The CNAs confirmed that resident #1 was known to grab food from others. CNA E said that resident #1 needed feeding assistance and monitoring during meals because she ate so fast and could choke. She said she avoided giving resident #1 snacks and sat her at a table by herself to ensure she would not grab foods from others. The six other CNAs corroborated the behaviors saying that prior to the choking incident they had observed resident #1 grabbing food from other residents and on one occasion a CNA attempted to remove food from her mouth to prevent her from choking. On 1/16/25 at 12:42 PM, the MDS Coordinator stated she was one of two staff members responsible for resident care plans and attended care plan meetings with residents and representatives. She explained the whole clinical team was responsible for developing and revising care plans. The MDS Coordinator said that in general, the care plan was updated when there were changes in the resident's condition, behavior, or preferences. She said she attended clinical meetings every morning with the administrative team and clinical staff where they reviewed resident changes such as falls, behaviors, and orders. The MDS Coordinator reported that if the resident developed any behaviors that were constant or posed risk to their safety, staff were responsible for reporting the behavior to a supervisor so that a care plan could be developed and implemented. She explained that the Social Service Department was responsible for developing care plans for a resident's behavior. The MDS Coordinator confirmed resident #1 had behaviors but said that none were related to grabbing food and did not recall speaking about these behaviors during clinical meetings with the resident's son. On 1/16/25 at 1:10 PM, in a joint interview with the Unit Manager (UM) for the memory care unit and the Director of Nursing (DON), the UM stated she was not aware that resident #1 had behaviors of grabbing food from others. She said she frequently observed staff in the dayroom to ensure that residents were properly monitored during meals but had not noticed any behaviors during mealtime. The UM explained she attended clinical meetings, and the choking incident had been discussed. She stated she expected staff to report any changes in resident behavior to their immediate supervisor. The DON reported she first learned about resident #1's behavior of grabbing food after the choking incident. She said they had discussed the choking incident during clinical meetings, but her behaviors had not been mentioned at that time. The DON confirmed the Social Service Department was responsible for behavioral care plans and her expectation was for staff to report any changes in behaviors to their immediate supervisor to ensure care plans were updated accordingly. On 1/16/25 at 1:51 PM, the Social Services Assistant confirmed she was responsible for creating the behavioral care plans and reported she attended the daily clinical meetings. She did not recall discussing resident #1 having unsafe behaviors during meals. Review of the facility's Policies and Procedures revised 9/25/17 revealed an individualized person-centered plan of care would be established by the interdisciplinary team (IDT) with the resident and/or representative and updated in accordance with state and federal regulatory requirements. The policy detailed that the care plan must be reviewed, updated and/or revised based on changing goals, preferences, and needs of the resident and in response to current interventions as needed. The document indicated that the IDT should ensure the plan of care addressed any resident needs and that the plan was oriented towards attaining or maintaining the highest practicable physical, mental, and psychosocial wellbeing.

Based on interview, and record review, the facility failed to appropriately document, investigate, follow up, and promptly resolve grievances for 1 of 3 sampled residents, (#1). Findings: Resident #1 was initially admitted to the facility on [DATE] with diagnoses that included type II diabetes, chronic kidney disease stage III, major depressive disorder, vascular dementia with agitation, hemiplegia/hemiparesis following stroke affecting the right dominant side, and persistent mood disorder. The Quarterly Minimum Data Set assessment dated [DATE] revealed resident #1 had a Brief Interview of Mental Status score of 5 out of 15 which indicated severely impaired cognition. The assessment revealed she required substantial to maximum assistance for toileting, dressing, and personal hygiene. On 12/4/24 at 12:35 PM, a telephone interview with resident #1's daughter confirmed that she was the Power of Attorney (POA) and visited her mother daily. She said that she had been having issues with her mother's missing items for about six months but she was unsure of the exact date. She said that about six months earlier, her mother's dentures went missing when a staff member accidentally threw them away. She was told by the previous Administrator and Social Service Director (SSD) that they would work on replacing them. She said she did not hear anything else regarding the dentures until recently when the new SSD started working at the facility and told her that they were working on getting a new dentist for her mother. She explained that in October 2024 she had complained to staff because when her mother was moved to a different room, per her request, all her mother's belongings went missing. She reported that the facility lost her clothing, shoes, cellphone, and glasses. These items were listed on her mother's inventory sheet, and she was the one responsible for doing her mother's laundry. She said that she spoke with the facility Administrator, Assistant Administrator, SSD, and Business Office Manager (BOM) but nothing was done, and they did not offer to reimburse her for the lost items. She said that she was unsure if a grievance was ever filed for the missing items. Review of the facility Grievance log from June 2024 to November 2024 revealed that a grievance had been filed on 9/19/24 for resident #1's missing dentures. The investigation had been assigned to the Administrator but there was no resolution indicated. There were no other grievances found for resident #1 during that time period. Further review revealed that from June 2024 to November 2024 there were 155 grievances filed, with 9 unresolved, and 83 that were either not assigned to a staff member to investigate or not properly documented with a resolution and complainant notification date. There were 22 grievances related to missing items included. On 12/04/24 at 12:21 PM, the SSD confirmed she was the Grievance Officer and had started working in the facility in October 2024. She noticed that there were grievances dating back to July 2024 that had not been investigated or resolved by the previous SSD. She met with the current Administrator, previous SSD, and Regional SSD regarding the unresolved grievances and let them know that her plan would be to start with the unresolved grievances since September 2024. She explained that when a grievance was received from a resident either verbally or in writing, the staff member receiving the grievance would complete a grievance form and submit to the Grievance Officer. Then she would assign a department leader to investigate, resolve, follow up with the resident, and have them sign acknowledging the resolution was to their satisfaction. When a resident reported a missing item, the staff member receiving the grievance would attempt to find the item first and then if still not found the grievance was given to the SSD to be assigned for further investigation. She said that when items were not found they would replace or reimburse the resident. The SSD said that she was aware that resident #1's representative had reported the dentures were missing in June of 2024 but was unsure why the grievance had not been filed until September 2024. She confirmed that there were no grievances filed for resident #1's missing clothing, cellphone, shoes, or glasses. On 12/04/24 at 1:04 PM, the Social Service Assistant (SSA) said that she had been working at the facility since July 2024. She confirmed that based on the facility's grievance policy, grievances had to be resolved within seven days of receipt and not exceed 14 days. She said that one of the issues that prevented timely resolution of grievances was that when they were assigned to the department leaders for investigation, they would often return the forms to Social Services with no resolution or notification to the resident. On 12/05/24 at 12:31 PM, the Resident Council President confirmed that several grievances had been filed regarding missing items. She said that she had not received a resolution for the grievances and the facility did not follow up with her regarding the status of the grievances. On 12/05/24 at 4:15 PM, the facility Administrator confirmed that he was made aware by the SSD, shortly after being hired in September 2024, that there were grievances that had not been resolved since July 2024. He said that the issue had been discussed at the Quality Assurance and Performance Improvement (QAPI) meeting on 11/14/24, which was attended by the Administrator, Director of Nursing, Medical Director, SSD, and Assistant Administrator. The plan was to audit and review grievances that had been outstanding prior to the new team, review the grievances with the resident or representative, and to ensure the resolution was acceptable. The SSD, Administrator, and all departments would work together to audit and resolve the outstanding grievances. He said that the goal was for all outstanding grievances to be resolved by the end of the year and to ensure that new grievances were handled in a timely manner. When asked for audits or documentation to show the work that had been done from 11/14/24 to present, he said that they had no documentation to show what had been done. He confirmed that resident #1's missing items had been reported to him around October 2024 by the resident's representative, but he did not complete a grievance form. He said that the facility looked for the items but did not find them and he had not followed up with the resident's representative regarding a reimbursement for the items. He said that the expectation was for grievances to be documented, investigated, and resolved in a timely manner. Review of the Complaint/Grievance Policies and Procedures revised 10/24/22, revealed that the center would make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. The grievance procedures stated the following: an employee receiving a complaint/grievance from a resident, family member or visitor would initiate a Complaint/Grievance Form, the Grievance Officer or designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow up, the grievance follow up should be completed in a reasonable time frame, which should not exceed 14 days, and the individual voicing the grievance would receive follow up communication with the resolution, and a copy of the grievance resolution would be provided to the resident upon request.

Based on interview, and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with professional standards of practice for 1 of 3 sampled residents, (#1). Findings: Resident #1 was readmitted to the facility on [DATE] from an acute care hospital with new diagnoses that included urinary tract infection (UTI), need for assistance with personal care, and muscle weakness. She also had a past medical history of type II diabetes, chronic kidney disease stage III, major depressive disorder, vascular dementia with agitation, and persistent mood disorder. The Quarterly Minimum Data Set assessment dated [DATE] revealed that resident #1 had a Brief Interview of Mental Status score of 5 out of 15 which indicated she was severely cognitively impaired. The assessment revealed she required substantial to maximum assistance for toileting, dressing, and personal hygiene. On 12/04/24 at 12:35 PM, in a telephone interview, resident #1's daughter confirmed at she was the Power of Attorney (POA) for her mother. She said that she noticed her mother's functional abilities started to decline in October 2024 and she required more assistance with activities of daily living. She said that on 11/04/24 she had visited the facility and noticed that her mother was not acting like herself. She reported her mother's condition to the nurse and was told that they would notify the doctor. On 11/05/24 she visited resident #1 again and requested for her to be transferred to the emergency room (ER) because she had vomited and was lethargic. Resident #1 was transferred to the ER, but she felt that her mother had not been assessed appropriately, so she requested to see progress notes from 10/23/24 to 11/03/24. She said that the facility provided her the progress notes but they contained no care notes documenting her mother's change of condition. She said there were several notes regarding refusal of care by her mother. She confirmed that at the hospital they diagnosed resident #1 with a urinary tract infection and she was ordered antibiotics. Review of resident #1's daily progress notes revealed that on 10/23/24 she was seen by the doctor and there were no changes reported. The next entry starts on 10/29/24 with several notes that reported she refused medications and glucose monitoring. The daughter and Nurse Practitioner were notified of the refusals on 10/29/24. On 10/30/24 there was a single note entry at 5:34 AM, which documented that the resident refused glucose monitoring. There were no entries on 11/04/24 to indicate that staff assessed resident #1 after the daughter expressed concern with her altered mental status and medication refusals. On 11/05/24 at 4:46 AM, there was a note that documented that resident #1 refused lab work that was ordered due to lethargy. On the same day at 11:59 AM, there was a change of condition note for altered mental status and an order for resident to be transferred to the hospital per the daughter's request. On 12/05/24 at 12:59 PM, Registered Nurse (RN A) said that she documented any changes from baseline for the resident, such as changes in mood, behavior, or mental status. She would assess, report and document the changes even if it was reported by the family member. On 12/05/24 at 3:20 PM, the Director of Nursing (DON) stated that nurses were expected to document by exception meaning that any changes in condition or change from baseline would be documented in the resident's medical record. She said that she was not aware that resident #1's daughter had reported a change with her mother on 11/04/24. On 12/05/24 at 3:45 PM, the Medical Director stated that on 11/04/24 resident #1 was seen by the Physician Assistant (PA) after a staff member reported that she was lethargic, and labs were ordered to rule out a UTI. He stated that on 11/05/24 he ordered for the resident to be transferred to the ER by request of the daughter. The DON was present during the interview and stated that if the nurse identified a change in the resident's condition on 11/04/24, it should have been documented. Review of the facility's policies and procedure for Medical Records, revised 8/25/17, revealed that the policy required clinical records to be maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care. It stated that the purpose of the clinical record was to document the course of the resident's plan of care and to provide a medium of communication among health care professionals involved in the care. The policy indicated the clinical record should include a record of the resident's assessments, the plan of care and services, and progress notes which indicated a change toward achieving the care plan objectives.

Based on observation, interview, and record review, the facility failed to prevent the potential spread of infection by not ensuring Enhanced Barrier Precautions (EBP) were followed by not wearing personal protective equipment (PPE) for 1 of 5 residents reviewed for urinary catheter (#3), failed to identify the type of precaution staff needed to follow for EBP for 2 of 5 residents, (#3 and #12) and failed to follow manufacturer's guidelines for cleaning and disinfection of shared glucose meters for 1 of 5 residents reviewed for blood sugar monitoring (#11) of a total sample of 20 residents. Findings: 1. On 11/19/2024 at 9:44 AM, resident #3 was resting in bed. Urinary catheter tubing was noted near the siderail of the resident's bed. Certified Nursing Assistant (CNA) E was in the room at the time and confirmed the resident had a urinary catheter. The resident's room door did not have any signage to indicate type of precautions or the required PPE that staff needed for residents with urinary catheters. On 11/19/2024 at 3:55 PM, resident #3 was observed lying in bed and had indwelling urinary catheter in place. Registered Nurse (RN) C and CNA B were in the room providing care to the resident. CNA B applied ointment to the resident's buttocks. RN C assisted CNA B to apply incontinence brief on the resident then applied moisturizing lotion to the resident's lower legs and feet. Neither CNA B nor RN C wore a PPE gown while they provided high contact care to the resident #3 with an indwelling foley catheter. On 11/19/2024 at approximately 4:50 PM, RN C acknowledged resident #3 did not have identification outside of her room to indicate the type of precautions or the required PPE needed for high-contact care for residents with indwelling catheter. RN C noted the resident had an indwelling urinary catheter and staff should have worn gowns to provide incontinence care. 2. On 11/21/2024 at 12:55 PM, resident #12 was observed sitting up in bed. He stated he had an indwelling urinary catheter. There was no signage outside the resident's room to indicate the type of precautions or the required PPE, and high-contact areas that required use of PPE. On 11/21/2024 at 4:50 PM, RN D verified resident #12 had an indwelling urinary catheter. She stated EBP should be used when providing high contact care. She confirmed there was no signage on the resident's room to alert staff of the type of precautions and PPE needed when providing high contact care to the resident. Review of the policy and procedure effective date: 09/01/2022 read that enhanced barrier precautions (EBP) are used to reduce the spread of multi-drug resistant organisms among residents by utilizing gloves and gowns for high contact resident care activities. Residents who are appropriate for EBP include residents who have an indwelling medical device such as a urinary catheter. For those residents who have such indwelling medical devices like a foley catheter the procedure section notes to place an identification outside the resident room to include type of precaution, required personal protective equipment, and high-contact areas that require the use of personal protective equipment. High contact care activities, such as transferring, changing linens, incontinent care, provide an opportunity for transfer of multi-drug resistant organisms to staff hands and clothing. 3. On 11/19/2024 at 12:07 PM, Licensed Practical Nurse (LPN) A was observed as she checked resident #11's blood sugar with a glucometer. She said she used the same glucometer for 5 residents who needed blood sugar monitoring. LPN A completed the blood sugar monitoring, then returned to the cart to clean the glucose monitor. LPN A used a single use alcohol prep pad to wipe all the surfaces of the glucometer. She said she was supposed to wipe the glucometer with bleach wipes. She said there might be bleach wipes on other medication carts or they might be on back order. Review of resident #11's medical record revealed a physician order dated 05/10/2024 for Insulin Lispro with a sliding scale to be administered based on blood sugar taken prior to meals. Review of the glucometer's procedure guide section about cleaning and disinfecting the meter noted that to minimize the risk of transmitting blood borne pathogens, the cleaning and disinfecting procedure should be performed as recommended. to use specific disinfecting wipes, which did not include an alcohol prep pad, to wipe the entire surface of the meter.

Based on interview, and record review, the facility failed to make transportation arrangements for a resident to a specialty medical care appointment, for 1 of 6 sampled residents, (#1). Review of resident #1's record revealed an admitted [DATE]. His diagnoses included: cardiomyopathy, type 2 diabetes mellitus with diabetic neuropathy, idiopathic progressive neuropathy, chronic pain syndrome, and acquired absence of left leg below the knee. Review of resident #1's Minimum Data Set Significant Change in Condition assessment dated [DATE] indicated his Brief Interview for Mental Status Summary Score was 15, the highest score value, which suggested the resident is cognitively intact. Review of Resident #1's medical record under Order Details revealed an order dated 07/23/24 at 2:41 PM, which read resident #1 had a neurology appointment scheduled for 09/04/24 at 1:00 PM. The order included a direction for [sic] transportation service to be used for the transportation and for them to arrive 15 minutes early. On 09/05/24 at 10:00 AM, resident #1 stated he was not taken to his neurology appointment the previous day on 9/04/24 at 1:00 PM, although the facility was supposed to arrange transportation to the appointment. On 09/05/24 at 3:06 PM, the Director of Nursing acknowledged the facility was responsible for arranging resident #1's transportation to his neurology appointment on 09/04/24 at 1:00 PM, but did not do it. On 09/06/24 at 11:45 AM, the 200 Unit Manager confirmed she should have arranged with the ordered transportation service to take Resident #1 to the neurology appointment on 09/04/24 at 1:00 PM, but it did not get done. She said the next nurse on the shift should have told her. On 09/06/24 at 12:21 PM, the Administrator could not provide documentation that the transportation service had been contacted by the facility to arrange transport for Resident #1 to his neurology appointment on 09/04/24 at 1:00 PM.

Based on observation and interview, the facility failed to store raw foods (e.g., produce) in a manner to reduce the risk of contamination of ready-to-eat foods and failed to store other food items by sealing, labeling and dating when opened. The facility also failed to ensure dishes and flatware were cleaned and stored under sanitary conditions and equipment was clean and in safe working order. These issues had the potential to negatively affect the health of 154 of the 166 residents in the facility. Findings: On 07/15/24 at 9:55 AM, surveyors entered the kitchen for the initial tour accompanied by the Certified Dietary Manager (CDM). In the walk-in refrigerator, liquid was dripping from the refrigerator condenser onto raw produce including tomatoes, 6 vented plastic containers of strawberries, and other boxes of fresh produce. An approximately 18 inch by 18-inch puddle as well as most of the floor was wet. The CDM stated it was not sanitary to have liquid from a piece of equipment dripping onto food items, but she didn't have anywhere else to put the produce. The surveyors pointed out several other storage area options for the raw, ready-to-eat food items. An open, unsealed box of chocolate chips dated 6/03 were found in the walk-in refrigerator. The exterior of the box had circular spots of discoloration resembling mold on it. The CDM removed this box from the walk-in and stated their policy was to have all food items sealed, dated and discarded after 7 days of opening. The CDM also discarded six undated hardboiled eggs wrapped in plastic wrap. In the walk-in freezer, there were 2 boxes of opened, unsealed and undated hard/frozen food items; one was tilapia fish and the other, burgers. The CDM noted these 2 items were not stored properly and removed them to seal and date them. On a kitchen counter, an opened, unrefrigerated, half-full jar of jelly dated 6/04 was found and the CDM threw it away stating this did not follow their food storage policy. When the CDM ran the dish machine, the wash and rinse temperature dials did not move so their temperatures could not be verified. When she submerged a test strip into the dish machine liquid to measure the concentration of sanitizer, it appeared clear, indicating the amount of sanitizer running in the machine did not register to the minimum 50 points per million. The CDM stated she could not be sure how long the dish machine had been without working temperature dials or sanitizer. Paper products were then used at the next meal until the dish machine could be put into proper working order for cleaning and sanitizing. The nozzles on the juice dispenser were noted to have a dark, slimy film on them. The CDM stated it was obvious cleaning of the juice nozzles had been neglected. She removed both nozzles, with one of the nozzles being very difficult to remove and set them in a pan of hot water. A second visit to kitchen on 7/16/24 revealed the raw produce including the strawberries and tomatoes, were still stored with liquid from the walk-in refrigerator condenser dripping on them. This issue was pointed out as a concern to the facilities Manager-In-Training who verified the findings. The juice dispenser nozzle was found being stored in a large plastic bucket as it continually dripped. The morning cook stated a repair company had been called to fix it. During a 3rd visit to the kitchen on 7/17/24, the District Manager verified the raw produce, including the strawberries and tomatoes, was still stored in the same spot under the condenser now with a sheet pan, approximately 1/2 high, placed on top of it. The shallow sheet pan was catching, and almost filled from, the dripping liquid. The surveyor expressed concern the shallow pan would soon be full and overflow onto the produce again. The District Manager agreed and stated he would take care of it. On the 4th visit to the kitchen on 7/18/24, the pipes from the condenser had been defrosted and were no longer dripping. The produce was still located under the condenser, including one half-full container of strawberries. The District Manager acknowledged concern ov possible contamination of the food items and discarded the remaining strawberries. The food service department Food Storage policy dated 02/23 stated all foods would be appropriately stored in accordance with guidelines of the FDA food code and would be stored wrapped or in covered containers, labeled, and dated and arranged in a manner to prevent cross-contamination. The facility's food service department's equipment policy dated 09/17 indicated all equipment would be kept in proper working order and all food contact equipment would be cleaned and sanitized after every use.

Based on observation, interview and record review, the facility failed to maintain the walk-in refrigerator in safe operating condition for all mechanical and electrical equipment. This issue had the potential to negatively affect the health of 154 of the 166 residents in the facility who received food and nutrition by mouth. Findings: On 07/15/24 at 9:55 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), it was noted the walk-in refrigerator's condenser was leaking liquid onto food products including raw produce. Most of the floor was wet along with a puddle measured approximately 18 inches by 18 inches. The CDM stated they dry mopped the walk-in floor regularly to remove liquid from it. She stated the condenser had been dripping liquid for more than 6 months. The CDM demonstrated the floor underneath the condenser was soft and boggy from the moisture when it dipped down as she jumped on it. She stated she had informed the Maintenance Department and Administration about the leak. The facility's food service equipment policy with revision date of September 2017 stated all food service equipment would be clean, sanitary, and in proper working order.

Based on observation and interview the facility failed to maintain clean and soiled utility rooms to ensure proper storage of contaminated and clean linens, and failed to maintain adequate handwashing supplies on 2 of 2 units, out of a total of 3 units, to prevent cross contamination, and exposure to blood-borne pathogens and infectious microorganisms according to established guidelines. Findings: The Infection Prevention and Control Program policy revised 10/18 read, An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Coordination and Oversight .The infection prevention and control program is coordinated and overseen by an infection prevention specialist [infection preventionist] .Important facets of infection prevention include .educating staff and ensuring that they adhere to proper techniques and procedures . On 7/16/24 at 10:51 AM, interview and observations were conducted with the Infection Preventionist (IP) Registered Nurse (RN) who said she had been in her current position for only 4 days and had not yet toured the laundry areas or clean and soiled utility rooms in the facility. On the 300/400/500 unit soiled utility room was not organized and the countertops and floors were noticeably dirty. The lid on 1 of 2 soiled laundry bins was open with exposed soiled linens, hand sanitizer on the wall was inaccessible, plastic storage bins used for isolation rooms still needed to be cleaned and sanitized, the handwashing sink drain had a thick layer of black colored film and was plugged with paper/debris which caused the sink to not drain properly. The handwashing sink in the utility room was obstructed by various items on and around the sink which included crutches, lift device battery, open sharps container, 2 flower vases, wheelchair rests, used resident continuous positive airway pressure machine, and other miscellaneous resident equipment items in unlabeled plastic bags. A few minutes later in the clean utility room on the 300/400/500 unit with the IP nurse the handwashing sink was dirty with black residue noted around the sink handle base the soap dispenser was broken and had no soap. The room was not organized and the countertops and floors were noticeably dirty. No garbage can was noted in the room for disposal of soiled paper towels or other trash. On 7/16/24 at 11:36 AM, an interview was conducted with the 300/400/500 Unit Manager (UM) and IP Nurse who validated all the concerns noted in the clean and soiled utility rooms. The UM added that the cleaning and restocking of handwashing supplies should be done by housekeeping staff at least daily for both clean and soiled utility rooms. The UM added the used resident equipment should be labeled once cleaned and put back into circulation by the nursing staff. The IP nurse verbalized the staff should always keep the soiled laundry bins closed to help reduce potential spread of infection from the presence of soiled/wet linens. On 07/16/24 at 11:45 AM, the soiled and clean utility rooms on the 200 unit were observed with the IP Nurse. The soiled utility room had 1 of 2 large bins overflowed with soiled/wet laundry which billowed over the top so the lid would not close. The sink on the right of the room had no hand sanitizer for hand hygiene and the hand sanitizer dispenser outside the soiled room was empty as well. The mini fridge in the right corner of the room was dirty and had brownish, sticky residue/streaks outside the door. In the small, clean utility room, 2 large carts were noted with clean linens. The floor was visibly soiled with brown dust and numerous insects lying dead on the floor. On 7/16/24 at 11:50 PM, the IP nurse validated the condition of the soiled/clean rooms on 2 of 2 units (300/400/500 and 200) were not maintained in clean or sanitary condition, nor were the clean/soiled linens stored properly to prevent cross contamination and exposure to blood-borne pathogens and infectious microorganisms according to established guidelines. On 7/17/24 at 3:44 PM, the Housekeeping and Laundry Supervisor was informed of the concerns noted on 300/400/500 and 200 units soiled and clean utility rooms. He said the housekeeping staff were supposed to clean the countertops, sinks, exterior refrigerator surface, sweep and mop floors, refill hand soap at least daily. He said all staff should make sure the soiled laundry was covered to prevent potential spread of infections as well. The Environmental Services Account Managers and Laundry Employees policy revised 10/23 read, Handling, Transport and Storage of Laundry .Regardless of the location where laundry is processed, facility staff is required to handle, store, process and transport all linens and laundry in line with accepted national standards .prevent the spread of infection to the extent possible all use laundry as potentially contaminated

Based on observation, interview, and record review, the facility failed to ensure a resident had a timely appointment for vision care and services for 1 out of 2 residents reviewed for vision and hearing, of a total sample of 59 residents, (#156). Findings: Resident #156 was admitted to the facility on [DATE] from the hospital with diagnoses including hypoglycemia, adjustment disorder, anxiety disorder, and symbolic dysfunctions. Resident #156's Annual Minimum Data Set (MDS) assessment with a reference date of 3/27/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status exam which indicated he was not cognitively impaired. The MDS assessment indicated resident #156 had adequate vision and did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Resident #156's Order Summary Report showed the resident had an order on 4/19/24 for Optometry/Ophthalmology as needed and an Ophthalmology Appointment order was placed on 7/17/24 for the date of 7/30/24. Review of resident #156's medical record revealed a care plan was initiated on 4/19/24 for impaired visual function related to double vision of the left eye with interventions that included arrange consultation with eye care practitioner as required. The physician's progress noted dated 4/19/24 for resident #156 revealed the chief complaint was a follow up visit for double vision in the left eye. It noted the resident had asked to be seen by an eye doctor and would discuss with facility staff about an eye appointment. The physician' progress note dated 5/09/24 and 5/30/24 for resident #156 noted the chief complaint was a follow up visit for left eye double vision. It also noted social services was to assist with an eye appointment. The physician's progress note dated 7/08/24 for resident #156 revealed the chief complaint again was a follow up visit for double vision. It noted the resident still had double vision which was discussed with social services to set up an eye appointment. On 07/15/24 at 1:27 PM, resident #156 stated he asked to see an eye doctor about a month ago and no appointment had been set up. He acknowledged he had trouble seeing out of both eyes. On 7/18/24 at 2:31 PM, the Social Service Director (SSD) indicated nursing would inform her when the provider requested an eye appointment to be scheduled for a resident. She stated it was her responsibility to schedule eye appointments when ordered. The SSD accessed resident #156's medical record and verified that on 4/19/24, 5/09/24, 5/30/24, and 7/08/24, the provider had requested an eye appointment be scheduled for the resident. She stated she was not informed of the eye appointment request until yesterday, 7/17/24, by the Administrator. The SSD conveyed the resident had not had an eye appointment since being admitted . She acknowledged there should have been an eye appointment scheduled for the resident on 4/19/24 when the provider first requested one. On 7/18/24 at 3:12 PM, the 300/500 Unit Manager (UM) stated he started working at the facility on 5/23/24. He accessed the progress notes for residents #156 and confirmed on 4/19/24, 5/9/24, 5/30/24, and 7/08/24 the provider had requested for the resident to be scheduled an eye appointment. He acknowledged there should have been an eye appointment scheduled for the resident on 4/19/24 when the provider had first requested it. The UM stated he was not informed of the resident needing an eye appointment until yesterday, 7/17/24, when notified by social services. The facility's Medical Consultation policy read, Members of the medical staff will request a medical consultation when appropriate .The member of the medical staff requesting a consultation will order the consultation and a Request for Consultation (Attachment A) will be initiated by nursing to the consulting physician .

Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, out of a total sample of 59 residents, (#321). Findings: Resident #321 was admitted to the facility on [DATE] with diagnoses including a nondisplaced zone 1 fracture of the sacrum, subsequent encounter for fracture with routine healing, type 2 diabetes, chronic kidney disease, and depression. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 7/11/24 revealed the resident's mental cognitive status as alert, oriented, and followed instructions. On 7/15/24 at 03:19 PM, resident #321 was observed lying in bed with her son standing beside her. A 1.5-ounce Major Deep-sea Saline nasal moisturizing spray, Tylenol PM, Magnesium 400 milligrams (mg), and Cranberry extract 500 mg were on the resident's nightstand. Resident #321 stated she used the nasal spray in her nose because it got dry. On 7/15/24 at 3:26 PM, the resident's bedside table was observed with the primary care nurse, License Practical Nurse (LPN) A. She acknowledged the 1.5 ounces of Major Deep-sea Saline nasal moisturizing spray, Tylenol PM, Magnesium 400 mg, and Cranberry extract 500 mg were noted on the resident's nightstand. Resident #321's son stated he brought the nasal spray, Magnesium, Tylenol, and Cranberry to her in the hospital. A review of the resident's physician orders was conducted with LPN A, which revealed no orders for the Saline nasal spray, Tylenol PM, Magnesium, or Cranberry found on the resident's nightstand. The LPN explained for someone to self-administer medications, they must have a physician order and a self-administration evaluation completed. LPN A stated there was no order for self administration of the medications nor had a self-administration evaluation been completed for the resident. On 7/15/24 at 3:34 PM, the 300-500 Unit Manager stated if a resident was to self-administer medications, they had to have a physician's order. The Unit Manager explained nursing would have done a self-administration evaluation, and a care plan for self-administration of medication would have been initiated for the resident. Then the facility would provide the resident with a lock box to store the medication safely. The 300-500 Unit Manager acknowledged those protocols were not in place for resident #321. On 7/18/24 at 2:10 PM, the Regional nurse confirmed resident #321 did not have a self-administration evaluation assessment completed prior to 7/15/24 for medication self-administration. A review of the facility's policy and procedure for Medication Administration Self-Administration at the Bedside, dated 11/30/2014 and revised 8/22/2017, revealed, Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete Self-administration of Medication Evaluation. Complete the Care Plan for approved self-administered drugs.

Based on observation, interview, and record review, the facility failed to review or revise the individualized fall plan of care to include a new intervention after every fall for 1 out of 3 residents reviewed for care plans, from a total sample of 59 residents, (#62). Findings: Review of the medical record revealed resident #62 was admitted to the facility from an acute care hospital on 10/13/23 and had diagnoses that included history of falls, difficulty walking, paranoid schizophrenia, anxiety disorder, and dementia. The Quarterly Minimum Data Set with Assessment Reference Date 6/29/24 noted the resident scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated she was cognitively impaired. The assessment noted the resident required significant/maximum staff assistance to complete Activities of Daily Living. The comprehensive fall care plan included focus items for an actual fall with a goal that resident #62 would resume usual activities and minimize the risk of further incident through the next review date. The care plan was dated 3/23/23 and revised on 5/01/24. The interventions for the care plan did not include interventions for every fall. On 7/18/24 at 10:32 AM, the Regional Nurse Consultant explained a new intervention relative to the actual fall should be added to the care plan after each fall. She reviewed resident #62's medical record for falls that occurred on 1/08/24 and 1/20/24 and acknowledged there were no new individualized interventions added to the care plan for these and and the other falls identified. She could not explain why new interventions were not included in the fall care plan for all of resident #62's falls. Review of resident #62's medical record revealed she had five falls including the falls on 1/08/24 and 1/20/24 which had no new intervention on the Fall care plan. Review of the Fall Management policy and procedure dated 11/30/14 and revised 7/29/19 included the purpose to identify residents at risk for falls and establish/modify interventions to decrease the risks of future falls and minimize the potential for a resulting injury. Post fall strategies included, Update care plan and Nurse Aide Kardex with interventions.

Based on interview, and record review, the facility failed to provide proof of consent, refusal, or medical contraindication for Pneumococcal vaccine for 2 of 5 residents reviewed for immunizations, (#5, and #129). Findings: 1. Resident #105, a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition, dysphagia, malignant neoplasm of prostate, anemia and chronic obstructive pulmonary disease. Review of resident #105's medical record on 7/17/24 revealed no documentation of consents, refusal, or medical contraindication for the Pneumococcal vaccine. 2. Resident #129, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of muscle weakness, type 2 diabetes, dysphagia, hypertension, cerebrovascular disease, syncope and collapse. Review of resident #129's medical record on 7/17/24 revealed no documentation of consent, refusal, or medical contraindication for the Pneumococcal vaccine. On 7/17/24 at 4:42 PM, the Regional Registered Nurse (RN) verified the prior Infection Preventionist Nurse was no longer working in that role and the new one started within the last week. The Regional RN explained residents #105 and #129 should have been offered the Pneumococcal vaccine and given education upon admission to the facility. Review of the facility's Policy and Procedure for Pneumococcal Vaccine revised October 2019 read, All resident will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, resident will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty [30] days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .

Based on record review and interview, the facility failed to honor the right to refuse treatment related to implementing a Do Not Resuscitate Order (DNRO) to prohibit aggressive resuscitation measures at the end of life for 1 of 7 residents reviewed for advance directives, (#1). On [DATE] at approximately 5:00 AM, Licensed Practical Nurse (LPN) A discovered resident #1 in bed, unresponsive and without a pulse. She directed staff to use the facility's overhead paging system to announce a Code Blue while she called 911. Registered Nurses (RNs) B and C responded from another unit and asked about the resident's resuscitation status. LPN A informed them resident #1 had Full Code or full resuscitation status, which meant she should receive Cardiopulmonary Resuscitation (CPR) procedures including chest compressions, intubation, and defibrillation to keep her alive. RNs B and C entered resident #1's room and initiated CPR. LPN D responded from another unit and joined the resuscitation effort. The three nurses took turns doing chest compressions and manually forcing air into her lungs with a bag valve mask as they continued aggressive measures to revive resident #1. When Emergency Medical Services (EMS) personnel arrived at approximately 5:10 AM, they found resident #1 still had no pulse or respirations, so they took over CPR. Continued resuscitation efforts in the hospital Emergency Department (ED) were unsuccessful, and resident #1 was pronounced dead at 5:55 AM. On [DATE] at approximately 9:45 AM, during review of resident #1's medical record, the Unit Manager (UM) discovered a Do Not Resuscitate Order (DNRO) form and realized the resident received CPR against her wish for a natural, peaceful, and dignified death. The facility's failure to honor the right to choose DNR status to promote a natural death contributed to resident #1 suffering unwanted, aggressive resuscitation efforts for approximately one hour, and placed all residents who had DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's removal of immediacy. Findings: Cross reference F678. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE]. Her diagnoses included Coronary Artery Disease, Hypertension, Hyperlipidemia, Dementia, and Schizophrenia. The hospital record included a history and physical progress note dated [DATE] that described resident #1's neurological status as awake, alerted oriented [to] person place situation. The note indicated the resident's resuscitation status was Full Code. Resident #1's medical record was updated on [DATE] to include a State of Florida DO NOT RESUSCITATE ORDER that was signed by the resident and her attending physician. The document showed the resident's signature under the statement, Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld. The physician's statement read, I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation.in the event of the patient's cardiac or respiratory arrest. The resident's revised advance directive related to DNR status was reflected in the Order Review Report for February and [DATE]. The DNRO was transcribed to the electronic medical record (EMR) on [DATE] and remained an active physician order until the date of resident #1's death. Review of resident #1's paper chart revealed the canary yellow-colored DNRO form was displayed prominently as the first page of the chart. Review of the Quarterly Minimum Data Set (MDS) assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 11 out of 15, which indicated she had moderately impaired cognition. The MDS assessment showed the resident had clear speech, was usually able to make herself understood and usually understood others. A Change in Condition form dated [DATE] at 6:23 AM, was completed by LPN A. The document revealed resident #1 was found unresponsive at 5:00 AM, CPR was started, and 911 was called for assistance. LPN A inaccurately documented resident #1's code status as Advance Care Planning Information (the resident/patient has orders for the following advance care planning) Full Code. An associated Nursing Progress Note dated [DATE] at 9:06 AM revealed LPN A discovered resident #1 unresponsive in bed at 5:00 AM when she attempted to administer the resident's medication. The note indicated nurses initiated CPR and 911 was contacted. The progress note indicated EMS personnel arrived ten minutes later and continued resuscitation efforts in the facility until 5:30 AM, after which they transported resident #1 to the hospital. On [DATE] at 10:01 AM, in a telephone interview, LPN A stated she was familiar with resident #1 as she was often on her assignment on the 200 Unit. She recalled on [DATE] at approximately 5:00 AM, she was passing morning medications and found resident #1 unresponsive in bed. LPN A stated she instructed the CNAs to page Code Blue over the intercom while she called 911 and printed the resident's face sheet with demographic information. When asked if she informed the nurses who responded to the Code Blue announcement that resident #1 had Full Code status, she said, I don't recall the other nurses asking me anything. LPN A explained later that morning, the UM of the 300 Unit discovered a DNRO form in resident #1's chart. LPN A said, I did not check the code status. It happened so fast; I didn't check the chart. I didn't check the chart. I'm sorry this happened. It was a mistake. On [DATE] at 10:19 AM, in a telephone interview, RN B recalled on [DATE] at approximately 5:00 AM, he was working on the 300 Unit. He stated he was about to administer medications when he heard the Code Blue announcement. RN B explained he and RN C, the other nurse on the 300 Unit, responded to the 200 Unit where LPN A informed them resident #1 had Full Code status. He stated RN C accompanied him to resident #1's room where they assessed the resident and determined she did not have a pulse and was not breathing. He confirmed they initiated and continued CPR until EMS personnel arrived. RN B explained he returned to work later that day on the afternoon shift of [DATE] and was informed resident #1 had a DNRO. RN B said, In hindsight, yes. I should have looked in the medical record for the resident's code status myself. He indicated if he had seen the DNRO form in the medical record, he would not have initiated CPR. On [DATE] at 10:49 AM, in a telephone interview, RN C recalled the events of [DATE]. She verified she was assigned to residents on the 300 Unit and was starting medication administration when she heard the Code Blue announcement at about 5:00 AM. She stated on arrival at the 200 Unit nurses' station, resident #1's assigned nurse told her the resident had Full Code status. RN C confirmed she participated in CPR efforts with RN B and another LPN who responded to the room. RN C described resident #1's assigned nurse as a veteran nurse and said, She had been at the facility ten-plus years. That's why they believed her when she said resident was a Full Code. RN C stated the following morning, the Director of Nursing (DON) informed her resident #1 had a DNRO. RN C acknowledged she should have checked resident #1's code status before performing CPR. On [DATE] at 5:04 PM, the facility's Social Services Director (SSD) explained she discussed advance directives with residents and/or their representatives upon admission. She stated during these discussions she reviewed the implications of both CPR and DNR status and includes information on the potential adverse consequences of CPR. The SSD said, Advance directives including DNROs are a matter of life and death. They are very important, and they should be honored by all staff. A DNRO is the resident's wish to go in peace. On [DATE] at 3:09 PM, in a telephone interview, resident #1's son described his mother's medical history as including multiple hospitalization s, a heart valve replacement and recent early signs of Parkinson's Disease or dementia. He recalled a telephone call from the facility on [DATE], when a staff member informed him that his mother was found unconscious and had been sent to the hospital. Resident #1's son stated the facility never informed him staff performed CPR on his mother. He explained when he arrived at the ED, hospital staff told him his mother already passed away. Resident #1's son stated his mother made her own decisions and might had been upset that she got CPR because it was against her wishes. He verified the DNRO was his mother's choice and said, If she had chosen that; that's what they should do. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *From [DATE] to [DATE], the SSD completed an audit of the code status for all 144 current residents of the facility and no discrepancies were found. *On [DATE], the facility initiated education for licensed nurses, including agency nurses, on policies and procedures for Advanced Directives, CPR, the Nurse Practice Act, and Florida DNROs. Licensed nurses who scored less than 80% on the post-test received re-education until a passing score was achieved. *On [DATE], all staff, including licensed and non-licensed personnel, received educated on the Abuse/Neglect prohibition policy and procedure and Resident Rights. *On [DATE], mock Code Blue drills were initiated for all three nursing shifts, 7am to 3pm, 3pm to 11pm, and 11pm to 7am. As of [DATE], five Code Blue drills have been completed. Mock Code Blue drills will continue twice weekly on all shifts to include weekends. *As of [DATE], staff members who did not receive education related to Advanced Directives, CPR, the Nurse Practice Act, Florida DNROs, Abuse/Neglect prohibition, and Resident Rights were notified by telephone that they may not return to work until education is received. Newly hired staff will receive education at the time of new hire orientation. *As of [DATE], the facility educated 91% of licensed staff. Review of in-service attendance sheets validated the participation of licensed staff in education on the above topics. The attendance sheets contained the signatures of 29 of 32 nurses, 14 RNs and 15 LPNs. Review of the code status audits with the SSD revealed no concerns. On [DATE], interviews were conducted with two RNs, seven LPNs, and one CNA who represented all three shifts, and weekend and weekday schedules. The nurses were able to demonstrate the ability to locate residents' code status in the paper medical chart and EMR, and all verbalized it was necessary for two nurses to verify code status prior to the initiation of CPR. All staff interviewed verbalized understanding of the education provided. The resident sample was expanded to include six additional residents. Interviews and record reviews revealed residents #2, #3, and #4 had Full Code status, and there were no concerns related to honoring advance directives for residents #5, #6, and #7 who had DNROs.

Based on record review and interview, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of resuscitation or code status in an emergency for 1 of 7 residents reviewed for advance directives, (#1). On [DATE] at approximately 5:00 AM, Licensed Practical Nurse (LPN) A discovered resident #1 in bed, unresponsive and without a pulse. She directed staff to use the facility's overhead paging system to announce a Code Blue while she called 911. Registered Nurses (RNs) B and C responded from another unit and asked about the resident's resuscitation status. LPN A informed them resident #1 had Full Code or full resuscitation status, which meant she should receive Cardiopulmonary Resuscitation (CPR) procedures including chest compressions, intubation, and defibrillation to keep her alive. RNs B and C entered resident #1's room and initiated CPR. LPN D responded from another unit and joined the resuscitation effort. The three nurses took turns doing chest compressions and manually forcing air into her lungs with a bag valve mask as they continued aggressive measures to revive resident #1. None of the nurses verified the resident's code status prior to implementing CPR. When Emergency Medical Services (EMS) personnel arrived at approximately 5:10 AM, they found resident #1 still had no pulse or respirations, so they took over CPR. Continued resuscitation efforts in the hospital Emergency Department (ED) were unsuccessful, and resident #1 was pronounced dead at 5:55 AM. On [DATE] at approximately 9:45 AM, during review of resident #1's medical record, the Unit Manager (UM) discovered a Do Not Resuscitate Order (DNRO) form and realized the resident received CPR against her wish for a natural, peaceful, and dignified death. The facility's failure to ensure staff followed procedures related to honoring an advance directive to withhold CPR contributed to resident #1 suffering unwanted, aggressive resuscitation efforts for approximately one hour, and placed all residents who had valid DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's removal of immediacy. Findings: Cross reference F578. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE]. Her diagnoses included Coronary Artery Disease, Hypertension, Hyperlipidemia, Dementia, and Schizophrenia. Resident #1's medical record revealed a State of Florida DO NOT RESUSCITATE ORDER dated [DATE] that was signed by the resident and her attending physician. The document showed the resident's signature under the statement, Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld. The physician's statement read, I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation.in the event of the patient's cardiac or respiratory arrest. Review of the Order Review Report for February and [DATE] revealed resident #1 had an active physician DNRO at the time of her death. The resident's electronic medical record (EMR) showed the advance directive DNR was noted on the ribbon of the resident information screen. Review of resident #1's paper chart revealed the canary yellow-colored DNRO form was displayed prominently as the first page of the chart. A Nursing Progress Note dated [DATE] at 9:06 AM revealed LPN A discovered resident #1 unresponsive in bed at 5:00 AM when she attempted to administer the resident's medication. The note indicated nurses initiated CPR and 911 was contacted. The progress note indicated EMS personnel arrived ten minutes later and continued resuscitation efforts in the facility until 5:30 AM, after which they transported resident #1 to the hospital. Review of the facility's policy and procedure Cardiopulmonary Resuscitation (CPR) revised [DATE] read, Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a valid Do Not Resuscitate (DNR) order. The procedure directed staff to first call for assistance immediately, and then two staff members are to verify the current physician order for code status. The documented indicated if there was no DNRO, nurses would initiate CPR. On [DATE] at 1:02 PM, the facility's the Director of Nursing (DON) and the Administrator discussed the incident investigation and Root Cause Analysis related to resident #1 receiving CPR despite documentation of a DNRO. They provided the facility's policy and procedure for CPR and the DON explained the document included the instruction for two nurses to verify a resident's code status prior to the initiation of CPR. The DON and Administrator were informed the document indicated two staff, not two nurses, needed to verify code status. The DON stated the facility staff had been educated that the code status verification had to be done by two licensed nurses, and this protocol had existed for a while. The DON explained on [DATE], during the investigation of incident, the UM of the 300 Unit discovered resident #1's DNRO form in the medical record. The DON explained DNRO forms were printed on yellow paper to ensure they were easily visible, and resident #1's DNRO form was found on the first page in her paper chart. The DON recalled the UM for the 300 Unit opened resident #1's paper chart and said, It was right there, the first page you see. The Administrator and DON stated during the investigation, LPN A acknowledged she never checked resident #1's medical record after she found her unresponsive. They stated they tried to get her to elaborate, but LPN A could not explain why she did not check the resident's medical record for her code status. Review of the facility's investigation showed a focus on LPN A's failure to check resident #1's code status, but it did not fully address the other three nurses who initiated and performed CPR without verification of the resident's code status. When asked if staff were required to bring the resident's paper chart to the bedside for proof of code status during a Code Blue situation, the DON stated the facility had no such requirement. She acknowledged if the chart was brought to the room for a Code Blue, all nurses who responded would be able to view the resident's code status to ensure the circumstances required provision of CPR. On [DATE] at 10:01 AM, in a telephone interview, LPN A explained she had been on staff at the facility for over [AGE] years. She confirmed she had received education regarding necessary actions if a resident was found unresponsive, not breathing, and/or without a pulse. LPN A explained the resident's code status must be verified by two licensed nurses prior to the initiation of CPR. She stated that protocol had been in place for as long as she could remember. LPN A confirmed she was aware resident who elected DNR status had a DNRO form placed in the paper chart and a copy was scanned into the EMR. She recalled on [DATE] at approximately 5:00 AM, she was passing morning medications and found resident #1 unresponsive in bed. LPN A stated she instructed the CNAs to page Code Blue over the intercom while she called 911 and printed the resident's face sheet with demographic information. When asked if she informed the nurses who responded to the Code Blue announcement that resident #1 had Full Code status, she said, I don't recall the other nurses asking me anything. LPN A explained later that morning, the UM of the 300 Unit discovered a DNRO form in resident #1's chart. LPN A said, I did not check the code status. It happened so fast; I didn't check the chart. I didn't check the chart. I'm sorry this happened. It was a mistake. On [DATE] at 10:19 AM, in a telephone interview, RN B recalled on [DATE] at approximately 5:00 AM, he was on the 300 Unit with RN C when the Code Blue announcement was made. He stated they arrived at the 200 Unit nurses' station, and LPN A told them resident #1 had Full Code status. RN B stated he and RN C entered resident #1's room and found she had no pulse and was not breathing. RN B stated as the staff at bedside tried to decide who would go first, RN C started chest compressions and he grabbed the bag valve mask. He recalled there was a third nurse present, LPN D, and he said, They did a couple of rounds of CPR, apiece. RN B recalled LPN A did not do participate in the resuscitation efforts but she came in and out of the room three to four times while resident #1 received CPR. RN B stated when EMS personnel arrived, they asked for the resident's code status and LPN A said, Full Code. He stated the resident's paper chart was not in the room while they performed CPR. RN B said, In hindsight, yes. I should have looked in the medical record for the resident's code status myself. He indicated if he had seen the DNRO form in the medical record, he would not have initiated CPR. On [DATE] at 10:49 AM, in a telephone interview, RN C confirmed she responded to the 200 Unit nurses' station with RN B. She stated she asked LPN A about the resident's code status and LPN A told her the resident had Full Code status. RN C recalled when she arrived in the room, another nurse was already performing CPR, then RN B took over. She stated when he was tired, he called for relief, and she took over. RN C recalled LPN A came back and forth to the room, and repeated resident #1 had Full Code status. RN C acknowledged she did not verify resident #1's code status in the medical record because LPN A was an experienced nurse. RN C said, All the time I thought the resident was a Full Code because [name of the assigned nurse] said so. But it's my bad too, because I did not check the chart. On [DATE] at 11:15 AM, in a telephone interview, LPN D stated she was on the 100 Unit when she heard the Code Blue paged on the intercom system. She stated when she arrived in resident #1's room, CPR was already in progress. LPN D stated she did not ask anyone about the resident's code status. She recalled she performed two to three rounds of CPR and said, It seemed like it took forever for 911 to arrive. She stated she was the last nurse to do a round of chest compressions before EMS personnel took over. LPN D emphasized the resident's assigned nurse was responsible for verification of the code status but added, I could have looked in the medical record too, but it was not my unit. It was not my resident. On [DATE] at 3:09 PM, in a telephone interview, resident #1's son described his mother's medical history as including multiple hospitalization s, a heart valve replacement and recent early signs of Parkinson's Disease or dementia. He stated his mother made her own decisions and the DNRO was her choice. The resident's son said, If she had chosen that; that's what they should do. On [DATE] at 5:04 PM, the facility's Social Services Director (SSD) explained she discussed advance directives with residents and/or their representatives upon admission. She stated during these discussions she thoroughly explained the differences between Full Code and DNR status. The SSD stated a resident's code status can be revised at any time, and if a new DNRO was obtained, several copies of the document were made. She stated one copy was placed directly in the resident's paper chart, and another added to the designated Red Binder for DNRO forms that was located at the nurses' stations on all units. The SSD stated a copy of the DNRO was also scanned into the resident's EMR and a physician's order for the new code status was entered into the EMR. She explained a DNRO would be reflected in the resident's the care plan for Advance Directives. The SSD explained prior to staff performing CPR on resident #'1 she had conducted twice weekly audits to ensure each resident's code status was accurately reflected in the paper chart, the EMR, all Red Binders, physician orders and care plans. She validated no discrepancies were noted during the audits for resident #1's advance directives related to her code status. The SSD said, Advance directives including DNROs are a matter of life and death. They are very important, and they should be honored by all staff. A DNRO is the resident's wish to go in peace. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *From [DATE] to [DATE], the SSD conducted an audit of all 144 current residents' advance directives to include DNROs and Full Code status. *On [DATE], the Human Resources Coordinator reviewed all nurses' CPR certification and found none to be expired. *On [DATE], all staff, licensed and non-licensed staff were educated the policies and procedures for Abuse/Neglect prohibition and Resident Rights. *From [DATE] to [DATE], the facility's licensed nurses, to include licensed agency nurses, were educated by the DON with regards to Advanced Directives, CPR policy and procedure, and the Nurse Practice Act related to Unprofessional Conduct. *As of [DATE], licensed nurses, including nurses from staffing agencies, completed post-tests on the topic of Florida DNROs. Nurses who scored less than 80% received re-education by the Regional Director of Clinical Services and re-tested until they demonstrated understanding with a score of 80% or above. *On [DATE], mock Code Blue drills were initiated for all three nursing shifts, 7am to 3pm, 3pm to 11pm, and 11pm to 7am. As of [DATE], five Code Blue drills have been completed. Mock Code Blue drills will continue twice weekly on all shifts to include weekends. *As of [DATE], the facility educated 91% of licensed staff. Any staff members who did not receive education related to CPR, Advanced Directive, Abuse/Neglect prohibition, and Resident Rights were notified by phone and informed they may not return to work until the education was received. The nurses who performed CPR for resident #1 on [DATE] were removed from the schedule. Newly hired staff will receive education at new hire orientation. Review of in-service attendance sheets validated the participation of licensed staff in education on the above topics. The attendance sheets contained the signatures of 29 of 32 nurses, 14 RNs and 15 LPNs. Review of the code status audits with the SSD revealed no concerns. On [DATE], interviews were conducted with two RNs, seven LPNs, and one CNA who represented all three shifts, and weekend and weekday schedules. The nurses were able to demonstrate the ability to locate residents' code status in the paper medical chart and EMR, and all verbalized it was necessary for two nurses to verify code status prior to the initiation of CPR. All staff interviewed confirmed they were made aware of the incident that involve a resident who selected DNR status receiving CPR. They verbalized understanding the education provided and verified they were required to pass a post-test. Each staff member verified participation in at least one mock Code Blue drill. The resident sample was expanded to include six additional residents. Interviews and record reviews revealed residents #2, #3, and #4 had Full Code status, and there were no concerns related to honoring advance directives for residents #5, #6, and #7 who had DNROs.

Based on observation, interview and record review, the facility failed to keep residents free from neglect by not providing care and services to avoid physical harm due to elopement for 1 of 17 residents reviewed for elopement out of a total of 21 residents identified by the facility to be at risk for elopement (#1). The facility staff neglected to supervise resident #1 who was known to be an elopement risk. The resident left the facility without the knowledge of facility staff on 7/29/16 during the night. The resident ambulated 1.2 miles East of the facility in the dark of night and while attempting to cross a six lane divided highway and was struck by a car. Resident #1 sustained a fractured wrist, lacerations and a hematoma to the forehead and was taken to a local hospital by emergency medical services (EMS). The facility staff did not know resident #1 was not in the facility until EMS called the facility and informed them that resident was being transported to the hospital. The failure to prevent neglect for resident #1 and continued failure to prevent potential neglect for other residents at risk for elopement resulted in Immediate Jeopardy starting on 7/29/16. This deficiency resulted in Substandard Quality of Care. Immediate Jeopardy was determined to be ongoing as of 8/06/16. Findings: Cross Reference F323, F353 and F490. The City of Winter Garden Police Crash Report dated 7/29/16 at 11:40 PM noted that at the intersection of State Road 50 and Park Avenue in Winter Garden, Florida, resident #1 was involved in a car accident. The resident was in the cross walk and was struck by a west bound car. According to the police report, the pedestrian signal was red, indicating resident #1 should not have been crossing the street. The resident was taken to a local hospital and was assessed with [REDACTED]. The hospital employees informed the police officer that the resident had dementia and possibly escaped from the nursing home. The nursing home was notified, and the nursing home staff were unaware that resident #1 had eloped from the facility. On 8/03/16 at 10:30 PM, the accident site at the intersection of State Road 50 and Park Avenue, Winter Garden, Florida was observed. State Road 50 is busy six lane divided highway that runs from the East Coast to the West Coast of Florida. This highway literally bisects the State. This intersection was dimly lit and at this time, several cars and semi-trucks were observed on highway. On or about this intersection were several bushiness including Super Markets, Restaurants and Car Rentals that lined both sides of the street. Using the car odometer, the facility in approximately 1.2 miles West of the intersection. As you drive towards the facility, there are significantly less businesses and more wooded areas. Street lights were scarce, which means the resident walked in the dark to reach the intersections. On 8/04/16 at 3:15 PM, certified nursing assistant (CNA) I stated that she worked the 11 PM-7:30 AM shift on 7/29/16 and was assigned to resident #1. CNA I stated she was late getting to work and indicated she arrived at the facility at 11:20 PM. This contradicts licensed practical nurse (LPN) F's statement that all assigned CNAs were at the facility at the beginning of the night shift on 7/29/16. Time sheet records provided by Payroll Staff revealed that CNA I clocked in at 11:22 PM on 7/29/16. CNA I stated when she got to the unit, nobody gave her a change of shift report since the 3 PM-11:30 PM shift CNA had already left. CNA I said, in general in nursing homes, the off-going CNA gives a report to the on-coming CNA. These reports are done verbally and they usually include resident behaviors, resident condition, unusual occurrence or anything else that the on-coming CNA needs to follow up or check. CNA I stated that on the evening of 7/29/16, she first gave incontinence care to the resident #18. CNA I stated the incontinence care took 12 to 15 minutes to complete. She stated she was checking her residents as she was making her way to resident #1's room. CNA I stated she entered resident #1's room at approximately 11:35 PM and gave incontinence care to resident #'1's roommate. After she finished with the incontinence care, she noticed that resident #1 was not in his bed. At that time, she notified LPN F that resident #1 was not in the room and went to look for him in the room across the hallway. When she did not find the resident, she informed LPN F again that the resident was missing. LPN F then instructed her to inform the 2 other CNAs on the unit to search for the resident. CNA I's version conflicts with LPN F statements because LPN F had stated that staff did not report that the resident was missing prior to the phone call from EMS. CNA I also stated that the Executive Director (ED) came to the facility and she wrote out her statement. CNA I stated that she finished her shift and clocked out at 7:45 AM on 7/30/16. On 8/04/16 at 5:09 PM, a meeting was held with the ED, Director of Clinical Services (DCS) and the Corporate Nurse. They stated that they did not know how resident #1 got out of the facility. They suspected that he followed someone out of the building 500 hall. At the end of the 500 hall is a door that leads to the parking lot. This door is locked and their is a numbered keypad on both sides of the door. In order to unlock the door, a four digit code must be entered on the keypad. The ED confirmed that staff and visitors use this door to enter or exit the facility. This door is used as an entry/exit point by staff and visitors in the evening hours when the front lobby doors closed at the end of the day. The ED stated that after resident #1's elopement, the door code was changed. The staff understood that CMS regulations address elopement under neglect. However, the ED indicated that all staff working on the night in question finished their respective shifts and no one was suspended until their shift was completed. The ED did not respond when asked why staff continued to work when it was known that resident #1 had eloped from the facility. When asked about the policy and procedures for the change of shift and staffing, the ED stated, The off-going nurse is supposed to complete rounds before she gives report. Then the on-coming nurse will use a census sheet and put a check mark next to the resident's name when they see the resident. Then they fill out a census form and put it under the door to admissions. The on-coming nurse and CNA never saw the resident on the 11-7 shift, and the facility staff could not account for the whereabouts of resident #1 from 10:40 PM to approximately 11:30 PM; no one knew the resident was gone. On 8/05/16 at 11 AM, an observation of the secured door in the 500 hall was completed with the ED. This observation was completed after the ED stated, during his interview, what steps the facility had implemented to prevent future elopements as part of their action plan. The ED stated, We changed the pass code to this door yesterday. All staff were educated not to give the code out to any family members from now on. During this observation, a resident's family member walked up to the door, took out his cell phone, looked up something, and entered the security code. The door opened and the family member began to exit the facility. The family member was stopped and asked where he got the new code from, and replied, I know people. He then turned and exited the building. The ED stated, I don't know how he got the code. On 8/05/16 at 12:30 PM, LPN F stated she arrived at the facility on 7/29/16 at about 11 PM. LPN F worked the 11 PM-7:30 AM shift on 7/29/16 and was resident #1's direct care nurse. After she got report from both 3-11:30 PM shift nurses and counted the medication carts, she checked on a newly admitted resident, and then provided incontinence care to another resident. LPN F admitted she never saw resident #1 that night, and did not know he was missing until she received a call from EMS, informing her that the resident was at the hospital. While LPN F was talking to EMS, she said she told certified nursing assistant (CNA) I to check on resident #1 and see if he was in his room. CNA I went to the resident's room, and confirmed he was not there. LPN F stated that none of the staff had informed her that resident #1 was missing prior to the telephone call. LPN F then called the Director of Clinical Services (DCS) and the facility's ED. After her calls were placed, LPN F checked the rest of her residents, and completed her rounds. When asked what the facility's procedure is for resident rounding at change of shift, LPN F stated that the off-going nurse is to check and see if the residents are there before report, and then tell the on-coming shift if there are any concerns. After report, the on-coming nurse is to take the census report sheet and complete a head count. LPN F stated that she was not able to observe all the residents within the first hour of the shift because she was distracted. LPN F said that all three scheduled CNAs were at the facility at the start of the 11 PM-7:30 AM shift, including resident #1's direct care CNA I. LPN F stated the facility's ED came to the facility and questioned staff. LPN F said she wrote out a statement for the ED's investigation. LPN F stated that an elopement drill was conducted when the ED came to the facility on [DATE] AM. The facility uses a teddy bear, named Cody, and hides it in the facility. LPN F explained that an announcement is made on the intercom system and someone will say Cody 120 or something like that, then staff have to search for Cody. LPN F stated that the drill was done on the 200 wing and all of the 100 wing staff left the unit to go to the 200 wing to respond to the drill. The person running the drill shows a picture of who is missing and then we go back and search for the missing resident. When Cody is found, they announce an all clear. When asked who monitors the residents on the 100 wing when all the staff responded to the drill on the 200 wing, LPN F did not answer. During the on-site survey, several attempts were made via phone to contact LPN Y but LPN Y did not return the calls. LPN Y worked the 3 PM-11:30 PM shift on 7/29/16. Finally on 8/09/16 at 1:11 PM, LPN Y was contacted by phone and said she worked on the 3-11:30 PM shift on 7/29/16. She stated that resident #1 was in his usual condition and did not have any unordinary behaviors. She stated that there were times when resident #1 would try to leave the building. The resident would say he was going home or to Panama. LPN Y stated that resident #1 wandered throughout the facility including the 500 wing. She stated he liked to walk around and talk to the Spanish speaking residents. LPN Y recalled on 7/29/16 sometime after 10 PM, she encouraged the resident to go to bed and took him to his room. She stated that the resident laid in the bed but did not change into a gown of pajamas. The resident wore long pants, a short sleeve button down shirt and shoes while he was on top of the bed. LPN Y stated she answered about 3 call lights and saw the resident when she walked past his room on or about 10:20 PM. LPN Y stated that the on-coming nurse, LPN F, arrived at 11 PM. LPN Y stated that all 3 scheduled CNAs on the 11 PM-7:30 AM shift were at the facility and did not remember if any of the CNAs were late. LPN Y stated that she did not do a head count of residents at the change of shift because I knew everyone was in bed. The facility's Abuse Policy N-1265, effective date 11/30/14 and revision date of 6/01/15, included neglect and read, Neglect .Failure to take precautionary measures to protect the health and safety of the resident Failure to adequately supervise a resident known to wander from the facility without the staff knowledge Preliminary investigation Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from resident pending the investigation resident of the allegation. Investigation Any suspect(s), who is an employee, once he/she has been identified, will be suspended pending the investigation. The facility's Change of Shift Policy N-107, effective date 11/30/14 read, Procedure: Nursing rounds should be made by the Clinical Nurse before beginning report to make a final check on resident condition and activity Specific and pertinent remarks are made concerning the resident's conditions which may include any of the following: .Changes in physical and emotional condition, pertinent remarks or unusual occurrences From 10:45-11:55 PM, the facility could not account for resident #1. The ED said, Based on the investigation, at this time I can't say when and how (resident #1) got out. I don't know if it could have been prevented. He said LPN F, LPN Y, CNA I and CNA W were all suspended after finishing their shifts but not as soon as the ED found out about the elopement. The nursing staff neglected their duties and did not provide the needed supervision to prevent resident #1's elopement. Staff failed to follow policy and procedures in regards to Change of Shift Reports and Rounding/Head Counts to ensure residents are present and safe during change of shifts. Even after resident #1's elopement, administrative staff neglected to ensure that the door code was not given out to visitors, thus placing residents assessed to be exit seeking at risk for elopement.

Based on observation, interview and record review, the facility failed to adequately supervise residents with known exit seeking behaviors. The facility failed to prevent the elopement of 1 of 17 sampled residents with a WanderGuard device, (a personal departure alert system device) out of 21 residents. The cognitively impaired resident walked 1.2 miles on a busy highway in the night, with some areas being poorly lit, was struck by a car in the crosswalk while crossing against the traffic light, and sustained injuries requiring emergency transportation to an acute care hospital. (#1) The deficiency resulted in Substandard Quality of Care and resulted in Immediate Jeopardy which is currently ongoing as of 8/06/16. Findings: Cross Reference F224. Resident #1 is an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial social service history dated 10/29/12 showed resident #1 had a history of [REDACTED].>mental disorder, psychosis mild cognitive impairment . An Elopement Risk Evaluation was completed for resident #1. This is an assessment that consists of seven yes or no questions, to identify residents at risk for elopement. The evaluation is conducted on admission to the facility, and the seven questions included: 1. Is the resident cognitively impaired? 2. Is the resident independently mobile ( ambulatory or wheel chair)? 3. Does the resident have poor decision-making skills? 4. Has the resident demonstrated exit seeking behavior? 5. Does the resident wander oblivious to safety needs? 6. Does the resident have a history of elopement? if yes, # of times, if known:, 7. Does the resident have the ability to exit the facility?. An answer of yes to questions 4,5, and 6 automatically places the resident at risk for elopement. All the questions were answered yes for evaluation conducted for resident # 1 on 6/30/16 indicating resident # 1 and was at risk for elopement. Review of the City of Winter Garden Police Department crash report dated 7/29/16 at 11: 35 PM revealed resident #1 was struck in the roadway as he crossed on the crosswalk suffered minor injuries and lacerations to his head was transported to (a local hospital) .had a laceration above his right eye and a cut above his left eye as well as a cut on his nose . Colonial Lakes was notified and they stated they were unaware he had left . On 8/03/16 at 10:30 PM, an observation was conducted at the accident site. The site was located at the intersection of South Park Avenue and State Road 50, Winter Garden, Florida, approximately 1.2 miles from the facility. This is a busy 6 lane highway with right and left turn lanes. The facility is located in a rural area. The sidewalk runs from the nursing facility to the accident site, but the area is dimly lit. In a telephone interview on 8/04/16 at 10:42 AM resident #1's spouse said she was at the hospital with resident #1, and has sutures to his face and nose, he does not look well. She said she was called by the facility on Friday, 7/29/16 at approximately 11:30 PM Texas time (Central time) 1:30 AM Orlando time, (Eastern time). She said the nurse told her resident #1 ran away from the facility, they did not know when, and was involved in a motor vehicle accident. She said she called her son, who called the facility and the hospital, and was told the resident was stable. Her granddaughter went to the hospital, found a police card in the resident's belongings, and her son was told by the police that the resident was found 1.6 miles from the facility. Resident #1's spouse said if the resident walked, he would have taken a long time to walk that distance. She said resident #1 has tried to leave the facility before, two years ago when he was on the 500 wing. He was found outside and bought back into the facility. She said resident #1 was an army veteran, and probably thinks he has to escape. This was not addressed in the resident's care plan. Resident #1's spouse said, she knows that he refuses care at times, has fallen at the facility, but cannot tolerate them not knowing the resident left the facility. On 8/04/16 at 3:50 PM, in a telephone interview certified nursing assistance (CNA) W said she worked the 3-11:30 PM shift on 7/29/16, and had resident #1 on her assignment. The CNA said resident #1 had no behaviors he was very calm, was walking around the unit, going from the nurses' station to his room. He had supper in his room between 7-7:30 PM. CNA W reported the last time she saw resident #1 was at 10:35 PM, by the nurses' station, wearing his WanderGuard bracelet. She said the 11 PM-7:30 AM CNA was late, there was no one to relieve her, so she gave report to CNA X. CNA W said she did not know resident #1 had left the building at the time she gave report to CNA X. On 8/04/16 at 5:09 PM, an interview was conducted with the executive director (ED), director of clinical services (DCS), and corporate nurse. The ED said he started his investigation when he got the phone call from licensed practical nurse (LPN) F on the 100 wing, stating she received phone call from EMS, reporting that 1 of his resident was at the Hospital. The ED told LPN to start an investigation. He said the LPN started a head count, and notified the physician and family. He said on 7/30/16 at approximately 12:20 AM, he came to the facility, then went to the hospital to see the resident, and spoke with him in the emergency department. He said the resident had a laceration to his left eyebrow, and a bruise to his nose. He said he spoke with the resident's wife, who wanted to make sure the resident was OK, and came back to facility. In a telephone interview on 8/05/16 at 9:19 AM, registered nurse (RN) G said she worked 11 PM-7 AM on 7/29/16 with LPN F resident #1's direct care nurse. RN G had residents on the 100 and 200 wings. When she had finish seeing residents on the 200 wing, she was sitting at the nurses' station on the 100 wing around 11:55 PM, when emergency medical system (EMS) called, stating that a gentleman by the name of (resident #1) was involved in a car accident. RN G asked LPN F if she had a resident by the name of resident #1. LPN F said yes. RN G said she gave LPN F the phone, and ran to the resident's room. She found his empty bed made, not slept in, and signaled to LPN F that the bed was empty. RN G reported CNA I had resident #1, and said the CNA said she did notice the resident was not in his room, but since he loved to walk throughout the facility, she thought he was walking around. After LPN F hung up the phone, she called staff, and did a search, but it was already confirmed the resident was not there. RN G said LPN F called the director of clinical services (DCS) and she (RN G) called the ED, who came to the facility with the regional director, and had a staff meeting with the 11-7:30 AM shift regarding elopement on 7/30/16 at approximately 1:45 AM. Per the facility's information, the WanderGuard system alerts staff when a wandering resident gets close to or exits a door outside. The system will announce door alert and which. A number correlating to that wanderguard will appear on the screen of the code box. The number and the resident name can then be located in the Green Elopement book. This book has a photo and some information on residents at risk for elopement and can be located at each unit and the front lobby. When the alarm goes off staff should check the area for the resident inside and out. The code box by the door will display on the screen a number that correlates to the wanderguard last in the area. The number/resident can then be looked up in the Green Elopement book. A code can be entered if the resident is located to stop the alarm. If the resident is not located, the elopement search will then be announced and followed by protocol. Review of the Wander Control Systems, Inc. reflected that since the tags operate on battery power, This battery will discharge and ultimately fail over time. This is normal, so daily .tag testing is recommended. According to facility policy, these tags are tested daily per the manufacturer's recommendations. There are no video cameras near exit doors or in the halls and common areas. On 8/05/16 at 11 AM, observation of the WanderGuard activated doors were conducted, along with the maintenance director, ED and restorative aide (RA) T. Doors were tested with three Wander Guard sensors. The lobby/main entrance door has two key pads. The Wander Guard sensor alarmed, and did not stop until the code was entered. The B door on the 500 hall exit has one key pad, and is also an egress/fire door. The display panel indicated that the sensor's identifying number was near the door, and there was no audible alarm. The ED explained that this door did not have an audible alarm because it was near the rehabilitation department and patients in the community access the rehabilitation department on an outpatient basis and if there was an audible alarm, it would sound every time a resident came close to it, disturbing the patients and residents receiving treatment in the rehabilitation department. The ED said when the door code is entered, there is a five seconds delay for the door to be pushed open. At that point, the system then converts to Escort time, this is a twenty second delay. After the twenty seconds is up, the door then begins to alarm that it was open. The ED reported the facility has two WanderGuard activated doors, which were checked immediately and found to be functioning appropriately, alarming when a WanderGuard was near the door. When asked if investigation determined how resident #1 left the facility, the ED said he could have followed a visitor out on the 500 exit, explaining that once the code is placed for visitors to go out, the WanderGuard alarm is disabled. This was tested on [DATE] at 11 AM with the ED, maintenance director, and RA T. The ED also said, A couple of family members know the code for the door but he could not identify which family members, and said the door code had been changed twice in 10 months, and also have been changed since the incident on 7/29/16, last changed on 8/04/16. The ED said he obtained statements from nurses and CNAs, and the last time the resident was seen was on 7/29/16 at 10:35 PM by LPN Y in his room. He said she tried to take his clothes off, but the resident refused; she went back at 10:40 PM and he was in bed. He said at 11:30 PM CNA I noted resident was not in his room, so she started checking bathrooms, came out in the hall, and alerted her peers. He said all 3 CNAs started to look for the resident,and by the time CNA I got to LPN F, he said LPN F had received the call from EMS. He said assigned CNA W, on the 3-11 PM shift, last saw resident #1 at 10:30 PM on 7/29/16. The ED said LPN F reported she started rounds, but something came up which diverted her attention, she did not check on resident #1. From 10:45-11:55 PM, the facility could not account for resident #1. The ED said, Based on the investigation, at this time I can't say when and how (resident #1) got out. I don't know if it could have been prevented. He said LPN F, LPN Y, CNA I and CNA W were all suspended after finishing their shifts but not as soon as the ED found out about the elopement. On 8/05/16 at 11:05 AM, the ED and maintenance director said the door code was changed the night of the incident, and again on 8/04/16. Staff was re-educated on 8/04/16, and told not to give the code to anyone. During the observation of the 500 hall door, a family member of a resident on the 500 wing walked up to the key pad, took his phone out, then entered the door code, and was able to open the door. When asked how he got the code, he said, I know people, smiled and exited the building. This showed that interventions initiated after resident #1 eloped were not effective. On 8/05/16 at 12:25 PM, LPN F said on 7/29/16 she clocked in at 11 PM. She normally looks into rooms while going down the hallway, towards the nursing station. She had to count narcotics on two medication carts with two nurses, and received report, a verbal update of each resident's condition, which may include observations, and any unusual occurrences, from LPN Y, and LPN B. She had rooms to the front and back of the 100 wing. After report, around 11:30 PM she said she was getting ready to start rounds on the back side of the unit. A resident got up, and she assisted the CNA with her. LPN F said she received a call from EMS around 12:05 AM on 7/30/16. She said EMS asked if she had a resident by the name of resident #1, and said the reason they asked, was because the resident gave his name and room number. EMS reported the resident was hit by a car. LPN F asked CNA I to look in the resident #1's room. CNA I told her the resident was not there. LPN F said she called the DCS, medical director (MD), and the resident's spouse, and informed them that there was an accident. She then called the ED and informed him. LPN F said LPN Y reported she was trying to get resident #1 into bed, and directed him to his room. When he went to his room, he stood there by the door. LPN F said she did not see resident #1 when she came to work on the 11PM-7AM shift. When asked the expectation for change of shift, LPN F said after receiving report from the off- going nurse, the on-coming staff is responsible to get a head count of the residents. She said, I do my head count around the time I get there, but that night we had distractions, so I didn't look at everyone within the first hour. On 8/06/16 at 10:44 AM, CNA L said resident #1 was known for trying to elope. She said she has personally responded to the Wander Guard alarm when he tried to elope at the front door of the lobby. She indicated she has re-directed resident #1 from the front door on several occasions, and said the resident would say he's going to Puerto Rico, Texas or Mexico. On 8/06/16 at 2:19 PM, the care plan coordinator said resident #1 did not have 1:1 (one to one) intervention prior to his elopement. She said he was a wanderer, and in the situation where he did not want to change his clothes, and was at the door, a 1:1 intervention would have been warranted. The care plan coordinator said she uses the behavior monitoring documentation, the attending physician notes, psychiatric notes, and the nurse's notes to update the care plan. She said elopement and elopement attempts should be documented. In a written statement by licensed practical nurse (LPN) Y on 7/31/16, she indicated that resident #1 was walking in the 100 hallway, or sitting by the nurses' station. Sometimes he would walk as far as the double door leading to the lobby. She wrote, Resident was encouraged to go to bed (on 7/29/16), but kept saying, I am waiting for my wife, which is his typical behavior At around 10:35 PM, I walked the resident to his room and attempted to help him go to bed, he sat on the bed and did not want me to pull the cover At 10:40 PM, I walked back passed resident #1's room. He was still laying on the bed I did not observe (resident#1) coming out his room. The quarterly minimum data set assessment ((MDS) dated [DATE] revealed resident #1 had a brief interview for mental status (BIMS) score of 3/15, meaning the resident was severely impaired cognitively. Resident #1 was not able to report the correct year, correct month, or the correct day of the week. He was assessed as being independent for bed mobility, transfer, walk in room and walk in corridor. He required supervision for locomotion on or off the unit, personal hygiene, and limited assistance with dressing. His balance during transition and walking was assessed as steady at all times. Focus of the care plan for behavior/mood implemented on 10/30/14, and last reviewed on 7/26/16 was Potential for impaired or inappropriate behaviors exit seeking behavior, with the goal listed as, resident will not demonstrate behavior of exit seeking. Interventions included, elopement risk assessment, increase 1:1 (one on one) monitoring as needed, personal wander prevention device-check for placement each shift and function daily, psychiatry consults as needed, and check exit door alarms daily. This care plan did not address how often an elopement risk assessment should be conducted, and did not include any previous attempts to exit by resident #1, in order to determine possible causes for his exit seeking behavior. The quarterly minimum data set (MDS), dated [DATE], reflected that wandering was exhibited in the last 1-3 days. A care plan, initiated 7/25/16, reflected the resident exhibits signs and symptoms of BPSD (behavioral & psychotic symptoms of dementia) related to exit seeking. The goal was, Resident will not demonstrate BPSD of resisting care, wandering daily. Additional intervention included safety checks as indicated. The July 2016 medication administration records (MARs) and the medical record did not find any documentation entered for any type of behavior displayed. The list describing behaviors to be documented included wandering. The PsychCare Services progress notes dated 6/03/16 and 6/08/16 reflected that resident #1 was notable for exit seeking comments/behavior and indicated the behavior was managed by redirection and reorienting. The physician's orders [REDACTED]. Review of the CNA's WanderGuard check sheet indicated resdient #1's WanderGuard was checked on during the day on 7/29/16, prior to his elopement that night. Resident #1's medications included Zyprexa, an antipsychotic medication, 2.5 milligrams (mg.), Metoprolol, an antihypertensive medication, 25 mg.- 0.5 tab, Venlafaxine HCL, an antidepressant, 75 mg., Mirtazapine, an antidepressant medication, 7.5 mg., Melatonin 3 mg., Donepezil, a medication for Alzheimer's disease and dementia, 10 mg., and Alprazolam, an anti-anxiety medication, 0.25 mg. every 24 hours as needed. Review of the MARs showed resident #1 received Donepezil, Melatonin, and Zyprexa at 9 PM on 7/29/16. Several attempts were made to contact LPN Y during the onsite survey were unsuccessful. On 8/09/16 at 1:11 PM, LPN Y returned a telephone call, and said she worked on 7/29/16 on the 7 AM- 330 PM, and 3-11:30 PM shifts, and had resident #1 on her assignment. LPN Y said she saw the resident after 10 PM, when she encouraged him to go to bed. She verified he wore a WanderGuard bracelet, and said during the day he did trigger the WanderGuard alarm, she believes it was the lobby door. LPN Y said she did not do a head count at the change of shift, because I knew everyone was in bed. The policy and procedures for Change of shift report N-107, Effective date 11/30/2014 read, The Clinical nurse of a nursing unit shall report to the on-coming shift (nurses and CNAs) about the condition of each resident under his/her care, in order to fully inform nursing personnel of each resident's condition and maintain continuity of resident care from one shift of personnel to the next. Procedure: Nursing rounds should be made by the clinical nurse before beginning report to make a final check on resident condition and activity This was not done by LPN Y, and LPN F did not round, or do a head count of all her residents, until after she received the call from EMS dispatch about the resident's accident. Resident #1's hospital record revealed the resident arrived at the emergency department on 7/30/16 at 12:13 AM. Nursing assessment read, A single laceration over the right forehead, and nose. The hospital history and physical reflected resident #1's date of hospital admission as 7/30/16 with chief complaint of headache and pain in the hands. Documentation for history of present illness read, This is an [AGE] year-old who resides at the Colonial Lakes nursing and rehabilitation facility found wandering in the street with head trauma and complaining of hand pain Impression was listed as Left hand fracture, laceration to the right frontal area, and worsening dementia. CAT Scan (Computerized axial tomography) a scan that combines a series of x-ray images taken from different angles and uses computer processing to create cross-sectional images. These images provide more detailed information than plain X-rays do. (Mayo Clinic). CT of the head and maxillofacial revealed medium-sized subcutaneous hematoma overlying the right frontal calvarium. Three view X-ray of the left hand/wrist showed an acute fracture. Orthopedic consult dated 7/31/16 recommended non-operative care, immobilization with a thumb Spica splint, anti-inflammatory medications, activity modifications, and follow up in two weeks after discharge. The resident has since been discharged from the hospital on [DATE] to another nursing facility.

Based on record review and interview, the facility failed to provide sufficient staff to provide care and services to prevent elopement, and failed to provide supervision for a resident known to be an elopement risk, allowing the resident to elope from the facility on 7/29/16, ambulate 1.2 miles East of the facility, was struck by a car while attempting to cross against the traffic light, and sustained a fractured left wrist, and left [MEDICAL CONDITION] and hematoma. The facility staff did not have any knowledge of the resident's elopement until emergency medical services (EMS) dispatch contacted the facility and informed the facility that the resident was transported to the hospital (#1). These findings resulted in serious injury to resident #1. Findings: Cross Reference F224 and F323. Resident #1, an [AGE] year-old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He resided on the long-term care unit, the 100 unit which was not a secured unit. Nine residents on the 100 hall wore wanderguards because they were at risk for elopement. The City of Winter Garden Police Department crash report, dated 7/29/16 at 11:35 PM, revealed resident #1 was struck in the roadway as he crossed on the crosswalk suffered minor injuries and lacerations to his head was transported to hospital .had a laceration above his right eye and a cut above his left eye as well as a cut on his nose .Colonial Lakes was notified and they stated they were unaware he had left On 8/04/16 at 3:50 PM in a telephone interview, certified nursing assistant (CNA) W said she worked the 3-11 PM shift on 7/29/16, and had resident #1 on her assignment. The CNA said resident #1 did not have any behaviors, he was very calm, walked around the unit, going from the nurses' station to his room. She said he had supper in his room between 7-7:30 PM. CNA W reported the last time she saw resident #1 was at 10:35 PM by the nurses' station wearing the WanderGuard bracelet. She said the 11 PM-7:30 AM CNA I was late and there was no one to relieve her, so she gave report to CNA X, who also worked the 11 PM-7:30 AM shift that night. CNA W said she did not know resident #1 had left the building at that time. On 8/04/16 at 5:09 PM, the executive director (ED) said he obtained statements from nurses and CNAs, and the last time the resident was seen was in his room on 7/29/16 at 10:35 PM by licensed practical nurse (LPN) Y. She said she tried to take resident #1 clothes off, but the resident refused. She said she went back to his room at 10:40 PM and he was in bed. The ED said at 11:30 PM, CNA I noted resident was not in his room, started checking bathrooms, came out in the hall, and alerted her 3 peers, who started to look for him, by the time CNA I got to the LPN, LPN F had received the call from EMS. The assigned CNA on the 3 PM-11:30 PM shift, CNA W, last saw resident #1 at 10:30 PM. The ED said LPN F reported she started rounds but something came up which diverted her attention, she did not check on resident #1. From 10:45 PM until 11:55 PM, the time the facility received the call from the EMS dispatcher, the facility could not account for resident #1's whereabouts. On 8/05/16 at 12:25 PM, LPN F said on 7/29/16 she clocked in at 11 PM. She said she normally looks into rooms while going down the hallway, towards the nurses' station. She said she had to count narcotics on two medication carts with two different nurses, and received a verbal update report of each resident's condition, including observations, and any unusual occurrences from LPN Y, and LPN B. She said she had rooms to the front and back of the 100 wing. Resident #1's room was on the 100 hall. After report, around 11:30 PM on 7/29/16, she started rounds on the back side of the unit but a resident got up, and she assisted the CNA with the resident. LPN F said she received a call from the EMS dispatcher around 12:05 AM, who asked her if she had a resident by the name of resident #1, and said the resident gave his name and room number to them. The EMS dispatcher told her the resident was hit by a car. LPN F said LPN Y told her she was trying to get resident #1 into bed, and directed him to his room. When the resident went to his room, he stood there by the door. LPN F said she did not see resident #1 when she came in to work on the 11 PM-7:30 AM shift on 7/29/16. LPN F was asked the expectation for change of shift, and said after receiving report from the off-going nurse, the on-coming staff is responsible to get a head count of the residents. She said, I do my head count around the time I get there, but that night we had distractions, so I didn't look at everyone within the first hour. LPN F said when the ED came into the facility that night, they did an elopement drill. She explained when a drill is called, all staff leave the area, all staff respond. When asked about response to door alarms, LPN F said, when you hear the alarm once, it means someone is going in or out of the door. If a resident with a WanderGuard approaches the door, it will set off a more intense sound. No one is assigned to check. She said, I don't know if a CNA really goes and checks, I guess if I hear it, then I look that way, and if there is a CNA down there, then they are going to get it. Several attempts were made to contact licensed practical nurse (LPN) Y during the onsite survey without success. On 8/09/16 at 1:11 PM, LPN Y returned a telephone call, and said she worked on 7/29/16 on the 7 AM-3 PM, and 3-11 PM shifts, and had resident #1 on her assignment. LPN Y said she saw the resident after 10 PM, when she encouraged him to go to bed. She verified he wore a WanderGuard bracelet, and said during the day he did trigger the WanderGuard alarm, stating she believes it was the lobby door. LPN Y said she did not do a head count at the change of shift, because I knew everyone was in bed. The Elopement Drills Policy N-1032, effective date: 11/30/2014 read, All staff is to report to a central location. This would leave all the other residents unsupervised while the drill was being conducted. The policy and procedure for Staffing N-1047, effective date 11/30/2014 read, Staffing will be maintained by the facility in accordance with State and Federal requirements. The facility will have appropriate staff to provide for the needs of the residents at all times. The policy and procedures for Change of Shift report N-107, effective date 11/30/2014, read, The Clinical nurse of a nursing unit shall report to the oncoming shift (nurses & CNAs) about the condition of each resident under his/her care, in order to fully inform nursing personnel of each resident's condition and maintain continuity of resident care from one shift of personnel to the next. Procedure: Nursing rounds should be made by the clinical nurse before beginning report to make a final check on resident condition and activity This was not done by LPN Y, and LPN F did not round, or do a head count of all her residents, until after she received the call from the EMS dispatcher. Both LPN Y and CNA W worked a double shift on 7/29/16, 7 AM-3:30 PM and 3-11:30 PM. Staff failed to adequately supervise resident #1. They could not account for the resident from 10:45 PM-12:05 AM, when LPN F received a call from EMS dispatcher informing her of the resident's status. On 7/29/16 on the 3-11:30 PM shift there were 2 LPNs. On 7/29/16 on the 3-11:30 PM shift, the facility's schedule reflected 2 LPNs and 6 CNAs assigned to the 100 wing. The 11 PM-7:30 AM shift on the 100 wing had 1 registered nurse (RN), 1 LPN, and 3 CNAs scheduled to work. These schedules were verified with the facility. Their time clocks indicted they did work on their scheduled shift. CNA I clocked in to work at 11:23 PM, which made her late to work. She was to report by 11 PM on 7/29/16. Nine residents on the 100 hall wore wanderguards because they were at risk for elopement. Resident #1's hospital record revealed the resident arrived in the emergency department on 7/30/16 at 12:13 AM via ambulance. The nursing assessment read, A single laceration over the right forehead, and nose. The hospital history and physical showed resident #1's date of hospital admission was 7/30/16 with chief complaint of headache and pain in the hands. Documentation for history of present illness read, This is an [AGE] year-old who resides at the Colonial Lakes nursing and rehabilitation facility. He was found wandering in the street with head trauma and complaining of hand pain Impression was listed as Left hand fracture, laceration to the right frontal area, and worsening dementia. The resident was discharged from the hospital on [DATE] to another long-term care facility.

Based on observation, record review and interview, the facility failed to ensure administration of it's resources effectively to ensure the safety of 1 of 21 sampled resident's safety (#1), their security door codes, staffing, and WanderGuard system. This failure resulted in the facility being unable to ensure the highest practical physical well-being for 1 of 21 residents assessed for being at risk for elopement (#1). Resident #1, an elderly cognitively impaired [AGE] year old resident, identified to be at risk for elopement, eloped from the facility on 7/29/16, walked east of the facility in the dark, and traveled 1.2 miles away. Resident #1 was involved in a car accident when he attempted to cross the street against the light, and walked in front of a moving vehicle. The facility's failure resulted in resident #1 sustaining a fractured left wrist, and laceration and hematoma to the forehead. Resident #1 was transported via Emergency Medical Services (EMS), and admitted to the hospital. The administration failed to use their resources effectively and efficiently to ensure resident #1, at risk for elopement, was free from neglect, and failed to provide adequate supervision in a safe and secure environment. These finding resulted in Immediate Jeopardy which is currently ongoing. Findings: Cross Reference F224, F323 and F353. On 8/04/16 at 3:15 PM, certified nursing assistant (CNA) I stated she worked on 7/29/16 on the 11 PM-7:30 AM shift. She confirmed she was late getting to the facility and arrived around 11:20 PM. She did not get report from the 3-11:30 PM CNA because all of the staff were gone when she arrived. CNA I said she then went and gave incontinence care to a resident and it took her 12 to 15 minutes to complete. After that, she made her way to resident #1's room. At approximately 11:35 PM, she said she notified the nurse that resident #1 was not in bed. While searching for resident #1, LPN F received all call that resident #1 was found outside the facility. A review for CNA I's time punch for 11/29/16 was at 11:22 PM, which means she arrived at the facility and clocked in at 11:22 PM, 22 minutes past the expected start of her shift. On 8/04/16 at 5:09 PM, the Executive Director (ED) reported that on 7/29/16 after 11:30 PM, resident #1 eloped from the facility. After going to the hospital to check on Resident #1, the ED returned to the facility and started his investigation. The facility at this time does not know how Resident #1 eloped from the building or what time he left the building. The last time resident #1 was seen was about 10:40 PM on 7/29/16 by licensed practical nurse (LPN) Y, the resident's direct care nurse for the 3-11:30 PM shift. The on-coming nurse, Nurse F, and CNA I, for the 11 PM-7 AM shift, never saw the resident from 10:40 PM to approx. 12 AM on 7/30/16. He said no one knew the resident was gone. 8/04/16 at 5:09 PM, the facility's immediate action plan was reviewed. This plan included placing the other 20 residents at Risk for Elopement on 15-minute security checks. The door code for the 500 unit exit door was changed, and staff were educated not to give out the code to anyone, including family members. Staff was educated on elopement, and an elopement drill was completed. Staff members who were not educated were not allowed to return to work until they had received the education on elopement. The oncoming nurses are now to view all residents assigned to their care prior to starting their shift. All other possible interventions were currently with the Safety Committee being reviewed. On 8/04/16 at 5:09 PM, the ED was asked about his policy for abuse, which covers neglect. He stated the night of the investigation, there were no staff members suspended. All of the employees involved were suspended at the end of their shift and allowed to care for residents until the end of the shift. The ED confirmed that resident #1's elopement, was by definition on their abuse policy, considered neglect. The ED did not respond when asked why staff continued to work, when their policy states that the employees involved will be suspended pending the investigation. On 8/04/16 at 5:09 PM, the ED was asked about his policy for change of shift and staffing. He stated, The off-going nurse is supposed to complete rounds before she gives report. Then the on-coming nurse will use a census sheet and put a check mark next to the resident's name when they see the resident. Then they fill out a census form and put it under the door to admissions. The on-coming nurse and CNA never saw the resident on the 11 PM-7:30 AM shift on 7/29/16, the day resident #1 eloped. From 10:40 PM to approximately 11:30 PM, staff did not know resident #1 left the facility. On 8/05/16 at 11 AM, an observation of the secured door in the 500 hall was completed with the ED. This observation was completed after the ED stated during his interview the steps the facility had implemented to prevent future elopements as part of their action plan. The ED stated, We changed the passcode to this door yesterday. All staff were educated not to give the code out to any family members from now on. During this observation, a resident's family member walked up to the door, took out his cell phone, looked up something, and entered the security code. The door opened and the family member began to exit the facility. The family member was stopped by the ED, at the 500 hall exit door, and was asked where he got the new code from. He replied, I know people. He then turned and exited the building. The ED stated, I don't know how he got the code. On 8/05/16 at 12:30 PM, LPN F said she arrived at the facility on 7/29/16 at about 11 PM and went to the 100 hall medication cart, got shift report from LPN B and counted the medication cart with her. She then received report from LPN Y on the 200 hall, and counted that medication cart. She stated after she received report, she checked on a new resident admission, then provided incontinence care to another resident. LPN F said she never saw resident #1 that night, and did not know he was missing until she received a call from EMS called informing the facility that the resident was at the hospital. While LPN F was talking to EMS, she told CNA I to check on resident #1 and see if he was in his room. CNA I confirmed he was not in the room. LPN F then called the director of nursing (DON) and the administrator. After she informed the DON and administrator, LPN F checked the rest of her residents, and completed her rounds. When asked what the facility ' s procedure is for resident rounding at change of shift, LPN F said the off going nurse is supposed to see if the residents are there before report, and then tell the oncoming shift if there are any concerns. Then, after report, the oncoming nurse is supposed to take the census report sheet and complete a resident head count, but said, I didn't look at everyone within the first hour. I was distracted on 7/29/16. On 8/05/16 at 1:30 PM, a United States Postal worker walked up to the building to the main facility entrance door, entered the security code for the front door, and entered the building. When the Administrator was asked about it, he stated, We are changing the code right now for the front door. In a written statement by LPN Y on 7/31/16, she wrote, At around 10:35 PM, I walked the resident (#1) to his room and attempted to help him go to bed. Resident sat on the bed and did not want me to pull the cover. At 10:40 PM, I walked back past (resident #1's) room. He was still laying on the bed. I continued to walk down to 125 and 127 to check on alarms. I came back to the nursing station and started my cleaning. I did not observe (resident #1) coming out his room. When the oncoming nurse arrived, I gave report and continued cleaning until I was ready to leave. Clocked out at 11:32. On 8/09/16 AT 1:11 PM in a telephone interview, LPN Y stated, I worked on the 29th (7/29/16) from 7 AM till after 11 PM. I worked a double that day. He (resident #1) is always trying to leave. I saw him after 10 PM, when I encouraged him to go to bed. He was wearing his clothes (street clothes) and had his shoes on. I returned to the nursing station after that and was doing work. I left the nursing station around 10:15 PM or 10:20 PM, and when I passed his room, he was still in bed. The on-coming nurse got to the nursing station shortly after 11 PM, and I gave her report. I did not do a head count of my residents because I knew everyone was in bed. I had 28 residents that night, and I told LPN F there were 28 (residents). The Change of Shift Report policy N-107, Effective Date 11/30/14, read, Procedure: Nursing rounds should be made by the Clinical Nurse before beginning report to make a final check on resident condition and activity Specific and pertinent remarks are made concerning the resident's conditions which may include any of the following Changes in physical and emotional condition. Pertinent remarks or unusual occurrences The Staffing Document policy N-1047, Effective Date 11/30/14, read, The facility will have appropriate staff to provide for the needs of the residents at all times The Resident Abuse policy N-1265, Effective Date 11/30/14, Revision Date 6/01/15, read, Definitions Neglect Failure to take precautionary measures to protect the health and safety of the resident Failure to adequately supervise a resident known to wander from the facility without the staff knowledge Preliminary investigation. Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from resident pending the investigation resident of the allegation. Investigation Any suspect(s), who is an employee, once he/she has (have) been identified, will be suspended pending the investigation. The ED job description read, Purpose of Your Job Position: The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulation that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times As ED, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for the day-to-day clinical and administrative activities of the facility, including ensuring compliance with state and federal regulations. Duties and Responsibilities: Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal and other regulatory guidelines. Ensure a safe, clean and comfortable environment for residents, visitors and staff

Based on staff and resident interviews and record reviews, the facility failed to ensure each resident's pain was managed to attain or to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 4 sampled residents (#2 & 3). The findings include: 1. Record review for resident # 2 revealed the resident was admitted to the facility on [DATE] at 4:30 PM with [DIAGNOSES REDACTED]. Her admitting physician orders [REDACTED].) extended release every 12 hours for pain and [MEDICATION NAME] (Oxyir) 60 mg. every 4 hours as needed for pain. During an interview with the Director of Nursing (DON) on 12/02/10 at 11:30 AM she stated both medications required a written prescription or a phone call by the physician to the pharmacy before they could be filled and sent to the facility for administration to the resident. She also stated the nurse practitioner who verified the medications and was on call for the attending could not write a prescription for these class 2 narcotics. Nurses' notes on 11/25/10 at 5 PM indicated the resident denied any pain at this time, but on 11/20/10 at 12 AM nurses' notes indicated the resident was "complaining of severe pain 9/10 in her lower back radiates to both legs. Requested pain medications for which she is aware (the physician) will be faxing Rx in the morning. Gave patient the option to be transfer to the ER, patient refused. encouraged repositioning every 2 hours." Another nurses' note on 11/26/10 at 1:33 PM revealed the resident was "resting in bed - resident complaining of severe pain - still waiting script from doctor for pain medication - MD contacted on 11/25/10 two times at approximately 5 PM and 8:30 PM. Doctor was also contacted today at approximately 10 AM and given orders and facility fax number - script still not received. Resident refused her skin check due to severe pain." A review of the medication administration records (MAR) for 11/25-26/2010 revealed the resident's pain assessment indicated she was experiencing either severe or moderate pain each shift. Further record review revealed no plan of care (POC) for pain management was developed until 11/29/10, 4 days after admission to the facility; the only intervention listed on the POC was to ask about and/or observe for pain/discomfort when interacting with the resident. During an interview with the Assistant Director of Nursing on 12/02/10 at 11 AM revealed she was on call over weekend and was not notified about lack of pain medication for resident. During an interview with the DON on 12/02/10 at 1:45 PM, she stated she talked to the nurse responsible for the resident's care on 11/25/10 and that nurse stated she did not know she should have called the supervisor or the medical director to get help with obtaining the script. During an interview with the Corporate Clinical Liaison and the Admissions Coordinator on 12/01/10 at 12:30 PM, both stated the standard practice for new admissions from hospitals is for a script to be sent for residents receiving schedule 2 medications. During an interview with the DON on 12/02/10 at 11:30 AM, she agreed the first dose of [MEDICATION NAME] was not given until 8:52 PM on 11/26/10, more than 24 hours after the resident was admitted to the facility. Although the resident was given [MEDICATION NAME] 1 mg. on 11/25/10 at 10:10 PM and on 11/26/10 at 9:52 AM and [MEDICATION NAME] 15 mg. on 11/25/10 at 9 PM for [MEDICAL CONDITION], the only other pain medication she received was [MEDICATION NAME] 100 mg. on 11/26/10 at 2:16 PM and at 6:29 PM which the resident had stated was totally ineffective. During an interview with the resident on 12/02/10 at 11:15 AM, she stated the concerns called in were valid. She stated she has been on pain management for 6 years and needed her meds to control her pain. She was in excruciating pain for first 24 hours after admission to the facility until an order was obtained for [MEDICATION NAME] which did not help at all. She has been on [MEDICATION NAME] ER 120 mg. every (q)12 hours (h) and Oxycodon 60 mg q4h as needed for breakthrough pain. She did not receive her pain medications until after 8 PM. She stated she did not understand why a physician who was on call could not be reached to obtain a script for the medications she needed. 2. Record review for resident #3 revealed the resident was admitted to the facility on [DATE] at 8:30 PM with [DIAGNOSES REDACTED]. Her Admission Data collection and Initial Plan of Care done 11/19/10 at the time of admission indicated her current pain intensity level was 7/10, with severe aching lower back which was intermittent and was relieved with pain medication. No care plan for pain management had been developed since she had been admitted to the facility 11/19/10; the Care Management Summary done 11/30/10 indicated the pain was not controlled but no care plan was developed to address this. Her physician order [REDACTED]. A review of the MAR revealed the resident did not receive her [MEDICATION NAME] ordered at 9 PM; documentation on the MAR indicated she did not receive the 9 PM dose of the pain medication because the medication was a new order and the facility was awaiting delivery from the pharmacy. A review of the medications available in the Emergency Drug Kit (EDK) revealed the medication was available in the EDK. Her pain assessment on the 3-11 shift on 11/19/10 revealed the resident had severe pain in her back; further pain assessment on the 11-7 shift on 11/20/10 indicated she continued to have moderate pain in her back. Nurses' notes on 11/20/10 at 12 AM revealed the "resident in bed alert and crying for severe pain in lumbar area, [MEDICATION NAME] 90 mg. given from EDK. Further nurses' notes on 11/20/10 at 3 PM revealed the resident was quiet. During an interview with the DON on 12/02/10 at 1: 45 PM, she stated she talked to the nurse responsible for the resident's care. The nurse said the resident was drowsy and not complaining of pain so she did give the medication. The decision not to give the medication was neither documented on the MAR nor was the physician notified of the resident being drowsy. The DON also stated the computer program for the MARs automatically times the pain assessment for 5 AM, 1 PM, and 9 PM and that assessment could have been documented at any time during the shift. The DON agreed the resident should have received the medication at 9 PM as it was ordered.