Every finding on record at Aviata at Fletcher

Based on interviews and record reviews the facility failed to ensure medical records were complete and accurate related to alleged incidents of abuse and neglect for three residents (#3, #8, #9) of five sampled residents.Findings included: On 01/07/2026 at 10:00 a.m. Resident #3 was observed sitting in his wheelchair in the hallway. He described an incident that had occurred during medication administration with the night nurse. He stated he knew his insulin orders and that he gets a fast-acting type of insulin. Resident #3 stated Staff A, RN (Registered Nurse), disagreed and told him, Don't tell me how to do my job. Staff A, told him, EXPLICIT. Resident #3 stated Staff A kept coming back and harassing him. The resident stated he reported the incident to the administration.Review of Resident #3's medical record revealed he was admitted on [DATE] with diagnoses included but not limited to osteomyelitis, diabetes, mood (affective) disorder, history of falling, hypertension, lymphedema, and acquired absence of left leg below knee.Review of the admissions Minimum Data Set (MDS) dated [DATE] showed Section C, Brief Interview for Minimum Status (BIMS) score of 15, meaning cognitively intact.Review of a psych progress note dated 12/19/25 revealed, Patient had a verbal incident with a staff member. At time of psychiatric evaluation, patient is calm and cooperative. He denies depression exacerbation, anxiety, irritability, suicidal ideation, or homicidal ideation. He reports no ongoing psychiatric distress related to the incident.During an interview on 01/07/26 at 2:45 p.m. the Nursing Home Administrator (NHA) stated on 12/16/25 the Director of Nursing (DON) had alerted her that they had a possible reportable. The NHA and floor nurse went to talk to Resident #3 who stated the nurse (Staff A) was disrespectful the night before. The resident stated he asked Staff A about the fast-acting insulin that night and again at 6 a.m. The resident said Staff A stated he did not have an order for it (fast acting insulin) and would have to check it after medication pass. The resident stated Staff A said, Don't tell me how to do my job. The resident said Staff A made comments about his mother. The resident said Staff A came back multiple times and he kept arguing with him. The resident stated he felt like Staff A was being verbally abusive. The NHA stated she interviewed the roommate who stated he did not remember specifics of the interchange between them, but Staff A was disrespectful and yelling. The NHA said the roommate said Staff A was the first to start yelling and came back multiple times yelling. The NHA stated she interviewed Staff A with Human Resource person present, and Staff A said Resident #3 did ask for the fast-acting insulin, and he did not give it because it was not correct. Staff A stated he checked the chart and Resident #3 did not have an order for fast acting insulin. The NHA verified that Staff A did give the fast-acting insulin based on the documentation on the MAR. Staff A told the NHA Resident #3 called him bad names. Staff A verified what he had said to the resident and said he told Resident #3, if you do not respect me, I will not respect you. Staff A stated he was not ever going to hit Resident #3. The NHA stated Staff A admitted he was wrong. The NHA stated based on the interview with Staff A, the allegation was substantiated because of calling names. The NHA stated Resident #3 was seen by psych on12/23/25. The NHA and the Nurse Consultant both stated there should have been documentation in the progress notes about the altercation with the resident. They stated the documentation needed was a progress note or a Situation, Background, Assessment, Recommendation (SBAR) which would include an assessment, and notification of needed parties. The NHA verified there was no documentation about the incident in the medical record.2. Resident #8 was admitted on [DATE] with diagnoses included but not limited to interstitial pulmonary diseases, Chronic Obstructive Pulmonary Disease, diabetes, asthma, cognitive communication deficit, depression, dialysis, Congestive Heart Failure, and hypertension. Review of the MDS dated [DATE] showed a BIMS score of 15, meaning the resident was cognitively intact.Review of a psych progress note for Resident #8 showed on 11/06/2025, the patient was seen at staff request following an episode of agitation during which he reportedly pushed another resident's walker. He is newly admitted for rehabilitation. Stated he has had a hard year but declines to elaborate and requested to stop the interview, stating he was becoming paranoid. Denies history of psychiatric treatment and declines medication for mood or anxiety at this time. Patient is not in need of additional referral or follow-up services.Review of Resident #8's medical record revealed there were no progress notes and no SBAR assessment was documented regarding the resident-to-resident incident on 11/06/2025.Review of the care plans showed there were no care plan updates related to the incident on 11/06/2025. 3. Resident #9 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to schizoaffective disorder, bipolar type, COPD, seizures, chronic pain, anxiety, depression, and hypertension. Review of the quarterly MDS dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired).Review of a psych services progress note for Resident #9 showed on 11/11/2025, Pt (patient) was seen today for follow-up after a resident-to-resident incident in which she was bumped by another resident while in her wheelchair. Upon evaluation, the patient was calm, cooperative and showed no adverse effects from the incident. She denied any abuse or neglect, and no psychosocial distress or injuries were noted.Review of Resident #9's medical record revealed there were no progress notes and no SBAR assessment was documented regarding the resident-to-resident incident on 11/06/2025.During an interview on 01/07/2026 at 3:21 p.m. the Nursing Home Administrator (NHA) and the Nurse Consultant stated on 11/06/25 at 2:00 p.m. Resident #9 alleged that Resident #8 was hitting her wheelchair with his wheelchair and when Resident #9 asked Resident #8 to stop, Resident #8 said, I will do worse to you. The NHA stated the residents were separated immediately and placed on frequent monitoring. The NHA stated they were placed on different smoke breaks. The NHA stated the Activities Director stated Resident #9 was trying to go out to smoke and Resident #8 was sitting next to her and bumped into her with his wheelchair, like bumper cars. The NHA stated the other residents on the patio were interviewed. All the other residents but one denied hearing the incident. A resident witness said that Resident #8 was in line to get out the door for smoking and he bumped into Resident #9. The resident witness stated he heard Resident #8 say to Resident #9, I will do worse. The NHA stated they both self-propel their wheelchairs. The NHA stated that Resident #9 stated Resident #8 hit her wheelchair but never hit her. The NHA verified Resident #8 was seen by psych services on 11/06/2025. The NHA stated Resident #9 was seen by the medical provider on 11/06/2025 and had no behaviors or issues. The Nurse Consultant stated the expectation would be for the nursing staff to document a progress note, an assessment and/ or an SBAR in the medical record for the incident on 11/06/2025. The NHA reviewed Resident #8's medical record and found no documentation related to the 11/06/2025 incident, no progress note, no SBAR, no assessment and no care plan update. The NHA stated she would expect to find both the documentation and a care plan update. The NHA reviewed Resident #9's medical record and found no documentation related to the 11/06/2025 incident, no progress note, no SBAR, and no assessment. The NHA stated she would expect to find documentation. The NHA stated there had not been any education provided to the nursing staff related to documentation post an incident, related to progress notes, SBAR, assessment, and updating the care plan. The NHA stated all incidents were discussed at morning meetings. The NHA stated all staff are made aware of incidents during the Abuse and Neglect education provided. The NHA stated that during the investigation, the medical record was reviewed for cognition, why the resident was admitted , diagnoses. The NHA stated they may not have looked at the progress notes for documentation of the incident. When asked the reportable showed the resident's progress notes were reviewed. The NHA verified she wrote that they were reviewed.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation, revised 11/06/2022 showed It is inherent in the nature and dignity of each resident at the center that he / she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and / or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse.Definitions:Mental and Verbal Abuse: Mental Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation for degradation. Verbal abuse may be considered a form of mental abuse.Verbal Abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age ability to comprehend our disability.Mental and verbal abuse include, but are not limited to:Harassing a residentMocking, insulting, ridiculingYelling or hovering over a resident, with the intent of intimidateMonitoring of residents who may be at risk is the responsibility of all facility staff2. Training: Employee Obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights.3. Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property and exploitation.Preliminary investigation: Immediately opened an allegation of abuse or neglect, the suspect (s) shall be segregated from residents pending the investigation of the resident allegation.The nurse or Director of Nursing / designee shall perform and document a thorough nursing evaluation and notify the attending physician.An incident report shall be filled by the individual in charge you received the report in conjunction with the person who reported the abuse. The report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion and submitted to the abuse coordinator.6. Protection: the resident will be evaluated for any signs of injury, including a physical exam and / or psychosocial assessment, as appropriate.Provide the resident with emotional support and counselling during and after the investigation, if needed.Review of the facility's policy, Plans of Care, revised 09/25/2017 showed Review, update and / or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completed of each OBRA MDS assessment, and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Based on interview and record reviews the facility failed to ensure residents were free from significant medication errors for three residents (#4, #5 and #6) of three sampled residents.Findings included: 1. Resident #4 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. Review of the admission Record showed diagnoses included but were not limited to cerebrovascular disease, atrial fibrillation, diabetes, anemia in chronic kidney disease, neuromuscular dysfunction of bladder, stage IV chronic kidney disease, hypertension, stage III sacral pressure ulcer, stage III left heel pressure ulcer, and urine retention. Review of the quarterly, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 14 or cognitively intact. Review of the Section GG, Functional Abilities showed the resident was dependent for toileting, showering and bathing. Section J showed he had no pain for last 5 days. Review of the physician orders showed: Morphine Sulfate concentrate oral solution 20 mg (milligram) / ml (milliliter) give 0.25 ml by mouth every 3 hours as needed for pain as of [DATE] Do not resuscitate (DNR) Assess resident every shift for pain Terminal Diagnosis: the resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis of Sequelae of Cerebrovascular Disease. Hospice services provided Review of the [DATE] Medication Administration Record (MAR) showed Assess resident for pain every shift. [DATE], Pain assessed on days at a level of 0 [DATE], Pain assessed on evenings at a level of 0 Review of [DATE] MAR showed Morphine Sulfate concentrate oral solution 20 mg (milligram) / ml (milliliter) give 0.25 ml by mouth every 3 hours as needed for pain as of [DATE] [DATE] at 09:19 a.m. pain level of 7; given and effective; given by Staff G, Registered Nurse (RN) [DATE] at 1629 or 4:29 p.m. level of 8 given and effective; given by Staff G, RN [DATE] at 08:16 a.m. level of 7 given; given by Staff G, RN Review of Medical Provider and nursing progress notes revealed the following: On [DATE] at 10:44 a.m. resident in hospice care. Resident noted with low blood pressure, 100/30, heart rate of 94, O2 (oxygen) saturation level was 80% with Oxygen at 2 Liters, respirations were 20. Resident appears weak and lethargic. Comfort measures provided by hospice protocol. Hospice nurse called. Staff H, Nurse Practitioner (NP) from insurance company was in facility. Primary Physician MD was aware and advised writer to stop regular medications on [DATE]. On [DATE], Staff H, Nurse Practitioner (NP) from insurance company wrote resident was being seen visit to follow-up on chronic conditions. (Resident) Was seen lying in bed, chronically ill appearing, eyes closed, sleep, appears weak/fatigued. Minimal conversation. Drifts back to sleep. Denies chest pain, shortness of breath, fever, chills, cough/congestion. Per nursing this a.m., the blood pressure was 100/32, with oxygen saturation at 80% at 2 liters per minute. Rechecked by NP, blood pressure was 100/60, heart rate 51, respirations 20, oxygen saturation at 94% with 4 liters of oxygen via nasal cannula. Call placed to Hospice services, waiting on return call from Hospice MD to discuss. Discussed with Primary Provider MD in agreement to discontinue Atorvastatin, iron, GDR of Desvenlafaxine, defer work up of leukocytosis, presumptive UTI (Urinary Tract Infection) with chronic indwelling Foley/recurrent UTIs, Hospice status. Discussed Plan of Care with nursing requested nursing notify provider for any changes in status. On [DATE] at 8:00 a.m. Staff F, LPN (Licensed Practical Nurse) weekend supervisor wrote upon assessment this writer observed resident exhibiting signs of labored breathing, audible moaning, and involuntary twitching. Hospice was informed of change in condition. Awaiting call back from Hospice Nurse for estimated time of arrival. On [DATE] at 8:38 a.m. Staff F, LPN, weekend supervisor entered the resident's room, upon assessment the resident was noted with no pulse or respirations. His code status was verified with two nurses. The resident's code status was verified as Do Not Resuscitate. The DON (Director of Nursing) was notified. On [DATE] at 8:55 a.m. showed at 8:39 a.m., call received from Hospice Nurse, indicating an estimated time of arrival of 15 minutes. The resident expired at 8:42 a.m., and the Hospice Nurse arrived at 8:50 a.m., pronouncing the resident's death at 8:58 a.m. The family was notified at 9:00 a.m.: however, there was no answer, and a message was left. Resident's insurance company was notified at 9:02 a.m., and communication occurred with their staff. Staff H, Nurse Practitioner (NP) with insurance company was notified at 9:28 a.m. On [DATE] at 1:06 p.m., a Change in Condition (CIC) showed resident had expired. Resident pronounced dead by hospice nurse. Family and MD notified. Review of the care plans showed: Resident had a terminal prognosis related to Cerebrovascular disease and was receiving hospice services. Interventions included but not limited to observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Date Initiated: [DATE] Review of the Weights and Vitals Summary showed [DATE] at 12:35 a.m. blood pressure: 102/70 [DATE] at 4:26 p.m. blood pressure: 112/52 [DATE] at 1:34 a.m. blood pressure: 123/55 During an interview on [DATE] at 10:12 a.m. with the Nursing Home Administrator (NHA), Regional Registered Nurse (RN) and Director of Nursing (DON). The DON stated she was called in on [DATE] for what they identified as a discrepancy of the narcotic count. She stated she came in and reconciled all the medication carts with all the nurses at 7 p.m. At that time, she verified there was a discrepancy with Resident #4's liquid Morphine. Staff I, RN was working the day shift and was doing the medication pass from 7 a.m. to 7 p.m. Staff J LPN was coming on at 7 p.m. and found the discrepancy during narcotic reconciliation. Staff I, RN, was suspended due to possible drug diversion. The DON stated on [DATE] she came in and questioned Staff G, RN after looking at the inventory form and discovering she was the last person to administer the Morphine to Resident #4. The DON asked Staff G, RN how she administered the Morphine. Staff G picked up a medication cup and stated she administered it using the cup. Staff G was then pulled into office for a more in-depth interview. Staff G admitted to using the medication cup for measuring the morphine instead of a syringe. Staff G was asked to review the dosage she poured up of 2.5 ml to the actual order of 0.25 ml. Staff G, RN, was taken off the medication cart. The DON stated during the interview with Staff G, she disclosed she administered 2.5 ml of morphine for the three doses. The DON stated, once we calculated the 2.5 ml for three doses, that was what was removed or missing that we originally thought was a drug diversion. Staff G RN did a return demonstration of what she delivered. The DON asked Staff G why she gave the pain meds, and she stated that she guessed the pain level. The DON asked Staff G what the appropriate way would be to assess the pain level. Staff G stated using the PAINAD (Pain Assessment in Advance Dementia) scale. The DON stated Staff G was suspended at that time pending an investigation. On [DATE], Resident #4 received 2 doses and 1 dose on [DATE]. The NHA stated Staff G realized she made a medication error during her demonstration. The NHA stated it was documented on the Hospice note that the resident had a slow decline on the visit note of [DATE]. The NHA stated on [DATE] a note from Staff I, RN showed the resident was a hospice resident and was weak and lethargic, blood pressure of 100/30 (documented in a progress note). The NHA stated the progress note from Staff H, NP showed he was chronically ill, eyes closed, appears weak and fatigue, minimal conversation, back to sleep, blood pressure 100/32, oxygen saturation at 80% on 2 liters of oxygen. The NHA stated Staff H, NP documented she rechecked the blood pressure and it was 100/60, Oxygen saturation to 94% on 4 liters of oxygen. The note showed Staff H contacted hospice and was awaiting on return call. Staff H discussed the resident with his Primary Provider MD to discontinue medications and discounted plan of care with nurse. The NHA stated the Medical Director, and his Primary Provider could not say whether the added medication added to his (Resident #4's) decline or not. The NHA stated she interviewed Staff H, NP and she could not say whether the dosage caused anything or not. During an interview on [DATE] at 11:21 a.m. Staff H, NP with insurance company stated they specialize in long term care, and they work in conjunction with the Primary Provider MD. She stated they are another set of eyes and ears. She stated she was at the facility a couple days a week. She stated when she saw the resident she saw he was declining. Staff H stated she was not surprised that he had passed over the weekend. He had stage 4 chronic kidney disease. He had more than 9 lives due to kidneys and co-morbidities. She stated he was normally alert and awake, and he was not doing that on her last visit. He was in hospice. They were starting to cut medications. She stated she made numerous calls to the family trying to let them know he was declining. She confirmed with the nurse on [DATE] that he was on morphine and it had already been ordered. She stated he did not appear to be in any pain on [DATE] but she wanted it to be available to him. Staff H, NP stated she found out about the med error the following week. She stated they called her to let her know he had passed. She stated later that week, she found out about the discrepancy in meds and a med error had been made. She stated she thinks death was imminent. She stated the pain medication helped with the comfort. She stated on [DATE] he looked like a limp rag. His vitals were abnormal. She stated she called the family and Hospice that he was rapidly declining. She stated she spoke with the Primary Provider MD about an antibiotic for possible UTI. He was on medication for anemia, but it was not helping. During an interview on [DATE] at 1:02 p.m. the pharmacy consultant stated he has a form he uses to audit narcotic counts and provide education. The nursing staff are to identify the resident, look for the medication in the narcotic logbook, use the MAR in the PCC, check to see if medication was scheduled or PRN (as needed), assess the pain level. The staff is supposed to use a medication cup on the cart, stable surface, eye level for pouring into. If using small doses should use a syringe to draw up. He stated to make sure the resident was sitting up and swallowed the medication completely. Ensure both logbook and the electronic chart or MAR are documented / signed. If order was less than 2- or 3-ml dosage, use a syringe to draw the medication up. He stated that reconciliation of medications should come after change of shift at a minimum. On 9/30 at 12:58 p.m. a telephone call was made to Staff G, RN. Staff G would not speak with this surveyor. During an interview on [DATE] at 1:51 p.m. Staff F, LPN, weekend supervisor stated she had just come on shift on a Saturday. She stated she overheard the night nurse give a report to the oncoming day nurse. The night nurse said Resident #4 had been actively dying. He was only opening his eyes. Staff F stated she went in and checked on him, he did not act like he normally does. She checked on him through the shift. She stated staff H, NP had followed up with hospice already. Staff F stated he was fine on Saturday, comfortable. Staff F stated we left Saturday night ([DATE]) and he was comfortable. She stated she checked on him Sunday morning ([DATE]) and he was twitching and moaning. She asked the evening nurse if she had given him anything throughout the night. Staff F stated she told Staff G, RN to give him some pain meds and she would call hospice. Staff F told hospice he was actively dying. Hospice placed her on hold to locate a nurse in the area. Hospice office told Staff F that they were sending a nurse over. Staff F reported to the Hospice office that the resident had an order for Morphine, but it had not been given yet. Staff F informed Hospice office the morphine was being given now. Staff F stated the Hospice nurse called her and stated she would be at the facility in 15 minutes. Staff F told the Hospice nurse she would wait to assess the resident until she (hospice nurse) got there. Staff F stated later the CNA (Certified Nursing Assistant) told her the resident was gone. Staff F stated she grabbed his chart and checked his code status. He was a DNR. She checked him and he had no pulse or respirations. Staff F stated she called the hospice nurse back and informed her of his passing. The hospice nurse was just coming into the building. Staff F walked the hospice nurse to the room. The hospice nurse pronounced him expired and she let the team know. Staff F stated she did not know about the medication (morphine) error until after the fact. Staff F stated that when drawing up morphine we are to use syringes for small doses. Staff F stated, We are to check the orders to the medication. Once the nurses check the medication and order they check the order again. Staff F stated they need to check the dose again to make sure it is correct. Stated they are to check it is the right resident, right time, right route. Staff F stated the oncoming shift does the narcotic count with the off going shift. The narcotic sheets are to be checked to the medication in the cart. Staff F stated, we even check the empty cards. Staff F stated she did not know anything about a medication error. She stated the nurses started having education on medication pass and she heard it was because of Resident #4. Staff F stated as far as she knew Resident #4 was stable but actively dying. Staff F stated the aide told her he would do an occasional moan. During an interview on [DATE] at 2:42 p.m. the Medical Director and /or Primary Provider MD stated the staff told her about the morphine missing. She stated that days later the DON stated she had spoken with the nurse that had worked with on the weekend and realized he (Resident #4) was given the wrong dosage. Medical Director stated Resident #4 was her resident. She stated he was elderly and on hospice. Medical Director stated, It was hard to say if the med (morphine) affected him or not. He was really declining. The Medical Director stated she spoke with Staff H, NP that Friday ([DATE]) and they said he was declining. The Medical Director stated she was informed he passed away. The Medical Director / Primary Provider MD stated, I am not able to say if the morphine error contributed to his death or not, hard to say. She stated, It was a high dose. She stated he was declining before the med error, difficult to contribute. Review of the facility's policy titled, Physician Orders, revised [DATE] showed The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure: admission orders: information received from the referring facility for agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. Routine orders: A nurse may accept a telephone order from the physician, physician assistant or nurse practitioner. The order will be repeated back to the physician, PA or ARNP for his / her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR / eTAR). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date to order as soon as practicable after it is provided to maintain an accurate medical record. 2. On [DATE] at 1:00 p.m , Resident #5 was observed lying down in bed with her call light within reach. She was observed with no signs of distress. She said approximately 2 weeks ago the nurse assigned to their room gave her, her roommate's medication and gave her roommate her medication. She said she did not have any negative effects, but she thought it was strange it happened. Resident #5 said she received 3 Tylenol tablets and 1 Gabapentin tablet. Review of an admission Record dated [DATE] revealed Resident #5 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent encounter, pressure ulcer of other site stage 3, nonrheumatic tricuspid (valve) insufficiency, nonrheumatic mitral (valve) insufficiency, cardiomyopathy, unspecified Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) summary score of 15, which indicated Intact cognitive abilities. Review of physician order showed: Acetaminophen tablet 325 milligram (MG), give 2 tablets by mouth every 6 hours as needed for pain, fever, order date [DATE] Coreg Oral Tablet 3.125 MG (Carvedilol), give 1 tablet by mouth two times a day for hypertension, order date [DATE] Gabapentin Oral capsule 30 milligram (MG) (Gabapentin) give 1 capsule by mouth three times a day for Nerve pain, order date [DATE] Midodrine hydrochloride (HCI) oral tablet 10 milligram (MG) (Midodrine HCI) give 1 tablet by mouth three times a day for hypotension hold for systolic blood pressure 120, order date [DATE] 3. On [DATE] at 1:00 p.m., Resident # 6 was observed sitting up in her wheelchair watching television and talking to her roommate. She was observed well-groomed with no signs of distress. Resident # 6 said their nurse came in the room and gave her roommate's medication to her. She said when the nurse gave her the medication, she took all the pills, but when she got to the last pill, she noticed it was not familiar. She said when she asked the nurse about the medication, the nurse realized she made a mistake and gave her and her roommate the wrong medication. Review of Resident # 6 admission record dated [DATE] revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy, peripheral vascular disease, unspecified polyarthritis, unspecified Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 which indicated Review of physician order showed Acetaminophen tablet 325 milligram (MG), give 3 tablets by mouth every 8 hours as needed for pain, order date [DATE] Gabapentin Oral tablet (Gabapentin) Give 3000 milligrams (MG) by Prescriber mouth every 8 hours for Nerve pain hold if sedated or confused, order date [DATE] Zofran Oral Tablet 4 milligram (MG) Ondansetron Hydrochloride (HCI), give 1 tablet by mouth every 6 hours as needed for nausea and vomiting, order date [DATE] Review of a nursing progress note dated [DATE] revealed, Nurse Practitioner was notified about medication error. Resident # 6 vital signs noted. Medical Doctor (MD) ordered to monitor blood pressure every hour notify MD regarding changes. On [DATE] at 12:45 p.m., an interview was conducted with the Director of Nurses, DON. The DON said on [DATE] she received a phone call to inform her that the nurse gave Resident #5 her roommates medication and gave her roommate her medication. She said it was not clear on the incident report what medications were given to each resident, but she was made aware that it was during the 5 p.m. med pass. The DON said as she reviewed the incident report that Resident #5 received Resident # 6 Tylenol. The DON said as she continued to review the documentation, Resident # 6 incident report does not list the medication she was given at the time of the incident. The DON said her expectations are if there is a medication error the nurse should document the medication that was given to the residents, notify the MD and the family and follow any recommendation the physician may have. On [DATE] at 1:00 p.m. an interview was conducted with Staff A, Registered Nurse, RN. Staff A said she was in the middle of med pass when someone approached her, and she got distracted. Staff A said she made a mistake and gave Resident her roommate's Tylenol, and gave Resident # 6 her roommates Midodrine, Amlodipine, and Gabapentin. Staff A said she did not notify Resident #5's provider about the incident because the resident already has a PRN (as needed) order for Tylenol, she just received it without her request. On [DATE] at 2:30 p.m., an interview was conducted with the Medical Director. The Medical Director said her expectation were nurses need to verify who they are giving medications to before the medications are administered. Review of the facility's policy, Administering Medications, revised [DATE] showed Medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and Implementation 1. Only persons licensed or permitted by the state to prepare, administer and document the administration of medication may do so. 2. The director of nursing services supervises and directs all personnel who administer medication and / or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frames. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. 9. The individual administering medications verifies the resident's identity before giving the resident his / her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking for photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 23. As required or indicated for a medication, the individual administering the medication records is in the residence medical record: a. the date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when these results were observed; and g. The signature and title of the person administering the drug. Review of the facility's policy, Notification of Change in Condition, revised [DATE] showed The center to promptly notify the patient / resident, the attending physician, and the resident representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and resident representative when there is a (n): Accident Significant change in the patient / resident's physical, mental, or psychosocial status Need to alter treatment significantly New treatment Discontinuation of a current treatment due to but not limited to: Adverse consequences Acute condition Exacerbation of a chronic condition The nurse to complete an evaluation of the Patient / Resident. Document evaluation in the medical record. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. Notify the Patient / Resident and the resident representative of the change in condition. Documentation notification in the medical record. Document resident / patient change and condition on a 24-hour report. Complete SBAR as indicated.

Based on record review and interviews, the facility failed to notify the physician a medication error had occurred for one resident (#5) out of four residents sampled.Findings included: On 09/30/2025 at 1:00 p.m , Resident #5 was observed lying down in bed with her call light within reach. She was observed with no signs of distress. She said approximately 2 weeks ago the nurse assigned to their room gave her, her roommate's medication and gave her roommate her medication. She said she did not have any negative effects, but she thought it was strange it happened. Resident #5 said she was not able to remember what medication was given to her, but she thinks she received 3 Tylenol tablets and 1 Gabapentin tablet. Review of an admission Record dated 09/30/2025 revealed Resident #5 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent encounter, pressure ulcer of other site stage 3, nonrheumatic tricuspid (valve) insufficiency, nonrheumatic mitral (valve) insufficiency, cardiomyopathy, unspecified. Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated intact cognitive abilities Review of physician order showed:Acetaminophen tablet 325 milligram (MG), give 2 tablets by mouth every 6 hours as needed for pain, fever, order date 07/12/2025 Gabapentin Oral capsule 30 milligram (MG) (Gabapentin) give 1 capsule by mouth three times a day for Nerve pain, order date 05/03/2025On 09/30/2025 at 12:45 p.m., an interview was conducted with the Director of Nurses (DON). She said Resident #5 was given her medication out of order during med pass. The DON said on 09/02/2025 she received a phone call informing her that the nurse gave Resident #5 her roommate's medication. She said it was not clear on the incident report what medications were given to each resident, but she was made aware that it was during the 5 p.m. medication pass. The DON stated, I don't see any documentation showing Resident #5 provider was notified regarding the incident. The DON said as she reviewed the chart, Resident #5 received her roommates Tylenol. She stated, Resident #5 has a PRN order for Tylenol, but she received the medication without requesting it. The DON said her expectations were if there is a medication error, the nurse should document the medication that was given to the resident, notify the MD, and the family and follow any recommendation the physician may have. On 09/03/2025 at 1:00 p.m. an interview was conducted with Staff A, Registered Nurse, RN. Staff A said she was in the middle of medication pass when someone approached her, and she got distracted. She said she made a mistake and gave Resident #5 her roommate's Tylenol. Staff A said she did not notify Resident #5's provider about the incident because the resident already had a PRN order for Tylenol, she just received it without her request. On 09/30/2025 at 2:30 p.m., an interview was conducted with Resident #5' provider. The provider said she was not notified about the medication error regarding Resident #5 receiving her roommate's medication. The provider said her expectation was that she should be notified about everything that goes on with her patients. She said she is at the facility at least twice a week, and no one had informed her about the medication incident. On 09/30/2025 at 4:20 p.m., an interview was conducted with The Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). The RNC said they don't have a policy specific to medication errors and notification to the provider. She said notifications for medication errors are considered a change in condition and should fall under those guidelines. Review of the facility policy titled, Notification of Change in Condition, Revision Date 12/16/2020 revealed, Policy: The Center to promptly notify the patient/ resident, the attending physician, and the resident representative when there is a change in the status or condition.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to the administration of Vancomycin. The facility failed to obtain and follow physician orders for Vancomycin laboratory services, and failed to report laboratory results to the physician and pharmacy for one resident (#2) of two residents sampled.Findings included: Resident #2 was admitted to the facility on [DATE] and discharged on 07/25/2025. Review of the admission Record showed diagnoses included but not limited to cellulitis of right lower limb and left lower limb, non-pressure chronic ulcer of left calf with fat layer exposed, non-pressure chronic ulcer right calf, diabetes, polyneuropathy, Chronic Obstructive Pulmonary Disease (COPD), muscle weakness, hypertension, encounter for therapeutic drug level monitoring, end stage renal disease (ESRD), anemia, edema, peripheral vascular disease (PVD), gastrostomy, myocardial infarction, and Methicillin-resistant Staphylococcus aureus (MRSA). Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, meaning cognitively intact. Section GG, Functional Abilities showed the resident required substantial/ maximal assistance for toileting and shower and bathing. Review of the physician orders showed the following orders:Vancomycin HCl in Normal Saline (NaCl) Intravenous Solution 1.25-0.9 GM (gram)/250ML (milliliter)-% every 18 hours for bilateral lower extremities (BLE) infected wound for 14 days as of 6/17/25 to 07/01/25Vancomycin HCl in NaCl Intravenous Solution 1.25-0.9 GM/250ML-% in the morning for BLE (bilateral lower extremity) Infected wound from 07/08/2025 starting 07/09/25Pharmacy to dose Vanco as of 06/18/25Pharmacy to dose Vanco as of 07/21/25Pharmacy to dose Vanco as of 07/09/25Complete Blood Count (CBC) with differential (diff), Comprehensive Panel (CMP) ordered on 06/18/25 for 06/18/25Basic Metabolic Panel (BMP), Vancomycin Pre-dose (trough), sed rate (Erythrocyte sedimentation rate which monitors inflammation and infection) for 06/18/25Vancomycin pre-dose (trough), BMP ordered 06/19/25 for 06/23/25Vancomycin pre-dose (trough), sed rate, CMP, CBC with diff, hemoglobin A1C ordered 06/18/25 for 06/26/25Vancomycin pre-dose (trough), sed rate, CMP, CBC with diff, A1C ordered 06/18/25 for 06/27/25Vancomycin pre-dose (trough), sed rate, CMP ordered on 06/18/25 for 07/03/25Vancomycin Random ordered 07/14/25 for 07/14/25CBC with diff, CMP, sed rate, CRP Quantitative, Vancomycin random ordered on 07/14/25CBC with diff, CMP, sed rate, CRP (C-reactive protein) Quantitative, Vancomycin random as of 07/21/25Vancomycin pre-dose (trough) ordered on 07/23/25 for 07/24/25Vancomycin Random ordered 07/24/25 for 07/25/25BMP for 07/24/25Ok to transfer to ER (emergency room) per Infectious Disease (ID) Medical Doctor (MD) on 07/25/25 Review of Inpatient consult to Care Management dated 06/10/25 showed to perform CBC, BMP every Monday and Thursday. Vancomycin trough every Monday. Review of a handwritten script from the ID physician dated 07/07/25 showed CBC, CMP, UT or VT, ESR, CRP on Mondays and CBC, BMP on Thursdays and fax results to ID physician. Review of the Medication Administration Record (MAR) for June 2025 showed:Vancomycin HCL in NaCL Intravenous Solution 1.25-0.9 gm/250 ml every 18 hours for LLE (left lower extremity) infected wound for 14 days as of 06/17/25 discontinued on 06/19/25 administered on 06/17/25 to 06/19/25.Vancomycin HCL in NaCL Intravenous Solution 1.25-0.9 gm/250 ml in the morning for BLE infected wound as of 06/20/25 until 07/01/25 administered 06/20/25 to 06/27/25; on hold for 06/28/25 and 06/29/25; administered on 06/30/25. Review of the Medication Administration Record (MAR) for July 2025 showed:Vancomycin HCL in NaCL Intravenous Solution 1.25-0.9 gm/250 ml in the morning for BLE infected wound as of 07/09/25 until 07/24/25 administered 07/09/25 through 07/16/25; 07/17/25 dose was not administered; administered 07/18/25 to 07/21/25; 07/22/25 dose was not administered and the 07/23/25 was administered. Review of Lab results showed06/18/25 showed Vancomycin random was 14.7 (trough 10-20 ug/ml); (peak 18-40 ug/ml)06/19/25 showed Vancomycin trough was 27.8; sed rate of 82 (0-20)06/23/25 showed unable to obtain06/26/25 showed unable to obtain06/27/25 showed unable to obtain06/30/25 showed Vancomycin trough was 27.6; sed rate of 4607/03/25 showed vancomycin trough of 14.5; no sed rate; (after medications were stopped on 07/01/25)07/14/25 showed sed rate of 102 (Vanco trough not performed)07/21/25 showed sed rate of 121 (Vanco trough not performed)07/24/25 showed Vancomycin trough 33.907/25/25 showed Vancomycin random 32.6 Review of the physician and nursing progress notes showed:On 06/18/25, Resident new admit to facility, resident admitted on IV antibiotics Cefepime and Vancomycin until 07/01/25 for wound infection. Resident has history of ESBL (Extended - Spectrum Beta-Lactamase), active MRSA in right lower extremity (RLE) and positive for C. Auris. Resident educated on contact precautions and isolation.On 06/19/25, initial note Staff B, Nurse Practitioner (NP) showed his was a [AGE] year-old male with history of PAD (Peripheral Artery Disease) who presented with worsening wound on LE (lower extremity) to the hospital. Vascular surgery was consulted. Patient underwent excisional debridement of bilateral legs. Cultures done and grew gram-negative rod. ID consulted. Patient managed at the hospital with ABX (antibiotics), then once stable, was discharged to SNF (Skilled Nursing Facility) with IV Vancomycin, Cefepime and metronidazole. Now remains at SNF for continued IV ABX, wound care management and therapy services. Labs reviewed, 06/18/25 results.On 06/19/25 the Vanco trough: 27.l8, results relayed to the pharmacy, recommendations received to continue same dose of Vanco 1.25 at 6 a.m. q(every) 24 hrs (hours) instead of q18hrs, repeat Vanco trough on 6/23/25 30 mins prior to administration.On 06/21/25, Staff C, NP, initial note. An extensive chart review was completed and included a review of eh initial chief complaint, progress notes, vital signs, lab results, diagnostic results, therapy evaluation, consultations, and medication reconciliation. Pharmacy to dose (Vancomycin).On 06/23/25, The Vanco Though lab ( [SIC] trough) did not collect; the lab tech was not able to draw blood from the resident; writer and the nurse to try over again, it could not.On 06/24/25 late entry, Primary Provider MD note, history and physical. The patient is currently receiving wound care and antibiotic treatment, including Flagyl, cefepime, and Vancomycin, scheduled July 1, 2025, with weekly labs. Has a poor treatment adherence. Vancomycin level 27.8. Medications and labs reviewed. Pharmacy to dose Vancomycin. Obtain weekly labs.On 06/25/25, received call from ID office with follow-up appointment on 07/07/25.On 06/26/25 at 6:30 a.m., nursing note showed lab technician, DON (Director of Nursing) and writer tried to collect resident sample, but it was not possible. Lab will send another technician but at 8 a.m.On 06/26/25 late entry, Primary Provider MD note, Multiple complaints from staff about poor compliance with treatment. He refuses to elevate his lower extremities during the day and when not in therapy he was on the smoking patio. Tolerating IV antibiotics well. Wounds not improving. Plan: Medications reviewed. Pharmacy to dose Vancomycin. Weekly labs.On 06/27/25 nursing progress note showed, Vanco is on hold per MD order.On 06/27/25, Staff B, NP note showed patient seen today. No labs today. Pharmacy to dose.On 06/30/25, late entry, Primary Provider MD note, no acute changes in condition. He will complete antibiotics tomorrow and ID follow-up is scheduled for 07/07/25. Plan to continue current treatment.On 07/02/25 Primary Provider MD note, participating in therapy. Medications reviewed. Infectious disease follow-up on 07/07/25. Antibiotics completed.On 07/09/25, Infectious Disease by MD order to restart Vancomycin the same dose and start Zosyn 4.5 gm every 8 hours. CBC, CMP, UT, ESR, CRP every Monday and CBC, BMP every Thursday. Fax results to ID MD. Primary Provider MD notified.On 07/09/25, late entry, Primary Provider MD note, Patient came back from ID follow-up with new orders to continue antibiotics. He will be on Vancomycin 1. 25 grams daily and Zosyn 3.375 every 6 hours. No stop date given but he will need follow-up in 2 weeks. Weekly labs. Patient still poorly compliant with recommendations to elevate lower extremities. Instead, he spent all day on the patio in his wheelchair in high temperatures. Wounds not improving. Plan: medication reviewed. Vancomycin 1.25 g IV daily. Pharmacy to dose Vanco. Labs weekly and fax results to ID.On 07/09/2025 2:48 p.m. DON and Primary Provider MD present during wound care. Aware of wound condition.On 07/11/25, late entry - pharmacy follow up. Medications and labs reviewed. Vancomycin 1.25 g IV daily. We need a stop date from ID. Pharmacy to dose Vanco. Labs in a.m.On 07/22/25 at 6:34 a.m. on- call MD was notified that a new prescription for the antibiotic (Vancomycin 1.25 gram) was needed. She said she would call after 8 a.m. so the person on-call could send the prescription. She would follow up with the next shift.On 07/22/25 at 7:47 p.m. Staff B, NP progress note showed met with patient today. He continues treatment with Vancomycin for lower extremity cellulitis, with close monitoring of response. Continue Vancomycin IV in the morning. Pharmacy to dose Vanco. Next labs are pending. Continue Vancomycin. Pharmacy to dose Vanco.On 07/24/25 at 7:37 a.m., The pharmacy was calling. Resident was without a vancomycin dose for this morning. Pharmacist was informed medication was on hold due to vancomycin trough. They (pharmacy) stated they sent a fax on 07/17/25 because they don't have the results (Vanco trough). Vancomycin trough was drawn this morning. Oncoming nurse was informed about the situation. Pharmacy requested the result to send the medication back to the facility.On 07/24/25 Primary Provider MD note, showed I was notified by nurse about critical Vanco level 33.9. I gave orders to discontinue Vancomycin and wrote an order for BMP in am. Nurse called ID office. Vancomycin last day was 07/21/25 and he missed his follow up appointment (ID MD). New appointment for 07/29/25 was scheduled. Nurse also received orders from pharmacy for random Vanco level in a.m. and BMP.On 07/24/25 showed pharmacy & MD advised writer to discontinue Vanco. Vanco end date was 07/21/25. All labs were faxed to the ID office. The resident had an appointment with ID on 07/29/25. Resident's Vanco was Discontinued due to HIGH trough. Primary provider MD notified of situation.On 07/25/25, Primary Provider MD note, we received a call from ID earlier today with request to transfer patient to local hospital for continuation of care. Wounds seen by wound specialist and dressed this morning. Wounds continue to get worse. Transportation pending per patient request for a smoking break before he leaves. Vancomycin toxicity.On 07/25/25, Change in Condition showed send to ER.On 07/25/25, ID assistant called the writer and instructed the writer to send the resident to local hospital due to abnormal lab results. The resident was advised and sent to the ER. The resident's family was notified of the transfer and situation. Review of the care plans showedResident had infection of the BLE cellulitis, MRSA, Morganella, Enterobacter, C. Auris as of 06/18/2025. Interventions included but not limited to administer antibiotics as per MD orders.Resident had anemia as of 06/18/2025. Interventions included but not limited to obtain and monitor lab/diagnostic work as orders. Report results to MD and follow up as indicated.Resident was at risk for malnutrition related to cellulitis, diabetes, COPD, ESRD, anemia, anxiety, bipolar disorder, hypertension, altered skin integrity, and altered lab values. Interventions included but not limited to administer medications as ordered. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Resident has potential actual impairment to skin integrity related to BLE cellulitis, edema, fragile skin, impaired skin integrity, susceptible to bruising, medication and use, PAD / PVD, diabetes, chronic BLE ulcers as of 6/18/2025. interventions included but not limited to obtain blood work such as CBC with DIF, blood cultures and C and of any open wounds as ordered by physician. During an interview on 09/29/2025 at 1:12 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) they stated on 07/24/25 they noted a critical Vanco trough level. The Vanco trough lab was drawn on 07/24/25 and the results were 33.9. The DON stated at that time the ADON (Assistant) spoke with the Primary Provider MD. The ADON asked the Primary Provider MD if she wanted the resident transferred to the hospital due to the critical Vanco trough. Primary Provider MD said no. Primary Provider MD ordered a redraw of the Vanco trough on 07/25/25. The 07/25/25 redraw results were 32.6. The NHA and the DON stated on 07/25/25 the Infectious Disease (ID) received the 07/25/25 Vanco trough results and ID recommended sending the resident to the ER. Resident #2 was sent to the ER for evaluation. The NHA and the DON stated they started an investigation due to the ID sending the resident to the hospital. The NHA and the DON stated It was identified Resident #2's Vanco troughs were not obtained prior to administration of the Vanco, and it resulted in critical Vanco levels. The DON stated they initially schedule a Vanco trough level to be performed on either Mondays or Thursdays depending on when a resident was admitted to the facility. The DON stated from there it was determined by a physician's order when the Vanco troughs were to be performed for the duration of the IV antibiotic administration. The DON stated the physicians normally have the pharmacy dose the antibiotic depending on the Vanco troughs. The DON stated once the Monday or Thursday trough was obtained, they will get the orders from pharmacy for dosage. The DON stated the pharmacy gives the order to redraw the trough depending on the dosage. The DON stated there was not a set day of the week after the initial draw for the Vanco troughs to be performed. The DON verified the pharmacy had not received a Vanco trough since 07/08/25 based on documentation. The DON stated Resident #2's original order on admission was for the Vanco to be administered through 07/01/25. The DON stated that the Primary Provider MD wrote an order on admission, 06/18/2025, for Vanco troughs twice a week. The scheduled dates were 6/19/25, 6/23/25, and 6/27/25. On 06/23/25 and 06/27/25 the Vanco trough level showed, but the lab results showed unable to obtain The DON stated there was no documentation the physician or pharmacy was informed of the lack of Vanco trough results. The DON stated she would expect to see documentation informing both the Primary Provider MD and the pharmacy. The DON verified based on the MAR that the Vanco was not administered on 06/27/25, 06/28/25, nor 06/29/25. The DON stated the progress notes/documentation showed Vanco was on hold per MD order. The DON stated the nurse inputted the hold of the medication order under Primary Provider MD. The DON stated the Primary Provider MD inputted a late note from 06/26/25, and the note was inputted on 07/02/2025 which showed tolerating IV antibiotics well. The DON verified that on 06/27/25 an order to hold the Vanco for 2 days until 6/29 was from the Primary Provider MD due to lab issues. The due to lab issues was documented on the orders. The DON verified the Vanco restarted on 06/30/25 (after the hold). The DON stated Resident #2 was seen again on 06/30/25 by the Primary Provider MD and her note showed Resident #2 will complete IV antibiotics on tomorrow (07/01/25) and follow up with the ID MD on 07/07/25. The DON and the NHA stated the pharmacy did not question the lack of Vanco troughs nor did the nurses call the MD regarding lack of Vanco troughs. The DON stated the 07/03/25 Vanco trough order was originally ordered on 06/18/25 on admission to occur on 07/03/25 even though the Vanco was discontinued on 07/01/25. The nurses did not cancel the order for the Vanco trough. The Vanco level was 14.5. On 07/07/25 Resident #2 went to the ID MD. The DON stated the ID MD ordered to continue Vanco at the same dose and it was started again on 07/08/25. The order was handwritten from the ID MD as follows: CBC, CMP, UT or VT, ESR, CRP every Monday and CBC and BMP every Thursday. The DON stated the labs were not clarified with the ID MD, questioning a UT vs. VT as being a Vancomycin trough. The DON stated the order was entered as UT by the nurse. The DON stated the new orders would have been reviewed the following day in clinical / morning meeting. The DON stated it (UT vs. VT) was missed in morning meeting also. The DON stated the Primary Provider MD saw Resident #2 on 07/11/25 and documented in her note she had reviewed Resident #2's orders. The Primary Provider MD did not order a Vanco trough either (meds reviewed). The DON stated the note showed the pharmacy was to dose and labs weekly and fax to ID per the Primary Provider MD. The DON stated the pharmacy sent a 3-day supply of Vanco on 07/14/25 even though they had not received a Vanco trough. The DON stated on 07/14/25 Resident #2 was seen by the Primary Provider MD, and she ordered a CBC, CMP, CRP, sed rate and Vanco random to be drawn. The DON stated the Primary Provider MD entered the order into the computer herself but entered the orders incorrectly. The orders were in a pending status. The orders did not get to the lab for collection. The orders did not come to the nursing dashboard either. The DON stated the labs the ID MD had ordered on 07/08/24 were performed on 07/14/25 but they did not contain a Vanco trough because a UT was ordered instead. The DON stated the documentation does not show the labs were sent to the ID MD. The DON stated the pharmacy told them they had suspended refills, and the last refill was on 07/14/25. The DON stated Resident #2 was seen by the Staff B, NP on 07/15/25. The DON verified the Vanco was not administered on 07/17/25 and no documentation in the progress notes. The DON stated there must have been doses here to administer. The DON stated she does not know why the nurse did not administer on 07/17/25. The NHA and the DON stated they are assuming there was Vanco doses here and the nurse administered them. The DON stated the Primary Provider MD saw Resident #2 on 07/21/25 but wrote the note late on 07/24/25. The DON stated the Primary Provider MD on 07/21/25 ordered a CBC, CMP, Vanco random, sed rate and CRP, and inputted the order herself. the Primary Provider MD reviewed the labs herself on 07/21/25. The DON stated after 07/24/25, but during the investigation it was found in the lab portal that the 07/21/25 labs had all been done but the Vanco random was not performed. The DON stated there was no explanation as to why the Vanco random was not done. The DON stated on 07/22/25, the Vanco was not available and so they called the on-call NP (Nurse Practitioner) for a new script. The DON stated on 07/22/25 the Vanco was missed, and the Primary Provider MD was notified. The DON stated on 07/23/25, the Vanco order was not placed on hold. The DON stated when they interviewed Staff E, Registered Nurse (RN), she stated she found Vanco for Resident #2 in the fridge and that was how she gave it on 07/23/25. The DON stated on 07/24/25, the pharmacy requested a Vanco trough. The Vanco trough level was given to the Primary Provider MD. The Nurse called the ID MD office also. The Primary Provider MD told them to discontinue the Vanco and fax labs to ID MD office. ID MD said to send the resident to the ER. The DON stated the pharmacy did not order labs nor did they communicate with the facility. The DON stated the pharmacy told them on 07/24/25 (during the investigation) that they (pharmacy) had sent a fax on 07/14/25 and 07/17/2025 regarding trough levels to be drawn and had not received a response. The DON stated the pharmacy told them they will not call the facility for follow-up, only fax. The NHA stated the pharmacy cannot show confirmation that they sent the faxes. The NHA stated the Primary Provider MD was interviewed on 07/29/25 by the DON and Regional Nurse Consultant, and the Primary Provider MD stated the pharmacy was to dose and the ID MD was following. The NHA stated the Medical Director was notified on 07/25/25 of the lack of Vanco levels. The NHA stated she asked the Medical Director to do a chart review. The NHA stated the Medical Director followed up with the NHA on 07/28/25. The Medical Director stated there was lack of oversight by the attending provider, pharmacy, and ID as well as in house nurse practitioner. A call was made to the ID MD's office on 09/29/2025 at 3:10 p.m. and received a return call from staff on 09/29/25 at 4:00 p.m. The Practice Administrator stated he read from the resident's notes and the resident was non-compliant at the facility and the ID MD suggested they bring him back to the hospital. The Practice Administrator stated the resident was in the hospital from [DATE] to 08/04/25. He stated he will speak with the doctor regarding any effects of the elevated vancomycin levels may have had and get back with surveyor. Did not receive a return call. During an interview on 09/30/25 at 12:15 p.m. with Staff D, Licensed Practical Nurse (LPN), Unit Manager (UM) and the NHA present, stated she inputted the lab order from the ID MD as UT. Staff D, LPN stated she remembered getting the script for labs from the ID MD. She stated she recalled it had a UT on it. Staff D stated she had never heard of a lab by that name but did not know all the labs out there. She stated she did not call the ID MD to clarify, because the orders were clear. Staff D, LPN stated Vanco troughs are normally done on a resident on Vanco, yes. She stated she does not recall seeing if he was on Vanco troughs or not. She stated she never gave him his medications. Staff D was the Unit Manager (UM) on the floor, on his floor. She stated she works Monday through Friday normally. Staff D stated she goes to the morning meetings. She stated she does not remember if the UT order was reviewed in morning meeting or not, she don't recall. She stated normally there are orders from the hospital for their Vanco. Staff D, LPN stated the orders are placed in the computer and the Vanco troughs are scheduled. She stated that our pharmacy does our (Vanco) dosing. Staff D stated the pharmacy decides when to do troughs and then the doctor reviews the orders from the pharmacy and the lab results. Staff D stated most of the doctors go into the system to review their own labs. She stated, You can see on the lab in computer that it has been reviewed. She stated if the lab was not reviewed then we will print it out and hand it to the doctor. Staff D state she checks labs daily. Staff D stated the UM would not have seen the labs the Primary Provider MD did if they had not been sent properly. She stated Resident #2 was being followed by ID MD and the Primary Provider MD. The NHA stated the care would be the Primary Provider MD due to primary care MD. Staff B, NP talks to the Primary Provider MD also. They all communicate with each other. During an interview on 09/30/25 at 12:30 p.m. Staff B, NP with NHA present stated she remembered the resident. She stated she was managing his chronic conditions that he came in with. She stated she would address any acute concerns that were brought to her attention. Staff B stated she alternates care with his Primary Provider MD. She stated so on the day she sees him; she would be involved in his care, and his Primary Provider MD would be on the alternate days. She stated on the day the resident was sent to the hospital it was brought to her attention a Vanco trough was not done. She verified her note on 06/18/25 it was documented she reviewed labs and addressed with staff/ pharmacy to dose and consult per protocol. She stated she saw him on 06/27/25 and her note showed labs were pending for the 06/30/25. She verified the note on 06/27/25 showed no labs were available. Staff B stated she saw him on 07/15/25. She stated she saw him on 07/22/25. She stated in the lab portal it will show who reviewed the labs. Staff B, NP stated If the Primary Provider comes in and addresses the labs then she would not address it again. During an interview on 09/30/2025 at 1:02 p.m. with pharmacy consultant stated a lot of the times the MD will order the Vancomycin trough. The trough was to be done 30 minutes to one hour before the fourth or fifth dose. The facility was to perform troughs continually. He stated the orders for the troughs were ordered by the prescriber. He stated the MD admitting or managing the Vanco gives the orders when the labs are to be done. He stated if the Vanco labs are drawn after the administration or not during the allotted time frame it may be incorrect. He stated sometime a consultation will be put in for the pharmacy to manage the dosing. If the Vanco trough was elevated, they will give the orders hold the Vanco. He stated if the trough was okay, they may increase the dosage as needed. The consultant stated the expectation would be for the troughs to be done as ordered and sent to the pharmacy. The consultant stated if he saw the troughs were not being done, he would put in a recommendation. He stated once the lab results are sent to the pharmacy, the pharmacy will give recommendation dosage. He stated if the resident was therapeutic for a while, they may do Vanco trough levels less. He stated the hospital will due Vanco randoms especially for dialysis residents. During an interview on 09/30 at 2:09 p.m. Staff E, Registered Nurse (RN) stated she remembered the resident. She stated she found the last dose of Vancomycin in the fridge. She stated she called the pharmacy because it was the last dose. She stated the pharmacy said they will not send another dose because they (pharmacy) had sent a fax, they did not how many days ago, requesting a Vanco trough and they had not received the results yet. She stated the pharmacy sent a recommendation in the medication packet, the next day, with the request for a Vanco trough. She stated she was leaving after her evening shift and saw it. She stated she stayed and helped the day nurse put in the vancomycin trough order. Staff E stated she only worked with the resident that one day. During an interview on 09/30/25 at 2:42 p.m. the Medical Director stated she was asked to review the resident's chart. She stated there were a lot of people involved. She stated the facility was supposed to check the Vanco levels. The Medical Director stated there were orders placed and not done. She stated she spoke with both the Primary Provider MD and Staff B, NP about this. The Medical Director stated the nurses should be updating the orders. She stated the nurses should be looking at the lab results before giving the medication. She stated pharmacy should be checking the levels before dosing. The Medical Director stated there was nursing, NP and pharmacy involved. She stated a few people missed that meds were being given and not checking the (Vanco) levels. The Medical Director stated her expectation was for the labs to be checked and then give the meds. During an interview on 09/30/2025 at 3:08 p.m. the Primary Provider MD stated her expectations were for the Vanco troughs to be performed and receive the lab results. She stated the ID MD sends the order for the weekly labs. Primary Provider stated she prefers the pharmacy to dose the Vancomycin and keep track of the Vanco trough levels. She stated she had notified the UM that she had not seen levels (Vanco trough), and she asked for random Vanco levels. She stated the resident was usually on long term care labs 1-or-2-week. She stated she preferred the resident to be watched by the pharmacy. She stated they discussed this case. The Primary Provider MD stated the new way we order labs came in around this time. She started they were putting in orders into the electronic chart and then paper. She stated now it was automatically into the electronic chart. She stated that sometimes it was not automatically transmitted. She stated when she went into the order section of the electronic chart you would click on the labs and then it would give you another tab to click. This tab you would pick the diagnosis and date and time of the order and date and date and time to be performed. She stated the resident was getting the Vanco, but the pharmacy did not send any orders for Vanco levels. She stated the resident was at the facility for a couple of months. She stated he had a follow up with the ID MD and he put the resident back on the Vanco. She stated she ordered a couple of times to perform random Vanco levels. She stated she was seeing the Vanco levels in the lab portal and then stopped seeing the Vanco levels. When they did do a Vanco level it came back high. The Vanco levels were in the 30's. The labs were sent to the ID MD, and he wanted the resident to go back to the hospital. She stated the resident never returned to the facility. Primary Provider MD stated she was seeing the resident as well as the facility's NP. She saw him at least weekly and the NP 1-2 times per week. The Primary Provider MD stated she did not know what happened to the labs. She stated she did not hear from the pharmacy. She stated if the pharmacy had not been sent the labs, then they should not have kept sending the meds. She stated she did not hear from the facility the pharmacy was not sending the meds. She stated sometimes the resident would not come to the room for her to see him. She stated he was not getting his wound care done, he was refusing. He was not available at times. He was non-compliant. Review of the facility's policy, Laboratory, Diagnostic and X-ray, revised 06/21/2021 showed To provide guidance on ordering, obtaining, documenting and reporting laboratory, diagnostic and X-ray results. Procedure: Obtain a physician's order for laboratory work, diagnostic testing an X-ray Complete the required requisition forms Schedule laboratory work, diagnostic test and or X-ray as indicated Results of laboratory work, diagnostic tests, and X-ray to be sent to the center or electronically uploaded to the resident ERM Stat testing results are critical values to be called to the center The center to notify the ordering practitioner (or the covering physician if after hours) of values outside the reference range or per physician order Document any new orders Document notification of the practitioner and resident / resident representative of results Laboratory work, diagnostic testing and X-rays to be filed in the electronic medical record Review of the facility's policy, Physician Orders, revised 3/3/2021 showed The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure: admission ORDERS: information received from the referring facility for agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. ROUTINE ORDERS: A nurse may accept a telephone order from the physician, physician assistant or nurse practitioner. The order will be repeated back to the physician, PA or ARNP for his / her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR / eTAR). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date to order as soon as practicable after it is provided to maintain an accurate medical record. Review of the facility's policy, Administering Medications, revised April

Based on observation, record review, and interview, the facility failed to implement their Abuse, Neglect, Exploitation, & Misappropriation Policies and Procedures regarding a failure to attempt to verify information from former employers prior to hire for one (Staff A, Certified Nursing Assistant) of four sampled staff members. Findings Included: Review of the facility's Abuse, Neglect, Exploitation, & Misappropriation policies and procedures, Document Name N-1265, effective 11/30/2024, last reviewed 11/16/2022, documented in Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, polices, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Included in the Procedure: 1. Screening: Persons applying for employment with the center will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property. This includes but not limited to: - Employment history. - Criminal background check. - Abuse check with appropriate licensing board and registries, prior to hire. - Sworn disclosure statement prior to hire. - Licensure or registration verification prior to hire. - Documentation of status of any disciplinary actions form (sic) licensing or registration boards and other registries. - Information from former employers. The center will ensure that all prospective consultants, contractors, volunteers, caregivers, and students are pre-screened as required by law. A phone interview was conducted on 12/9/2024 at 1:14 p.m. with the Director of Nursing (DON) regarding an allegation of sexual abuse for Resident #8, and Resident #9. The DON stated the Assistant Director of Nursing (ADON) was notified by Staff H, Certified Nursing Assistant (CNA), Resident #8 had stated Staff A, CNA touched his genitals inappropriately and kissed his hands. The police were called. The DON stated Staff A, CNA, was home at the time they learned of the allegation on 11/22/2024 and was suspended. The DON also stated Staff A, CNA worked 3 p.m. to 11 p.m. on 11/21/2024 and it was the next shift where Staff H, CNA became aware of the allegation. The DON stated local police came to the facility interviewed Resident #8. The police turned to ask Resident #9 if he saw anything and that was when Resident #9 said Staff A, CNA, inserted his finger into his rectum for about 10 seconds. The DON said, After that was done, DCF (Department of Children and Families) was notified. They came out and questioned both residents. Both the residents' stories were consistent. I did a quality assurance questionnaire. That was when [Resident #6] said, he slapped my butt when I was getting care. When asked if there was anything that could have been done different, the DON stated, no, we educate on abuse and neglect; we do a great job for education. A review of Resident #6's clinical chart documented an admission on 3/15/2024. Her diagnosis list included but not limited to cerebral infarction due to thrombosis of right middle cerebral artery; need for assistance with personal care and muscle weakness (generalized). A review of Resident #6's Minimum Data Set (MDS) quarterly assessment, dated 9/19/2024, documented under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident is cognitively intact. On 12/9/2024 at 9:45 a.m., an observation was conducted of Resident #8, dressed in seasonally appropriate clothing, clean, groomed, self-propelling in wheelchair. He declined to speak about the incident with Staff A, CNA and stated he had told others the information. A review of Resident #8's clinical chart revealed the resident was admitted to the facility on [DATE]. His diagnosis list included but not limited to hemiplegia and hemiparesis following cerebral infarction and muscle weakness (generalized). A review of Resident #8's MDS Quarterly assessment dated [DATE] revealed under Section C - Cognitive Patterns a BIMS score of 15, which indicated the resident is cognitively intact. On 12/9/2024 at 9:50 a.m., an observation was conducted of Resident #9 in bed head watching television and an interview was conducted with the consent of the resident. The resident was hard to understand, paused between sentences, but able to answer questions. When asked if he had been abused or neglected, he stated not since the aid, but did not disclose the particulars of the event. A review of Resident #9's clinical chart revealed he readmitted to the facility on [DATE]. His diagnosis list included but not limited to other sequelae following unspecified cerebrovascular disease and muscle weakness (generalized). A review of Resident #9's MDS quarterly assessment, dated 11/2/2024, documented under Section C - Cognitive Patterns, a BIMS score of 11, which indicated Resident #9 has moderate cognitive impairment. An interview was conducted on 12/9/2024 at 11:08 a.m. with the Human Resource Generalist (HRG). When asked if she had a protocol for new hires, she provided an untitled one-page document which included seven sections titled Exhibit X. She stated the form was basically the check list for the employee to be hired. She stated the first two sections were to be completed before the new employee would start. During the interview, a review of the form Exhibit X was conducted and revealed the following in the first section of the document: Signed offer letter Employment Application Resume 1st Reference 2nd Reference Direct Deposit W4 form The HRG stated there should be a first and a second reference documented by the employee on the employment application and/or the Applicant Reference Check form. The HRG also stated, We typically call the reference and ask how the person was as an employee. Review of the Applicant Reference Check form, effective 5/2014, reflected a single page document with the following four sections: Section 1: To be completed by Applicant. Section 2: Reference Responses. Section 3: Telephone Reference only-to be completed by company representative. Section 4: Written Reference-to be completed by reference source. A review of Staff A, CNA's personnel file was conducted. The Level II background screening with an eligibility date of 4/23/2021, print date of 6/07/2024, reflected the employment history of seven providers. Further review of Staff A, CNA's personnel file revealed no documentation of an effort by the hiring facility to verify employment history with any of the providers listed on the Level II Background screening Clearinghouse. Review of Staff A, CNA's employment application revealed the listing of two private employers. The personnel file reflected no documentation of an effort to verify Staff A, CNA's employment with the two private employers. Further review of Staff A's employment application revealed a box to list three professional references of individuals who are not related to you. The form documented three people's names with the relationship of daughter, wife, and cousin. No documentation was present in the file to indicate an attempt to contact the references. In addition, no other references were listed that were not related to Staff A, CNA. A follow up interview was conducted on 12/9/2024 at 2:18 p.m. with HRG. She was able to show the application for employment Staff A, CNA and confirmed the application listed three relatives of Staff A, CNA as the professional references. She confirmed she did not locate the form to verify the references. No further evidence was provided by the HRG to indicate an attempt to verify employment history or verification of references had been conducted. She confirmed part of the hiring process was to verify references. She said, the form (Exhibit X) was a newer form, but she did not state when the form had been initiated by the facility.

Based on observations, interviews, and record review, the facility failed to ensure treatment and care for management of pain was provided in accordance with professional standards of practice for one resident (Resident #7) of three residents sampled for pain management. Findings included: Review of Resident #7's Admission Record revealed an admitted [DATE] and a readmitted [DATE]. Resident #7 was admitted to the facility with diagnoses of spinal stenosis, morbid severe obesity, chronic pain syndrome, and intervertebral disc disorders, lumbar region. Review of Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed under Section H - Health Conditions, Resident #7 was on a scheduled pain medication regimen and received PRN (as needed) pain medications within the five day assessment period. Section H of the Assessment also revealed Resident #7 experienced pain almost constantly, which occasionally affected her sleep and day-to-day activities. Review of Resident #7's physician orders revealed the following orders: - An order dated 3/12/2024 for Percocet (Oxycodone with Acetaminophen) 5 mg (milligrams)-325 mg give one tablet by mouth every eight hours as needed for moderate pain. - An order dated 3/12/2024 for Percocet (Oxycodone with Acetaminophen) 5 mg-325 mg give two tablets by mouth every eight hours as needed for severe pain. An observation on 12/9/2024 at 12:50 p.m., of the [NAME] Side medication cart revealed Resident #7 did not have Percocet 5 mg-325 mg in the medication cart. Further review of the Narcotic Logbook revealed there was not a log for Percocet 5 mg-325 mg. During an interview on 12/9/2024 at 12:40 p.m., Staff I, Registered Nurse (RN), stated if a resident is receiving a narcotic medication, the medication should be in the medication cart and there should be a narcotic log for it. During an interview on 12/9/2024 at 2:49 p.m., Staff K, RN stated generally she gets a count of narcotic medications in the morning, gets a signature, wipes down the cart, look at the census, and starts passing medications. Staff K, RN also stated she looks at the orders and then checks her carts. If a medication has run out, she will reorder the medication from the pharmacy and checks the emergency drug kit (EDK) to see if they have the medication so she can dispense it. She stated she has a few residents who take narcotics, and she checks to see when they were last given to confirm if she can dispense the pain medication. Staff K, RN stated she cross references the narcotics book, documents the administration in the narcotics book, dispenses the medication, and then subtracts one pill from the current count before watching the resident take the medication and documenting the administration in the resident's medication administration record. During an interview on 12/9/2024 at 3:30 p.m., the Assisted Director of Nursing (ADON) stated Resident #7 is seen by pain management and was not able to explain why Resident #7 did not have Percocet in the medication cart. Her expectation would be for the nurses to follow the physician's order and Resident #7 has an order for Percocet, so it should be in the medication cart. During an interview on 12/9/2024 at 4:52 p.m., Staff J, RN, stated Resident #7's Percocet should have been reordered. Staff J, RN also stated Resident #7's pain management team comes to the facility on Tuesday and Thursdays and when she notices a resident is out of pain medication, she texts the physician who will then place the order for more.

Based on observations, interviews, and record review, the facility failed to ensure accuracy of the medical record by failing to document administration of medications for one resident (Resident #7) of three residents sampled for pain management. Findings Included: During an interview on 12/9/2024 at 9:30 a.m., Resident #7 stated she was recently admitted to the hospital because during morning medication pass, her face turned blue. She stated on 11/23/2024, in the morning, she had just removed her oxygen mask when the nurse came into provide her with her medication. Resident #7 stated she took the medication and immediately her face turned blue, and the nurse had to call other staff members into the room. She stated she remembers the Director of Nursing (DON) coming in and calling the physician so they could send her to the emergency room (ER), and she remembers being in an ambulance with Emergency Medical Services (EMS) staff trying to keep her awake. Resident #7 stated when she got to the ER, they took for a CT (computed tomography) scan and the physician came in to see her. She stated she was told by the ER physician that she had overdosed. Review of Resident #7's Admission Record revealed an admitted [DATE] and a readmitted [DATE]. Resident #7 was admitted to the facility with diagnoses of spinal stenosis, morbid severe obesity, anxiety disorder, chronic pain syndrome, and intervertebral disc disorders, lumbar region. Review of Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C - Cognitive Patterns, A Brief Interview for Mental Status (BIMS) score of 15 out of 15, showing Intact cognition. The MDS Assessment also revealed under Section N - Medications, Resident #7 received antidepressant and opioid medications during the assessment period. Review of Resident #7's Order Summary Report, active as of 11/30/2024, revealed the following orders: - An order dated 3/12/2024 for Percocet (Oxycodone with Acetaminophen) 5 mg (milligrams)-325 mg give one tablet by mouth every eight hours as needed for moderate pain. - An order dated 3/12/2024 for Percocet (Oxycodone with Acetaminophen) 5 mg-325 mg give two tablets by mouth every eight hours as needed for severe pain. - An order dated 4/23/2024 for clonazepam 1 mg by mouth every 12 hours for anxiety disorder. - An order dated 11/17/2024 for fentanyl transdermal patch 72 hour 50 mcg (micrograms) per hour, apply one patch transdermally every 72 hours for pain, remove from skin every 3rd day and remove per schedule. - An order dated 4/13/2024 for Naloxone HCl (hydrochloride) injection solution 0.4 mg per mL, inject 1 mL intramuscularly as needed for opioid toxicity. May give an additional 1 mL in 3 minutes if resident is still unresponsive. During an interview on 12/9/2024 at 2:49 p.m., Staff K, RN stated she was assigned to Resident #7 on 11/23/2024 and she was at lunch when she came down the hallway and noticed other staff members in Resident #7's room. She stated the resident was sweaty, and the DON (Director of Nursing), and another nurse were in the resident's room. Staff K, RN stated the DON told her Naloxone HCl was administered to the resident. She stated she was in charge of Resident #7's medication pass that morning and she did not give her any pain medications that day. During an interview on 12/9/2024 at 2:50 p.m., the DON, stated on 11/23/2024 the CNA assigned to Resident #7 came and got her due to Resident #7's face being bright red and lips being blue. She stated when she went into Resident#7's room her oxygen was on, and she was not at her baseline. She called the nurse and the physician, and the physician authorized for her to give Naloxone HCl and Zofran IM (intramuscularly). The DON also took Resident #7's fentanyl patch off, and the resident became more responsive. She stated Resident #7's oxygen level was low, and she administered oxygen via a non-rebreather. The DON stated when EMS arrived, they confirmed the resident's fentanyl patch was off. The DON also stated while Resident #7 was at the hospital, no labs were drawn, but they gave her a diagnosis of an overdose, which she thinks is because Naloxone HCl was administered to the resident prior to going to the hospital. The DON stated the Naloxone HCl administration should be found on the resident's MAR (Medication Administration Record) and there should be documentation of the event from the nurse. Review of Resident #7's Medication Administration Record (MAR), for the month of November 2024 did not show Naloxone HCl was administered. During an interview on 12/9/2024 at 6:00 p.m., Regional of Clinical Services stated if a resident was given Naloxone HCl, she would expect it to be on the resident's MAR. She also stated she was not able to find any documentation regarding Resident #7 needing to be administered Naloxone HCl and being sent to the ER.

Based on observation, interview and record review, the facility failed to follow food menus for two (#4 and #5) of two sampled residents and failed to act upon the grievances of the Resident Council Committee related to food menus. Findings included: During an interview and observation on 10/24/2024 at 9:15 a.m., Resident #5 was sitting in her bed looking at her breakfast in a Styrofoam container. Resident #5 stated she did not get on her tray what was on the menu slip. The slip with her name on it showed Thursday Breakfast 10/24/2024: Double Protein, buttermilk pancakes - 4 each; Margarine - 2 each; Syrup - 2 each; Bacon - 2 slices; Hot Cereal - 6 oz; milk - 8 oz; orange juice - 4 oz; coffee or hot tea-6 oz. Resident #5 stated and on observation she had scrambled eggs, and an untoasted English muffin and oatmeal. Resident #5 stated she got her juice and no milk. She did not get any meat; she was supposed to get bacon. She stated this happened often, what was on the slip was not what she got. Resident #4, Resident #5's roommate, stated she also did not get what was on her menu slip. Her slip with her name on it showed Thursday Breakfast 10/24/2024: Pureed buttermilk pancakes - #8 scp; Margarine - 1 each; Syrup - 1 each; ground sausage patty - #16 scp; Pureed Hot Cereal - #6 scp; milk - 8 oz; orange juice - 4 oz; coffee or hot tea-6 oz; house shake - 1 srv. Resident #4 stated, I ate my eggs. Resident #4 stated she did not get her sausage, she liked sausage. On observation Resident #5 had pureed English muffin and oatmeal. (Photographic evidence) During an interview on 10/24/2024 at 9:45 a.m., the Certified Dietary Manager (CDM) stated he had just arrived and did not know why the menu had been changed. He stated he would have to ask the cook. The cook stated he had to swap the menu with Friday's due to not having enough bacon for today (Thursday). The CDM stated the scrambled eggs today was their protein, they had an English muffin and oatmeal. The CDM stated the bacon would be here on Sunday with the next order. Review of the Week-At-A-Glance showed Thursday the menu for breakfast was Buttermilk pancakes, margarine, syrup and bacon. Friday the menu showed, scrambled eggs, English muffin, margarine and jelly. Review of the Resident Council Minutes dated 09/06/2024 showed food is terrible, no follow up with dietary getting other food besides what is on the ticket. Action taken was blank as well as person responsible. Review of the Resident Council Minutes dated 10/07/2024 showed in Old Business: food is terrible, no follow up with dietary getting other food besides what is on the ticket. During an interview on 10/25/2024 at 3:09 p.m., the Nursing Home Administrator (NHA) stated he spoke with the CDM. The NHA said he would talk to the cook regarding when he (the cook) switched the menu it needed to be communicated to the staff and residents. The NHA stated the education would be provided by the end of next week. He stated he was going to get bacon when the survey was completed (for tomorrow's breakfast). The NHA stated the CDM just told him the bacon did not come in with their Monday order. During an interview on 10/25/2024 at 4:11 p.m., the Traveling Social Worker (SW) verified the complaint of food is terrible and no follow-up with tray getting other food besides what is on the ticket was on the 09/06/2024 Resident Council Minutes. She stated she would go check on the education provided to the dietary staff regarding the concern and follow-up. During an interview on 10/25/2024 at 4:15 p.m. the Traveling SW and the Director of Nursing (DON) stated they were unable to locate any documentation the kitchen staff was educated regarding changing the menus and informing staff, NHA, and the dietician. During an interview on 10/25/2024 at 4:46 p.m., the Dietician stated she expected the kitchen staff to follow the plan. She stated, If they can't follow it they need to create a substitution log and let me know what changes they have planned. I did not get a call this morning. She stated, In the last month they have not informed me of any changes in the menu except for swapping of a vegetable or something. She stated they had not informed her of swapping a whole menu. Observed dietician texting CDM about the changes and the dietician was awaiting a response. The Dietician stated they were to report menu changes to her and the facility. The Dietician, stated, I have had conversations with the CDM about this in the past, to let me know, do not remember when. I know I have said it but will put in writing next time. Review of the facility's policy, Menus, revised 9/2017 showed menus will be planned in advance to meet the nutritional needs of the residents / patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures: 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternative meal, and any always offered food and beverage items. 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file. 8. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas. Review of the facility's policy, Resident Council Meeting, dated 11/01/2021 showed residents will be provided the opportunity to meet together at least monthly in an organized group setting to discuss current issues/topics of their choice. Thes topics may include events, activities, resident rights, care as service and concerns. In addition, a review of old business, problem resolution, and development of action plans may be discussed. Procedure: 5. Utilize the Resident Council Minutes - for any issues requiring a follow-up response. Resident Council will review this section each meeting to determine if Concern was resolved, not resolved, or partially resolved. Unresolved or partially resolved concerns are brought forward to the next set of minutes for Resident Council Review. 6. Review Resident Council information at the Quality Assurance Performance Improvement meeting monthly for opportunities for improvement and to address any concerns/grievances. Review of the facility's policy, Complaint/Grievance, revised on 10/24/2022 showed the Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and informed the resident of progress towards resolution. Procedure: 3. The Grievance Officer / designee shall act on the grievance and begin follow up on the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 8. The individual voicing the grievance will receive a follow-up communication with the resolution .

Based on observation, interview and record review, the facility failed to establish and implement a Quality Assurance and Performance Improvement (QAPI) Program that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to failing to follow food menus for four residents (Resident #4, Resident #14, Resident #15, and Resident #16) of five sampled residents, failing to act upon the grievances of the Resident Council Committee related to food menus, and failing to collaborate with the Registered Dietician related to menu substitutions (F565) during the revisit survey conducted on 12/9/2024. Finding included: Review of the facility's policy titled Quality Assurance and Performance Improvement, revised 10/24/2022, showed the Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of care and quality of life. Procedure: Program Design and Scope: 1. The Center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to e. Dining Services. 2. Important functional areas may include but are not limited to: e. Quality of life. 3. Review of activities may include but not be limited to: c. Resident/family complaints/satisfaction. Leadership: the Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to a) implementation; b) identify priorities; d) ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities; e) ensure corrective actions are implemented to address identified problems in systems; f) evaluates the effectiveness of actions. 4. The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents and families. Feedback: the center will obtain feedback to assist in identifying problems and areas of opportunity feedback may be obtained including but not limited to the following sources: c) residents d) resident representatives. 7. The Center may choose multiple processes to obtain feedback, including but not limited to: c. Resident Council. Data Collection System and Monitoring the center will collect and monitor data form different departments reflecting its performance. 8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to a. grievance logs. Systematic Analysis and Action: the center will ensure systems and actions are in place to improve performance. 11. The center will establish and utilize a systematic approach to identify underlying causes of problems, including but not limited to: a. root cause analysis; b. failure mode effect analysis. 12. The center will develop corrective actions based on the information gathered and review effectiveness of the actions. Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 14. The center will review department system data. Performance Improvement Projects: the center utilizes performance improvement projects to improve a systemic problem or improve quality in absence of a problem. Performance Improvement Projects (PIPs) are based on the centers services and resources identified in the Facility Assessment During an interview on 12/9/2024 at 9:25 a.m. Resident #4 stated, it is a hit or miss regarding getting food on the menus. They are doing better. During an interview on 12/9/2024 at 9:38 a.m. Resident #16 stated, sometimes the meals are a surprise. They will change the dessert or vegetable, not usually the whole plate. During an interview on 12/9/2024 at 10:45 a.m. Resident #14, who was the previous Resident Council President, stated the food was a little bit better. She stated, What is on the ticket is not what they receive all the time. The problem is not completely resolved. She stated on Thanksgiving they had deli turkey instead of real turkey, no mashed potatoes, stuffing, or cranberry sauce. Resident #14 stated Staff G, Kitchen Manager (KM) came last week and spoke to them at the food meeting, for the first time. Resident 14 stated, [Staff G, KM] told us he ordered too late to get real turkey, they were out of the product. Resident #14 stated, Last night we were supposed to get tomato soup, we did not get any soup. During an interview on 12/9/2024 at 11:00 a.m. Resident #16, current Resident Council President, stated they were still having problems with meals. She stated they had Styrofoam plates since yesterday and the food was not warm. Resident #16 stated, They did not give us tomato soup last night even though it was on the menu. I was supposed to get two grilled cheese sandwiches and only got one. It had some type of white cheese not American cheese in it. For Thanksgiving we did not get real turkey, it was deli. We did not get mashed potatoes or stuffing, and I don't remember about the sweet potatoes. I was supposed to get French fries last night and got mashed potatoes instead. I wanted French fries because we always get mashed potatoes. We are still not getting what is on the ticket, not every time. Review of the purchase order dated 11/26/2024 showed condensed cream of mushroom soup out of stock and substituted with cream of potato soup; fancy cut yams out of stock and substituted with 85 count of fresh sweet potatoes; skinless turkey breast (Staff E, District Dietary Manager, verified was deli sliced turkey). Review of the Menu Substitution Log showed: 11/21/2024, dinner, food item substituted was apple crisp; food item omitted was gelatin; RD (Registered Dietician) initials. 11/27/2024, dinner, food item substituted was baked ziti with meat sauce; food item omitted was lasagna; RD initials. 11/28/2024, lunch, food item substituted was Thanksgiving meal; food item omitted was entire lunch menu; RD initials. 11/28/2024, dinner, food item substituted was entire lunch menu; food item omitted was entire dinner menu; RD initials. 12/2/2024, dinner, food item substituted was French fries, food item omitted was tater tots, RD initials. Review of the Week-At-A-Glance menus for 12/8/2024 showed grilled two cheese sandwich, French fries, tomato soup. Review of the purchase order dated 12/4/2024 and 12/6/2024 showed no tomato soup ordered. Review of the Meal Substitution Daily Audit 12/8/2024 showed breakfast, lunch, and dinner meals matched the daily menu (no mention of lack of tomato soup). Review of the Resident Council Minutes dated 10/7/2024 showed under Old Business, food is terrible, no follow up with dietary getting other food besides what's is on the ticket. Review of the Resident Council Minutes dated 11/5/2024 showed under New or Old Business, nothing regarding food issues or resolution. Review of the Resident Council Minutes dated 12/5/2024 showed under New or Old Business, nothing regarding food issues or resolution Review of a dated 12/4/2024 at 1:30 p.m., yellow lined paper given to surveyor by the Nursing Home Administrator (NHA) on 12/9/2024 at approximately 5:45 p.m. showed, Food Committee will be held once a week on Wed. The kitchen manager came in and spoke a little about the food and what he was going to do different. The yellow lined paper was not signed. Review of the Education In-Service Attendance Record dated 10/31/2024 performed by Staff G, KM showed meeting preferences on tickets are a must, not providing items that the resident requested on the ticket is abuse. Signed by 6 of 13 Dietary staff members. Review of the Education In-Service Attendance Record dated 10/31/2024 performed by Staff G, KM showed missing items are a bit no, nutritional value is compromised, every item is necessary. Signed by 7 of 13 Dietary staff members. Review of the Education In-Service Attendance Record dated 10/31/2024 performed by Staff G, KM showed preferences must be keep and provided to ensure resident satisfaction. Signed by 6 of 13 Dietary staff members. During an interview on 12/9/2024 at 10:50 a.m. Staff G, KM, stated the dish machine was not working as of last night, he had called an outside company, and they were coming this afternoon. They were using Styrofoam plates as of last night. Staff G, KM reviewed the substitution log, and it was not documented as the tomato soup was substituted. The kitchen pantry was observed, and no cans of tomato soup were on the shelves. Staff G, KM stated he did not know why the tomato soup was not served, maybe they (the grocer company) substituted it for the potato soup, they (the grocer company) have been substituting a lot. When asked about the serving of deli turkey instead of a baked turkey, Staff G, KM stated, I have been too busy, I don't remember when I have had a day off, I ordered it late, and they (grocer company) were out of turkey. During an interview on 12/9/2024 at 12:20 p.m. with Staff G, KM and Staff E, Dietary District Manager (DDM) from another area, verified the turkey that was ordered was the deli type not the raw turkey needing to be cooked. Staff E, DDM stated his expectation was to get a raw turkey and cook it for Thanksgiving dinner; cook it and carve it. Staff G, KM was reminded he had told the Resident Council last week they were out of turkey which was why they had deli turkey. Staff E, DDM stated he meant they were out of the ingredients for green bean casserole, not the turkey. Staff G, KM stated ordering the deli turkey was a mis-order. Staff G, KM stated, They have food committee meetings with the Resident Council Meetings. and he had been to the food committee meeting, not that long ago. Staff G, KM stated the food committee meetings used to be monthly but now they are weekly. Staff G, KM stated he does not do any documentation regarding the food committee meetings, and he takes his laptop to the meetings but does not have any documentation. Staff G, KM stated they have had a meeting for the last three months but cannot provide any documentation or sign in sheet. Staff E, DDM stated they do our half (food committee) after the Resident Council Meetings. Staff G, KM stated he had no documentation of participation to verify a food committee meeting. Staff G, KM also stated they ask Resident Council if there are any concerns, but it does not appear there is any documentation that they are concerned. Staff E, DDM stated there was a standard list of questions asked at a food committee meeting. Staff G, KM stated regarding the Plan of Correction for the deficiencies, stated they were to post menus and make sure all the menu items are here. If a substitution was needed, he was to speak with the dietician. Staff G, KM stated again he was not aware of the tomato soup not being served and verified it was not on the substitution log. Staff G, KM stated he was here at lunch (Sunday) but not here for dinner. Staff G, KM stated he thought he checked the menu for Sunday night (for menu items) but must not have. Staff E, DDM and Staff G, KM stated the menu generates a shopper list to order the food from the outside grocer. The shopping list tells you what is needed to make the menu items. Staff E, DDM stated Staff E, KM was to take the shopper list and check the pantry and was to order them whatever items were needed from the outside grocer. They order on Tuesdays and Fridays by 2 p.m. Tuesday orders come in on Wednesdays and Friday orders comes in on Saturdays. Staff E, DDM stated by the end of the day the outside grocer emails Staff G, KM showing substitutions for out-of-stock items. Staff E, DDM also stated it was the responsibility of Staff G, KM to see the email and act accordingly. Staff E, DDM and Staff G, KM verified there was no tomato soup ordered either Tuesday or Friday for Sunday's dinner menu. During an interview on 12/9/2024 at 12:53 p.m. the facility's Registered Dietician (RD) stated she had educated Staff G, KM on the substitution log. She stated she was at the facility 5 days a week. The RD stated her expectation was to be called prior to the substitution for an okay. The RD also stated, They do not call before. One time they have asked in advance. The RD stated her expectation was if tomato soup was on the menu, to give them (the residents) tomato soup. The RD stated she had not been made aware at the present time regarding the lack of tomato soup with the dinner meal and she was at the facility on Wednesday before Thanksgiving and had not been told of any needs for substitutions. The RD stated Staff G, KM reviewed the Thanksgiving menu with her, of green bean casserole, turkey, pumpkin pie for dessert, sweet potato, and stuffing. The RD stated Staff G, KM reviewed the Thanksgiving menu with her the week before and she expected a cooked turkey versus deli turkey for a Thanksgiving dinner. The RD also stated Staff G, KM told her he was talking to different residents about what they wanted for Thanksgiving. The RD asked Staff G, KM how it (Thanksgiving dinner) went, and he was supposed to show her a picture of the meal but never sent it. The RD verified the green bean casserole was not on the substitution list for Thanksgiving. The RD stated she was planning on going to the Food Committee Meeting on Wednesday and she had not been to any of the Food Committee Meetings but planned to start going weekly. The RD stated, The food could be better. and the purpose of the Food Committee Meetings was to listen to the residents. The RD also stated the residents had been complaining about the grits being dry and hard and she talked to Staff G, KM, who had a new cook to make sure they are looser, so they didn't harden by the time they got to the floor. The RD stated the kitchen staff keeps logs on the food temperature, but she does not monitor them. The RD also stated the food temperature for breakfast was the biggest concern and they have warming plates in the kitchen, but one staff member was not using them. Staff G, KM was told that staff member was not using the warming plates, and to talk to them. The RD stated she did not personally see the education (regarding the use of the warmers) but has seen an improvement. During an interview on 12/9/2024 at 1:46 p.m. with Staff G, KM and Staff F, DDM of the area verified Staff G, KM's picture of the Thanksgiving menu showed yams, a slice of turkey with gravy, green beans, roll and pumpkin pie. Staff F, DDM stated the menu goes to the tracker, the tracker generates the order guide based on the menu, resident diets, and how many meals are needed. Staff F, DDM also stated if they have the food on the shelf and Staff G, KM has three cans of yams and needs six cans of yams, Staff G, KM will order the three cans only. Staff F, DDM stated one truck will deliver for four days and one truck will deliver for three days, and the Friday order would include the Sunday meal. Staff F, DDM stated Staff G, KM should have double checked what was on the shelf and what was needed to be ordered. Staff G, KM stated the expectation was to check the day before for the menu items needed for the next day's meals. Staff G, KM also stated one of the dietary aides puts up the food product and makes sure all the food for the menu was there. Staff G, KM stated the dietary aide verifies on Saturday and the dietary aide would let him know if anything was missing. Staff G, KM stated the missing tomato soup was not told to him until the surveyor brought it up and the dietary aide should have called him to let him know they had no (tomato) soup. Staff G, KM also stated they should have called the dietician, and he had to ask the dietician beforehand for substitutions. Staff G verified gelatin was substituted with apple crisp on 11/21/2024 (switched days of dessert); and French fries was substituted for tater tots on 12/2/2024. Staff E, DDM stated they needed more education, and they needed to use the food report weekly at the Food Committee Meeting. During an interview on 12/9/2024 at 3:30 p.m. the Human Resource Director (HR) provided the job descriptions for Staff G, KM and the Registered Dietician. The HR Director also stated both the employees were contracted employees. Review of the Clinical Dietician Job Description showed under Responsibilities and Duties: Monitor food service operations to ensure adherence to nutritional standards, sanitation, safety, and quality requirements in accordance with all applicable state and federal regulations. Review of the Dining Services Director/Account Manager Job Description, signed by Staff G, KM on 5/26/2024, showed the Dining Services Director/Account Manager provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met and makes sure the facility has sufficient supplies. Training, quality control and in-servicing staff to standards is an essential part of the Manager's responsibility and includes touring kitchen several times per day to assess work quality. Customer Service: responds to customer preferences and industry trends to plan menus; insuring food is prepared by methods that conserve nutritive value, is palatable and attractive to residents, and of a quality that is acceptable to and meets the needs of residents. During an interview on 12/9/2024 at 4:59 p.m. the Nursing Home Administrator (NHA) and the Regional [NAME] President of Operations (RVPO) verified the education provided to the kitchen staff was not 100% of the staff. They stated 6 or 7 staff members educated out of 13 was not acceptable. They stated they expected to see all dietary employees to be documented as to attending the education. They reviewed the Menu Substitution Log and verified the tomato soup substitution for 12/8/2024 was not on the log. They verified there were Menu Substitution Daily Audits performed from 11/15/24 to 12/8/2024 and The Menu Substitution Daily Audit dated 12/8/2024 showed no substitutions, and no documentation of tomato soup. The NHA and the RVPO stated the dietary aide was to check in the supplies, not check the supplies to the menus. The RVPO stated the other facilities were able to obtain the appropriate food for the Thanksgiving meal. The RVPO also stated the prior NHA had educated Staff G, KM and provided a copy of the October 2024 QAPI as education for Staff G, KM. The NHA and the RVPO stated the expectation was for Staff G, KM to be informed about the lack of tomato soup on Sunday (the day of the omission). The NHA and the RVPO stated the expectation was for the menus to be followed unless the RD has approved prior for a substitution. The NHA stated they were going to have a Food Committee Meeting weekly separate from the Resident Council Meeting for the next three or four months and they were going to check the progress bi-weekly. The NHA and RVPO stated they had a QAPI meeting on 11/26/2024 with the current NHA in attendance and found more problems and are addressing them. The RVPO stated, They were going to have to go back and add some things.

Based on observation, interview and record review, the facility failed to establish and implement a Quality Assurance and Performance Improvement (QAPI) Program that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to failing to follow food menus for four residents (Resident #4, Resident #14, Resident #15, and Resident #16) of five sampled residents, failing to act upon the grievances of the Resident Council Committee related to food menus, and failing to collaborate with the Registered Dietician related to menu substitutions (F565) during the revisit survey conducted on 12/9/2024. Finding included: Review of the facility's policy titled Quality Assurance and Performance Improvement, revised 10/24/2022, showed the Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of care and quality of life. Procedure: Program Design and Scope: 1. The Center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to e. Dining Services. 2. Important functional areas may include but are not limited to: e. Quality of life. 3. Review of activities may include but not be limited to: c. Resident/family complaints/satisfaction. Leadership: the Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to a) implementation; b) identify priorities; d) ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities; e) ensure corrective actions are implemented to address identified problems in systems; f) evaluates the effectiveness of actions. 4. The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents and families. Feedback: the center will obtain feedback to assist in identifying problems and areas of opportunity feedback may be obtained including but not limited to the following sources: c) residents d) resident representatives. 7. The Center may choose multiple processes to obtain feedback, including but not limited to: c. Resident Council. Data Collection System and Monitoring the center will collect and monitor data form different departments reflecting its performance. 8. The center will identify data sources and timeframe for collection. Data sources may include but are not limited to a. grievance logs. Systematic Analysis and Action: the center will ensure systems and actions are in place to improve performance. 11. The center will establish and utilize a systematic approach to identify underlying causes of problems, including but not limited to: a. root cause analysis; b. failure mode effect analysis. 12. The center will develop corrective actions based on the information gathered and review effectiveness of the actions. Identifying Quality Deficiencies and Corrective Action: The center will monitor department performance systems to identify issues or adverse events. 14. The center will review department system data. Performance Improvement Projects: the center utilizes performance improvement projects to improve a systemic problem or improve quality in absence of a problem. Performance Improvement Projects (PIPs) are based on the centers services and resources identified in the Facility Assessment During an interview on 12/9/2024 at 9:25 a.m. Resident #4 stated, it is a hit or miss regarding getting food on the menus. They are doing better. During an interview on 12/9/2024 at 9:38 a.m. Resident #16 stated, sometimes the meals are a surprise. They will change the dessert or vegetable, not usually the whole plate. During an interview on 12/9/2024 at 10:45 a.m. Resident #14, who was the previous Resident Council President, stated the food was a little bit better. She stated, What is on the ticket is not what they receive all the time. The problem is not completely resolved. She stated on Thanksgiving they had deli turkey instead of real turkey, no mashed potatoes, stuffing, or cranberry sauce. Resident #14 stated Staff G, Kitchen Manager (KM) came last week and spoke to them at the food meeting, for the first time. Resident 14 stated, [Staff G, KM] told us he ordered too late to get real turkey, they were out of the product. Resident #14 stated, Last night we were supposed to get tomato soup, we did not get any soup. During an interview on 12/9/2024 at 11:00 a.m. Resident #16, current Resident Council President, stated they were still having problems with meals. She stated they had Styrofoam plates since yesterday and the food was not warm. Resident #16 stated, They did not give us tomato soup last night even though it was on the menu. I was supposed to get two grilled cheese sandwiches and only got one. It had some type of white cheese not American cheese in it. For Thanksgiving we did not get real turkey, it was deli. We did not get mashed potatoes or stuffing, and I don't remember about the sweet potatoes. I was supposed to get French fries last night and got mashed potatoes instead. I wanted French fries because we always get mashed potatoes. We are still not getting what is on the ticket, not every time. Review of the purchase order dated 11/26/2024 showed condensed cream of mushroom soup out of stock and substituted with cream of potato soup; fancy cut yams out of stock and substituted with 85 count of fresh sweet potatoes; skinless turkey breast (Staff E, District Dietary Manager, verified was deli sliced turkey). Review of the Menu Substitution Log showed: 11/21/2024, dinner, food item substituted was apple crisp; food item omitted was gelatin; RD (Registered Dietician) initials. 11/27/2024, dinner, food item substituted was baked ziti with meat sauce; food item omitted was lasagna; RD initials. 11/28/2024, lunch, food item substituted was Thanksgiving meal; food item omitted was entire lunch menu; RD initials. 11/28/2024, dinner, food item substituted was entire lunch menu; food item omitted was entire dinner menu; RD initials. 12/2/2024, dinner, food item substituted was French fries, food item omitted was tater tots, RD initials. Review of the Week-At-A-Glance menus for 12/8/2024 showed grilled two cheese sandwich, French fries, tomato soup. Review of the purchase order dated 12/4/2024 and 12/6/2024 showed no tomato soup ordered. Review of the Meal Substitution Daily Audit 12/8/2024 showed breakfast, lunch, and dinner meals matched the daily menu (no mention of lack of tomato soup). Review of the Resident Council Minutes dated 10/7/2024 showed under Old Business, food is terrible, no follow up with dietary getting other food besides what's is on the ticket. Review of the Resident Council Minutes dated 11/5/2024 showed under New or Old Business, nothing regarding food issues or resolution. Review of the Resident Council Minutes dated 12/5/2024 showed under New or Old Business, nothing regarding food issues or resolution Review of a dated 12/4/2024 at 1:30 p.m., yellow lined paper given to surveyor by the Nursing Home Administrator (NHA) on 12/9/2024 at approximately 5:45 p.m. showed, Food Committee will be held once a week on Wed. The kitchen manager came in and spoke a little about the food and what he was going to do different. The yellow lined paper was not signed. Review of the Education In-Service Attendance Record dated 10/31/2024 performed by Staff G, KM showed meeting preferences on tickets are a must, not providing items that the resident requested on the ticket is abuse. Signed by 6 of 13 Dietary staff members. Review of the Education In-Service Attendance Record dated 10/31/2024 performed by Staff G, KM showed missing items are a bit no, nutritional value is compromised, every item is necessary. Signed by 7 of 13 Dietary staff members. Review of the Education In-Service Attendance Record dated 10/31/2024 performed by Staff G, KM showed preferences must be keep and provided to ensure resident satisfaction. Signed by 6 of 13 Dietary staff members. During an interview on 12/9/2024 at 10:50 a.m. Staff G, KM, stated the dish machine was not working as of last night, he had called an outside company, and they were coming this afternoon. They were using Styrofoam plates as of last night. Staff G, KM reviewed the substitution log, and it was not documented as the tomato soup was substituted. The kitchen pantry was observed, and no cans of tomato soup were on the shelves. Staff G, KM stated he did not know why the tomato soup was not served, maybe they (the grocer company) substituted it for the potato soup, they (the grocer company) have been substituting a lot. When asked about the serving of deli turkey instead of a baked turkey, Staff G, KM stated, I have been too busy, I don't remember when I have had a day off, I ordered it late, and they (grocer company) were out of turkey. During an interview on 12/9/2024 at 12:20 p.m. with Staff G, KM and Staff E, Dietary District Manager (DDM) from another area, verified the turkey that was ordered was the deli type not the raw turkey needing to be cooked. Staff E, DDM stated his expectation was to get a raw turkey and cook it for Thanksgiving dinner; cook it and carve it. Staff G, KM was reminded he had told the Resident Council last week they were out of turkey which was why they had deli turkey. Staff E, DDM stated he meant they were out of the ingredients for green bean casserole, not the turkey. Staff G, KM stated ordering the deli turkey was a mis-order. Staff G, KM stated, They have food committee meetings with the Resident Council Meetings. and he had been to the food committee meeting, not that long ago. Staff G, KM stated the food committee meetings used to be monthly but now they are weekly. Staff G, KM stated he does not do any documentation regarding the food committee meetings, and he takes his laptop to the meetings but does not have any documentation. Staff G, KM stated they have had a meeting for the last three months but cannot provide any documentation or sign in sheet. Staff E, DDM stated they do our half (food committee) after the Resident Council Meetings. Staff G, KM stated he had no documentation of participation to verify a food committee meeting. Staff G, KM also stated they ask Resident Council if there are any concerns, but it does not appear there is any documentation that they are concerned. Staff E, DDM stated there was a standard list of questions asked at a food committee meeting. Staff G, KM stated regarding the Plan of Correction for the deficiencies, stated they were to post menus and make sure all the menu items are here. If a substitution was needed, he was to speak with the dietician. Staff G, KM stated again he was not aware of the tomato soup not being served and verified it was not on the substitution log. Staff G, KM stated he was here at lunch (Sunday) but not here for dinner. Staff G, KM stated he thought he checked the menu for Sunday night (for menu items) but must not have. Staff E, DDM and Staff G, KM stated the menu generates a shopper list to order the food from the outside grocer. The shopping list tells you what is needed to make the menu items. Staff E, DDM stated Staff E, KM was to take the shopper list and check the pantry and was to order them whatever items were needed from the outside grocer. They order on Tuesdays and Fridays by 2 p.m. Tuesday orders come in on Wednesdays and Friday orders comes in on Saturdays. Staff E, DDM stated by the end of the day the outside grocer emails Staff G, KM showing substitutions for out-of-stock items. Staff E, DDM also stated it was the responsibility of Staff G, KM to see the email and act accordingly. Staff E, DDM and Staff G, KM verified there was no tomato soup ordered either Tuesday or Friday for Sunday's dinner menu. During an interview on 12/9/2024 at 12:53 p.m. the facility's Registered Dietician (RD) stated she had educated Staff G, KM on the substitution log. She stated she was at the facility 5 days a week. The RD stated her expectation was to be called prior to the substitution for an okay. The RD also stated, They do not call before. One time they have asked in advance. The RD stated her expectation was if tomato soup was on the menu, to give them (the residents) tomato soup. The RD stated she had not been made aware at the present time regarding the lack of tomato soup with the dinner meal and she was at the facility on Wednesday before Thanksgiving and had not been told of any needs for substitutions. The RD stated Staff G, KM reviewed the Thanksgiving menu with her, of green bean casserole, turkey, pumpkin pie for dessert, sweet potato, and stuffing. The RD stated Staff G, KM reviewed the Thanksgiving menu with her the week before and she expected a cooked turkey versus deli turkey for a Thanksgiving dinner. The RD also stated Staff G, KM told her he was talking to different residents about what they wanted for Thanksgiving. The RD asked Staff G, KM how it (Thanksgiving dinner) went, and he was supposed to show her a picture of the meal but never sent it. The RD verified the green bean casserole was not on the substitution list for Thanksgiving. The RD stated she was planning on going to the Food Committee Meeting on Wednesday and she had not been to any of the Food Committee Meetings but planned to start going weekly. The RD stated, The food could be better. and the purpose of the Food Committee Meetings was to listen to the residents. The RD also stated the residents had been complaining about the grits being dry and hard and she talked to Staff G, KM, who had a new cook to make sure they are looser, so they didn't harden by the time they got to the floor. The RD stated the kitchen staff keeps logs on the food temperature, but she does not monitor them. The RD also stated the food temperature for breakfast was the biggest concern and they have warming plates in the kitchen, but one staff member was not using them. Staff G, KM was told that staff member was not using the warming plates, and to talk to them. The RD stated she did not personally see the education (regarding the use of the warmers) but has seen an improvement. During an interview on 12/9/2024 at 1:46 p.m. with Staff G, KM and Staff F, DDM of the area verified Staff G, KM's picture of the Thanksgiving menu showed yams, a slice of turkey with gravy, green beans, roll and pumpkin pie. Staff F, DDM stated the menu goes to the tracker, the tracker generates the order guide based on the menu, resident diets, and how many meals are needed. Staff F, DDM also stated if they have the food on the shelf and Staff G, KM has three cans of yams and needs six cans of yams, Staff G, KM will order the three cans only. Staff F, DDM stated one truck will deliver for four days and one truck will deliver for three days, and the Friday order would include the Sunday meal. Staff F, DDM stated Staff G, KM should have double checked what was on the shelf and what was needed to be ordered. Staff G, KM stated the expectation was to check the day before for the menu items needed for the next day's meals. Staff G, KM also stated one of the dietary aides puts up the food product and makes sure all the food for the menu was there. Staff G, KM stated the dietary aide verifies on Saturday and the dietary aide would let him know if anything was missing. Staff G, KM stated the missing tomato soup was not told to him until the surveyor brought it up and the dietary aide should have called him to let him know they had no (tomato) soup. Staff G, KM also stated they should have called the dietician, and he had to ask the dietician beforehand for substitutions. Staff G verified gelatin was substituted with apple crisp on 11/21/2024 (switched days of dessert); and French fries was substituted for tater tots on 12/2/2024. Staff E, DDM stated they needed more education, and they needed to use the food report weekly at the Food Committee Meeting. During an interview on 12/9/2024 at 3:30 p.m. the Human Resource Director (HR) provided the job descriptions for Staff G, KM and the Registered Dietician. The HR Director also stated both the employees were contracted employees. Review of the Clinical Dietician Job Description showed under Responsibilities and Duties: Monitor food service operations to ensure adherence to nutritional standards, sanitation, safety, and quality requirements in accordance with all applicable state and federal regulations. Review of the Dining Services Director/Account Manager Job Description, signed by Staff G, KM on 5/26/2024, showed the Dining Services Director/Account Manager provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met and makes sure the facility has sufficient supplies. Training, quality control and in-servicing staff to standards is an essential part of the Manager's responsibility and includes touring kitchen several times per day to assess work quality. Customer Service: responds to customer preferences and industry trends to plan menus; insuring food is prepared by methods that conserve nutritive value, is palatable and attractive to residents, and of a quality that is acceptable to and meets the needs of residents. During an interview on 12/9/2024 at 4:59 p.m. the Nursing Home Administrator (NHA) and the Regional [NAME] President of Operations (RVPO) verified the education provided to the kitchen staff was not 100% of the staff. They stated 6 or 7 staff members educated out of 13 was not acceptable. They stated they expected to see all dietary employees to be documented as to attending the education. They reviewed the Menu Substitution Log and verified the tomato soup substitution for 12/8/2024 was not on the log. They verified there were Menu Substitution Daily Audits performed from 11/15/24 to 12/8/2024 and The Menu Substitution Daily Audit dated 12/8/2024 showed no substitutions, and no documentation of tomato soup. The NHA and the RVPO stated the dietary aide was to check in the supplies, not check the supplies to the menus. The RVPO stated the other facilities were able to obtain the appropriate food for the Thanksgiving meal. The RVPO also stated the prior NHA had educated Staff G, KM and provided a copy of the October 2024 QAPI as education for Staff G, KM. The NHA and the RVPO stated the expectation was for Staff G, KM to be informed about the lack of tomato soup on Sunday (the day of the omission). The NHA and the RVPO stated the expectation was for the menus to be followed unless the RD has approved prior for a substitution. The NHA stated they were going to have a Food Committee Meeting weekly separate from the Resident Council Meeting for the next three or four months and they were going to check the progress bi-weekly. The NHA and RVPO stated they had a QAPI meeting on 11/26/2024 with the current NHA in attendance and found more problems and are addressing them. The RVPO stated, They were going to have to go back and add some things.

Based on observation, interview and record review, the facility failed to assess and determine it was safe for a resident to self-administer medications for one (#2) of three sampled residents related to nebulizer treatments. Findings included. During interview and observation on 10/24/2024 at 9:15 a.m., Resident #2 was sitting at the bedside in a wheelchair eating. She was dressed and groomed for the day. Her call light was within reach. Observed a nebulizer with medication in the cup sitting on the resident's bed. She stated she did her own nebulizer treatments. She stated the nurse brought in the medication and put it into the cup. Resident #2 stated when she finished eating, she would do her treatment. She finished eating, placed the mask on her face and turned on the machine. The resident's nurse was not in the room. A staff member walked in and asked the resident if she was alright. Resident #2 answered yes. The staff member exited the room. Resident #2 was admitted on [DATE] and readmitted on [DATE]. Admission record showed diagnoses included but not limited to Cerebral Infarction due to embolism, aphasia, and hypertension. Review of the Minimum Data Set, dated dated dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section GG Functional Abilities and Goals showed substantial assistance for toileting and bathing. Review of the physician order dated 4/23/2024, showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram) / 3 ml (milliliter) give 3 ml inhale orally every 8 hours as needed for Shortness of Breath Review of the October 2024 Medication Administration Record (MAR) showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram) / 3 ml (milliliter) give 3 ml inhale orally every 8 hours as needed for Shortness of Breath was administered at 6:18 a.m. and was effective. Review of the Quarterly Data Collection dated 10/08/2024 showed N. Medication Review: 1. Does the resident wish to self-administer medication. No. Review of the care plans showed a lack of self-administration of medication care plan. During an interview on 10/24/2024 at 2:20 p.m., the DON (Director of Nursing) stated Resident #2 had not been assessed to perform her own medication administration. The DON stated the process for self-medication included performing an assessment and following-up with the physician. If the physician was okay with the self-medication, an order would be written. They would assess and educate the resident on understanding the times the medications were to be given. It would be care planned. The DON verified Resident #2 did not have a self-administration of medication evaluation or physician orders. Review of the facility's policy, Self-Administration of Medication at Bedside, revised 08/22/2017 showed the resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administrating medication and to keep accurate documentation of these actions. Procedure: Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete Self-administration of Medications Evaluation. The Interdisciplinary Team will review the evaluation and will document Section III. Approval granted must be checked Yes or No. Interdisciplinary team member sign the evaluation section. If approval is not granted, a statement must be written as to reason for denial. Complete the care plan for approved self-administered drugs. Self-administration of meds is reviewed by the Care Plan Team with each quarterly review, and when and change in status is noted. The MAR must identify meds that are self-administered, and the medication nurse will need to follow-up with resident as to documentation and storage of medication during each med pass. If kept at bedside, the medication must be kept in a locked drawer. When a resident is unable to self-administer medications, they will be given by nursing staff until the resident can be reevaluated by the Interdisciplinary Team.

Based on observation, interview and record review, the facility failed to follow standard and enhanced barrier precautions when performing urinary catheter care and services for one (#3) of three sampled residents Findings included During an observation on 10/24/2024 at 1:45 p.m., Resident #3 was lying in bed. His urinary catheter bag was lying on the floor. Yellow urine was observed in the bag. No ants noted. During observation and interview with Staff A, Licensed Practical Nurse (LPN) she entered the room and moved the urinary catheter bag from the floor. She attached it to the bed. She entered the bathroom and washed her hands. During an interview, Staff A stated the resident went to the bathroom by himself and must have left the bag on the floor. She stated the catheter bag needed to be off the floor. She reviewed the Enhanced Barrier sign on the door and stated he was on enhanced precautions due to his catheter. Staff A stated she did not put on gloves nor a gown to move his catheter bag. She stated enhanced barrier precautions means to use gowns, gloves and hand sanitize when giving care. She stated she should have put on a gown and gloves to provide care. Resident #3 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to heart failure, cirrhosis of liver, hypertension, and Benign Prostatic Hyperplasia (BPH). Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Form showed Resident #3 had a urinary catheter that was inserted on 10/18/2024. Review of the physician orders showed change catheter as needed, catheter care every shift, catheter bag to be changed as needed, monitor catheter for patency and drainage every shift, all as of 10/23/2024. Review of the care plans showed Resident #3 had a indwelling catheter, initiated 10/24/2024. Interventions include but not limited to check tubing for kinks each shift. Review of the Admission / Readmission Data Collection dated 10/23/2024 Section K. Genitourinary: Bladder always continent. 2a. Catheter used was blank. 2c. Catheter used, specify type was blank. During an interview on 10/24/2024 at 2:20 p.m., the Director of Nursing (DON) stated Resident #3 was on Enhanced Barrier Precautions due to having a urinary catheter. She stated the nurse should have put on gowns and gloves to touch the bag. The staff was to be fully dressed if doing care. She stated the urinary drainage bag was not to be laid on the floor. She stated that some of the negative outcomes could be an infection issue, pooling of the urine and leaking of urine. She stated the staff was supposed to follow the Enhanced Barrier Precautions with urinary catheter. Review of the facility's policy, Enhanced Barrier Precautions, dated August 2022 showed Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDRSs) to residents. Policy interpretation and implementation 2. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include g. Device care or use (central line, urinary catheter, feeding tube, tracheostomy / ventilator, etc.). 5. EBP's are indicated when contact precautions do not otherwise apply for residents with wounds and or indwelling medical devices regardless of MDRO colonization. 6. EBP's remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

Based on interviews and record review, the facility failed to protect the resident's right to be free from deprivation of goods and services, by staff failing to provide one resident (#1) with Cardiopulmonary Resuscitation (CPR) per the resident's wishes out of eight residents sampled for advance directives. On [DATE] at approximately 3:00 a.m., Resident #1 became unresponsive during routine care. Nursing staff assessed Resident #1 and Emergency Medical Services (EMS) was called to the facility. Prior to EMS arrival, nursing staff reviewed the medical record and determined Resident #1 had a Do Not Resuscitate (DNR) order. Nursing staff provided oxygen at a high concentration via mask, and sternal rubs were intermittently applied with no response from the resident. The EMS team arrived and conducted an initial assessment. Resident #1 was noted with no heart rate and no respirations and was pronounced deceased at 3:29 a.m. At 3:40 a.m., nursing discovered the DNR order in Resident #1's chart belonged to Resident #11, and Resident #1 had an order for Full Resuscitation. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: A review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, Type I Diabetes Mellitus without complications, dysuria, muscle weakness, dysphagia following unspecified cerebrovascular disease, sleep apnea unspecified, obstructive and reflux uropathy unspecified, acquired absence of other right toe(s), and major depressive disorder single episode in full remission. A review of physician orders for Resident #1 showed an order for Full Code, dated [DATE]. A review of Resident #1's care plan, dated [DATE], showed a focus area of advanced directives FULL CODE with an initiated date of [DATE] by the Social Services Director (SSD) and an intervention for this focus area to include: discuss advance directives with resident and or resident's representative. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. A review of Section GG-Functional Abilities and Goals Section GG0130-Self-Care showed Resident #1 dependent for toileting and hygiene. A review of Resident #1's 3008/ Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated [DATE], Section H: Advance Care Planning had the following areas checked as NO: Do not Resuscitate, Do Not Intubate, Do Not Hospitalize, No Artificial Feeding and Hospice. A review of Resident #1's medical progress notes, dated [DATE], showed the following: Code Status: Full Code. A review of Resident #11's chart showed an admitted on [DATE], with a discharge date of [DATE]. DNR paperwork was scanned in Resident #11's chart on [DATE]. On [DATE] at 5:00pm., a phone interview was conducted with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN stated, she was working on the east wing on a new admission when she heard a Certified Nursing Assistant (CNA) screaming from the west side needing help. Staff E, LPN along with Staff F, Registered Nurse, (RN) went running over. Staff E, LPN stated two separate blood sugar checks (accucheck) were done with results Around 112 and 117. Staff E, LPN stated, Resident #1 was lying in bed and breathing but Light more SOB [shortness of breath], no suction was required. Staff E, LPN stated, she placed a NRM (non-rebreather mask) on him, and his pulse ox (oximetry) was in the 80's with a heart rate of 77, stating, I remember that. Staff E, LPN stated the resident's nurse (Staff D, LPN) had called 911 and got the paperwork needed to go the hospital, stating, I'm just assuming because she was not in his room. It's normal for the nurse to get the paperwork ready. Staff E, LPN stated, While waiting we were standing by the bedside, pulse ox on right hand, manual blood pressure taken by CNA, but I can't remember who took the blood pressure or what it was. Staff E, LPN stated, Staff G, CNA brought the hard chart and Staff D, LPN looked into the chart. Staff E, LPN stated EMT (Emergency Medical Technicians) arrived 6 minutes later and took over. Staff E, LPN stated the EMT's stated, We can't do CPR if he's breathing, and hooked him up to the machine. Staff E, LPN stated she did not know what the machine showed. Staff E, LPN, stated, Staff D, LPN, said he was a DNR. Staff E, LPN stated, EMT stated, there was nothing they could do. Staff E, LPN stated a discussion was made between the staff and the EMT's regarding transporting the resident to the hospital. Staff E, LPN stated the resident had a peripherally inserted central catheter (PICC), So I figured he must have been treated. Staff E, LPN stated Staff D, LPN was talking to the EMT about being a DNR. Staff E, LPN state Staff D, LPN asked the EMT team why Resident #1 could not go to the emergency room . Staff E, LPN, stated, I felt they were giving us roundabout answers, so I left and ten minutes later I let the EMT team out the door without the resident, no communication from them as what the outcome was. On [DATE] at 6:17 a.m., an interview was conducted with Staff A, CNA. Staff A, CNA stated on [DATE] she made her rounds to check on her residents and at approximately 12:30 to 12:45 a.m. She stated she changed Resident #1 for incontinence of urine. Staff A, CNA stated, the resident was talking to her. Staff A, CNA stated, she took her lunch break at 2:00 a.m. and clocked back in at 2:30 a.m. and went to room [ROOM NUMBER] to answer the call light and changed both residents in there. Staff A, CNA stated she continued with her rounds and went into Resident #1's room. She stated, He was a little groggy but talking to me. Staff A, stated she rolled Resident #1 to his right, He was talking to me but when I rolled him back onto his back, I noticed something different with him. Staff A stated Resident #1 was not responding to her. She stated she went out and yelled code blue three times. Staff A stated, Staff G, CNA brought the crash cart and went to get the chart. She stated, I was trying to distract his roommate who was waking up. Staff A stated she was not sure who opened the chart but heard someone say Resident #1 was a DNR. She stated, He was breathing though, and someone put a mask on him, and a pulse ox [oximeter] on his finger. I know someone did a sternal rub. I think one of the nurses may have taken his blood pressure but I'm not sure. Staff A, CNA stated she was in the room attending to the roommate but would look over the curtain. Staff A, CNA stated the resident coughed when they did the sternal rub. When the paramedics arrived, she said He stopped breathing. Staff A, stated, the resident's [family member] asked for her to come in when the priest showed up. She stated, It was hard because all my residents are like family to me. On [DATE] at 6:34 a.m., an interview was conducted with Staff B, CNA with Staff C, RN utilized as an interpreter. Staff B, CNA stated, she was working on the west hall when she heard yelling for help from the other hallway. Staff B, CNA stated she ran into the room and there were three nurses in the Resident #1's room (Staff D, LPN, Staff E, LPN and Staff F, RN). Staff B, CNA stated the resident looked pale and witnessed a nurse, Staff F, RN, place a pulse oximeter on the resident's finger and a CNA brought in the crash cart. Staff B, CNA stated, someone put oxygen on the resident and Staff E, LPN squeezed the bag. Staff B, CNA stated the mask had a bag on his chest. Staff C could not recall who called 911. Staff B stated the resident was breathing and had a pulse before the paramedics arrived. Staff B, CNA stated she stayed to see if they needed assistance and when the crash cart arrived, the resident was placed on a back board. On [DATE] at 6:45 a.m., an interview was conducted with Staff G, CNA. Staff G, CNA confirmed she was working [DATE]. Staff G stated on [DATE] at approximately 3:05 a.m., I heard a CNA yell Code Blue. Staff G, CNA stated, she immediately grabbed the code cart and ran it to Resident #1's room. When Staff G, CNA, arrived Staff E, LPN, Staff D, LPN, Staff, F, RN and Staff A, CNA were in the room. Staff G, CNA stated, she pushed the code cart in and went to get the resident's chart. She pulled the chart and started back down the hallway when Staff D, LPN took the chart from her and Staff D, LPN told everyone in the room he was a DNR. When Staff G, CNA got back to the room Staff E, LPN, was doing a sternal rub on the patient. Staff G then left to wait at the door for the EMT's but could not recall when they were called. On [DATE] at 7:11 a.m., an interview was conducted with Staff H, CNA with the assistance of Staff I, RN for interpretation. Staff H, CNA stated she had worked the evening of [DATE] into [DATE] shift, stating she was working in a resident's room on the east wing, when she heard the code blue. I ran to help the staff. Staff H, CNA stated a nurse had asked her to get the Accu-Check machine. Staff H stated, I don't know names but there were three nurses in the resident's room and one CNA. Staff H, CNA stated, all the staff were taking care of him so I could not really see how he was doing. I went to the door to wait for the EMT to arrive. On [DATE] at 7:29 a.m., an interview was conducted with Staff J, LPN/Unit Manager. (UM). Staff J, LPN/UM stated, she was not here during the event but was on her way to work early. Staff J, LPN/UM stated while on her way, there was a management group text chat which stated Resident #1 had expired. I was like wow. When Staff J arrived at work, the Director of Nursing (DON) was talking to Staff D, LPN, Resident #1's nurse, and the other nursing staff. That's when everything started to come together. Staff J, LPN/UM was told Resident #1 was fine during the cleaning but when Staff A, CNA turned to him onto his back, he wasn't breathing. Staff J stated, EMS was called, and they couldn't revive him. Staff J, LPN/UM stated the family member had been in the facility and had left before she arrived. Staff J, LPN/UM stated the family member called her later in the morning on her cellphone. Staff J, LPN/UM stated, She was like [Staff J] I don't know what happened, I can't believe he's gone. The family member asked me, Can you do me a favor? Staff J, LPN/UM stated the family member asked if she could get a copy of the DNR signed by the resident. Staff J, LPN/UM stated she explained to the family member, she could not do obtain the DNR paperwork but Staff K in social services could assist her. Staff J, LPN/UM stated his family member had stated something was wrong and stated, Staff D, LPN, told me they started CPR and then they stopped because he's a DNR. Staff J, LPN/UM stated the family member had said, Resident #1 and I never signed that paperwork. Staff J, LPN/UM stated when the family member was in the facility, she was looking through the resident's chart and noticed the DNR was of a different resident's name. Staff J, LPN/UM stated, she immediately informed the DON to listen to the remainder of the conversation on her cell phone. The family member wanted a copy of the DNR. Staff J, LPN/UM stated, she told her to come in and talk to the DON and medical records. The DON then took Staff J's cell phone to continue the conversation with the family member. Staff J, LPN/UM stated the family member was asking about the DNR and stated, Maybe [he] signed without my knowledge, but I know [he] would not sign it, he would not even let them take his leg. Staff J stated, once the family member told the DON about this, the DON went to the hard chart and saw the wrong DNR name in the chart. Staff J, LPN/UM stated, I've heard different stories on whether CPR was done. Only one staff member stated CPR was done but must of the staff interviewed stated CPR was not initiated. Staff J, LPN/UM stated, Once you start compressions regardless of DNR status on paper, you must continue with CPR. On [DATE] at 10:10 a.m., an interview was conducted with Staff J, LPN/UM. Staff J stated, on a newly admitted resident, the nurse will place the resident in the computer as active. After the resident is active, the nurse will assess the resident and input all orders, allergies, code status etc. The nurse will contact the physician and verify the medications. The nurse will let the physician know if the resident decides they want to be a DNR. We will contact the physician and the Social Services Director regarding the resident's code status. Social Services Director is the one who will place the proper paperwork in the chart stating, he's the only one. If the resident comes in with their DNR paperwork it will get uploaded into the chart and placed in front of the hard chart. Staff J, LPN/UM stated, multiple copies are always available in chart. If not, we will get yellow paper from Social Services and make copies. Social Services will come to us with yellow paper if resident is new to DNR and we will place the order in his chart. Staff J, LPN/UM, stated she does not know his process, only what the nursing staff responsibilities. Staff J, LPN/UM stated if a resident states their code status to the staff, the nurse will contact, inform and obtain an order for the Code Status and the nurse will write a note of the conversation with the physician in the progress note. From there, the resident would sign the form if they chose to be a DNR and this form will be faxed or emailed to the physician to sign. Once signed by the physician, the form is faxed or emailed back and social services will place into the hard chart; however, the order was placed in the electronic chart. There may be a short time lapse of twenty-four to forty-eight hours before social services place the yellow DNR paperwork in chart, especially over the weekend, but the staff will have the physician orders to go by. Staff J stated when a resident leaves the facility with plans to return, a bed hold is initiated for seven days, and the hard chart will be saved as is until the resident returns. Staff J stated usually after ten to fourteen days, medical records will take the hard chart of the resident, and a new hard chart would be started upon the resident's return to the facility. On [DATE] at 11:10 a.m., a telephone interview was conducted with Staff A, CNA. She stated, Resident #1 was a diabetic so she thought his sugar may be low, but they did do an accucheck, and it was fine. Staff A, CNA could not recall the time the resident's family member showed up. Staff A, CNA told the family member she did not know what happened. Staff A, CNA told the family member, He was fine when I changed him the first time. Staff A talked to the family member and told her the care provided throughout the night for the resident. Staff A, CNA was answering a call light for another resident, when Staff D, Licensed Practical Nurse (LPN), went and got her after talking to his family member in his room and the family member was requesting to speak with Staff A. Staff A, stated, I don't know what Staff D, LPN and his family member talked about. On [DATE] at 12:10 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated he was the Gate keeper and he makes sure the code status regarding medical records is accurate. The SSD stated weekly audits are completed to ensure code status for the residents. The SSD stated, if the resident comes in with a DNR, he will ensure it is legally correct (signatures) and validate with the resident, their desires, etc. On new residents, he would discuss code status. If needed, he would explain in detail what this entails. If the resident would like to become a DNR, he would use a white form of the state Florida 'golden rod' form, have the resident sign and have MD [medical doctor] sign and when completed, copy on to yellow paper. The SSD stated, Then I upload the white form into the electronic medical chart, enter code status into electronic medical record and notify the nursing for transcription of the order into electronic medical record, then I update the Care Plan. The SSD stated, I then place the resident on the ongoing audit form for Advance Directives. The SSD stated the audits are completed weekly, stating, I review the care plan for advance directives, I look for the physical order in the computer and if a DNR is on the chart. The SSD stated, on the morning of [DATE], he noted a white DNR on the chart of Resident #1, and stated, If I put this on the chart it would have been yellow, this was a white form, so I did not do this. The SSD stated, I still have no idea on how the form was in the chart. On [DATE] at 12:15 p.m., a second phone interview was conducted with Staff E, LPN. Staff E, LPN stated Staff D, LPN came into room and stated Resident #1 was a DNR, but I did not see the actual form. Staff E, LPN stated for the EMT to state the resident was a DNR means the DNR form had to have been on yellow paper. Staff E, LPN stated the ambu bag and backboard were out but We never had to use it. Staff E, LPN stated, I assume Staff D. LPN, looked into the electronic medical chart because she had to print the paperwork needed for the EMT team. Staff E stated, the EMT team kept telling us he's a DNR and not to be hospitalized . Staff E, LPN stated, I could not understand that. On [DATE] at 12:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, she received a text between 5:00 or 6:00 in the morning from Staff D, LPN, stating, Resident #1 expired. The DON stated she texted her to ask if he was a DNR but Staff D, LPN did not respond back. When she arrived, Staff J, LPN/ UM was in her office on her cell phone. The DON stated she talked to the family member and the family member was inquiring about the DNR stating he was not a DNR. The DON stated the family member said, this was new to me. The DON stated, she would get back with her. The DON then called the Nursing Home Administrator (NHA), to inform the conversation with the family member and Resident #1 was not a DNR. The DON found Staff D, LPN and brought her into my room for an interview. The DON stated Staff D, LPN said the resident died and she had the hard chart with her. The DON stated, she looked and saw a DNR for another resident on white paper in Resident #1's hard chart. The DON stated, At that time I saw the error, we talked about the incident. The DON stated, during my interview with Staff D, LPN, she said the resident was fine during medication administration earlier on her shift until his CNA screamed for help. During her interview, Staff D, LPN, stated to the DON, Staff E, LPN and Staff F, RN were the first to arrive. A glucometer was used by Staff F, LPN and Staff E, LPN put on pulse ox. The DON stated, Staff D, LPN stated, Staff G, CNA brought the crash cart and chart. The DON stated, Staff D, LPN went to get paperwork, and she called 911. A NRM (non-rebreather mask) was placed because of low O2 (oxygen) sat's. The DON stated Staff D, LPN, checked his carotid and said it was in the 70's. Staff D, LPN told the DON, Staff E, LPN gave report to EMT and left, and then Staff D, LPN, gave the paperwork to the EMT's. EMT ran an EKG, stating No mechanical activity. The DON stated, Staff D, LPN, inquired why the EMT would not take him to the hospital because he still has an IV (intravenous) for treatment. Staff D, LPN stated EMT took the paperwork with them. The DON denied seeing a golden rod in the chart/paper. The DON stated Staff L, CNA stated Staff E, LPN handed yellow/brown paper to EMT. The DON stated she suspects the social service assistant uploaded the DNR form into medical records of Resident #11 and then refiled it into the hard chart of Resident #1. The DON stated audits initially were desk reviews but now They have to physically go to each resident's chart. On [DATE] at 2:55 p.m., a phone interview was conducted with the Medical Director (MD) who was Resident #1's primary physician. The MD stated he was contacted on [DATE] at 4:00 a.m., regarding the passing of Resident #1. The MD stated at that time he was unable to recall the code status of the resident but was informed by the caller the resident was a DNR. The MD stated he was informed later Resident #1's chart had the wrong DNR paperwork from another resident with a similar last name. The MD stated resident wishes should be honored and validated. On [DATE] at 4:45 p.m., a telephone interview was conducted with Staff D, LPN. Staff D, LPN confirmed she worked on [DATE] on the 11 p.m. to 7 p.m. shift and was assigned to Resident #1. She stated around 1:30 a.m., when completing rounds, Resident #1 was sleeping and breathing, no concerns. She stated around 3:00 a.m., as she was exiting another resident's room, Staff A, CNA was out in the hallway by Resident #1's room calling out for help stating Resident #1 was unresponsive. She stated code blue was called, and staff were responding. She stated Resident #1 was diabetic, Staff E, LPN checked his blood sugar, but it was normal. Staff D, LPN stated she checked his vital signs, and he was breathing. Resident #1's oxygen saturation was in the 70%'s and heart rate 74. She stated Staff E, LPN, put a non-rebreather mask on Resident #1 and his oxygen saturation increased to 87% and his heart rate remained in the 70's. She stated Resident #1 kept breathing but would not verbally respond to staff. She stated she called 911 around 3:,d+[DATE]:05 a.m. She stated she printed his face sheet and physician orders to give to EMS, while Staff E, LPN and the other nurse stayed in the room with Resident #1. She stated Staff G, CNA had retrieved Resident #1 hard chart and gave to Staff E, LPN, It was sitting on the crash cart. She stated Staff G, CNA grabbed the DNR from hard chart. She stated when she saw the yellow paper (DNR form) she didn't confirm the name was Resident #1. She stated EMS arrived 3:,d+[DATE]:15 a.m. and the nurse relayed the situation. She stated Staff E, LPN, gave EMS the yellow paper. She stated that she told EMS that Resident #1 was still breathing and had a pulse, but states EMS said, But he is a DNR and declined to take him to the hospital. Staff D, LPN, stated, in general when you look into the electronic medical record to determine the code status of a resident, is not available. A review of the facility's Policy and Procedure titled Abuse, Neglect, Exploitation and Misappropriation, with a revision date of [DATE], showed the following: Policy statement: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. . Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. . failure to take precautionary measures to protect the health and safety of the resident. Procedure: . Any action that may cause or causes actual physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse. . Non-action, which results in emotional, psychological, or physical injury is viewed in the same manner as that caused by improper or excessive action. 1. Screening: The center will ensure that all prospective consultants, contractors, volunteers, caregivers and students are pre-screened as required by law. 2. Training: Employees of the center will receive education and training on Resident Rights, Resident Abuse, and Abuse Reporting during orientation and annually thereafter. Additional education and training will be provided as deemed necessary. 3. Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation. The following systems have been implemented: . Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other nonverbal indication of abuse. A review of the facility's Policy and Procedures titled Resident and Patient Rights, with a revision date of [DATE], showed the following: Policy statement: It is the policy of The Company that all employees will conduct themselves in a professional manner at all times, respecting the rights of each resident or patient to privacy, personal care, self-respect and confidentiality. Procedure: Employees will abide by the requirements for resident rights set forth in federal and state laws and regulations and the company policy and procedure, including the right to a dignified existence, and to be free from verbal, sexual, physical or mental abuse. A review of the facility's Policy and Procedures titled Physician Orders, with a revision date of [DATE], showed the following: Policy: the center will ensure the physician orders are appropriately and timely documented in the medical record. Procedure: Admission Orders: Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. Routine Orders: A nurse may accept a telephone order from the physician, physician assistant (PA) or nurse practitioner (ARNP) as permitted by state law. The order will be repeated back to the physician, PA or ARNP for his/her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR or eTAR). The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date the order as soon as practicable after it is provided to maintain an accurate medical record. Facility immediate actions to correct deficient practice included: o From [DATE] to [DATE], the licensed nurses involved received training regarding verifying resident code status, honoring advanced directives & CPR policy by the Director of Clinical Services (DCS)/Designee o [DATE] Assigned licensed nurse(s) suspended pending investigation. o On [DATE] an AD HOC Quality Improvement Performance Committee meeting was held to review the recommendation made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Regional Director of Clinical Services, MDS Coordinator, Unit Manager, Business Development Coordinator, Central Supply, Business Office Manager, Maintenance Director, Activities Director, and Director of Rehab Services. o On [DATE] a full house advance directive audit complete with one isolated finding. o On 08/ ,d+[DATE] The social services department was educated how to properly complete advance directive audits. o On [DATE] education completed with Interdisciplinary team (IDT) on ensuring accurate filing within the medical record. o On [DATE] an addendum to AD HOC Quality Improvement Performance Committee was held to review additional findings from investigation as well as implement further education and audits complete. The following team members were in attendance: Medical Director (via telephone), Executive Director, Regional Director of Clinical Services, MDS Coordinator, Unit Manager, Business Development Coordinator, Central Supply, Business Office Manager, Maintenance Director, Activities Director, and Director of Rehab Services. o On [DATE] The AD HOC QAPI Committee approved the recommendations. o Code Drills were completed 3 times a day on [DATE] [DATE],[DATE],[DATE], 1 completed [DATE], 3 completed on [DATE], 2 completed on [DATE], 2 were completed on [DATE], 1 completed on [DATE] and ongoing. o On [DATE] education provided to Social Services Department on how to properly complete an Advance Directive Audit. o On 08/ ,d+[DATE]-[DATE] all staff (I 00%) received education on Abuse/Neglect/Exploitation and Misappropriation CPR Policy, and Procedures to include drills, Paging System, and Resident Right. o On [DATE] IDT team was educated on filing of Medical Records. o On [DATE] of 29 licensed nurses received education on Nurse Practice Act and Following Physician Orders. Verification of the facility's removal plan was conducted by the survey team on [DATE] and included the following: A review of education provided to staff included: -Advance Directive dated [DATE] with 100% attendance verification nursing and department heads. -Following Physician Orders, dated [DATE] with 100% attendance verification licensed nursing staff. -Nurse Practice Act Florida dated [DATE] with 100% attendance licensed nursing staff. -Following Care Plans, dated [DATE] with 100% attendance verification all staff. -Paging System dated [DATE] with 100% attendance verification all staff. -Code Blue dated [DATE] with 100% attendance verification all staff. -Resident Rights dated [DATE] with 100% attendance verification all staff. -Abuse, Neglect, Exploitation dated [DATE] with 100% attendance verification all staff. -Clinical Records dated [DATE] with 100% attendance verification from social services. -Advance Directives Audits, DNR, Advance Directive Care Plan dated [DATE] with 100% verification from social services. -Code Blue mock drills immediately initiated on [DATE] to [DATE] and ongoing. -Staff D- investigatory suspension pending determination. -Review of Advance Directives audits [DATE] of the east wing showed 100% compliance and on [DATE] of the west wing showed 100% compliance with identified areas of non-compliance with DNR on yellow form. -On [DATE] at 4:30 p.m., interviews were conducted with 40 staff members individually and in groups on education. Staff members included RN's, LPN's, CNA's, and Social Services and represented multiple shifts. Staff members were able to state education received on Abuse, Neglect and Exploitation (ANE), reporting ANE, Code Status verification, Code Blue/CPR and Resident Rights. Staff members actively participated in the question session. Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to be removed on [DATE] at 5:00 p.m. and the non-compliance was reduced to a scope and severity of D.

Based on interviews and record reviews, the facility failed to ensure cardiopulmonary resuscitation (CPR) was performed according to the resident's expressed Advance Directive to honor their rights and professional standards for one resident (#1) out of eight residents reviewed for advance directives. On [DATE] at approximately 3:00 a.m., Resident #1 became unresponsive during routine care. Nursing staff assessed Resident #1 and Emergency Medical Services (EMS) was called to the facility. Prior to EMS arrival, nursing staff reviewed the medical record and determined Resident #1 had a Do Not Resuscitate (DNR) order. Nursing staff provided oxygen at a high concentration via mask, and sternal rubs were intermittently applied with no response from the resident. The EMS team arrived and conducted an initial assessment. Resident #1 was noted with no heart rate and no respirations and was pronounced deceased at 3:29 a.m. At 3:40 a.m., nursing discovered the DNR order in Resident #1's chart belonged to Resident #11, and Resident #1 had an order for Full Resuscitation. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: A review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, Type I Diabetes Mellitus without complications, dysuria, muscle weakness, dysphagia following unspecified cerebrovascular disease, sleep apnea unspecified, obstructive and reflux uropathy unspecified, acquired absence of other right toe(s), and major depressive disorder single episode in full remission. A review of physician orders for Resident #1 showed an order for Full Code, dated [DATE]. A review of Resident #1's care plan, dated [DATE], showed a focus area of advanced directives FULL CODE with an initiated date of [DATE] by the Social Services Director (SSD) and an intervention for this focus area to include: discuss advance directives with resident and or resident's representative. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. A review of Section GG-Functional Abilities and Goals Section GG0130-Self-Care showed Resident #1 dependent for toileting and hygiene. A review of Resident #1's 3008/ Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated [DATE], Section H: Advance Care Planning had the following areas checked as NO: Do not Resuscitate, Do Not Intubate, Do Not Hospitalize, No Artificial Feeding and Hospice. A review of Resident #1's medical progress notes, dated [DATE], showed the following: Code Status: Full Code. A review of Resident #11's chart showed an admitted on [DATE], with a discharge date of [DATE]. DNR paperwork was scanned in Resident #11's chart on [DATE]. On [DATE] at 5:00p.m., a phone interview was conducted with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN stated, she was working on the east wing on a new admission when she heard a Certified Nursing Assistant (CNA) screaming from the west side needing help. Staff E, LPN along with Staff F, Registered Nurse, (RN) went running over. Staff E, LPN stated two separate blood sugar checks (accucheck) were done with results Around 112 and 117. Staff E, LPN stated, Resident #1 was lying in bed and breathing but Light more SOB [shortness of breath], no suction was required. Staff E, LPN stated, she placed a NRM (non-rebreather mask) on him, and his pulse ox (oximetry) was in the 80's with a heart rate of 77, stating, I remember that. Staff E, LPN stated the resident's nurse (Staff D, LPN) had called 911 and got the paperwork needed to go the hospital, stating, I'm just assuming because she was not in his room. It's normal for the nurse to get the paperwork ready. Staff E, LPN stated, While waiting we were standing by the bedside, pulse ox on right hand, manual blood pressure taken by CNA, but I can't remember who took the blood pressure or what it was. Staff E, LPN stated, Staff G, CNA brought the hard chart and Staff D, LPN looked into the chart. Staff E, LPN stated EMT (Emergency Medical Technicians) arrived 6 minutes later and took over. Staff E, LPN stated the EMT's stated, We can't do CPR if he's breathing, and hooked him up to the machine. Staff E, LPN stated she did not know what the machine showed. Staff E, LPN, stated, Staff D, LPN, said he was a DNR. Staff E, LPN stated, EMT stated, there was nothing they could do. Staff E, LPN stated a discussion was made between the staff and the EMT's regarding transporting the resident to the hospital. Staff E, LPN stated the resident had a peripherally inserted central catheter (PICC), So I figured he must have been treated. Staff E, LPN stated Staff D, LPN was talking to the EMT about being a DNR. Staff E, LPN state Staff D, LPN asked the EMT team why Resident #1 could not go to the emergency room . Staff E, LPN, stated, I felt they were giving us roundabout answers, so I left and ten minutes later I let the EMT team out the door without the resident, no communication from them as what the outcome was. On [DATE] at 6:17 a.m., an interview was conducted with Staff A, CNA. Staff A, CNA stated on [DATE] she made her rounds to check on her residents and at approximately 12:30 to 12:45 a.m. She stated she changed Resident #1 for incontinence of urine. Staff A, CNA stated, the resident was talking to her. Staff A, CNA stated, she took her lunch break at 2:00 a.m. and clocked back in at 2:30 a.m. and went to room [ROOM NUMBER] to answer the call light and changed both residents in there. Staff A, CNA stated she continued with her rounds and went into Resident #1's room. She stated, He was a little groggy but talking to me. Staff A, stated she rolled Resident #1 to his right, He was talking to me but when I rolled him back onto his back, I noticed something different with him. Staff A stated Resident #1 was not responding to her. She stated she went out and yelled code blue three times. Staff A stated, Staff G, CNA brought the crash cart and went to get the chart. She stated, I was trying to distract his roommate who was waking up. Staff A stated she was not sure who opened the chart but heard someone say Resident #1 was a DNR. She stated, He was breathing though, and someone put a mask on him, and a pulse ox [oximeter] on his finger. I know someone did a sternal rub. I think one of the nurses may have taken his blood pressure but I'm not sure. Staff A, CNA stated she was in the room attending to the roommate but would look over the curtain. Staff A, CNA stated the resident coughed when they did the sternal rub. When the paramedics arrived, she said He stopped breathing. Staff A, stated, the resident's [family member] asked for her to come in when the priest showed up. She stated, It was hard because all my residents are like family to me. On [DATE] at 6:34 a.m., an interview was conducted with Staff B, CNA with Staff C, RN utilized as an interpreter. Staff B, CNA stated, she was working on the west hall when she heard yelling for help from the other hallway. Staff B, CNA stated she ran into the room and there were three nurses in the Resident #1's room (Staff D, LPN, Staff E, LPN and Staff F, RN). Staff B, CNA stated the resident looked pale and witnessed a nurse, Staff F, RN, place a pulse oximeter on the resident's finger and a CNA brought in the crash cart. Staff B, CNA stated, someone put oxygen on the resident and Staff E, LPN squeezed the bag. Staff B, CNA stated the mask had a bag on his chest. Staff C could not recall who called 911. Staff B stated the resident was breathing and had a pulse before the paramedics arrived. Staff B, CNA stated she stayed to see if they needed assistance and when the crash cart arrived, the resident was placed on a back board. On [DATE] at 6:45 a.m., an interview was conducted with Staff G, CNA. Staff G, CNA confirmed she was working [DATE]. Staff G stated on [DATE] at approximately 3:05 a.m., I heard a CNA yell Code Blue. Staff G, CNA stated, she immediately grabbed the code cart and ran it to Resident #1's room. When Staff G, CNA, arrived Staff E, LPN, Staff D, LPN, Staff, F, RN and Staff A, CNA were in the room. Staff G, CNA stated, she pushed the code cart in and went to get the resident's chart. She pulled the chart and started back down the hallway when Staff D, LPN took the chart from her and Staff D, LPN told everyone in the room he was a DNR. When Staff G, CNA got back to the room Staff E, LPN, was doing a sternal rub on the patient. Staff G then left to wait at the door for the EMT's but could not recall when they were called. On [DATE] at 7:11 a.m., an interview was conducted with Staff H, CNA with the assistance of Staff I, RN for interpretation. Staff H, CNA stated she had worked the evening of [DATE] into [DATE] shift, stating she was working in a resident's room on the east wing, when she heard the code blue. I ran to help the staff. Staff H, CNA stated a nurse had asked her to get the Accu-Check machine. Staff H stated, I don't know names but there were three nurses in the resident's room and one CNA. Staff H, CNA stated, all the staff were taking care of him so I could not really see how he was doing. I went to the door to wait for the EMT to arrive. On [DATE] at 7:29 a.m., an interview was conducted with Staff J, LPN/Unit Manager. (UM). Staff J, LPN/UM stated, she was not here during the event but was on her way to work early. Staff J, LPN/UM stated while on her way, there was a management group text chat which stated Resident #1 had expired. I was like wow. When Staff J arrived at work, the Director of Nursing (DON) was talking to Staff D, LPN, Resident #1's nurse, and the other nursing staff. That's when everything started to come together. Staff J, LPN/UM was told Resident #1 was fine during the cleaning but when Staff A, CNA turned to him onto his back, he wasn't breathing. Staff J stated, EMS was called, and they couldn't revive him. Staff J, LPN/UM stated the family member had been in the facility and had left before she arrived. Staff J, LPN/UM stated the family member called her later in the morning on her cellphone. Staff J, LPN/UM stated, She was like [Staff J] I don't know what happened, I can't believe he's gone. The family member asked me, Can you do me a favor? Staff J, LPN/UM stated the family member asked if she could get a copy of the DNR signed by the resident. Staff J, LPN/UM stated she explained to the family member, she could not do obtain the DNR paperwork but Staff K in social services could assist her. Staff J, LPN/UM stated his family member had stated something was wrong and stated, Staff D, LPN, told me they started CPR and then they stopped because he's a DNR. Staff J, LPN/UM stated the family member had said, Resident #1 and I never signed that paperwork. Staff J, LPN/UM stated when the family member was in the facility, she was looking through the resident's chart and noticed the DNR was of a different resident's name. Staff J, LPN/UM stated, she immediately informed the DON to listen to the remainder of the conversation on her cell phone. The family member wanted a copy of the DNR. Staff J, LPN/UM stated, she told her to come in and talk to the DON and medical records. The DON then took Staff J's cell phone to continue the conversation with the family member. Staff J, LPN/UM stated the family member was asking about the DNR and stated, Maybe [he] signed without my knowledge, but I know [he] would not sign it, he would not even let them take his leg. Staff J stated, once the family member told the DON about this, the DON went to the hard chart and saw the wrong DNR name in the chart. Staff J, LPN/UM stated, I've heard different stories on whether CPR was done. Only one staff member stated CPR was done but must of the staff interviewed stated CPR was not initiated. Staff J, LPN/UM stated, Once you start compressions regardless of DNR status on paper, you must continue with CPR. On [DATE] at 10:10 a.m., an interview was conducted with Staff J, LPN/UM. Staff J stated, on a new admitted resident, the nurse will place the resident in the computer as active. After the resident is active, the nurse will assess the resident and input all orders, allergies, code status etc. The nurse will contact the physician and verify the medications. The nurse will let the physician know if the resident decides they want to be a DNR. We will contact the physician and the Social Services Director regarding the resident's code status. Social Services Director is the one who will place the proper paperwork in the chart stating, he's the only one. If the resident comes in with their DNR paperwork it will get uploaded into the chart and placed in front of the hard chart. Staff J, LPN/UM stated, multiple copies are always available in chart. If not, we will get yellow paper from Social Services and make copies. Social Services will come to us with yellow paper if resident is new to DNR and we will place the order in his chart. Staff J, LPN/UM, stated she does not know his process, only what the nursing staff responsibilities. Staff J, LPN/UM stated if a resident states their code status to the staff, the nurse will contact, inform and obtain an order for the Code Status and the nurse will write a note of the conversation with the physician in the progress note. From there, the resident would sign the form if they chose to be a DNR and this form will be faxed or emailed to the physician to sign. Once signed by the physician, the form is faxed or emailed back and social services will place into the hard chart; however, the order was placed in the electronic chart. There may be a short time lapse of twenty-four to forty-eight hours before social services place the yellow DNR paperwork in chart, especially over the weekend, but the staff will have the physician orders to go by. Staff J stated when a resident leaves the facility with plans to return, a bed hold is initiated for seven days, and the hard chart will be saved as is until the resident returns. Staff J stated usually after ten to fourteen days, medical records will take the hard chart of the resident, and a new hard chart would be started upon the resident's return to the facility. On [DATE] at 11:10 a.m., a telephone interview was conducted with Staff A, CNA. She stated, Resident #1 was a diabetic so she thought his sugar may be low, but they did do an accucheck, and it was fine. Staff A, CNA could not recall the time the resident's family member showed up. Staff A, CNA told the family member she did not know what happened. Staff A, CNA told the family member, He was fine when I changed him the first time. Staff A talked to the family member and told her the care provided throughout the night for the resident. Staff A, CNA was answering a call light for another resident, when Staff D, Licensed Practical Nurse (LPN), went and got her after talking to his family member in his room and the family member was requesting to speak with Staff A. Staff A, stated, I don't know what Staff D, LPN and his family member talked about. On [DATE] at 12:10 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated he was the Gate keeper and he makes sure the code status regarding medical records is accurate. The SSD stated weekly audits are completed to ensure code status for the residents. The SSD stated, if the resident comes in with a DNR, he will ensure it is legally correct (signatures) and validate with the resident, their desires, etc. On new residents, he would discuss code status. If needed, he would explain in detail what this entails. If the resident would like to become a DNR, he would use a white form of the state Florida 'golden rod' form, have the resident sign and have MD [medical doctor] sign and when completed, copy on to yellow paper. The SSD stated, Then I upload the white form into the electronic medical chart, enter code status into electronic medical record and notify the nursing for transcription of the order into electronic medical record, then I update the Care Plan. The SSD stated, I then place the resident on the ongoing audit form for Advance Directives. The SSD stated the audits are completed weekly, stating, I review the care plan for advance directives, I look for the physical order in the computer and if a DNR is on the chart. The SSD stated, on the morning of [DATE], he noted a white DNR on the chart of Resident #1, and stated, If I put this on the chart it would have been yellow, this was a white form, so I did not do this. The SSD stated, I still have no idea on how the form was in the chart. On [DATE] at 12:15 p.m., a second phone interview was conducted with Staff E, LPN. Staff E, LPN stated Staff D, LPN came into room and stated Resident #1 was a DNR, but I did not see the actual form. Staff E, LPN stated for the EMT to state the resident was a DNR means the DNR form had to have been on yellow paper. Staff E, LPN stated the ambu bag and backboard were out but We never had to use it. Staff E, LPN stated, I assume Staff D. LPN, looked into the electronic medical chart because she had to print the paperwork needed for the EMT team. Staff E stated, the EMT team kept telling us he's a DNR and not to be hospitalized . Staff E, LPN stated, I could not understand that. On [DATE] at 12:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, she received a text between 5:00 or 6:00 in the morning from Staff D, LPN, stating, Resident #1 expired. The DON stated she texted her to ask if he was a DNR but Staff D, LPN did not respond back. When she arrived, Staff J, LPN/ UM was in her office on her cell phone. The DON stated she talked to the family member and the family member was inquiring about the DNR stating He was not a DNR. The DON stated the family member said, This was new to me. The DON stated, she would get back with her. The DON then called the Nursing Home Administrator (NHA), to inform the conversation with the family member and Resident #1 was not a DNR. The DON found Staff D, LPN and brought her into my room for an interview. The DON stated Staff D, LPN said the resident died and she had the hard chart with her. The DON stated, she looked and saw a DNR for another resident on white paper in Resident #1's hard chart. The DON stated, At that time I saw the error, we talked about the incident. The DON stated, during my interview with Staff D, LPN, she said the resident was fine during medication administration earlier on her shift until his CNA screamed for help. During her interview, Staff D, LPN, stated to the DON, Staff E, LPN and Staff F, RN were the first to arrive. A glucometer was used by Staff F, LPN and Staff E, LPN put on pulse ox. The DON stated, Staff D, LPN stated, Staff G, CNA brought the crash cart and chart. The DON stated, Staff D, LPN went to get paperwork, and she called 911. A NRM (non-rebreather mask) was placed because of low O2 (oxygen) sat's. The DON stated Staff D, LPN, checked his carotid and said it was in the 70's. Staff D, LPN told the DON, Staff E, LPN gave report to EMT and left, and then Staff D, LPN, gave the paperwork to the EMT's. EMT ran an EKG, stating No mechanical activity. The DON stated, Staff D, LPN, inquired why the EMT would not take him to the hospital because he still has an IV (intravenous) for treatment. Staff D, LPN stated EMT took the paperwork with them. The DON denied seeing a golden rod in the chart/paper. The DON stated Staff L, CNA stated Staff E, LPN handed yellow/brown paper to EMT. The DON stated she suspects the social service assistant uploaded the DNR form into medical records of Resident #11 and then refiled it into the hard chart of Resident #1. The DON stated audits initially were desk reviews but now They have to physically go to each resident's chart. On [DATE] at 2:55 p.m., a phone interview was conducted with the Medical Director (MD) who was also Resident #1's primary physician. The MD stated he was contacted on [DATE] at 4:00 a.m., regarding the passing of Resident #1. The MD stated at that time he was unable to recall the code status of the resident but was informed by the caller the resident was a DNR. The MD stated he was informed later Resident #1's chart had the wrong DNR paperwork from another resident with a similar last name. The MD stated resident wishes should be honored and validated. On [DATE] at 4:45 p.m., a telephone interview was conducted with Staff D, LPN. Staff D, LPN confirmed she worked on [DATE] on the 11 p.m. to 7 p.m. shift and was assigned to Resident #1. She stated around 1:30 a.m., when completing rounds, Resident #1 was sleeping and breathing, no concerns. She stated around 3:00 a.m., as she was exiting another resident's room, Staff A, CNA was out in the hallway by Resident #1's room calling out for help stating Resident #1 was unresponsive. She stated code blue was called, and staff were responding. She stated Resident #1 was diabetic, Staff E, LPN checked his blood sugar, but it was normal. Staff D, LPN stated she checked his vital signs, and he was breathing. Resident #1's oxygen saturation was in the 70%'s and heart rate 74. She stated Staff E, LPN, put a non-rebreather mask on Resident #1 and his oxygen saturation increased to 87% and his heart rate remained in the 70's. She stated Resident #1 kept breathing but would not verbally respond to staff. She stated she called 911 around 3:,d+[DATE]:05 a.m. She stated she printed his face sheet and physician orders to give to EMS, while Staff E, LPN and the other nurse stayed in the room with Resident #1. She stated Staff G, CNA had retrieved Resident #1 hard chart and gave to Staff E, LPN, It was sitting on the crash cart. She stated Staff G, CNA grabbed the DNR from hard chart. She stated when she saw the yellow paper (DNR form) she didn't confirm the name was Resident #1. She stated EMS arrived 3:,d+[DATE]:15 a.m. and the nurse relayed the situation. She stated Staff E, LPN, gave EMS the yellow paper. She stated that she told EMS that Resident #1 was still breathing and had a pulse, but states EMS said, But he is a DNR and declined to take him to the hospital. Staff D, LPN, stated, in general when you look into the electronic medical record to determine the code status of a resident, is not available. A review of the emergency fire rescue run report, dated [DATE], shows the following: Received 911 alert at 3:13:54 a.m. EMS arrived on [DATE] at 3:20 a.m. Patient contact at 3:22 a.m. Initial assessment of the resident has skin cold, capillary nail bed refill more than 4 seconds, pale with eye bilateral non-reactive and mental status unresponsive. At 3:24 a.m., EKG (electrocardiogram) in 4 leads was in PEA (pulseless electrical activity) which transitioned to asystole (the absence of ventricular contractions leading to imminent cardiac death). Nursing staff reports the patient has a valid DNR, which was requested and has at bedside. Signed and confirmed to be valid per State of Florida with MD (medical doctor) signature. Staff. Patient is unresponsive and has no palpable pulses currently. Patient placed on monitor via cardiac pads, found to be in an idioventricular rhythm with the rate less than 10. A 4-lead EKG monitoring is also placed currently with same findings and EMS crew confirms there is no mechanical pulse currently. Oxygen saturation pulse oximetry on and explain is with no arterial waveform noted. Patient was cool to touch, pale and has no capillary refill noted. Patient is apneic with a non-rebreather mask on high flow oxygen currently. Patient has no visible chest rise. Shortly after patient is placed on monitor rhythm is noted to be asystole with no electrical or mechanical cardiac activity. Discussion is had with staff members that the patient initially had an idioventricular PEA with no signs compatible with life, to which he is now asystole. Staff confirms that the DNR is active, and patient's wishes are to be granted at this time A yellow copy of valid DNR orders attached to chart. On [DATE] at 3:29 a.m., resident was declared dead. A review of the facility's Policy and Procedure titled Florida Cardiopulmonary Resuscitation (CPR), with a revision date of [DATE], showed the following: Policy statement: cardiopulmonary resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida do not resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: resident identification Fully executed Florida do not resuscitate order (DH1896), located in the advanced directive section of the medical record 3. Use the paging system and call Code Blue to room number or location of the event three times. 4. In the absence of a fully executed Florida Do Not Resuscitate order (DH1896) the facility will immediately begin CPR. 5. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: The resident responds. 6. Notify the physician and resident representative/legal representative. 7. Document in the medical record. A review of the facility's Policy and Procedure titled Advance Directives, with a revision date of [DATE], showed the following: Policy statement: The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by their resident and/or resident representative. Process: 1. Upon admission, Social Service Director or Business Development/designee will: a.) Communicate to resident and/or resident representative his or her right to make choices concerning health care and treatments, including life sustaining treatments. b.) Determine whether the resident has an advanced directive and, if not, determine whether the resident wishes to establish an advance directive. c.) Document in the residence record via the Advanced Discussion Form that the resident and/or resident representative has been apprised of his or her right to formulate an advanced directive. 2. Social services and or business development coordinator designee will assist the resident/ resident representative to complete the advanced directives discussion document. If an advance directive exists the Social Services and/or Business Development Coordinator/designee will obtain a copy and place it in the resident's medical record. 3. If the resident has not executed an advance directive but wishes to establish an advance directive, the Social Service will assist the resident/resident representative with obtaining the state approved advance directive documents formulating an advanced directive is the choice of the resident and is not required. No center employee shall act as a witness or notary for advance directive forms, but staff can assist in ensuring documentation is properly executed period. 4. Upon completion of advanced directives discussion document, social services or nurse will notify the physician of their residence wishes and procure a state approved do not resuscitate order if necessary. Notification will be documented in the medical record. 5. Advanced directives will be reviewed Quarterly Hospice administration Additional times as needed or requested by the resident/resident representative Reviews are designed to: Identify and clarify the content and intent of the existing care instructions, and whether the resident wishes to change or continue these instructions. Identify situations where health care decision-making is needed. Review the resident's condition, mental capacity to make health care decisions, and existing choices and continue to modify approaches. Any changes to advanced directives will require a new Advanced Directive Discussion Document to be completed and placed in the medical record. The previous document to be filed in the thinned record. 6. Upon notification from resident and/or resident representative of the desire to change or revoke an advance directive, or any issue concerning the capacity, the physician will be notified, and the medical record will be modified accordingly. Facility immediate actions to correct deficient practice included: o From [DATE] to [DATE], the licensed nurses involved received training regarding verifying resident code status, honoring advanced directives & CPR policy by the Director of Clinical Services (DCS)/Designee o [DATE] Assigned licensed nurse(s) suspended pending investigation. o On [DATE] an AD HOC Quality Improvement Performance Committee meeting was held to review the recommendation made from the root cause analysis. The following team members were in attendance: Medical Director (via telephone), Executive Director, Regional Director of Clinical Services, MDS Coordinator, Unit Manager, Business Development Coordinator, Central Supply, Business Office Manager, Maintenance Director, Activities Director, and Director of Rehab Services. o On [DATE] a full house advance directive audit complete with one isolated finding. o On 08/ ,d+[DATE] The social services department was educated how to properly complete advance directive audits. o On [DATE] education completed with Interdisciplinary team (IDT) on ensuring accurate filing within the medical record. o On [DATE] an addendum to AD HOC Quality Improvement Performance Committee was held to review additional findings from investigation as well as implement further education and audits complete. The following team members were in attendance: Medical Director (via telephone), Executive Director, Regional Director of Clinical Services, MDS Coordinator, Unit Manager, Business Development Coordinator, Central Supply, Business Office Manager, Maintenance Director, Activities Director, and Director of Rehab Services. o On [DATE] The AD HOC QAPI Committee approved the recommendations. o Code Drills were completed 3 times a day on [DATE] [DATE],[DATE],[DATE], 1 completed [DATE], 3 completed on [DATE], 2 completed on [DATE], 2 were completed on [DATE], 1 completed on [DATE] and ongoing. o On [DATE] education provided to Social Services Department on how to properly complete an Advance Directive Audit. o On 08/ ,d+[DATE]-[DATE] all staff (I 00%) received education on Abuse/Neglect/Exploitation and Misappropriation CPR Policy, and Procedures to include drills, Paging System, and Resident Right. o On [DATE] IDT team was educated on filing of Medical Records. o On [DATE] of 29 licensed nurses received education on Nurse Practice Act and Following Physician Orders. Verification of the facility's removal plan was conducted by the survey team on [DATE] and included the following: A review of education provided to staff included: Advance Directive dated [DATE] with 100% attendance verification nursing and department heads. Following Physician Orders, dated [DATE] with 100% attendance verification licensed nursing staff. Nurse Practice Act Florida dated [DATE] with 100% attendance licensed nursing staff. Following Care Plans, dated [DATE] with 100% attendance verification all staff. Paging System dated [DATE] with 100% attendance verification all staff. Code Blue dated [DATE] with 100% attendance verification all staff. Resident Rights dated [DATE] with 100% attendance [NAME] [TRUNCATED]

Based on record review and interview the facility failed to provide and honor the resident rights for choice related to health insurance for 3 of 3 (#21, #26, #50) residents reviewed for payer source changes. Findings included: 1. Review of the facility policy titled Resident Rights with an effective date of 11/30/24 revealed it is the policy of the company to provide on-going training on residents rights to staff members as required by state and/or federal regulations. Interview with the Business Office Manager (BOM) on 07/10/24 at 9:23 AM revealed that if a resident was admitted with straight Medicare their stay would be covered 100% for the first 20 days and at Day 21 the resident will have a deductible unless they have a secondary insurance. She reported that straight Medicare and a Medicare HMO (Health Maintenance Organization) are similar but with the HMO, the facility would have to report to a case manager every week. The BOM reported that when approaching the 20-day mark, the resident was encouraged to disenroll from the Medicare HMO and be placed on straight Medicare based on the residents clinical needs. She reported that the facility does encourage the switch to straight Medicare based on clinical needs; however, residents are not forced to disenroll from their Medicare HMO. 2. Review of Resident #21's Census page of his electronic medical record revealed he was admitted to the facility on [DATE] with a primary payer source of MCR LEVEL-[Company Name] Medicare Levels (Medicare HMO). On 6/1/24, the resident's primary payer source was changed to MCA-Medicare A (straight Medicare). Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] indicates a Brief Interview For Mental Status (BIMS) score of 13, indicating cognitively intact. Review of the Attestation of Resident or Legal Representative signed 5/29/24 by Resident #21 revealed the resident's signature. Additional review of the form revealed a section on the bottom of the form noting: By signing below, I am attesting that I witnessed the Resident/Legal Representative sign said attestation and in addition to signing the attestation that the Resident/Legal Representative had the opportunities to ask questions and fully understand the document he/she was signing. This section was blank and contained no signature, printed name, or date by the Administrator or Designee. Interview with Resident #21 on 07/10/24 at 10:48 AM confirmed the signature on 5/29/2024 was his, but he does not remember signing it. He reported that his Old Lady (significant other) told him that he changed his insurance form from a Medicare HMO and wanted to know why. He reported that it did not make sense to change because he had just started the HMO and there was no need to change it. He reported that he does not see the benefit of the new insurance. He stated he was familiar with the HMO and would not have wanted to change from it. During an interview with the BOM on 07/10/24 at 11:58 AM, she reported that the Assistant Business Office Manager (ABOM) communicated to the resident what was on the form and that they sign that they understand. She confirmed that the facility designee date and signature was not completed. 3. Review of Resident#26's Census page of the electronic medical record revealed he was admitted to the facility on [DATE] with a payer source of MCR LEVEL-[Company Name] Medicare Levels (Medicare HMO). On 5/1/24, the resident's primary payer source was changed to MCA-Medicare A (straight Medicare). Review of the MDS 5-day assessment dated [DATE] revealed the BIMS could not be completed, and the resident had long and short-term memory problems, no recall of season/location of room/staff names and faces, and had severely impaired cognitive skills for decision making. Review of Resident #26's record revealed a Certificate of Incapacity dated 4/15/24 Review of the Attestation of Resident or Legal Representative dated 4/16/24 revealed it had a resident signature dated 4/16/24. Additional review of the form revealed a section on the bottom of the form for the Administrator/Designee's signature, printed name, and date to attest to the resident's signature and that the resident/legal representative had the opportunity to ask questions and fully understood the document he/she was signing. This section was blank. On 07/10/24 at 11:49 AM, the BOM reported she communicated with the resident's ex-wife and informed her about other insurance options, and the ability to disenroll the resident and have him go on straight Medicare. She reported that this was all explained to the ex-wife in Spanish and that she understood the whole process. She reported that she explained to the ex-wife she needed to have the resident sign the disenrollment form. She reported she was not aware the resident was deemed incapacitated the day prior to signing. She confirmed the facility Administrator/designee section was also incomplete. Interview on 07/10/24 at 1:26 PM with the NHA and BOM revealed the resident's ex-wife was aware of the change in insurance and was agreeable to the change. The NHA and BOM reported they felt that the ex-wife signed the form but was unwilling to admit it. The NHA and BOM could not verbalize why the ex-spouse would not have signed her own name and why a facility representative did not witness/sign the attestation portion of the form. 4. Review of Resident #50's Census page of his electronic medical record revealed he was admitted to the facility on [DATE] with a primary payer source of MCR LEVEL-[Company Name] (Medicare HMO). On 6/1/24, the resident's primary payer source was changed to MCA-Medicare A (straight Medicare). Review of the resident's admission MDS assessment dated [DATE] revealed a BIMS score of 13, indicating cognitively intact. Review of the Attestation of Resident or Legal Representative revealed a resident signature dated 5/29/24. Additional review of the bottom of the form revealed the Administrator/Designee's signature, printed name, and date to attest to the resident's signature and that the resident/legal representative had the opportunity to ask questions and fully understood the document he/she was signing was blank. Interview on 07/10/24 at 10:36 AM with Resident #50 confirmed that the signature on the document was his, but when he was initially presented with the form he declined to sign it until he consulted with his sister and then he and his sister spoke to the facility. Resident #50 stated he was told if he stayed on his HMO the insurance would not cover his bills for his stay in the facility, but if he disenrolled and went on straight Medicare it would cover his stay. The resident was told he could change back to the Medicare HMO when he went back to the community. During an interview on 07/10/24 at 11:54 AM with the BOM, she reported speaking to Resident #50. She confirmed the resident initially declined and needed to speak to family before getting back to the BOM. She reported that the BOM and ABOM explained to the resident that he could change back to his previous insurance when he went back into the community. She confirmed the facility's Administrator/Designee signature, printed name, and date to attest to the resident's signature and that the resident/legal representative had the opportunity to ask questions and fully understood the document he/she was signing was blank.

Based on observations, staff interviews and review of records, the facility failed to ensure one (dining room) of two ice makers used for residents was free from bio-growth. Findings included: On 7/8/2024 at 12:30 p.m. and at 3:20 p.m. the main dining room was observed during the lunch meal dining service. The back wall area near the door leading to the kitchen was observed with a walled space containing a counter space, equipment storage area and a large ice maker. Observations revealed staff taking ice from the machine with an ice scoop. Further observations of the machine revealed heavy oxidation, calcification on the outside metal cover. When the ice machine door was opened, it was observed full with ice. Observations on the inner plastic ice chute revealed heavy black discoloration to include bio-growth spotting. It was determined this ice machine was used to serve ice to residents for consumption. On 7/9/2024 at 11:00 a.m., 2:00 p.m., 7/10/2024 at 7:30 a.m., 11:30 a.m., and 1:07 p.m., the dining room ice machine was again observed with black bio-growth in and surrounding the internal ice chute. On 7/11/2024 at 11:30 a.m., the Dietary Manager observed the dining room ice machine and confirmed the ice chute had black bio-growth spotted on it. The Dietary Manager was not sure who was responsible for cleaning this ice machine. Review of the policy titled Environment, with a revision date of 9/2017, revealed: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The procedure section showed:: 1. The Dining Service Director will ensure the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. Photographic evidence was taken.

Based on observation, interview and record review, the facility failed to establish a policy to ensure a safe smoking area where protection from excessive heat and access to hydration was provided to nine of nine ( #13, #108, #30, #106, #165, #98, #19, #317, #166) residents identified as smokers. Findings included: On 7/8/2024 the facility provided a Resident Smoking List which included Resident #13, #108, #30, #106, #165, #98, #19, and #166. Observations of the smoking patio from 7/8/2024 through 7/11/2024 revealed Resident #166 was also a smoker but was not included on the original list provided. Observations on 07/08/24 at 2:28 PM revealed approximately eight residents on the smoking patio. The smoking patio was noted to have no covered area to provide shade for the residents, who were observed to be lined up against the right side of the patio to get relief from the sun from the approximate 12 inches of shade created by the height of the building. Additional observations revealed there was no fluids to provide hydration. An interview was conducted at this time with Staff K, Certified Nursing Assistant (CNA). Staff K reported that she monitors the smoking patio. She reported that she brings out the cart with everyone's cigarettes, lighter and smoking aprons for those who need it. She reported that she brings nothing else out with her. During an interview with Resident #108 on 7/8/24 at 2:28 PM, the resident was observed against the right side of the wall smoking. Resident #108 stated liquids are not provided for residents on the smoking patio, but if they want to bring their own drink out; then they can. The resident reported he forgot his iced tea in his room and will have to drink it when he goes back in. The resident reported staff hold the cigarettes and the lighter and light the cigarettes for them. He reported that smoking times are six times a day and there is a two cigarettes max each time. Resident #108 reported they used to have umbrellas over the table, but over the years they got destroyed and were never replaced. Review of Resident #108's BIMS Evaluation, dated 5/9/24 revealed a score of 14, indicating cognitively intact. An observation of Resident #165 on 7/8/24 at 2:28 PM revealed the resident was actively smoking on the smoking patio against the right side of the wall under approximately one foot of shade provided by the height of the building. There was no other shade noted. Review of Resident #165's BIMS Evaluation, dated 6/21/24, revealed a score of 15, indicating cognitively intact. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-8, revealed on 7/8/24 at approximately 2:30 PM the temperature was 91 degrees Fahrenheit. During an interview on 7/9/24 at 9:14 AM the Activities Director revealed that each cigarette break is 15 minutes long and each resident gets a maximum of two cigarettes for each smoking session. She reported that she brings out the cart with the red boxes that contain each resident's cigarettes, one lighter and smoking aprons for those care planned to need the apron. She reported drinks are not provided on the patio, and the only shade provided was what the building makes. She reported there is no fan or other cooling devices used for the smoking patio. An observation on 7/9/24 at 10:27 AM revealed that smoking was in progress with approximately six residents on the patio. It was noted there was no shaded area and no fluids to provide hydration. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-9, revealed on 7/9/24 at approximately 10:30 AM the temperature was 85 degrees Fahrenheit. An observation on 7/9/24 at 12:20 PM revealed that smoking was in progress with approximately six residents on the patio. It was noted there was no shaded area and no fluids to provide hydration. Resident #106, on 07/09/24 at 12:28 PM, was observed sitting along the right wall with approximately a foot of shade created by the height of the building. Continued observations revealed fluids were not offered to provide residents with hydration. During an interview with Resident #106 at this time, she reported liquids were not provided and that she finds shade wherever she can. Review of Resident #106's Brief Interview for Mental Status (BIMS) Evaluation, dated 6/20/24, revealed a score of 15, indicating cognitively intact. An observation of Resident #166 on 7/9/24 at 12:28 PM revealed the resident was on the smoking patio actively smoking. It was noted that there was no shade, and no fluids in the area. During an interview with Resident #166 at this time, Resident #166 stated liquids were not provided and there was no shade. Review of Resident #166's BIMS Evaluation, dated 7/9/24, revealed a score of 14, indicating cognitively intact. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-9, revealed on 7/9/24 at approximately 12:30 PM the temperature was 87 degrees Fahrenheit. An observation on 7/10/24 at 10:32 AM revealed approximately six residents on the smoking patio with smoking in progress. No fluids were observed on the patio to provide hydration, and the only shade present was approximately two feet of shade created from the height of the building on the left side of the courtyard. The residents were noted to be lined up against the left wall in order to be shaded from the sun. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-10, revealed on 7/10/24 at approximately 10:30 AM the temperature was 89 degrees Fahrenheit. An observation on 7/10/24 at 2:26 PM revealed approximately six residents on the smoking patio. The smoking patio was noted to have no covered area to provide shade and the residents were observed to be lined up against the right side of the patio to get relief from the sun from approximately 12 inches of shade created by the height of the building. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-10, revealed on 7/10/24 at approximately 2:30 PM the temperature was 92 degrees Fahrenheit. An observation on 7/10/24 at 4:04 PM of the smoking patio revealed approximately five residents outside who were about to start smoking. The patio was noted to have no shade, and the sky was alternating between overcast and sunny. Continued observations revealed no fluids on the patio to encourage hydration. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-10, revealed on 7/10/24 at approximately 4:00 PM the temperature was 91 degrees Fahrenheit. During an interview on 7/10/24 at 4:10 PM with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the NHA confirmed there was no shade on the smoking patio. She reported Activities provides fluids if residents want it. The NHA, DON, and ADON could not verbalize how the residents would know they can get fluids while outside. An observation on 7/11/24 at 10:36 AM of the smoking patio revealed approximately five residents sitting under a small overhang by the door of the smoking patio with rain currently falling. Continued observations at this time revealed two maintenance staff members building a portable tent. While observing this, Resident #106, Resident #165, and Resident #166 were observed to come back inside from the smoking patio. Resident #106 said if it rains there is no smoking, and they never have water to drink on the patio, no fan, and no shade when it's hot. Resident #165 stated, This is crazy that there is no shade or fans for when it's hot. The resident reported if it rains they can't smoke. Resident #165 reported that if he wants something to drink while out in the heat smoking, he had to bring his own drink. Resident #166 stated if it rains there is no smoking, and usually there is no water on the patio, no fan and no shade. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-11, revealed on 7/11/24 at approximately 10:30 AM the temperature was 77 degrees Fahrenheit and raining.

Based on interview and record review, the facility failed to identify and report an allegation of physical abuse by a staff member for one (#314) of three residents reviewed for abuse. Findings Included: A review of the Admission Record showed Resident #314 was most recently admitted to the facility on [DATE] with diagnoses to include cerebrovascular Accident (CVA), aphasia, hemiplegia, depression, and legal blindness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #314 had a Brief Interview Status (BIMS) score of 14 out of 15, indicating intact cognition. Resident #314 needed maximum assistance with one-person physical assistance with bed mobility, dressing, toilet use, and personal hygiene, and extensive assistance with two plus persons physical assistance with transfers. During an interview on 7/8/2024 at 9:17 AM, Resident #314 reported a concern regarding not being able to get up into a wheelchair. Review of the grievance log, from April 2024 to current, revealed a grievance for Resident #314 dated 4/13/2024. Review of the grievance for Resident #314, written by the Nursing Home Administrator (NHA), revealed Resident #314 reported to Staff I, Licensed Practical Nurse (LPN) that the resident was uncomfortable when the Certified Nursing Assistant (CNA) was providing care. Attached to the grievance form was an In-Service Attendance record, with two pages of nursing staff signatures of attendance for the topic Customer Service, Summary our number one goal is to provide friendly and timely customer service with respect. When dealing with a resident, please ensure you are not rude or making a resident feel there is an issue. While providing Activities of Daily Living (ADL) care, CNA's must talk through every step with courtesy. If the resident/family asks something of you that you either don't have the answer to or can't perform, be sure to notify the immediate supervisor. Also attached to the grievance was the document titled Skills Competency Assessment: Positioning a Resident, dated 4/19/24 by Staff K, Certified Nursing Assistant (CNA) and the evaluator's signature. During an interview on 7/11/2024 at 9:10 AM Staff I, LPN stated the CNA let me know Resident #314 complained about something. Staff I, LPN stated she could not recall much other than informing the Nursing Home Administrator (NHA). Staff I LPN said the complaint could have gone in any direction (regarding abuse or not). During an interview on 7/11/2024 at 9:19 AM Staff K, CNA recalled the incident on 4/13/2024. Staff K, CNA stated Resident #314 told Staff I, LPN, I had hit him when providing care. Staff K, CNA continued to state the NHA had not spoken to her regarding the incident. Staff K, CNA said she only spoke to Staff E, LPN/West Unit Manager. Staff E, LPN/West Unit Manager changed my resident assignment so I was no longer caring for Resident #314. Staff K, CNA said she went back to Resident #314 and told stated, you can't say things that aren't true, you will get me in trouble. On 7/11/2024 at 9:31 AM, Staff E, LPN/West Unit Manager could not recall the incident that occurred in April 2024 involving Resident #314. Staff K, CNA was asked to join the interview with Staff E, LPN/West Unit Manager. Staff K, CNA recalled the event of Resident #314 alleging that she hit him. Staff E, LPN/West Unit Manager recalled Resident #314 hitting Staff K, CNA not Staff K, CNA hitting the resident. Staff E, LPN/West Unit Manager stated If the resident did say he was hit, we would have suspended Staff K, CNA until an investigation was completed as this would be reportable. On 7/11/2024 at 10:05 AM, the NHA stated not recalling the incident. Review of the Reportable Log dated April 2024 revealed no abuse report being completed for Resident #314. Review of the facility's policy and procedures with the subject: Abuse, Neglect, Exploitation and Misappropriation with a revision date of 11/16/2022 revealed: Policy: it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. Procedure: 7. Reporting/Response: any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident is obliged to report such information immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury to the administrator and to other officials in accordance with state law. In the absence of the executive director, the director of nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring the reporting is completed timely and appropriately to the appropriate officials in accordance with federal and state regulations, including notification of law enforcement if a reasonable suspicion of crime has occurred.

Based on observations, record review, and interview the facility failed to complete an accurate Minimum Data Set (MDS) assessment that accurately reflected the dental status for one (#21) of 48 sampled residents. Findings Included: Interview with Resident #21 on 07/08/24 at 3:38 PM revealed he has had some toothache pain recently and that the facility puts cream on it. He reported that the cream does not always work and that he has not seen a dentist. On 07/10/24 at 12:40 PM, the resident reported that he has a few teeth left and that one on the bottom has a hole and that one on top was cracked. The resident reported that other than his usual body pain he constantly has mouth pain. The resident reported that he has trouble eating and has to cut everything up small. The resident reported that his dental pain is at a level of 7 to 8 and that all staff give him a cream to rub on his teeth that does not work. The resident reported that the medication he takes for his general pain does not work for his mouth pain. Review of Resident #21's Admission Record revealed the most recent admitted was 5/28/24 with diagnoses to include Ataxia, Chronic Obstructive Pulmonary Disease and Hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Review of the dental section revealed resident was marked as having none of the above issues to include obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, and mouth or facial pain, discomfort or difficulty chewing. Review of the Social Service Progress Note dated 7/2/24 10:38 revealed Short Term resident is complaining of tooth pain, a referral has been sent to an outside provider. Review of the Social Service Progress Note dated 7/3/24 08:07 revealed the following: F/U [follow up] from dentist. Hi there, thank you for your email we are happy to see the patient. We accept cash or credit. We do not take Medicaid though. Thank You. Social Service Director (SSD) spoke with resident who expressed having no money, just cancel. This writer called leaving voice message for spouse, awaiting call back. Social Services will continue to assist. Interview on 07/10/24 at 1:15 PM with the SSD revealed the resident was not on a list for dental services. He reported that the resident had 3 teeth. The SSD reported that due to insurance concerns he scheduled an appointment for the resident at a dentist located down the road, but the resident did not go to the appointment because he would have to pay for the services. Interview on 07/11/24 at 9:33 AM with the MDS Coordinator/Licensed Practical Nurse (LPN) revealed the resident should have been coded differently as the coding was not accurate. She reported when doing the assessment, she actually takes a look at the resident's mouth and was aware of the broken teeth from the resident interview. She reported that every time the resident has an admission to the facility, the resident wants the facility to treat his dental concerns. A request was made of the facility to provide a policy related to accurate assessments. The facility did not provide the policy.

Based on observation, staff and resident interviews, and record review, the facility failed to implement care plan interventions for one (#96) of 48 sampled residents, during four of four days (7/8/2024, 7/9/2024, 7/10/2024, and 7/11/2024). Findings included: Review of Resident #96's care plan revealed: The resident has an activity of daily living (ADL) self-care performance deficit related to disease process, impaired balance and limited mobility (date initiated: 10/8/23, date revised: 3/2/24). An intervention for this area included a heel protective boot to bilateral feet while in bed. May remove for ADL care (date initiated: 5/2/2024). The resident has potential for pressure injury development related to immobility (date initiated: 1/25/2024, date revised: 3/2/24). An intervention for this area included follow facility policies/protocols for the prevention/treatment of skin breakdown (date initiated 1/25/2024). The resident has peripheral vascular disease (PVD) related to diabetes and heart disease (date initiated and revised: 10/08/2023). An intervention for this area included elevate legs when sitting or sleeping (date initiated 10/08/2023). On 7/8/2024 at 10:45 a.m., Resident #96 was observed in his room asleep in bed. Observation of the box shelf on the wall above the television revealed two large protective heel boots. Resident #96 was noted not wearing these boots on either of his feet. Both feet were under bed linen and did not appear to be propped up on any type of pillow/device and no other splints, braces, or protective footwear were present on his feet. On 7/9/2024 at 7:45 a.m., 10:00 a.m., 1:45 p.m., and 3:10 p.m. Resident #96 was observed in bed, under the bed linen. The resident's protective soft boots were observed stored on the box shelf above the television during all observations. On 7/10/2024 at 8:04 a.m., Resident #96 was observed lying in bed. Resident #96 was not wearing the soft protective foot boots on his feet. The boots were still observed in place on the box shelving just above the television. Resident #96 was non-verbal but was able to respond to yes and no questions by shaking his head. Interview with Resident #96 confirmed he was supposed to wear his soft boots on his feet when in bed and did not have them on. No staff have offered to put the boots on for him. He would wear them if offered and does not refuse to wear the boots. He indicated staff do not help him put the boots on. The resident understood that the boots were to be worn to prevent pressure sores on his feet. The resident expressed having pain in his feet at the time of the interview, and the resident gave permission for the surveyor to view his feet. Observation of Resident #96's feet revealed they were bare and positioned on the bed mattress alone with no splints, pillows, or floating devices in place. On 7/10/2024 at 8:45 a.m., 10:15 a.m., 11:45 a.m., 1:00 p.m. and 2:15 p.m., Resident #96 was in bed with his entire body length under the bed linen. At 2:15 p.m., Resident #96 allowed this surveyor to lift the sheets from his feet to make an observation. He was again observed not wearing any socks and both feet had no boots, pillows, or other devices to prop his feet on. Resident #96 confirmed he had not had any help putting his boots on today. He was asked if anyone attempted to assist him with the boots or offered the boots, and he shook his head in a no manner. Each observed time listed, the soft assistive heel boots were still on the wall shelf placed above the television and appeared to be undisturbed from the first observation made on 7/8/2024. On 7/11/2024 at 7:28 a.m., the resident could be seen in bed with the bed linen pulled up to his neck. Further observations revealed he was not wearing either of his soft protective boots while in bed. The boots were observed in the shelf area, directly on the wall above the television. On 7/11/2024 at 7:30 a.m., Staff I, Licensed Practical Nurse (LPN) said she was going to hang the resident's tube feeding and find out about the boots. On 7/11/2024 at 8:30 a.m., Resident #96 was observed in bed with his eyes open. The resident was wearing both protective heel boots. The resident expressed that staff assisted with placement of the boots. On 7/11/2024 at 9:45 a.m. an interview with Staff C, Certified Nursing Assistant (CNA) revealed she was a floating CNA but had the resident on her assignment many times before. She revealed that she provides activities of daily living (ADL) care, while he was usually receiving his tube feeding supplement. Staff C was asked if the resident utilized any splints or positioning devices and she revealed that he did not. She was asked if he wore any soft positioning boots and then she remembered that he did. Staff C revealed that it was usually direct care staff's responsibility as well as the restorative nurse to place the boots on when he was in bed. She did confirm at the beginning of the shift the boots were not on and that they were now. Staff C said Resident #96 had refused or taken the boots off and threw them on the floor in the past. She revealed if that happens during her shift, she reported it to the nurse. Staff C was unsure if the resident was care planned for behaviors of taking off or refusing use of the boots. On 7/11/2024 at 10:00 a.m., an interview with Staff D, LPN/Restorative Nurse revealed she was familiar with the resident. She verbalized Resident #96's orders for exercises and use of weights for range of motion (ROM) exercises and also confirmed he uses soft protective boots to wear at all times when he is in bed. She revealed it was the responsibility of all direct care staff to put the boots on, and not just restorative nursing staff. Staff D confirmed she put the boots on herself at around 8:15 a.m. today as he was not wearing them. Staff D confirmed she would have expected the boots would have been put on already, as he was in bed. She was not aware the boots had not been on the previous three days when observed in the bed. She revealed staff should know but there was no indication in the CNA Kardex plan of care documentation of when to place the boots on. She also revealed that Resident #96 had at times refused, but she could not verify this though documentation. Staff D revealed she would need to talk to the nurse and care planning team each time he refused, in order for the team to come up with other interventions in order to make sure the boots are placed on while he was in bed. On 7/11/2024 at 10:20 a.m. an interview with Staff E, [NAME] Unit Manager confirmed Resident #96 utilized protective soft boots when in bed. She was unaware the boots were not offered and put on when observations were made on 7/8/2024, 7/9/2024, and 7/10/2024. She also revealed it was the direct care staff's responsibility to put the boots on when he is in bed. Staff E revealed that the boots were sometimes refused by the resident, but there was no documentation to support that. Review of the current Physician's Order Sheet dated July 2024 revealed an order for protective boots to bilateral feet while in bed. May remove for ADL care each shift (original order date 5/2/2024). Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2024 revealed: protective boots to bilateral feet while in bed. May remove for ADL care every shift. (Start date 5/2/2024) - MAR/TAR documented for all ten days in July the resident had the protective boots on during the day and evening. Review of the quarterly Minimum Data Set (MDS) assessment, dated 6/4/2024, revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired cognition, The resident was not documented as having any mood or behavior problems, and was marked as a yes for risk of pressure injury. Review of the nurse progress notes from 5/1/2024 - 7/11/2024 did not reveal any documentation indicating Resident #96 had ever refused or had a history of refusing to wear the protective boots while in bed. There were no notes that mentioned use of boots at all during this same timeframe reviewed. It was noted the current care plans did not have any problem areas, goals and interventions that reflect any type of behaviors of removing, resisting, or refusing the use of protective soft assistive boots prior to discussing with facility staff on 7/11/2024. Photographic evidence was obtained of the boots on the shelf.

Based on observations, review of medical records, facility policies, interviews with facility staff, agency nursing staff, the Medical Director, and Advanced Registered Nurse Practitioners, the facility failed to provide supervision and services to prevent an unwitnessed exit from the facility for one resident (#1) of two residents sampled for high-risk of elopement. The facility failed to ensure frequent monitoring was provided for a resident known to wander, and failed to address frequent alarming of exit doors, resulting in the resident leaving the facility without staff intervention and failed to follow elopement policy and procedures by not doing an immediate head count following the incident. Resident #1 was cognitively impaired and was known to facility staff to wander throughout the facility at nighttime. On [DATE] at approximately 9:15 p.m. the resident self-propelled in a wheelchair exiting the facility through an alarmed exit. Resident #1 had been assessed at risk for wandering and wore an electronic monitoring device. The resident left the building without staff knowing. The resident set off an alarm with his electronic monitoring device as he approached the West exit door. Resident #1 proceeded to the West exit door and pushed on the egress release bar for 15 seconds which set off a second alarm connected to the fire system and proceeded to exit the facility. Both alarms were loud enough to be heard at both the East and West nurses' stations. The staff did not respond to either alarm. Resident #1 propelled himself in his wheelchair outside the West exit door in the dark, approximately 42-feet from the West exit door. Resident #1's wheelchair could not navigate the uneven pavement transition, causing him to fall to the ground. The resident suffered injuries to his right elbow and was transferred to the hospital for evaluation. Resident #1 was at risk of propelling his wheelchair into a six-lane traffic road, putting him at risk of being struck by a vehicle and suffering serious injury or death. Staff L, Licensed Practical Nurse (LPN), who found Resident #1, stated the resident was found outside at the back of the building, near the service receiving area. The resident was found face down on the pavement in the parking lot with his wheelchair tipped to the side. Resident #1 suffered injuries to his elbow and was observed to be bleeding and was transferred out for acute care. Due to the facility staff's failure to respond to the alarms in a timely manner and provide supervision, Resident #1 and other residents with cognitive impairment and the ability to ambulate or self-propel were at risk for serious injury that could have resulted in death. Resident #1 self-propelled in his wheelchair approximately 42 feet from the building. The resident and other impaired residents had the likelihood to ambulate or self-propel a short distance through an ungated driveway leading to a six-lane traffic road. This failure created a situation that resulted in injury with likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 4:39 p.m. and the severity and scope was reduced to a D. Findings included: A telephone interview was conducted with Staff G, LPN agency on [DATE] at 12:45 p.m. She confirmed she worked the night Resident #1 left the facility unsupervised. Staff G said, It was my second time working at this facility. Another agency nurse and I were assigned to hall 200 where Resident #1 resided. The alarm went off around 8:00 p.m., not sure the exact time. I was in another patient's room and after finishing what I was doing, another aide and I went outside searched perimeters, checked the door in front of the West nurses' station and also around the corner and did not see anyone. I thought someone was going out to smoke and set off the alarm. I don't know the Certified Nursing Assistant's (CNA's) name. After a few minutes, the CNA called out and said she saw him [Resident #1] on the ground behind the concrete partition. Staff G stated she saw an elderly gentleman on the ground. Staff G stated she was not assigned to him. He was assigned to the other nurse (Staff L, LPN), who was on break. Staff G said, When I went outside, he [Resident #1] was lying on the ground in a prone position, face down, wheelchair turned over, his elbow was bleeding. I assessed him and called 911 on my cell phone. Staff G said, At the time, the resident was telling us to get him up . I told him to wait for EMS (emergency medical service). EMS arrived and took him to the hospital. Staff G stated she did not know the resident's history or if he wandered. Staff G stated the alarm kept going and no one knew the location of the alarm or how to silence it. A nurse on the other side said she would call the administration because apparently there was a key. She stated she had not been part of any training and did not know the resident was at risk for wandering. The LPN stated she did not know this facility's elopement process but knew mostly all nursing homes keep a book at the desk. Staff G stated the alarm went off for quite a while, longer than 15 minutes. She stated the Director of Nursing (DON) came in that night and she (Staff G)provided a statement. A telephone interview was conducted on [DATE] at 3:48 p.m. with Staff H, CNA. Staff H stated she was an agency CNA at the time of the incident but is now a facility staff. Staff H stated the day the resident eloped she was working the 3:00 p.m. to 11:00 p.m. shift in the West wing. The CNA stated they had a problem between 9:00 p.m. and 10:00 p.m. She heard the alarm going off when she was assisting a resident. The CNA stated the unit nurse was giving medications. Staff H said, I had come out of a room around 9:25 p.m. and went out to the nurses' unit and the alarm was still beeping. I am new to the facility, about 3 weeks. I did not know what to do. The CNA stated the alarm kept going off and she did not know how long. The other CNAs were in the rooms assisting other residents. Staff H said, Finally, the nurse came and said to go to the West exit door and check. I came back and I told the nurse the door to the breakroom/kitchen area was slightly open and another CNA was outside smoking. Staff H stated she did not see [Resident #1] outside the West exit door. On [DATE] at 4:36 p.m., another interview was conducted with Staff H, CNA. Staff H stated the alarm went off sometime between 9:00 p.m. and 10:00 p.m. The CNA stated she was in a resident's room with another CNA [Staff N] when the alarm started beeping. Staff H stated when she left the room she walked towards the West nurses' station and a nurse [Staff G] and another nurse, she does not know, were sitting at the nurses' station. The alarm was still going off. Staff H stated the nurse asked her to look in the back, the West exit door. Staff H went to the West exit door. The West exit door was not open, but the breakroom/kitchen door was open. The breakroom/kitchen door opens to the staff breakroom and leads to another exterior door. Staff H stated the breakroom/kitchen door is also alarmed. Staff H stated there was a nurse and a CNA out the door. Staff H stated the alarm was still beeping and no one knew why it was going off, or how to silence it. The CNA said, The alarm went off for more than 15 minutes. We needed the key to shut it down, but we didn't have it. The DON had to come from home to silence the alarm. Staff H stated when she walked outside, she saw the nurse (Staff L) with the resident. Staff H said, I saw the resident on the ground his wheelchair on the side of him, tipped over. The resident was bleeding on his arm. The nurse told the Resident to remain seated as she called 911. Staff H stated after the incident, the DON asked her to write down what happened. The CNA stated she was trained to respond to alarms and participated in elopement training after the incident. An interview was conducted on [DATE] at 2:36 p.m. with Staff M, CNA agency. Staff M stated she was familiar with Resident #1 and was the assigned CNA the evening of [DATE], when the elopement incident occurred. The CNA stated Resident #1 normally sleeps all day and would be up in the evening. The CNA reported when the resident is out of bed, he will wheel himself around the facility and will verbally tell staff I'm going around the circle. The CNA stated on the evening of [DATE] at 8:30 p.m., the resident was up, and she provided toileting care. Staff M reported at approximately 8:45 p.m., another staff [Staff N] asked her to help provide care to another resident. They both went into the other resident's room. While providing care, both staff could hear an alarm going off but were unaware as to what alarm was sounding. Staff M stated they were in the room approximately 5 minutes. Staff M reported at the time of exiting the room, two nurses and two aides were at the nurses' station, and she questioned why the alarm was going off and no one was aware why. Staff M stated she and Staff N started checking to see what door was on alarm. Staff M reported she went left, and Staff N went right. Staff M stated when she circled around her area and went out the West exit door, she saw Staff N and a nurse [Staff L] with Resident #1 who was on his side, his wheelchair tipped to the side and was being assessed by the nurse. Staff M said, Prior to this incident, I had heard the alarm go off, many times. It would start alarming and then stop . not sure why. Staff M reported prior to the elopement she knew Resident #1 would wander but was not aware that he was an elopement risk. The CNA stated after the elopement is when she started hearing more about the resident's wandering risk. On [DATE] at 10:15 a.m., an interview was conducted with Staff I, Registered Nurse (RN). Staff I was currently assigned to Resident #1. Staff I stated she was not working the day Resident #1 left the facility unsupervised. She heard on [DATE] the resident got out through one of the West exit doors and went outside. Staff I stated she has worked with the resident for a long time, he never said he wanted to leave, but he wanders around the building all the time. Staff I said, [Resident #1] has dementia and is confused. He normally will push the door sometimes, but very rarely does he set off the alarm. He kind of touches it and we redirect him. The RN stated she does not know if he had the electronic monitoring device on the day he left. The RN stated if a resident has the electronic monitoring device on, the door will not open. On [DATE] at 10:09 a.m. Resident #1 was observed in his room. Resident #1 was sleeping and did not respond to the interview. An electronic monitoring device was observed on his right ankle. An interview was conducted with Staff J, Personal Care Attendant (PCA). The PCA was providing 1:1 supervision (one staff assigned to one resident). The PCA stated they have been staying with the resident since he left the facility and are providing 15-minute checks. The PCA stated the resident sleeps almost all day, but he wanders all night. The PCA stated this is his typical routine. The PCA stated this resident is known to wander all over the facility, he is very confused, and he has dementia. The PCA stated the resident is not alert and would not recall what happened. Review of Resident #1's medical record showed Resident #1 is an [AGE] year-old male who was readmitted to the facility on [DATE], originally admitted on [DATE]. Resident #1 was admitted with diagnoses to include metabolic [CONDITION(S)], altered mental status, muscle weakness, hypertensive heart and [CONDITION(S)], [CONDITION(S)] disorder [CONDITION(S)] type, Type 2 diabetes mellitus, chronic obstruction pulmonary disease, [CONDITION(S)], muscle wasting with atrophy, difficulty in walking, [CONDITION(S)] heart disease and mild cognitive impairment of uncertain or unknown etiology. A Quarterly Minimum Data Set (MDS) assessment for Resident #1, dated [DATE], showed the resident's Brief Interview for Mental Status (BIMS) was left blank, resident was unable to complete the interview. The MDS further showed Resident #1 had memory problems and was moderately impaired. Section G, Functional Status, showed the resident is dependent for transfers and bed mobility, and required extensive assistance. Section G0300 balance during transitions and walking, showed the resident was not steady, only able to stabilize with staff assistance. During an interview with the Director of Rehabilitation (DOR) on [DATE] at 3:40 p.m., the DOR stated she has worked with Resident #1 several times. She stated the last time was from [DATE] to [DATE] for Physical Therapy (PT), Occupational therapy (OT), and Speech Therapy (ST). She stated the resident was picked up during a quarterly review due to declines he had shown. The DOR stated the resident gets along in his wheelchair well and would go up and down the hallways. The DOR stated Resident #1 could only stand up or walk with assistance. The DOR stated the resident was only at wheelchair level, and he was not going to be given a walker and due to his cognition. The DOR said, It would not be safe for him to have a walker and he is definitely not safe to ambulate outside. A document titled, Change in Condition SBAR [situation background assessment recommendation], dated [DATE] at 9:15 p.m., revealed, resident observed on ground lying on rt (right) side, wheelchair flip over. The documented showed interventions included to call 911, notify family and primary care physician. Review of hospital medical records for Resident #1 revealed an Emergency Department (ED) discharge information triage note, dated [DATE] at 10:28 p.m., which included: Patient is an [AGE] year-old male with a history of dementia who presents by EMS (emergency services) from the facility for chief complaint of fall. Patient was found on the ground outside after he reportedly attempted to run away from the facility. Per chart review patient ambulates with a wheelchair at baseline. Patient was found near his wheelchair. History and review of systems limited due to patient's history of dementia. Neurological evaluation showed confused, minimal insight into current situation/today's events. Completed radiology imaging studies showed: XR Elbow 3V RT [auth (verified)] [DATE] at 08:05 a.m., Final impression: No evidence of acute osseous (bone) injury. Dorsal elbow tissue injury. Hip impression: cortical lucency suggesting fracture of the right acetabulum extending to the ramus. On [DATE] at 2:38 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she received a phone call at 10:00 p.m. because one of the alarms was going off and the staff could not find the key to reset it. The DON stated she entered the building through the East entrance and immediately proceeded to try and figure out which door was alarming. The DON stated it was at this moment she found out that a resident got out unsupervised. The DON stated she spoke to the nurse who was assigned and asked why she was not notified. The nurse stated she was busy because she had to send the resident to the hospital following an injury from a fall. The DON said, They did not call me. The alarm was still going on . after I disabled it, I checked outside, and I did not see anyone. I asked can someone tell me what happened? . I should have received the call. I asked if we had completed a headcount for everybody . they did not say yes, no one answered, so I figured they had not. The DON stated she completed a head account, and all residents were accounted for except [Resident #1] who had been sent out. The DON stated she asked how the resident got out and staff said he held the bar to the fire door and wheeled himself out. The DON stated it was unclear how long Resident #1 was outside. The DON stated Staff L, LPN was leaving as the alarm was going off and found the resident outside on the ground. The DON stated the resident was found at approximately 9:20 p.m. and he had his electronic monitoring device on. The DON stated if a resident with an electronic monitoring device gets close to a door with an electronic monitoring device box, it sets off the alarm then locks the door. If the fire door egress bar is held greater than 15 seconds, it cancels the electronic monitoring device system and unlocks the door. The DON stated what went wrong was that no one responded to the alarm in a timely manner. The DON stated they had too many new agency staff working that night. The agency staff did not know what to do. The DON stated the resident typically roams and everyone knows that. The DON confirmed it was not the first time the resident had pushed an egress bar on the exit door, but this time he pushed long enough. The DON stated Resident #1 prefers to sleep during the day but is awake at night. The DON stated she conducted an investigation and initiated in-services. The DON educated them on how to respond to an alarm, to make sure they notify administration. Review of progress notes for Resident #1 showed: [DATE] Resident tried to exit building, door alarm sounded, and resident was redirected. [DATE] Resident is a wander risk. Continue POC (plan of care) [DATE] Resident is a wander risk. Continue POC. [DATE] Family notified Resident #1 attempted to leave the facility [Family member #1] called back to the facility and was informed of [Resident#1] attempting to leave the facility and getting out the door before overturning his wheelchair. [DATE] Spoke to [Family member #2] and told him of [Resident #1's] actions last night. Let him know the resident was wandering. [Family member #2] said he was aware of that behavior. [DATE] Skin assessments completed. The resident has skin tear to right elbow and generalized discoloration on right hand and arm. Resident denies pain verbally and shows no facial grimaces, wound care in place for skin tear. Review of a document titled, Elopement Risk Evaluation, dated [DATE], signed by Staff R, LPN, showed Resident #1 was assessed as not at risk for elopement. Question #3 showed the resident has poor decision making. Question #4 showed the resident has not demonstrated exit seeking behaviors. Question #5 showed the resident does not wander. Question #6 showed the resident does not have a history of elopement. Review of a document titled, Elopement Risk Evaluation, dated [DATE] and signed by the DON, showed Resident #1 was assessed at risk for elopement. The assessment showed the resident was cognitively impaired. Question #3 showed the resident has poor decision making. Question #4 showed the resident has demonstrated exit seeking behaviors. Question #5 showed the resident does wander, oblivious to safety needs. Question #6 showed the resident has a history of elopement. An interview was conducted on [DATE] at 10:32 a.m. with the [NAME] President of Clinical Services (VPCS) related to the computer view of the elopement assessments which showed Resident #1 scored a 0 on [DATE] and a 4 on [DATE]. The VPCS stated the highest score on their elopement risk assessments is a 4 and anyone scoring above a 0 is considered at risk. The VPCS stated if the answer to questions 4, 5 and 6 is a Yes, the resident is automatically considered at risk. The VPCS stated she would review the care plan and see why the assessment on [DATE] showed the resident was not at risk. The VPCS said, It would probably be an error. Review of a care plan, initiated on [DATE], revealed a Focus showing Resident #1 is an elopement risk r/t (related to) dementia, wanders into other's rooms, impaired safety awareness. The goal showed the resident will not leave the facility unattended through the next review date. The interventions were to assess the resident for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books, electronic monitoring device and on [DATE] 1:1 monitoring was initiated. Review of a psychiatry (psych) note dated [DATE] showed on [DATE], the patient was seen today via telehealth as staff reports he had an episode of elopement last night; the patient left the facility in his wheelchair . He was sent to the hospital to ensure no injuries were caused . The patient has advanced dementia, he was unable to recall the incident. The staff has however, instituted interventions to ensure the patient's continued safety. The patient's Primary Care Physician (PCP) has him currently taking [MEDICATION(S)] during the morning and he is staying asleep during the morning and is up during the night. The recommendation for today's visit is to change [MEDICATION(S)] to at night to help improve his sleep schedule. The psych note dated [DATE] further showed, Patient being seen for a follow-up visit. Current medications include [MEDICATION(S)] 6 mg (milligram) every HS (hours of sleep) and [MEDICATION(S)] ([MEDICATION(S)]) oral tablet 15 mg QD (daily). Patient is at high risk for elopement, the last incident occurred in the early morning of [DATE]. Patient was found outside the facility by a staff member and sent to the hospital for an evaluation. Found to have a skin tear due to a fall outside the building. He is currently on 1:1. Patient is severely confused, wanders at night, and would benefit from a secure environment due to a history of multiple elopements in the past. Assessment plan: as per collected information, it appears the patient is unstable and is a candidate for a facility with a locked-down unit. All current psych medications were continued. Continue with 1:1 until patient is transferred out to a secure environment. Will continue monitoring for response/potential adverse reactions. Staff to monitor, document and report behaviors. A telephone interview was conducted on [DATE] at 10:47 a.m. with the Advanced Registered Nurse Practitioner (ARNP-1). The ARNP-1 stated she saw Resident #1 on [DATE] to conduct a follow-up to a telehealth visit conducted [DATE]. The ARNP-1 stated the reason for the visit was the patient eloped the night prior. It was recommended he be placed on 1:1 supervision, which he was. The ARNP-1 stated at the time of the visit the resident was very confused was not able to communicate. She stated she spoke to the sitter and the nurse assigned to him. They stated he stays in bed during the day and wanders all night. The ARNP-1 stated the plan of care is to keep him on a 1:1 until he is transferred to a secured unit. She stated based on interviews with staff, she became aware the resident had prior elopement attempts. The ARNP-1 stated the day she conducted the assessment, Resident #1 was awake, laid in bed but could not engage in a conversation due to confusion. She stated he is on [MEDICATION(S)] and [MEDICATION(S)]. The ARNP-1 stated she did not know he was taking [MEDICATION(S)] ([MEDICATION(S)]) during the day. Typically, it is given at night. She stated it should definitely be given at night. The ARNP-1 stated the fact that he takes the sleeping medication in the morning contributed to his wandering in the evenings. The ARNP-1 stated she would follow-up. On [DATE] at 10:57 a.m., a telephone interview was conducted with the ARNP-2. The ARNP-2 stated she sees Resident #1 regularly for psych. The ARNP-2 stated she saw the resident on [DATE] via tele health. She stated she conducted the assessment because he flipped his wheelchair and was sent to the hospital. The ARNP-2 stated the resident had wandered to the door and he got out without staff stopping him. She stated she was not sure he had a history of elopement. The ARNP-2 reviewed Resident's #1's record and on [DATE] at 11:30 a.m. confirmed they have been seeing him [Resident #1] since March of 2020. The ARNP-2 said, On [DATE]th he got close to the door, and they redirected him inside. I was not aware of any other attempts. On [DATE]th, I saw him for inappropriate behaviors with a female and he was placed on 1:1. This resident has a [CONDITION(S)] disorder and takes [MEDICATION(S)]. The facility put an electronic monitoring device on him on [DATE]th because he was wandering all night. The ARNP-2 stated they had recommended the [MEDICATION(S)] be changed to nighttime to help the resident sleep. On [DATE] at 12:55 p.m. an interview was conducted with the Assistant Director of Nursing (ADON), Registered Nurse (RN). The ADON stated he received a call late at night, sometime around 9 p.m. The staff said they could not find the key to the alarm. The ADON stated the caller did not report a resident was missing at the time. The ADON stated he redirected the caller to contact the DON. The ADON stated later the same night he received a call from the DON to come in and provide elopement in-services. The ADON stated he has known Resident #1 for about a year. The ADON said, The resident is about the same, very confused and he is a nighttime wanderer. He goes around the entire facility at night. Psych sees him. The ADON stated the family had reported he used to work nights and has always slept all day. The ADON stated Resident #1 had not attempted to leave the building prior to this incident. The ADON said, He always says he wanted to catch the bus and join his parents, but his parents are deceased . The ADON stated the resident ambulates in his wheelchair and roams about freely. The ADON stated they have educated all staff since the incident and have conducted multiple drills. The ADON stated they have an orientation packet for agency staff. The ADON said, When they come in, we give them a tour of the unit, review standards of policy, responding to elopement and they complete a post elopement test. The ADON stated he could not confirm the education was happening prior to the incident, but for sure now they are. On [DATE] at 4:04 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA stated they initiated the investigation that night. The NHA stated the challenge with the investigation was that she was not able to reach the staff that worked with Resident #1 that night because they were all agency staff. The NHA stated the DON called her around 9:00 p.m. and was told Resident #1 got out of the building and was sent to the hospital following injuries of abrasion to his right elbow. The NHA stated she arrived at the facility around 10:45 p.m., and everyone had dispersed. The NHA stated the DON had already gathered statements and had done head counts. The NHA stated she called maintenance, and he came in and checked all doors and made sure they were functioning. She stated they started education with all the staff and filed the report. She stated Resident #1 returned to the facility approximately 4:30 a.m. and was put on 1:1 supervision. The NHA stated Staff G, the LPN agency who was assigned to Resident #1 was new to the facility and it was her first time. The NHA stated in her statement, she [Staff G] was passing medications when the alarm went off and she reported she did not stop administering the medications and, in her statement, Staff G confirmed she did not stop what she was doing to respond to the alarm. She had reported being busy. The DON said, She [Staff G] should have stopped and responded to the emergency. The DON stated she obtained a statement from Staff M, agency CNA who was assigned to Resident #1. In her statement, Staff M saw the resident in the day room [a resident lounge area outside West nurses' station], around 8 p.m. When the alarm sounded, she and another CNA (Staff N, CNA agency) were in the middle of changing another resident. They stated they waited until they finished assisting that resident. They did not say what time it was, or how long it took them. The DON said, there was no one in the nurses' station area at the time [Resident #1] propelled to the West exit door. They were all in the resident rooms. No one saw him leaving, but they all heard the alarm. [Staff M's] statement reported after providing care, she and [Staff N]asked the nurse [Staff G] what was going on. Everyone started looking for the reason for the alarm. Staff N, CNA agency walked out the back door and said she found the resident. The NHA stated statements collected at the time of the incident revealed, Staff M, CNA was heading to the alarm area (West exit door) as Staff N was going out to smoke. Staff N heard Staff L, LPN, say [Resident #1]is out there, at that time, Staff G had stopped administering medications and went to assess the resident. (Staff P, LPN agency) was also out there as she was heading to break. Both nurses, Staff P and Staff G assessed the resident. Staff G's statement revealed the resident had a skin tear to his elbow. Staff G called 911. EMS arrived at approximately 9:30 p.m. and transferred the resident out. The NHA said, I did not interview staff on the East side, they were all agency, yes, they heard the alarm, but they did not go and see why the alarm was going off. They should have helped. The NHA stated [Staff L's] statement read, At around 9:21 p.m., I heard the facility alarm, searched out exit door, found resident at the back door in baseline condition, resident was sitting on the ground legs crossed. I stayed with resident until 911 came. The DON stated they established Resident #1 was last seen approximately 8:30 p.m. at the West nurses' station. He was found on the ground behind the building at 9:21p.m. The DON stated they could not clearly state how long the resident was unaccounted for. The DON said, no one stated what time he went missing, how long the alarm was going off, or how long it took them to find him. The NHA stated she did not try to establish a timeline at the time. On [DATE] at 11:03 a.m., an interview was conducted with the facility's Medical Director (MD). The MD said, The facility called me the day it happened and said the resident pushed the door and set off the alarm and he left the building. They reported he fell and was sent out with minor injuries. The MD stated the resident was not his patient. The MD said, I would not have a reason to see him. He has a doctor who follows him. The MD stated the facility reported the incident. On [DATE] at 11:45 a.m., an interview was conducted with the ADON. The ADON stated he documented the progress note on [DATE] when Resident #1 wandered to the exit door. The ADON said, I was here when he got to the door , he had an electronic monitoring device, it sounded the alarm and he was redirected , he ended up going to bed, I called [family member] and the physician. I think I conducted an elopement assessment at that time. He was at risk and was care planned for elopement. He came in with [an electronic monitoring device system]. The ADON stated he made a psych referral. The ADON stated the resident was a nighttime worker, sleeps during the day and roams at night. The ADON stated the resident appears drugged during the day and wanders all night. Review of Resident #1's care plan with the ADON showed it did not address staying awake at night or show interventions on how to address the resident's active wandering at night. The ADON stated he wanders aimlessly because there are no activities. The ADON stated the resident should be care planned for staying awake at night and how to engage him. An interview was conducted on [DATE] at 1:17 p.m. with Staff B, LPN, MDS. Staff B stated she is responsible for part of the care plan process. Staff B confirmed a resident who wanders all night should be properly care planned. Staff B reviewed the psychosocial goal and activity's goal in the care plan and stated she did not see a plan to engage the resident with activities or address the resident's nighttime wandering. Staff B stated they should consider care planning the resident for activities at night to help distract him since he is awake anyway. Staff B stated they should put something in place to make sure someone knows where he is at because he wanders into other resident's rooms not just exit seeking. Review of Resident #1's current physician orders dated [DATE] to [DATE] showed: Resident is on 1:1 every shift for wandering/elopement, start date [DATE]. Check electronic monitoring device on right

Based on observations, review of medical records, facility policies, interviews with facility staff, agency nursing staff, the Medical Director, and Advanced Registered Nurse Practitioners, the facility failed to ensure nursing staff received adequate orientation and training to ensure competency in providing supervision to prevent an unwitnessed exit from the facility for one resident (#1) of two residents sampled for high-risk elopement. The facility failed to ensure agency staff were oriented and trained to the facility's alarm response protocols and failed to ensure staff provided an accurate assessment of Resident #1. The facility failed to ensure staff provided frequent monitoring for a resident known to wander, resulting in the resident leaving the facility without staff intervention. The facility staff failed to provide supervision and services to prevent an unwitnessed exit from the facility for Resident #1. The facility staff failed to follow the elopement policy and procedures by not doing an immediate head count following the incident. Resident #1 was cognitively impaired and was known to facility staff to wander throughout the facility at nighttime. On [DATE] at approximately 9:15 p.m. the resident self-propelled in a wheelchair exiting the facility through an alarmed exit. Resident #1 had been assessed at risk for wandering and was wearing an electronic monitoring device. The resident left the building without staff knowing. The resident set off an alarm with his electronic monitoring device as he approached the West exit door. Resident #1 proceeded to the West exit door and pushed on the egress release bar for 15 seconds which set off a second alarm connected to the fire system and proceeded to exit the facility. Both alarms were loud enough to be heard at both the East and West nurses' stations. The staff did not respond to either alarm. Resident #1 was able to propel himself in his wheelchair approximately 42-feet outside the West exit door in the dark. Resident #1's wheelchair could not navigate the uneven pavement transition, causing him to fall to the ground. The resident suffered injuries to his right elbow and was transferred to the hospital for evaluation. Resident #1 was at risk of propelling his wheelchair into a six-lane traffic road, putting him at risk of being struck by a vehicle and suffering serious injury or death. Due to the facility staff's failure to respond to the alarms in a timely manner and provide supervision, Resident #1 and other residents with cognitive impairment and the ability to ambulate or self-propel were at risk for serious injury that could have resulted in death. The resident and other impaired residents had the likelihood to ambulate or self-propel a short distance through an ungated driveway leading to a six-lane traffic road. This failure created a situation that resulted in injury with likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 4:39 p.m. and the severity and scope was reduced to a D. Findings included: Review of a facility document titled, Facility Assessment, revised [DATE], showed a facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. 1. Once a year and as needed, a designated team conducts a facility wide assessment to ensure that the resources are available to meet the specific needs of our residents. 4. The facility assessment also includes a detailed review of resources available to meet the needs of the resident population. this part of the assessment includes: all personnel including directors, managers, regular employees full and part time, contracted staff full and part time and volunteers. f. A breakdown of the training, licensure, education, skill level and measures of competency for all personnel. 6. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident's population and helps to determine budgeting staffing training and supplies needed. A telephone interview was conducted with Staff G, LPN agency on [DATE] at 12:45 p.m. She confirmed she worked the night Resident #1 left the facility unsupervised. Staff G said, It was my second time working at this facility. Another agency nurse and I were assigned to hall 200 where Resident #1 resided. The alarm went off around 8:00 p.m., not sure the exact time. I was in another patient's room and after finishing what I was doing, another aide and I went outside searched perimeters, checked the door in front of the West nurses' station and also around the corner and did not see anyone. I thought someone was going out to smoke and set off the alarm. I don't know the Certified Nursing Assistant's (CNA's) name. After a few minutes, the CNA called out and said she saw him [Resident #1] on the ground behind the concrete partition. Staff G stated she saw an elderly gentleman on the ground. Staff G stated she was not assigned to him. He was assigned to the other nurse (Staff L, LPN), who was on break. Staff G said, When I went outside, he [Resident #1] was lying on the ground in a prone position, face down, wheelchair turned over, his elbow was bleeding. I assessed him and called 911 on my cell phone. Staff G said, At the time, the resident was telling us to get him up . I told him to wait for EMS (emergency medical service). EMS arrived and took him to the hospital. Staff G stated she did not know the resident's history or if he wandered. Staff G stated the alarm kept going and no one knew the location of the alarm or how to silence it. A nurse on the other side said she would call the administration because apparently there was a key. She stated she had not been part of any training and did not know the resident was at risk for wandering. The LPN stated she did not know this facility's elopement process but knew mostly all nursing homes keep a book at the desk. Staff G stated the alarm went off for quite a while, longer than 15 minutes. She stated the Director of Nursing (DON) came in that night and she (Staff G)provided a statement. A telephone interview was conducted on [DATE] at 3:48 p.m. with Staff H, CNA. Staff H stated she was an agency CNA at the time of the incident but is now a facility staff. Staff H stated the day the resident eloped she was working the 3:00 p.m. to 11:00 p.m. shift in the West wing. The CNA stated they had a problem between 9:00 p.m. and 10:00 p.m. She heard the alarm going off when she was assisting a resident. The CNA stated the unit nurse was giving medications. Staff H said, I had come out of a room around 9:25 p.m. and went out to the nurses' unit and the alarm was still beeping. I am new to the facility, about 3 weeks. I did not know what to do. The CNA stated the alarm kept going off and she did not know how long. The other CNAs were in the rooms assisting other residents. Staff H said, Finally, the nurse came and said to go to the West exit door and check. I came back and I told the nurse the door to the breakroom/kitchen area was slightly open and another CNA was outside smoking. Staff H stated she did not see [Resident #1] outside the West exit door. On [DATE] at 4:36 p.m., another interview was conducted with Staff H, CNA. Staff H stated the alarm went off sometime between 9:00 p.m. and 10:00 p.m. The CNA stated she was in a resident's room with another CNA [Staff N] when the alarm started beeping. Staff H stated when she left the room she walked towards the West nurses' station and a nurse [Staff G] and another nurse, she does not know, were sitting at the nurses' station. The alarm was still going off. Staff H stated the nurse asked her to look in the back, the West exit door. Staff H went to the West exit door. The West exit door was not open, but the breakroom/kitchen door was open. The breakroom/kitchen door opens to the staff breakroom and leads to another exterior door. Staff H stated the breakroom/kitchen door is also alarmed. Staff H stated there was a nurse and a CNA out the door. Staff H stated the alarm was still beeping and no one knew why it was going off, or how to silence it. The CNA said, The alarm went off for more than 15 minutes. We needed the key to shut it down, but we didn't have it. The DON had to come from home to silence the alarm. Staff H stated when she walked outside, she saw the nurse (Staff L) with the resident. Staff H said, I saw the resident on the ground his wheelchair on the side of him, tipped over. The resident was bleeding on his arm. The nurse told the Resident to remain seated as she called 911. Staff H stated after the incident, the DON asked her to write down what happened. The CNA stated she was trained to respond to alarms and participated in elopement training after the incident. An interview was conducted on [DATE] at 2:36 p.m. with Staff M, CNA agency. Staff M stated she was familiar with Resident #1 and was the assigned CNA the evening of [DATE], when the elopement incident occurred. The CNA stated Resident #1 normally sleeps all day and would be up in the evening. The CNA reported when the resident is out of bed, he will wheel himself around the facility and will verbally tell staff I'm going around the circle. The CNA stated on the evening of [DATE] at 8:30 p.m., the resident was up, and she provided toileting care. Staff M reported at approximately 8:45 p.m., another staff [Staff N] asked her to help provide care to another resident. They both went into the other resident's room. While providing care, both staff could hear an alarm going off but were unaware as to what alarm was sounding. Staff M stated they were in the room approximately 5 minutes. Staff M reported at the time of exiting the room, two nurses and two aides were at the nurses' station, and she questioned why the alarm was going off and no one was aware why. Staff M stated she and Staff N started checking to see what door was on alarm. Staff M reported she went left, and Staff N went right. Staff M stated when she circled around her area and went out the West exit door, she saw Staff N and a nurse [Staff L] with Resident #1 who was on his side, his wheelchair tipped to the side and was being assessed by the nurse. Staff M said, Prior to this incident, I had heard the alarm go off, many times. It would start alarming and then stop . not sure why. Staff M reported prior to the elopement she knew Resident #1 would wander but was not aware that he was an elopement risk. The CNA stated after the elopement is when she started hearing more about the resident's wandering risk. On [DATE] at 10:15 a.m., an interview was conducted with Staff I, Registered Nurse (RN). Staff I was currently assigned to Resident #1. Staff I stated she was not working the day Resident #1 left the facility unsupervised. She heard on [DATE] the resident got out through one of the West exit doors and went outside. Staff I stated she has worked with the resident for a long time, he never said he wanted to leave, but he wanders around the building all the time. The RN said, [Resident #1] has dementia and is confused. He normally will push the door sometimes, but very rarely does he set off the alarm. He kind of touches it and we redirect him. The RN stated she does not know if he had the electronic monitoring device on the day he left. The RN stated if a resident has the electronic monitoring device on, the door will not open. On [DATE] at 11:14 a.m. an observation was conducted of the route Resident #1 took. The tour was facilitated by the Director of Maintenance (DOM). The DOM stated the resident self-propelled from his room, through the West nurses' station to the end of hall 200, then proceeded right to the West exit. The DOM stated the West exit door is alarmed with an electronic monitoring device system and a fire alarm system, meaning both alarms were sounding at the same time. The DOM demonstrated how the electronic monitoring device system alarm is set to alarm as he approached the West exit door holding an electronic monitoring device in his hand. As he approached approximately 6 feet to the exterior West exit, the electronic monitoring device set off the first alarm. The DOM proceeded to hold the egress release bar on the West exit door for 15 seconds, setting off a second alarm. Both alarms could be heard throughout the facility. Staff responded to the testing. The DOM stated that is how it sounded the night the resident left the facility. The DOM said, I do not understand why the staff did not respond that night. During the tour, an observation was made of the electronic monitoring device system keypad locked in a box. The DOM stated all the exterior doors have the same locked box, and the nurses have a key in the medication cart. The DOM stated if the alarm goes off, the annunciator [a device that provides location of the alarm] in the nurses' unit will show which location has tripped the alarm. During the tour of the outside area, an observation was made of the backdoor area where Resident #1 exited and fell . The receiving area was noted with a brick structure wall by the West exit door exit areas. The DOM stated one side is their trash receptacle area, and the other side has a picnic bench where staff take their smoke breaks. A significant decline/transition to pavement was observed during this tour, approximately 8 inches off the ground. The DOM said, The resident wheeled himself approximately 42 feet from the building before falling to the ground here, [pointing to the area where the resident fell ]. I think he lost his footing here and fell . The DOM stated if the resident would not have fallen, he probably would have gone around the building to the front. An observation was made of the parking lot and driveway area leading to the 6-lane road. During the tour, it was noted there was no gate that could have prevented Resident #1 from ambulating to the 6-lane road with a speed limit of 40 miles/hour. (Photographic Evidence Obtained). On [DATE] at 10:09 a.m. Resident #1 was observed in his room. Resident #1 was sleeping and did not respond to the interview. An electronic monitoring device was observed on his right ankle. An interview was conducted with Staff J, Personal Care Attendant (PCA). The PCA was providing 1:1 supervision (one staff assigned to one resident). The PCA stated they have been staying with the resident since he left the facility and are providing 15-minute checks. The PCA stated the resident sleeps almost all day, but he wanders all night. The PCA stated this is his typical routine. The PCA stated this resident is known to wander all over the facility, he is very confused, and he has dementia. The PCA stated the resident is not alert and would not recall what happened. Review of Resident #1's medical record showed Resident #1 is an [AGE] year-old male who was readmitted to the facility on [DATE], originally admitted on [DATE]. Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment for Resident #1, dated [DATE], showed the resident's Brief Interview for Mental Status (BIMS) was left blank, resident was unable to complete the interview. The MDS further showed Resident #1 had memory problems and was moderately impaired. Section G, Functional Status, showed the resident is dependent for transfers and bed mobility, and required extensive assistance. Section G0300 balance during transitions and walking, showed the resident was not steady, only able to stabilize with staff assistance. During an interview with the Director of Rehabilitation (DOR) on [DATE] at 3:40 p.m., the DOR stated she has worked with Resident #1 several times. She stated the last time was from [DATE] to [DATE] for Physical Therapy (PT), Occupational therapy (OT), and Speech Therapy (ST). She stated the resident was picked up during a quarterly review due to declines he had shown. The DOR stated the resident gets along in his wheelchair well and would go up and down the hallways. The DOR stated Resident #1 could only stand up or walk with assistance. The DOR stated the resident was only at wheelchair level, and he was not going to be given a walker and due to his cognition. The DOR said, It would not be safe for him to have a walker and he is definitely not safe to ambulate outside. An interview was conducted on [DATE] at 1:17 p.m. with Staff B, LPN, MDS. Staff B stated she is responsible for part of the care plan process. Staff B confirmed a resident who wanders all night should be properly care planned. Staff B reviewed the psychosocial goal and activity's goal in the care plan and stated she did not see a plan to engage the resident with activities or address the resident's nighttime wandering. Staff B stated they should consider care planning the resident for activities at night to help distract him since he is awake anyway. Staff B stated they should put something in place to make sure someone knows where he is at because he wanders into other resident's rooms not just exit seeking. On [DATE] at 2:38 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she received a phone call at 10:00 p.m. because one of the alarms was going off and the staff could not find the key to reset it. The DON stated she entered the building through the East entrance and immediately proceeded to try and figure out which door was alarming. The DON stated it was at this moment she found out that a resident got out unsupervised. The DON stated she spoke to the nurse who was assigned and asked why she was not notified. The nurse stated she was busy because she had to send the resident to the hospital following an injury from a fall. The DON said, They did not call me. The alarm was still going on . after I disabled it, I checked outside, and I did not see anyone. I asked can someone tell me what happened? . I should have received the call. I asked if we had completed a headcount for everybody . they did not say yes, no one answered, so I figured they had not. The DON stated she completed a head account, and all residents were accounted for except [Resident #1] who had been sent out. The DON stated she asked how the resident got out and staff said he held the bar to the fire door and wheeled himself out. The DON stated it was unclear how long Resident #1 was outside. The DON stated Staff L, LPN was leaving as the alarm was going off and found the resident outside on the ground. The DON stated the resident was found at approximately 9:20 p.m. and he had his electronic monitoring device on. The DON stated if a resident with an electronic monitoring device gets close to a door with an electronic monitoring device box, it sets off the alarm then locks the door. If the fire door egress bar is held greater than 15 seconds, it cancels the electronic monitoring device system and unlocks the door. The DON stated what went wrong was that no one responded to the alarm in a timely manner. The DON stated they had too many new agency staff working that night. The agency staff did not know what to do. The DON stated the resident typically roams and everyone knows that. The DON confirmed it was not the first time the resident had pushed an egress bar on the exit door, but this time he pushed long enough. The DON stated Resident #1 prefers to sleep during the day but is awake at night. The DON stated she conducted an investigation and initiated in-services. The DON educated them on how to respond to an alarm, to make sure they notify administration. On [DATE] at 4:04 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA stated they initiated the investigation that night. The NHA stated the challenge with the investigation was that she was not able to reach the staff that worked with Resident #1 that night because they were all agency staff. The NHA stated the DON called her around 9:00 p.m. and was told Resident #1 got out of the building and was sent to the hospital following injuries of abrasion to his right elbow. The NHA stated she arrived at the facility around 10:45 p.m., and everyone had dispersed. The NHA stated the DON had already gathered statements and had done head counts. The NHA stated she called maintenance, and he came in and checked all doors and made sure they were functioning. She stated they started education with all the staff and filed the report. She stated Resident #1 returned to the facility approximately 4:30 a.m. and was put on 1:1 supervision. The NHA stated Staff G, the LPN agency who was assigned to Resident #1 was new to the facility and it was her first time. The NHA stated in her statement, she [Staff G] was passing medications when the alarm went off and she reported she did not stop administering the medications and, in her statement, Staff G confirmed she did not stop what she was doing to respond to the alarm. She had reported being busy. The DON said, She [Staff G] should have stopped and responded to the emergency. The DON stated she obtained a statement from Staff M, agency CNA who was assigned to Resident #1. In her statement, Staff M saw the resident in the day room [a resident lounge area outside West nurses' station], around 8 p.m. When the alarm sounded, she and another CNA (Staff N, CNA agency) were in the middle of changing another resident. They stated they waited until they finished assisting that resident. They did not say what time it was, or how long it took them. The DON said, there was no one in the nurses' station area at the time [Resident #1] propelled to the West exit door. They were all in the resident rooms. No one saw him leaving, but they all heard the alarm. [Staff M's] statement reported after providing care, she and [Staff N]asked the nurse [Staff G] what was going on. Everyone started looking for the reason for the alarm. Staff N, CNA agency walked out the back door and said she found the resident. The NHA stated statements collected at the time of the incident revealed, Staff M, CNA was heading to the alarm area (West exit door) as Staff N was going out to smoke. Staff N heard Staff L, LPN, say [Resident #1]is out there, at that time, Staff G had stopped administering medications and went to assess the resident. (Staff P, LPN agency) was also out there as she was heading to break. Both nurses, Staff P and Staff G assessed the resident. Staff G's statement revealed the resident had a skin tear to his elbow. Staff G called 911. EMS arrived at approximately 9:30 p.m. and transferred the resident out. The NHA said, I did not interview staff on the East side, they were all agency, yes, they heard the alarm, but they did not go and see why the alarm was going off. They should have helped. The NHA stated [Staff L's] statement read, At around 9:21 p.m., I heard the facility alarm, searched out exit door, found resident at the back door in baseline condition, resident was sitting on the ground legs crossed. I stayed with resident until 911 came. The DON stated they established Resident #1 was last seen approximately 8:30 p.m. at the West nurses' station. He was found on the ground behind the building at 9:21p.m. The DON stated they could not clearly state how long the resident was unaccounted for. The DON said, no one stated what time he went missing, how long the alarm was going off, or how long it took them to find him. The NHA stated she did not try to establish a timeline at the time. Review of a document titled, Elopement Risk Evaluation, dated [DATE], signed by Staff R, LPN, showed Resident #1 was assessed as not at risk for elopement. Question #3 showed the resident has poor decision making. Question #4 showed the resident has not demonstrated exit seeking behaviors. Question #5 showed the resident does not wander. Question #6 showed the resident does not have a history of elopement. Review of a document titled, Elopement Risk Evaluation, dated [DATE] and signed by the DON, showed Resident #1 was assessed at risk for elopement. The assessment showed the resident was cognitively impaired. Question #3 showed the resident has poor decision making. Question #4 showed the resident has demonstrated exit seeking behaviors. Question #5 showed the resident does wander, oblivious to safety needs. Question #6 showed the resident has a history of elopement. An interview was conducted on [DATE] at 10:32 a.m. with the [NAME] President of Clinical Services (VPCS) related to the computer view of the elopement assessments which showed Resident #1 scored a 0 on [DATE] and a 4 on [DATE]. The VPCS stated the highest score on their elopement risk assessments is a 4 and anyone scoring above a 0 is considered at risk. The VPCS stated if the answer to questions 4, 5 and 6 is a Yes, the resident is automatically considered at risk. The VPCS stated she would review the care plan and see why the assessment on [DATE] showed the resident was not at risk. The VPCS said, It would probably be an error. Review of a care plan, initiated on [DATE], revealed a Focus showing Resident #1 is an elopement risk r/t (related to) dementia, wanders into other's rooms, impaired safety awareness. The goal showed the resident will not leave the facility unattended through the next review date. The interventions were to assess the resident for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Electronic monitoring device and a 1:1 monitoring initiated on [DATE]. Review of a psychiatry (psych) note dated [DATE] showed on [DATE], the patient was seen today via telehealth as staff reports he had an episode of elopement last night; the patient left the facility in his wheelchair . He was sent to the hospital to ensure no injuries were caused . The patient has advanced dementia, he was unable to recall the incident. The staff has however, instituted interventions to ensure the patient's continued safety. The patient's Primary Care Physician (PCP) has him currently taking [MEDICATION(S)] during the morning and he is staying asleep during the morning and is up during the night. The recommendation for today's visit is to change [MEDICATION(S)] to at night to help improve his sleep schedule. The psych note dated [DATE] further showed, Patient being seen for a follow-up visit. Current medications include [MEDICATION(S)] 6 mg (milligram) every HS (hours of sleep) and [MEDICATION(S)] ([MEDICATION(S)]) oral tablet 15 mg QD (daily). Patient is at high risk for elopement, the last incident occurred in the early morning of [DATE]. Patient was found outside the facility by a staff member and sent to the hospital for an evaluation. Found to have a skin tear due to a fall outside the building. He is currently on 1:1. Patient is severely confused, wanders at night, and would benefit from a secure environment due to a history of multiple elopements in the past. Assessment plan: as per collected information, it appears the patient is unstable and is a candidate for a facility with a locked-down unit. All current psych medications were continued. Continue with 1:1 until patient is transferred out to a secure environment. Will continue monitoring for response/potential adverse reactions. Staff to monitor, document and report behaviors. On [DATE] at 10:58 a.m. an interview was conducted with Staff R, LPN. Staff R stated she was newly hired in July when she assessed the resident and did not find him at risk for elopement. Staff R stated she decided to do the elopement because she noticed he is never awake during daytime. Staff R stated the resident scored a 0, indicating not at risk for elopement. The LPN said, I did not know he was an elopement risk. He is normally sleeping. During the 3-week period I saw him only in the daytime, and he is always asleep. I did not ask anyone about the resident's wandering behaviors in the evening or his history. Staff R stated looking back, she should have reviewed the MAR (medication administration record), care plan and previous elopement assessments. Staff R stated she found out Resident #1 was a wanderer later in September because she saw him roaming. Staff R stated the DON went back and reassessed the resident. On [DATE] at 12:55 p.m. an interview was conducted with the Assistant Director of Nursing (ADON), Registered Nurse (RN). The ADON stated he received a call late at night, sometime around 9 p.m. The staff said they could not find the key to the alarm. The ADON stated the caller did not report a resident was missing at the time. The ADON stated he redirected the caller to contact the DON. The ADON stated later the same night he received a call from the DON to come in and provide elopement in-services. The ADON stated he has known Resident #1 for about a year. The ADON said, The resident is about the same, very confused and he is a nighttime wanderer. He goes around the entire facility at night. Psych sees him. The ADON stated the family had reported he used to work nights and has always slept all day. The ADON stated Resident #1 had not attempted to leave the building prior to this incident. The ADON said, He always says he wanted to catch the bus and join his parents, but his parents are deceased . The ADON stated the resident ambulates in his wheelchair and roams about freely. The ADON stated they have educated all staff since the incident and have conducted multiple drills. The ADON stated they have an orientation packet for agency staff. The ADON said, When they come in, we give them a tour of the unit, review standards of policy, responding to elopement and they complete a post elopement test. The ADON stated he could not confirm the education was happening prior to the incident, but for sure now they are. A telephone interview was conducted on [DATE] at 10:47 a.m. with the Advanced Registered Nurse Practitioner (ARNP-1). The ARNP-1 stated she saw Resident #1 on [DATE] to conduct a follow-up to a telehealth visit conducted [DATE]. The ARNP-1 stated the reason for the visit was the patient eloped the night prior. It was recommended he be placed on 1:1 supervision, which he was. The ARNP-1 stated at the time of the visit the resident was very confused was not able to communicate. She stated she spoke to the sitter and the nurse assigned to him. They stated he stays in bed during the day and wanders all night. The ARNP-1 stated the plan of care is to keep him on a 1:1 until he is transferred to a secured unit. She stated based on interviews with staff, she became aware the resident had prior elopement attempts. The ARNP-1 stated the day she conducted the assessment, Resident #1 was awake, laid in bed but could not engage in a conversation due to confusion. She stated he is on [MEDICATION(S)] and [MEDICATION(S)]. The ARNP-1 stated she did not know he was taking [MEDICATION(S)] ([MEDICATION(S)]) during the day. Typically, it is given at night. She stated it should definitely be given at night. The ARNP-1 stated the fact that he takes the sleeping medication in the morning contributed to his wandering in the evenings. The ARNP-1 stated she would follow-up. On [DATE] at 10:57 a.m., a telephone interview was conducted with the ARNP-2. The ARNP-2 stated she sees Resident #1 regularly for psych. The ARNP-2 stated she saw the resident on [DATE] via tele health. She stated she conducted the assessment because he flipped his wheelchair and was sent to the hospital. The ARNP-2 stated the resident had wandered to the door and he got out without staff stopping him. She stated she was not sure he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #1] since March of 2020. The ARNP-2 said, On [DATE]th he got close to the door, and they redirected him inside. I was [TRUNCATED]

Based on observation, record review, and interviews, the facility failed to provide supervision to prevent resident to resident abuse for one (Resident # 12) of four residents reviewed for abuse allegations of a total of twenty-two sampled residents. Resident #12 was a victim of physical abuse which resulted in psychosocial harm as evidenced by pain, anxiety, and the feeling of being overwhelmed with an unsafe environment. Findings include: On 07/13/2022 at 12:47 p.m., a phone interview was conducted with Resident #12. He confirmed that he had resided in the facility and been placed in a room with Resident #8. He said, they did not tell me he was a mental case. The guy was crazy. They should have known he was not well. Resident #12 reported that he was in the bed on the evening of the event (05/29/2022). He talked about the air conditioner issue and how Resident #8 got up to adjust the temperature and how he had spoken to the resident about the nurse just being in to adjust it. Resident #12 said, Resident #8 said he was going to kick my ass. He came to the end of my bed and with his fist, he banged on my cast. I hollered out. The staff came. The staff stayed with me until I was moved. The leg, I did not know if he busted any of the stitches, I had a cast on. My leg hurt the next day; they gave me something for it. Once I was moved to the other room, every night Resident #8, he would come by and look in, this happened about 6 times; he would be in his wheelchair. I was really upset. I told one of the aids. I did not feel safe. It was so bad. I would sleep with the tray the meal is delivered with on my chest at night. I had trouble sleeping. I am still mad about it. Back in the room, (Resident #8) could get up and walk around. The facility did not offer me any counseling services afterwards. He confirmed he had discharged home, and subsequently been admitted to another facility. The facility I am at now is great, everyone is so nice. It is so different from over there. On 07/13/2022 at 12:32 p.m., a phone interview was conducted with Resident #12's spouse. She reported 2 days after her husband admitted to the facility, they moved him into a room with Resident #8. My husband was in a cast at the time. He had an operation on the 3rd. He was completely defenseless. Resident #8 was crazy. Even the sheriff that came said the man was mentally ill. The man was weird. He would walk all over the place. The man would scream and expect the aids to come and wait on him. What happened that evening. (Resident #8) wanted the air conditioning turned up. Not sure if he meant up warmer or colder. After the nurse left, the resident got up and went over to the air conditioner. My husband said to him, (resident's name), the nurse just turned it up. Resident #8 came back to the foot of the bed, raised both of his arms, both fists together, and came down as hard as he could on my husband's cast. My husband started screaming because he was in so much pain. All the nurses came running. And he told them what happened. The other resident said I just brushed him my husband said, I would not be screaming in pain if it were just a brush. They said they were going to move him. The sheriff came that night. They said Resident #8 said all he did was brush his cast. The facility called me. They moved my husband to another room. I was there the next day; that is when I talked to the sheriff. Sheriff came the next day; said the resident was mental; not sure why he is there. A review of Resident #12's clinical chart, the admission record, reflected an admission of 05/11/2022. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #12's Minimum Data Set (MDS) assessment, dated 05/14/2022, reflected a Brief Interview for Mental Status (BIMS) score of 15, which meant he was cognitively intact. Section G, Functional status, reflected Resident #12 was limited assistance (staff provide guided maneuvering of limbs) for bed mobility, transfer, and locomotion. A review of Resident #12's progress notes, reflected the following: 05/29/2022, 22:00: Writer (Risk Manager (RM)) was called by weekend supervisor that resident had been hit by his then roommate, writer spoke with resident who has a BIMS of 15 and he expressed that his roommate came to his side of the room and hit his cast with his fist. Writer asked he would like to press charges and he stated, if you move me I don't have to but if he stays in the room with me then yes, writer explained to him that they would be separated due to policy but informed him that the police would likely still come out to speak with him. Supervisor was instructed to move the resident immediately out of the room. ED (Executive Director) was notified as well as DCS (Director of Clinical Services). Investigation notified immediately (sic). 06/02/2022, 16:01, Writer (RM) received a phone call from resident spouse stating that they were going to pursue charges on the resident that assaulted her husband on 05/29/2022, writer then asked why was charges not pressed the night that [NAME] (law enforcement officer) came to facility, she stated that she didn't know but that the following day she was informed by the UM (unit manager) that the other resident would be removed out of the facility by yesterday. Writer informed that her husband and the other resident are on two different sides of the building and that they would not cross paths, . 06/03/2022, 09:06, Writer (RM) spoke with spouse this morning .she stated that he walked passed (sic) her husband room the previous night and a day before, writer informed wife that she could not give information about other resident, but that the facility is doing everything to keep her husband safe. Writer asked wife why do she feel (sic) like the resident is after her husband and she stated, well, he did hit him. A review of resident #8's clinical chart, the admission record, reflected an admission of 09/02/2021; re-admission of 11/08/2021. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Psych ARNP (Advanced Registered Nurse Practitioner) notes, dated 05/02/2022, documented, Assessment and plan for today's visit: Patient is alert and oriented and able to make needs known. He is being seen per request of staff who reports patient has not been able to get along with any roommate. He has been irritable. He reports he has been feeling anxious and irritable and complaining of pain in legs, back and neck Psych ARNP notes, dated 05/09/2022, documented: HPI general .Recently was started on [MEDICATION(S)] for both pain and anxiety. He does not want roommates, but he is getting along with current one since patient barely talks . Psych ARNP notes, dated 05/31/2022, documented: .Patient seen today after request of staff. According to staff, patient punched the roommate's cast after verbal altercation occurred. Writer spoke with patient who reports him (sic) and his roommate have not been getting along and tension has been building. He reports they had a verbal exchange regarding the temperature . On 07/12/2022 at 1:16 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed that her assignment included Resident #8. When asked if the resident had any behaviors, she stated, he will play with himself. He will put the call light on, you will go in and check on him, and 5 minutes later, he will put it on again. He is confused. Oh yes, he will yell. You can hear him at the nurses' station. He will always say his clothes are missing. This morning he complained about the toilet not flushing. I went in there, flushed it, it flushed fine. Staff A, LPN, confirmed that Resident #8 would yell at other residents. That is why is in a room by himself. Staff A, LPN, said, Resident #8 can get out of bed by himself, and he can ambulate independently to the bathroom. On 07/12/2022 at 1:32 p.m., an interview was attempted with Resident #8. He was observed in bed with a pile of handwritten notes on his bedside table. A moderate build man. When asked why he was in the room by himself, he said, I had problems with the other roommates. We did not get along. They did not want to get along. I did not want to put up with them. I complain, they do nothing. (He continued to ramble. He was watching television. He was confused in his dialogue). On 07/12/2022 at 2:10 p.m., an interview was conducted with the Social Services Director. She stated, My understanding is Resident #8 is difficult. I am trying to find him a Group home to discharge to. An interview was conducted on 07/12/2022 at 11:41 a.m. with the RM regarding Resident #8 and #12. The RM reported for the event, Staff C, CNA was the first staff member in the room at the time of the event, 05/29/2022. She provided a signed witness statement, dated 05/29/2022 by Staff C, CNA, which documented: Around 5:30 p.m., attending to the corridor lights. I entered door (#) and the clients had a disagreement about the air conditioning. At that moment were no offenses. When I get there, bed (Resident #12) told me that (Resident #8) hit him with a stick for the same issue. I immediately told the nurse and (Staff D, Supervisor, RN). A review of Staff D, RN, Supervisor's statement, dated 05/29/2022, dated 05/29/2022: West wing CNA (Staff C) came to me stating patients in (room #) were arguing and (Resident #12) verbally stated (Resident #8) hit him with a stick at 8:30 p.m. I went over to speak with both parties, including a head-to-toe assessment on (Resident #12). (Resident #12) stated they were arguing about the temperature in the room and (Resident #8) walked over to adjust the temperature. (Resident #12) stated (Resident #8) then struck him with his fist on his right shin and walked back over to his bed to lay down. (Resident #12) then stated then both proceeded to argue with each other and hit the call light for assistance regarding the situation which is when CNA (Staff C) went into the room. The RM reported she had interviewed all of the staff on the floor that night and they had reported not hearing anything. The RM said she did not recall the exact time, (Staff D, RN) called her, but thought it was around 8:30 or 9:00 p.m. The RM said, she called the DON and the ED (Executive Director). I made that call right after I got off the phone with (Staff D, RN). A conference with corporate, after the call, we reported it. The DON called DCF (Department of Children and Families. Staff D, RN called the sheriff. I submitted the 1-day Immediate Federal Report. The RM reported the measures implemented to attempt to prevent a future occurrence were a psychiatric evaluation for Resident #8, we placed him on 1:1, he does not have any one in the room with him. A review of the facility's Policies and Procedures for Abuse, Neglect, Exploitation & Misappropriation, N-1265, last revised 11/28/2017, documented the Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property . Definitions: Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled thru the use of technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes but is not limited to: Hitting; Slapping; Punching; Biting; Kicking; Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to; spanking, slapping of hands, flicking, or hitting with an object. Mental and Verbal Abuse: is the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal Abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age ability to comprehend or disability. Meant and Verbal Abuse include but are not limited to: Harassing a resident; Mocking, insulting, ridiculing; Yelling or hovering over a resident, with the intent of intimidate; Threatening residents, depriving a resident of care or withholding a resident from contact with family and friends Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: .Failure to report observed or suspected abuse, neglect or misappropriation of resident property to the proper authorities Procedure: Acts of abuse directed against residents are absolutely prohibited .Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse .Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action . Furthermore, the Administration of the Company recognizes that resident abuse can be committed by other residents . 1. Screening . 2. Training: .Employee obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the Administrator and to other officials in accordance with State law. 3. Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation. The following systems have been implemented: .Sufficient numbers of staff to meet the needs of the residents; Department Heads and supervisors that monitor staff to identify inappropriate behavior; Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse . 4. Identification: All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors will be investigated by the Director of Nursing. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse coordinator, and an abuse investigation will be conducted in the absence of the Executive director, the Director of Nursing will serve as Abuse Coordinator. 5. Investigation: The Abuse Coordinator or his /her designee shall investigate all reports or allegations of abuse, neglect, misappropriation, and exploitation . 6. Protection: .The resident will be evaluated for any signs of injury, including a physical exam or psychosocial assessment, if needed; increased supervision of the alleged victim and residents .Protection from retaliation; Provide the resident with emotional support and counseling during and after the investigation, if needed. 7. Reporting/Response

Based on clinical record review, facility record review, and interviews, the facility failed to promote the rights of residents to have their advance directives honored as were formulated. The facility failed to follow Do Not Resuscitate (DNR) orders and accurate advance directive information on the clinical record for one (Resident #3) out of thirty residents that were identified as having previously expressed their wishes to NOT receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Of one hundred eleven residents, thirty were identified by the facility to have current DNR orders, and eighty-one were identified as full code, or desiring CPR in the event of a [MEDICAL CONDITION]. Five out of 16 licensed nurses interviewed (Employees N, O, P, Q, and R) over two consecutive shifts provided statements in conflict to the facility's own policy and procedures regarding identification of the end-of-life wishes for residents that were identified as having current DNR orders thus posing a risk for not having their rights protected and wishes honored. The facility's failure to maintain accurate DNR information in the clinical record, and ensure that staff were knowledgeable of policies and procedures for implementing advance directives and DNR orders, resulted in findings of Immediate Jeopardy, which was removed on [DATE] at 8:10 p.m. and the severity reduced to a D. The Nursing Home Administrator, the Regional Nurse and the Director of Nursing were notified of the findings on [DATE]. Findings included: 1. A review of the facility's policy, Advanced Directives-Nursing, dated [DATE], revealed the facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with Federal and State regulations. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident. Medical records must contain the Advance Directives discussion document and a copy of the proxy, living will, or power of attorney if they are available. Social Services will provide these for the clinical record. Follow these steps in an emergency situation: A. if a resident stops breathing or there is an absence of pulse or heartbeat, staff will check to determine whether a DNR order has been entered. B. if there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately .C. If a DNR order has been entered (and this has been verified by checking the resident's chart), CPR will not be administered. All normal comfort measures will be administered and the attending physician must be called. If the order required withholding life support measures such as respirators, or IV or tube feeding, the order is in accordance with his best medical judgement, that the resident is in a terminal condition and that he has considered the resident's wishes as expressed by the resident or through the appropriate substitute decision - maker (s) or the resident's next-of-kin. Staff must also notify the attending physician and the Administrator if a resident verbally expresses a desire to change or revoke his/her advance directives. 2. On [DATE] at 4:40 p.m. Regional Director of Clinical Services, provided a list of 30 residents that were identified to have current Do Not Resuscitate (DNR) physician's orders [REDACTED]. She stated that these orders were in accordance with the resident's or their health care surrogate's choices for healthcare and medical interventions at the end of life. She stated that these residents would not receive CPR if they were found to be unresponsive and without pulse or respiratory effort. She stated that the facility was reviewing all the residents in the facility's medical record and filing the physician's written DNR order on the medical record. She stated that they had completed a 100% clinical record audit of all residents to ensure DNR / Full code status was correct. She stated that that they had reviewed all thirty residents having current DNR physician orders [REDACTED]. She stated that they had begun re-educating the licensed nursing staff regarding the facility's policy, Advance Directive-Nursing. Regional Director of Clinical Services stated that they had re-educated both the ,[DATE] shift and ,[DATE] shift. She also stated that they were calling the licensed staff at home and re-educating them on the facility's policy, Advance Directive-Nursing. She stated the nursing staff would not be able to work their assigned shift until after they had been re-educated on the Advance Directive - Nursing policy. 3. Resident #3 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. The Face sheet showed [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE], quarterly, showed a Brief Interview for Mental Status score of 01 (severe impairment). Further review of the monthly orders present on the clinical record showed a Do Not Resuscitate physician's orders [REDACTED]. Record review of the facility form titled Designation of Health Care Proxy / Acceptance of Designation showed this facility may designate an individual who shall be responsible for making healthcare decisions on behalf of Resident #3. The form documented that the attending physician for this resident has conducted a physical examination and has determined that he/she is incapacitated and incapable of making his/her own healthcare decisions. This facility wishes to designate you as the Healthcare Proxy. The form was signed and dated by Resident #3's son on [DATE]. Further review of Resident #3's clinical record included a form titled Certificate of Incapacity, which showed that the physician had examined this resident. My examination includes a review of all medical records in the resident's medical chart. Based on my physical examination and review on the above mentioned records, I find that this resident is unable to make health care decisions for himself or provide informed consent to medical treatment. It is my medical opinion that there is no reasonable probability that the resident will recover competency to make healthcare decisions. The form was signed and dated by a physician on [DATE]. Record review showed another Certificate of Incapacity form was signed and dated by a physician on [DATE]. Record review of the Nursing Progress notes showed the following: On [DATE] at 5:11 p.m. Staff C, RN and Staff D, Licensed Practical Nurse (LPN), as a witness, discussed Advanced Directive with Healthcare Proxy. The Healthcare Proxy agreed to a DNR order and comfort measures only. On [DATE] at 11:30 p.m., Resident #3 was lying in his bed with a temperature of 103.5 degrees. Tylenol was given at 10:45 p.m. when his temperature was 104 degrees per Staff B, RN. On [DATE] at about 1:30 a.m., the resident observed lying in his bed responsive, Staff B, RN. On [DATE] at 2 PM (Documented in nursing progress note as 2 p.m.) A nursing assistant observed that the resident was not responsive. The resident had no pulse. 911 (EMS) was called and CPR started, per Staff B, RN. On [DATE] at 2:20 a.m., documented that the resident did not have a DNR on his clinical record at this time, per Staff A, LPN. On [DATE] at 2:20 a.m., advised by the aide that the resident was unresponsive and not breathing. Upon arrival to the resident's room it was noted an absence of vital signs. Respirations were zero. Blood pressure was zero. CPR initiated with the assistance of the aide and second nurse (Staff G, RN), per Staff A, LPN. On [DATE] at 2:25 a.m., CPR continued with vital signs absent. 911 (EMS - Emergency Medical Services) was activated at 02:20 and awaiting their arrival to the facility, per Staff A, LPN. On [DATE] at 2:35 a.m., EMS was on site. CPR continued by EMS. Resident intubated by EMS. Vital signs remain absent per Staff A, LPN. On [DATE] at 2:40 a.m., CPR continued by EMS. Vital signs remain absent. Staff A, LPN. On [DATE] at 3:12 a.m., contacted Healthcare Proxy. Provided funeral home. Per Staff B, RN. Record review of Code Blue Documentation, dated [DATE] revealed Staff A, LPN, called Code Blue at 2:20 a.m. Staff A, LPN, started CPR at 2:22 a.m. An AMBU (Artificial Manual Breathing Unit; ventilation) /mask used for ventilation. Vital signs were absent at 2:25 a.m., 2:30 a.m., and 2:40 a.m. Blood glucose drawn at 2:20 a.m. was 72. Documentation showed resuscitation terminated at 2:55 a.m. Code team that was present was Staff A, LPN, Staff F, CNA and Staff G, RN. Recorder documented as Staff A, LPN. Record review of Record of Death dated [DATE] showed cessation of vital signs. Pronounced by EMS at 2:50 a.m., physician notified at 3:00 a.m. During an interview on [DATE] at 3:35 p.m. Staff B, RN, stated that the ,[DATE] shift nurses had received a report that the Resident #3 was declining from Staff D, LPN. Staff D told her they were trying to retrieve the State of Florida DNR order yellow form. Staff D told Staff B that Staff A, LPN was looking for the yellow form in the resident's old chart. Staff B stated that she was told verbally from Staff D that he was a DNR. Staff B stated that the resident did not have a yellow form in his chart nor a physician's DNR order in the clinical record. Staff B stated that she went to Staff A as she was also working that night, staffing a medication cart. Staff A, LPN, said that she would go check on the yellow form. Staff B, RN told Staff A, LPN, that she would have to do CPR if she had not physically seen the yellow form. Staff B stated that an aide came and got her, stating that the resident was unresponsive. She called Staff A and another nurse for assistance. Staff B stated that she started performing CPR on the resident due to absence of pulse and respirations. She stated that she called 911. Staff B stated that she called the healthcare proxy also. Staff B stated that the Emergency Medical Services (EMS) came into the room and began the CPR for the facility staff. She stated that EMS tried to revive the resident but could not revive and the EMS pronounced him expired. She stated that the funeral home came to the facility to pick up the resident. Staff B stated that she did not see a State of Florida DNR order yellow form or a physician's DNR order in the clinical record. Staff B stated that she was looking for the yellow form regarding the resident's DNR status. During an interview on [DATE] at 4:45 p.m. Staff A, LPN, MDS coordinator, stated that an aide advised her that Resident #3 was not breathing. She stated that she went to his room and verified he did not have a pulse and was not breathing. Staff A stated that she went to the clinical record and verified the resident did not have a DNR order and started CPR. She stated that she was looking for the yellow form on his clinical record. Staff A stated that she did not look for a physician's DNR order on the chart, only the yellow form. She stated that after reviewing the clinical record and not finding a yellow form, she activated 911. She then stated that she went to the resident's room to perform CPR. She stated that the aide stayed in the room with the resident while she was looking in the clinical record for the yellow form. Staff A stated that EMS came about ,[DATE] minutes later. She stated that EMS took over performing CPR on Resident #3. She stated that EMS staff pronounced the resident expired. Staff A stated that another nurse called the family and physician. Staff A stated that on this night she was looking for the State of Florida DNR order yellow form. She stated that she has been in-serviced that they were to look for a physician's DNR order in the clinical record instead of the yellow form. During an interview on [DATE] at 1:45 p.m., Healthcare Proxy / family member for Resident #3 stated that his end of life wishes for his father was for comfort measures only. He stated that he did not want him resuscitated or CPR done. He stated that he only had days to go after coming home from the hospital. He stated that he passed in his sleep, he just quit breathing. When asked if the facility had done CPR on his dad he stated, No. When asked if the facility staff had called an ambulance for his dad, he said, No, they have people there at the facility at night to watch after him. When asked again if the facility had performed CPR on his dad, he said, No. when asked again regarding the calling of an ambulance, he again stated, No, he just passed in his sleep. During an interview on [DATE] at 10:54 a.m., the attending physician stated that he did not remember the details regarding Resident #3 specifically. He stated that the resident did have a DNR order. He asked the surveyor if the facility had the yellow form on the clinical record. The surveyor stated that the facility policy showed the facility was to follow the physician's DNR order, not the yellow form. He stated that the facility had to abide by their policy. He stated that actually the yellow form was for transfers to a hospital anyway. He stated that he was not necessarily on call when it occurred, but normally the facility just calls and says the resident passed away and can they release the body. He stated that if the resident had a physician's DNR order, the facility was not to perform CPR. He stated that Resident #3 did not survive and end up on a respirator but it was still not right that the facility performed CPR and attempted resuscitation During a second interview on [DATE] at 5:42 p.m., Staff B, RN, was asked if she called the Healthcare Proxy about the passing of Resident #3. She stated that, yes she was the one that called the Healthcare Proxy, while they were performing CPR. She stated that she told the Healthcare Proxy that they had called 911 and that the response team had pronounced the resident dead. She stated that she was under the impression the Healthcare Proxy had made funeral home arrangements. She stated that she was unable to locate funeral home arrangements on the clinical record so she had to ask the Healthcare Proxy what he wanted to do. The Healthcare Proxy stated that he would have to call back. She stated that the Healthcare Proxy called back later about the funeral home arrangements. When asked again, if she had told the Healthcare Proxy about starting CPR on Resident #3, she stated that she told him the resident had passed, that EMS had pronounced him dead, and she needed the funeral home arrangements. She stated that it happened about a month ago and she does not remember word for word. She stated that she remembered speaking to the Healthcare Proxy. Staff B, RN was asked at least three times if she had told the Healthcare Proxy that the facility had performed CPR on Resident #3 and all three times, she did not give a definitive answer. Staff B, RN stated that she followed the policy that she had been taught, look for the yellow paper in the clinical record. She stated that obviously you are asking questions about CPR because we are not supposed to do it that way. During an interview on [DATE] at 6:20 a.m. Staff H, Certified Nursing Assistant (CNA), stated that she was working the night Resident #3 passed away. She stated she was not the resident's aide, but when the code was called, she went to the resident's room. She stated that she witnessed Staff A, LPN, Staff B, RN and Staff G, RN in the resident's room. She stated that they were performing CPR on resident. When asked the time of the incident, she stated it was between 2 and 3 a.m. During an interview on [DATE] at 6:22 a.m. Staff I, CNA stated that she was working the night of the incident. She stated that she did not have the resident but went to the resident's room when the code was called. She stated that she observed the resident lying in the bed and CPR being performed. She stated that Staff A, LPN, Staff G, RN and Staff B, RN were the nurses in the room. She stated that Staff A, LPN drew the curtain in her face and she walked out and went back to her unit. When asked why she thought Staff A, LPN, pulled the curtain in her face, she shrugged and stated because they didn't want me to see them doing CPR. She stated that there were no aides in the room at that time. She stated that Staff A, LPN, was on the right side of the bed, Staff B, RN, was at the foot of the bed and Staff G, RN was on the left side of the bed. During an interview on [DATE] at 8:12 a.m. the Social Service Director (SSD), stated that upon admission or within 72 hours she speaks with the family and/or resident regarding all the options they have regarding advance directives and provides them with resources. She stated that she assists them with making those choices and assists with their needs, notarizing, etc. She stated that usually they come from the hospital with the advance directive in place and the facility just verifies them. She stated that she performs an audit weekly reviewing the resident's advanced directives to ensure something was in place or if nothing was in place, that was still their wishes. If they do not have anything in place, we call them quarterly to see if anything had changed. She stated that this usually occurs at the quarterly care planning meeting or if they are not there, she will reach out to the family to ensure that was still their wish. She stated that it was documented in the quarterly assessment / SS progress review. She stated that she had only been here a little over a month. She stated that the prior SSD went to another building. She stated that the staff was educated in advance directives during orientation. She stated that part of the orientation that the SSD performs, was to go over the advance directives, resident rights, abuse and neglect with the new orientees. When asked if the the SSD monitors the system of ensuring resident's choice regarding advance directives are honored, she stated yes, on admission, and at least quarterly with care plan meetings and by review of the clinical records weekly. She stated that she also attends the Resident Council Meetings quarterly to review advance directives with them, that they have the right to choose. When asked about SSD documenting in the chart that Resident #3 was DNR and comfort measures only in February 2017, she stated that she was not here, but will look into it. The SSD never brought documentation to verify this statement in the SS progress notes from February 2017. 4. Surveyors performed interviews on [DATE] regarding the facility's Advance Directive policy. Five out of 16 nurses gave conflicting information regarding the facility policy. During an interview on [DATE] at 9:40 a.m., Staff N, LPN, when asked what she would do if she found a resident unresponsive and without a pulse. She stated The first thing, I'll check to see if breathing, take pulse, if not, then I'll say code blue and call out for help, and then I'll go check the chart to see what status they are because I'm not going to start CPR without checking their status. When asked how she would identify the resident's Code status, she stated, Look all over their chart to see if there is an order. First, I'll look for the yellow paper, if I don't find the yellow paper, then I'll look for the doctor's orders. If I find a yellow paper, then I check to see if it's signed. If it's signed, then it's all legal. If the yellow paper is all signed like it's supposed to be, then I'll go to the patient and check to see if no pulse and breathing and heartbeat. When asked if she had had any recent training. She stated, Yes, it was just last year, my CPR training. The facility did a training on DNR's a couple of months ago, and sometimes they'll do a simulation--they have someone appear non-responsive and then they'll call the code and see what people do next. No more recent training than that. When asked what was discussed in this training? She stated, What was done wrong, what could be done better. To check the pulse and respirations, then leave CNA with resident, then we go to see their status, bring crash cart just in case. We check the chart book, and we find the status in their DNR and their physician's orders [REDACTED]. If I don't find it, then I look in the orders. If it's not in one place, it will be in the other. During an interview on [DATE] at 9:57 a.m., Staff O, RN unit manager for long term, was asked what she would do if she found a resident unresponsive and without a pulse. She stated, I check not responsive, I start CPR, then I get someone to call 911, and then I verify in the record for DNR or advance direction, and notify the doctor. If I'm doing CPR and they find DNR, then I continue CPR and the doctor is called to say client found non responsive, started CPR and found a DNR order, does he want me to continue with CPR or stop. When asked if she had any recent training. She stated, No, my CPR certification is about one year old, and there hasn't been any facility training regarding DNRs. I was on vacation the last 12 days and this is my first day back. They would notify me of any training while I was gone by email. I arrived here at 8 a.m. and then had a staff meeting with the administrator and DON, discussing what's new in 24 hours. They discussed that now we need a doctor order for DNR on the record. It doesn't matter if there is a yellow form, we need a doctor order that specifies DNR or other advanced direction. After being told this, if I found someone non-responsive, I would verify doctor order before I start CPR. I just got the orientation changes a few minutes ago, and I know that for a non-responsive client that I have to verify orders. Specifically a doctor order or advance direction. During an interview on [DATE] at 3:16 p.m., Staff P, RN evening supervisor, was asked what she would do if she found a resident non-responsive. She stated, Going to assess patient first, and call out for someone to bring the chart physically. Then look to see if doctor signed and dated the yellow/orange DNR form. If it's signed and dated, then it's valid and not going to perform CPR. If you don't see a yellow paper, then the patient is considered full code, then call code blue, page 3 times overhead consistently with room number and bed, and the crash cart comes, and assignments are given. When asked if she had training recently. She stated she had received a verbal call at home on Monday. The procedure to get a doctors order if there isn't the yellow/orange paper yet. To go to the computer and see the doctor's order for the advance directive. They were explaining that if caught in the in-between time where the doctor's order was given, and in the computer, but no yellow paper, that finding that order in that computer is valid. During an interview on [DATE] at 3:40 p.m., Staff Q, RN, was asked what she would do if she found an unresponsive resident. She stated, First I stay with the patient, then I send a co-worker for the chart. I look in the front of the chart. The DNR is yellow, but full code is regular paper. After checking the front of the chart, I call 911 if there is a DNR or full code. If the patient is full code, then I start CPR with 911 coming. When asked if she had recent training. She stated, Yes, in orientation they said to check in the chart if DNR or full code, it will be in the front of the chart. About ,[DATE] weeks ago there was a paper to sign about CPR. I read and I review CPR. The DON brought an in-service talk with me, and then another, and another. Refresh about CPR. She said to review the chart for DNR or full code on the first page of the chart. DNR is yellow and full code is regular paper. During an interview on [DATE] at 4:04 p.m., Staff R, RN, was asked what she would do if she found an unresponsive resident. She stated, First run to chart which would be under the doctor's orders in the chart. The DNR form, the DNR itself is in the doctor order section of the patients chart--it's yellow. The DNR on the yellow paper is the doctor's order. The signature and date make it official. When asked if she had any recent training. She stated, A couple of days ago. Where we need to keep the DNR. We don't keep it in the front of the chart--we keep it in chart under the doctor's orders section. The yellow paper is now kept in the doctor order section. During an interview on [DATE] at 4:50 p.m., Regional Director of Clinical Services, NHA,and Regional Vice President acknowledged that 5 out of 16 nurses that had been interviewed had given conflicting information regarding the Advance Directive policy regarding following the physician's orders [REDACTED]. They stated that the five nurses would be re-educated regarding the policy. On ,[DATE] and [DATE], the 5 nurses were re-interviewed, and were able to verbalize the facility policy. Seventy-three percent of the nursing staff was interviewed and able to voice the Advanced Directive Policy. 5. During an interview on [DATE] at 2:15 p.m., Regional Director of Clinical Services, stated that they had an ad hoc meeting on [DATE] regarding the Advance Directive issue. She provided the agenda. The Nursing Home Administrator (NHA) and Regional Director of Clinical Services, stated that they had the meeting to address DNRs. Regional Director of Clinical Services stated the meeting lasted approximately 30 minutes. The attendees included the NHA, Regional nurse, Medical Director, ADON / interim DON and rehab director. The ad hoc meeting occurred because of the complaint survey, which alerted them to the problem with performing CPR on Resident #3. It was to put a plan into place from [DATE]. The plan included checking the advance directive status of the residents weekly, for the SSD to be educated on the process, to educate the nursing staff on the advance directive policy, to print out all DNR orders from electronic chart system and file into clinical record for easy access during an incident. When asked, the NHA and Regional Director of Clinical Services stated that they had not self-identified the DNR issue prior to the complaint survey. Regional Director of Clinical Services stated that she had looked at death records. She stated that they needed to improve on documentation of DNR but they had not noticed any serious issues. The NHA stated that our self-identifying at morning meetings should capture the issues. The morning meeting will identify residents with current physician DNR orders and any change in physician DNR orders will be discussed. Also, any change in a resident's or family wishes regarding advance directives will be discussed in morning meetings. The prior DON did not look at discharge records. The nurses did the discharge form only; they did not do a discharge progress note on discharge. A lot of documentation education is needed, regarding discharges also. An interview on [DATE] at 3:54 p.m. with the Medical Director, M.D., revealed she has been medical director at the facility for three years. She stated that this was her first time as a medical director. She was an Infectious Disease Specialist and was chief of IDD at a local hospital. She stated that she was the Medical Director due to her affiliation with the college, she thought. She stated that if a resident were to be admitted at midnight, the nurse would call and verify orders including the DNR status. She stated that she felt the staff was confused about the yellow paper versus a physician order. She stated that they do verify all the orders on admission. She stated that the last Social Services Director (SSD) was very obsessive-compulsive about the yellow papers. She stated that the prior SSD said the yellow paper confirmed that the doctor had a conversation with the resident or family about the DNR status, so the facility wanted the yellow form. She stated that the yellow form was confirming the hospital orders. She stated that the SSD would call us back (physicians) if there were any questions about the Advanced Directive. She stated that they discussed the incident regarding Resident #3 in the Quality Assurance (QA) meeting. She stated that the facility needed to reinforce with the nurses that they need to follow the physician's orders [REDACTED].#3 that had a DNR order in place. She stated that if there is a physician order, and it had been verified with the resident or family that they wanted a DNR, and no one in the family had changed their mind, then the facility should follow the physician's orders [REDACTED]. The SSD should have already assessed for any changes, if the family wanted any. She stated that during the QA meeting it was decided that we wanted to get all of us on the same page and educate the staff. She stated that the facility needed to educate the physicians also. She stated that as Medical Director she could send a letter to the doctors to educate them on DNR orders. She stated that her expectation was for the facility not to put the family or resident through that (CPR for a DNR resident). She stated that they were going to educate the staff and new hires. She stated that it was mainly the need for education. The facility has had many new hires and has a high turnover rate. She stated that she hoped the new hires stayed and it settled down. 6. A review and verification of the facility's corrective action plan revealed the following: A. On [DATE], an audit was completed by the facility for all residents that were listed as having current DNR orders to verify that the physician's orders [REDACTED]. The Medical Director was informed on [DATE] during the ad hoc meeting that occurred. According to current policy, if a physician's DNR order is present, CPR will not be administered, all normal comfort measures will be administered and the attending physician must be called. On [DATE] at approximately 7:00 p.m., it was verified that all thirty residents and or family members of residents who had expressed a wish to have CPR withheld had current physician DNR orders in place on their clinical record. It was also verified that for residents who had State of Florida DNR orders yellow forms, those forms were also in place on the clinical record. Regional Director of Clinical Services, Regional RN, acknowledged that the clinical records were not complete or correct, they did not have the physician's DNR order or yellow form in every clinical record, but the records had been audited and corrected. B. The SSD was educated that she is to conduct weekly audits on the clinical record for current residents that have physician DNR orders to ensure that they are maintained appropriately in the clinical record. She is to review all charts weekly, not just new admissions, due to possible changes or updates occurring when the resident / family change their mind or due to hospitalization s. During an interview on [DATE] at approximately 7:00 p.m., the SSD stated that she was re-educated on [DATE] to review all clinical records weekly for accurate advance directives. She was re-educated to review all residents with physician DNR orders to ensure that the physician DNR order was present on the clinical record as well as the State of Florida DNR order yellow form if applicable. C. Nursing staff were in-serviced between [DATE] and [DATE] on the Advance Directive- Nursing policy that stated if a DNR order has been entered, CPR will not be administered. All normal comfort measures will be administered and the attending physician must be called. E. A review of in-services provided revealed, date [DATE] Topic CNA's call nurse if someone is not breathing. Nurses check chart in physician order [REDACTED]. Follow physician orders. According to the 4 Point Plan provided by the Regional RN licensed

Based on review of the Florida Nurse Practice Act, the Clinical Nurse job description, clinical record review, and interviews with the staff, Medical Director, resident's son, and attending physician, it was determined that the facility failed to ensure that services provided met professional standards of quality relating to end-of-life health care choices for one (#3) of thirty residents with Do Not Resuscitate (DNR) orders and failed to provide oversight supervision to prevent injury from a fall for one (#1) of six residents who were reviewed for accidents and supervision. Resident #3 received Cardiopulmonary Resuscitation (CPR) by Employee A, Licensed Practical Nurse (LPN), Employee B, Registered Nurse (RN), and Employee G, Registered Nurse even though a physician order [REDACTED]. Resident #3 received CPR as well as intubation which were against the wishes of the HealthCare Proxy for a peaceful death with comfort measures only. Of one hundred and Eleven residents, thirty were identified by the facility to have current Do Not Resuscitate (DNR) orders, and eighty-one were identified as full code, or desiring Cardiopulmonary Resuscitation (CPR) in the event of a [MEDICAL CONDITION]. Resident #1 was an elderly resident with [DIAGNOSES REDACTED]. The resident was alert with confusion, had decreased safety awareness, a high risk for falls and stood up frequently from her wheelchair; she was unable to protect herself from harm. Documentation for Resident #1 detailed a lack of safety awareness and the need for supervision to ensure the resident was safe and free from harm. Though the documentation clearly demonstrated Resident #1 displayed poor safety awareness and restlessness throughout the day, the facility did not provide the level of oversight needed to prevent injury and harm from [DATE] to [DATE]. Consequently, at approximately 10:00 a.m. on [DATE], the resident stood up from her wheelchair at the nursing station / day room without supervision and fell , hit her head on the couch and suffered a catastrophic left subdural hematoma (bleeding in the brain). Resident #1 was transferred to the hospital where she required intubation and was placed on a ventilator (breathing for resident) and later expired on [DATE] at approximately 1:00 p.m. The facility's failure to ensure nurses met professional standards and acted in accordance with the Nurse Practice Act as defined in the Florida Statues, Chapter 464, to maintain accurate DNR information in the clinical record, and ensure that staff were knowledgeable of policies and procedures for implementing advance directives and DNR orders, resulted in findings of Immediate Jeopardy, which was removed on [DATE] at 8:10 p.m. and the severity reduced to a D. The Nursing Home Administrator, the Regional Director of Clinical Services and the Director of Nursing were notified of the findings on [DATE]. The facility's failure to ensure nurses met professional standards and acted in accordance with the Nurse Practice Act as defined in the Florida Statues, Chapter 464, to provide oversight supervision to prevent injury and ensure that staff were knowledgeable of the Fall Prevention protocol, resulted in findings of Immediate Jeopardy, which was removed on [DATE] at 3:25 p.m. and the severity reduced to a D. The Nursing Home Administrator, the Regional Director of Clinical Services and the Director of Nursing were notified of the findings on [DATE]. Findings included: 1. The 2015 Florida Nurse Practice Act; Florida Statutes chapter 464.003 includes: (20)Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to:(a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.(b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c) The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection. A professional nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Record review of the facility's Clinical Nurse I (RN), job description, not dated, revealed the primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. Responsible for providing direct resident care in accordance with established plans. Conduct and document a thorough assessment of each resident's medical status upon admission and throughout the resident's course of treatment. Complete required documentation in an accurate and timely manner. Ensure compliance with residents rights policies adhere to facility policies and procedures and participates in facility quality improvement and safety programs. Record review of the facility's Clinical Nurse (LPN), job description, not dated, revealed the primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. Responsible for providing direct resident care in accordance with established plans. Complete required documentation in an accurate and timely manner. Adhere to facility policies and procedures and participates in facility quality improvement and safety programs. A review of the facility's policy, Advanced Directives-Nursing, dated [DATE] revealed the facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with Federal and State regulations. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident. Medical records must contain the Advance Directives discussion document and a copy of the proxy, living will, or power of attorney if they are available. Social Services will provide these for the clinical record. Follow these steps in an emergency situation: A. if a resident stops breathing or there is an absence of pulse or heartbeat, staff will check to determine whether a DNR order has been entered. B. if there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately .C. If a DNR order has been entered (and this has been verified by checking the resident's chart), CPR will not be administered. All normal comfort measures will be administered and the attending physician must be called. If the order required withholding life support measures such as respirators, or IV or tube feeding, the order is in accordance with his best medical judgement, that the resident is in a terminal condition and that he has considered the resident's wishes as expressed by the resident or through the appropriate substitute decision - maker (s) or the resident's next-of-kin. Staff must also notify the attending physician and the Administrator if a resident verbally expresses a desire to change or revoke his/her advance directives. Record review of the facility's policy, Fall Risk, effective [DATE] reflected to identify risk factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevent falls to the extent possible, residents will have a fall risk evaluation completed on admission/readmission and quarterly. Fall risk evaluation will be completed by licensed nurses on admission/readmission, quarterly, with significant change, and as needed. A resident with a fall risk score of ten or more should be considered a risk for falls. Residents identified as risk for falls will have individualized prevention interventions added to the resident's care plan. Initiate appropriate intervention to reduce risk. Documented identified risk and intervention (s) in the resident's plan of care. 2. During an interview on [DATE] at 3:35 p.m. Staff B, RN, stated that the ,[DATE] shift nurses had received a report that the Resident #3 was declining from Staff D, LPN. Staff D told her they were trying to retrieve the State of Florida DNR order yellow form. Staff D told Staff B that Staff A, LPN was looking for the yellow form in the resident's old chart. Staff B stated that she was told verbally from Staff D that he was a DNR. Staff B stated that the resident did not have a yellow form in his chart nor a physician's DNR order in the clinical record. Staff B stated that she went to Staff A as she was also working that night, staffing a medication cart. Staff A, LPN, said that she would go check on the yellow form. Staff B, RN told Staff A, LPN, that she would have to do CPR if she had not physically seen the yellow form. Staff B stated that an aide came and got her, stating that the resident was unresponsive. She called Staff A and another nurse for assistance. Staff B stated that she started performing CPR on the resident due to absence of pulse and respirations. She stated that she called 911. Staff B stated that she called the healthcare proxy also. Staff B stated that the Emergency Medical Services (EMS) came into the room and began the CPR for the facility staff. She stated that EMS tried to revive the resident but could not revive and the EMS pronounced him expired. She stated that the funeral home came to the facility to pick up the resident. Staff B stated that she did not see a State of Florida DNR order yellow form or a physician's DNR order in the clinical record. Staff B stated that she was looking for the yellow form regarding the resident's DNR status. During an interview on [DATE] at 4:45 p.m. Staff A, LPN, Minimum Data Set (MDS) coordinator, stated that an aide advised her that Resident #3 was not breathing. She stated that she went to his room and verified he did not have a pulse and was not breathing. Staff A stated that she went to the clinical record and verified the resident did not have a DNR order and started CPR. She stated that she was looking for the yellow form on his clinical record. Staff A stated that she did not look for a physician's DNR order on the chart, only the yellow form. She stated that after reviewing the clinical record and not finding a yellow form, she activated 911. She then stated that she went to the resident's room to perform CPR. She stated that the aide stayed in the room with the resident while she was looking in the clinical record for the yellow form. Staff A stated that EMS came about ,[DATE] minutes later. She stated that EMS took over performing CPR on Resident #3. She stated that EMS staff pronounced the resident expired. Staff A stated that another nurse called the family and physician. Staff A stated that on this night she was looking for the State of Florida DNR order yellow form. She stated that she has been in-serviced that they were to look for a physician's DNR order in the clinical record instead of the yellow form. During a second interview on [DATE] at 5:42 p.m., Staff B, RN, was asked if she called the Healthcare Proxy about the passing of Resident #3. She stated that, yes she was the one that called the Healthcare Proxy, while they were performing CPR. She stated that she told the Healthcare Proxy that they had called 911 and that the response team had pronounced the resident dead. When asked again, if she had told the Healthcare Proxy about starting CPR on Resident #3, she stated that she told him the resident had passed, that EMS had pronounced him dead, and she needed the funeral home arrangements. She stated that it happened about a month ago and she does not remember word for word. She stated that she remembered speaking to the Healthcare Proxy. Staff B, RN was asked at least three times if she had told the Healthcare Proxy that the facility had performed CPR on Resident #3 and all three times, she did not give a definitive answer. Staff B, RN stated that she followed the policy that she had been taught, look for the yellow paper in the clinical record. She stated that obviously you are asking questions about CPR because we are not supposed to do it that way. During an interview on [DATE] at 6:20 a.m. Staff H, Certified Nursing Assistant (CNA), stated that she was working the night Resident #3 passed away. She stated she was not the resident's aide, but when the code was called, she went to the resident's room. She stated that she witnessed Staff A, LPN, Staff B, RN and Staff G, RN in the resident's room. She stated that they were performing CPR on resident. When asked the time of the incident, she stated it was between 2 and 3 a.m. During an interview on [DATE] at 6:22 a.m. Staff I, CNA stated that she was working the night of the incident. She stated that she did not have the resident but went to the resident's room when the code was called. She stated that she observed the resident lying in the bed and CPR being performed. She stated that Staff A, LPN, Staff G, RN and Staff B, RN were the nurses in the room. She stated that Staff A, LPN drew the curtain in her face and she walked out and went back to her unit. When asked why she thought Staff A, LPN, pulled the curtain in her face, she shrugged and stated because they didn't want me to see them doing CPR. She stated that there were no aides in the room at that time. She stated that Staff A, LPN, was on the right side of the bed, Staff B, RN, was at the foot of the bed and Staff G, RN was on the left side of the bed. During an interview on [DATE] at 10:54 a.m., the attending physician stated that he did not remember the details regarding Resident #3 specifically. He stated that the resident did have a DNR order. He asked the surveyor if the facility had the yellow form on the clinical record. The surveyor stated that the facility policy showed the facility was to follow the physician's DNR order, not the yellow form. He stated that the facility had to abide by their policy. He stated that actually the yellow form was for transfers to a hospital anyway. He stated that he was not necessarily on call when it occurred, but normally the facility just calls and says the resident passed away and can they release the body. He stated that if the resident had a physician's DNR order, the facility was not to perform CPR. He stated that Resident #3 did not survive and ended up on a respirator but it was still not right that the facility performed CPR and attempted resuscitation. An interview on [DATE] at 3:54 p.m. with the Medical Director, M.D., revealed she has been medical director at the facility for three years. She stated that this was her first time as a medical director. She stated that if a resident were to be admitted at midnight, the nurse would call and verify orders including the DNR status. She stated that she felt the staff was confused about the yellow paper versus a physician order. She stated that they do verify all the orders on admission. She stated that the last Social Services Director (SSD) was very obsessive-compulsive about the yellow papers. She stated that the prior SSD said the yellow paper confirmed that the doctor had a conversation with the resident or family about the DNR status, so the facility wanted the yellow form. She stated that the yellow form was confirming the hospital orders. She stated that the SSD would call us back (physicians) if there were any questions about the Advanced Directive. She stated that they discussed the incident regarding Resident #3 in the Quality Assurance (QA) meeting. She stated that the facility needed to reinforce with the nurses that they need to follow the physician's orders [REDACTED].#3 that had a DNR order in place. She stated that if there is a physician order, and it had been verified with the resident or family that they wanted a DNR, and no one in the family had changed their mind, then the facility should follow the physician's orders [REDACTED]. The SSD should have already assessed for any changes, if the family wanted any. She stated that during the QA meeting it was decided that we wanted to get all of us on the same page and educate the staff. She stated that the facility needed to educate the physicians also. She stated that as Medical Director she could send a letter to the doctors to educate them on DNR orders. She stated that her expectation was for the facility not to put the family or resident through that (CPR for a DNR resident). She stated that they were going to educate the staff and new hires. She stated that it was mainly the need for education. The facility has had many new hires and has a high turnover rate. She stated that she hoped the new hires stayed and it settled down. During an interview on [DATE] at 1:45 p.m., Healthcare Proxy / family member for Resident #3 stated that his end of life wishes for his father was for comfort measures only. He stated that he did not want him resuscitated or CPR done. He stated that he only had days to go after coming home from the hospital. He stated that he passed in his sleep, he just quit breathing. When asked if the facility had done CPR on his dad he stated, No. When asked if the facility staff had called an ambulance for his dad, he said, No, they have people there at the facility at night to watch after him. When asked again if the facility had performed CPR on his dad, he said, No. when asked again regarding the calling of an ambulance, he again stated, No, he just passed in his sleep. Resident #3 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. The Face sheet showed [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE], quarterly, showed a Brief Interview for Mental Status score of 01 (severe impairment). Further review of the monthly orders present on the clinical record showed a Do Not Resuscitate physician's orders [REDACTED]. Record review of the Nursing Progress notes showed the following: On [DATE] at 5:11 p.m. Staff C, RN and Staff D, Licensed Practical Nurse (LPN), as a witness, discussed Advanced Directive with Healthcare Proxy. The Healthcare Proxy agreed to a DNR order and comfort measures only. On [DATE] at 11:30 p.m., Resident #3 was lying in his bed with a temperature of 103.5 degrees. Tylenol was given at 10:45 p.m. when his temperature was 104 degrees per Staff B, RN. On [DATE] at about 1:30 a.m., the resident observed lying in his bed responsive, Staff B, RN. On [DATE] at 2 PM (Documented in nursing progress note as 2 p.m.) A nursing assistant observed that the resident was not responsive. The resident had no pulse. 911 (EMS) was called and CPR started, per Staff B, RN. On [DATE] at 2:20 a.m., documented that the resident did not have a DNR on his clinical record at this time, per Staff A, LPN. On [DATE] at 2:20 a.m., advised by the aide that the resident was unresponsive and not breathing. Upon arrival to the resident's room it was noted an absence of vital signs. Respirations were zero. Blood pressure was zero. CPR initiated with the assistance of the aide and second nurse (Staff G, RN), per Staff A, LPN. On [DATE] at 2:25 a.m., CPR continued with vital signs absent. 911 (EMS - Emergency Medical Services) was activated at 02:20 and awaiting their arrival to the facility, per Staff A, LPN. On [DATE] at 2:35 a.m., EMS was on site. CPR continued by EMS. Resident intubated by EMS. Vital signs remain absent per Staff A, LPN. On [DATE] at 2:40 a.m., CPR continued by EMS. Vital signs remain absent. Staff A, LPN. On [DATE] at 3:12 a.m., contacted Healthcare Proxy. Provided funeral home. Per Staff B, RN. Record review of Code Blue Documentation, dated [DATE] revealed Staff A, LPN, called Code Blue at 2:20 a.m. Staff A, LPN, started CPR at 2:22 a.m. An AMBU (Artificial Manual Breathing Unit; ventilation) /mask used for ventilation. Vital signs were absent at 2:25 a.m., 2:30 a.m., and 2:40 a.m. Blood glucose drawn at 2:20 a.m. was 72. Documentation showed resuscitation terminated at 2:55 a.m. Code team that was present was Staff A, LPN, Staff F, CNA and Staff G, RN. Recorder documented as Staff A, LPN. Record review of Record of Death dated [DATE] showed cessation of vital signs. Pronounced by EMS at 2:50 a.m., physician notified at 3:00 a.m. Record review of the facility form titled Designation of Health Care Proxy / Acceptance of Designation showed this facility may designate an individual who shall be responsible for making healthcare decisions on behalf of Resident #3. The form documented that the attending physician for this resident has conducted a physical examination and has determined that he/she is incapacitated and incapable of making his/her own healthcare decisions. This facility wishes to designate you as the Healthcare Proxy. The form was signed and dated by Resident #3's son on [DATE]. Further review of Resident #3's clinical record included a form titled Certificate of Incapacity, which showed that the physician had examined this resident. My examination includes a review of all medical records in the resident's medical chart. Based on my physical examination and review on the above mentioned records, I find that this resident is unable to make health care decisions for himself or provide informed consent to medical treatment. It is my medical opinion that there is no reasonable probability that the resident will recover competency to make healthcare decisions. The form was signed and dated by a physician on [DATE]. Record review showed another Certificate of Incapacity form was signed and dated by a physician on [DATE]. During an interview on [DATE] at 8:12 a.m. the Social Service Director (SSD), stated that upon admission or within 72 hours she speaks with the family and/or resident regarding all the options they have regarding advance directives and provides them with resources. She stated that she assists them with making those choices and assists with their needs, notarizing, etc. She stated that she performs an audit weekly reviewing the resident's advanced directives to ensure something was in place or if nothing was in place, that was still their wishes. If they do not have anything in place, we call them quarterly to see if anything had changed. She stated that this usually occurs at the quarterly care planning meeting or if they are not there, she will reach out to the family to ensure that was still their wish. She stated that it was documented in the quarterly assessment / SS progress review. She stated that she had only been here a little over a month. She stated that the staff was educated in advance directives during orientation. She stated that part of the orientation that the SSD performs, was to go over the advance directives, resident rights, abuse and neglect with the new orientees. When asked if the the SSD monitors the system of ensuring resident's choice regarding advance directives are honored, she stated yes, on admission, and at least quarterly with care plan meetings and by review of the clinical records weekly. She stated that she also attends the Resident Council Meetings quarterly to review advance directives with them, that they have the right to choose. When asked about SSD documenting in the chart that Resident #3 was DNR and comfort measures only in February 2017, she stated that she was not here, but will look into it. The SSD never brought documentation to verify this statement in the SS progress notes from February 2017. On [DATE] at 4:40 p.m. Regional Director of Clinical Services, provided a list of 30 residents that were identified to have current Do Not Resuscitate (DNR) physician's orders [REDACTED]. She stated that these orders were in accordance with the resident's or their health care surrogate's choices for healthcare and medical interventions at the end of life. She stated that these residents would not receive CPR if they were found to be unresponsive and without pulse or respiratory effort. She stated that the facility was reviewing all the residents in the facility's medical record and filing the physician's written DNR order on the medical record. She stated that they had completed a 100% clinical record audit of all residents to ensure DNR / Full code status was correct. She stated that that they had reviewed all thirty residents having current DNR physician orders [REDACTED]. She stated that they had begun re-educating the licensed nursing staff regarding the facility's policy, Advance Directive-Nursing. Regional Director of Clinical Services stated that they had re-educated both the ,[DATE] shift and ,[DATE] shift. She also stated that they were calling the licensed staff at home and re-educating them on the facility's policy, Advance Directive-Nursing. She stated the nursing staff would not be able to work their assigned shift until after they had been re-educated on the Advance Directive - Nursing policy. During an interview on [DATE] at 2:15 p.m., Regional Director of Clinical Services, stated that they had an ad hoc meeting on [DATE] regarding the Advance Directive issue. She provided the agenda. The Nursing Home Administrator (NHA) and Regional Director of Clinical Services, stated that they had the meeting to address DNRs. The attendees included the NHA, Regional Director of Clinical Services, Medical Director, ADON / interim DON and rehab director. The ad hoc meeting occurred because of the complaint survey, which alerted them to the problem with performing CPR on Resident #3. It was to put a plan into place from [DATE]. The plan included but not limited to educating the nursing staff on the advance directive policy, to print out all DNR orders from electronic chart system and file into clinical record for easy access during an incident. When asked, the NHA and Regional Director of Clinical Services stated that they had not self-identified the DNR issue prior to the complaint survey. She stated that they needed to improve on documentation of DNR but they had not noticed any serious issues. The NHA stated that our self-identifying at morning meetings should capture the issues. The morning meeting will identify residents with current physician DNR orders and any change in physician DNR orders will be discussed. Also, any change in a resident's or family wishes regarding advance directives will be discussed in morning meetings. A lot of documentation education is needed, regarding discharges also. Surveyors performed interviews on [DATE] regarding the facility's Advance Directive policy. Five out of 16 nurses gave conflicting information regarding the facility policy. During an interview on [DATE] at 9:40 a.m., Staff N, LPN, when asked what she would do if she found a resident unresponsive and without a pulse. She stated The first thing, I'll check to see if breathing, take pulse, if not, then I'll say code blue and call out for help, and then I'll go check the chart to see what status they are because I'm not going to start CPR without checking their status. When asked how she would identify the resident's Code status, she stated, Look all over their chart to see if there is an order. First, I'll look for the yellow paper, if I don't find the yellow paper, then I'll look for the doctor's orders. If I find a yellow paper, then I check to see if it's signed. If it's signed, then it's all legal. If the yellow paper is all signed like it's supposed to be, then I'll go to the patient and check to see if no pulse and breathing and heartbeat. When asked if she had had any recent training. She stated, Yes, it was just last year, my CPR training. The facility did a training on DNR's a couple of months ago, and sometimes they'll do a simulation--they have someone appear non-responsive and then they'll call the code and see what people do next. No more recent training than that. When asked what was discussed in this training? She stated, What was done wrong, what could be done better. To check the pulse and respirations, then leave CNA with resident, then we go to see their status, bring crash cart just in case. We check the chart book, and we find the status in their DNR and their physician's orders [REDACTED]. If I don't find it, then I look in the orders. If it's not in one place, it will be in the other. During an interview on [DATE] at 9:57 a.m., Staff O, RN unit manager for long term, was asked what she would do if she found a resident unresponsive and without a pulse. She stated, I check not responsive, I start CPR, then I get someone to call 911, and then I verify in the record for DNR or advance direction, and notify the doctor. If I'm doing CPR and they find DNR, then I continue CPR and the doctor is called to say client found non responsive, started CPR and found a DNR order, does he want me to continue with CPR or stop. When asked if she had any recent training. She stated, No, my CPR certification is about one year old, and there hasn't been any facility training regarding DNRs. I was on vacation the last 12 days and this is my first day back. They would notify me of any training while I was gone by email. I arrived here at 8 a.m. and then had a staff meeting with the administrator and DON, discussing what's new in 24 hours. They discussed that now we need a doctor order for DNR on the record. It doesn't matter if there is a yellow form, we need a doctor order that specifies DNR or other advanced direction. After being told this, if I found someone non-responsive, I would verify doctor order before I start CPR. I just got the orientation changes a few minutes ago, and I know that for a non-responsive client that I have to verify orders. Specifically a doctor order or advance direction. During an interview on [DATE] at 3:16 p.m., Staff P, RN evening supervisor, was asked what she would do if she found a resident non-responsive. She stated, Going to assess patient first, and call out for someone to bring the chart physically. Then look to see if doctor signed and dated the yellow/orange DNR form. If it's signed and dated, then it's valid and not going to perform CPR. If you don't see a yellow paper, then the patient is considered full code, then call code blue, page 3 times overhead consistently with room number and bed, and the crash cart comes, and assignments are given. When asked if she had training recently. She stated she had received a verbal call at home on Monday. The procedure to get a doctors order if there isn't the yellow/orange paper yet. To go to the computer and see the doctor's order for the advance directive. They were explaining that if caught in the in-between time where the doctor's order was given, and in the computer, but no yellow paper, that finding that order in that computer is valid. During an interview on [DATE] at 3:40 p.m., Staff Q, RN, was asked what she would do if she found an unresponsive resident. She stated, First I stay with the patient, then I send a co-worker for the chart. I look in the front of the chart. The DNR is yellow, but full code is regular paper. After checking the front of the chart, I call 911 if there is a DNR or full code. If the patient is full code, then I start CPR with 911 coming. When asked if she had recent training. She stated, Yes, in orientation they said to check in the chart if DNR or full code, it will be in the front of the chart. About ,[DATE] weeks ago there was a paper to sign about (TRUNCATED)

Based on clinical record review, facility record review, and interviews, the facility failed to ensure that Resident #3 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choice to follow Do Not Resuscitate (DNR) orders for one (#3) out of thirty residents that were identified as having previously expressed their end-of-life wishes to NOT receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Resident #3 received Cardiopulmonary Resuscitation (CPR) by Employee A, Licensed Practical Nurse (LPN), Employee B, Registered Nurse (RN), and Employee G, RN despite the presence of a physician's orders [REDACTED]. A Care Plan for Advance Directives was not evident in Resident #3's clinical record. Resident #3 received CPR as well as intubation which were against the wishes of the HealthCare Proxy for a peaceful death with comfort measures only. Of one hundred eleven residents, thirty were identified by the facility to have current DNR orders, and eighty-one were identified as full code, or desiring CPR in the event of a [MEDICAL CONDITION]. Five out of 16 licensed nurses interviewed (Employees N, O, P, Q, and R) over two consecutive shifts provided statements in conflict to the facility's own policy and procedures regarding identification of the end-of-life wishes thus posing a risk for not having residents' rights protected and wishes honored. The facility's failure to provide treatment and care in accordance with the resident and responsible party's end of life choices resulted in findings of Immediate Jeopardy, which was removed on [DATE] at 8:10 p.m. and the severity reduced to a D. The Nursing Home Administrator, the Regional Director of Clinical Services and the Director of Nursing were notified of the findings on [DATE]. Findings included: 1. During an interview on [DATE] at 1:45 p.m., Healthcare Proxy / family member for Resident #3 stated that his end of life wishes for his father were for comfort measures only. He stated that he did not want him resuscitated or CPR done. He stated that he only had days to live after coming back from the hospital. He stated that his father passed in his sleep, he just quit breathing. When asked if the facility had done CPR on his dad he stated, No. When asked if the facility staff had called an ambulance for his dad, he said, No, they have people there at the facility at night to watch after him. When asked again if the facility had performed CPR on his dad, he said, No. When asked again regarding the calling of an ambulance, he again stated, No, he just passed in his sleep. 2. The 2015 Florida Nurse Practice Act; Florida Statutes chapter 464.003 includes: (20)Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to:(a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.(b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c) The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection. A professional nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Record review of the facility's Clinical Nurse I (RN), job description not dated revealed the primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. Responsible for providing direct resident care in accordance with established plans. Conduct and document a thorough assessment of each resident's medical status upon admission and throughout the resident's course of treatment. Complete required documentation in an accurate and timely manner. Ensure compliance with residents rights policies adhere to facility policies and procedures and participates in facility quality improvement and safety programs. Record review of the facility's Clinical Nurse (LPN), job description not dated, revealed the primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. Responsible for providing direct resident care in accordance with established plans. Complete required documentation in an accurate and timely manner. Adhere to facility policies and procedures and participates in facility quality improvement and safety programs. A review of the facility's policy, Advanced Directives-Nursing, dated [DATE] revealed the facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with Federal and State regulations. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident. Medical records must contain the Advance Directives discussion document and a copy of the proxy, living will, or power of attorney if they are available. Social Services will provide these for the clinical record. Follow these steps in an emergency situation: A. if a resident stops breathing or there is an absence of pulse or heartbeat, staff will check to determine whether a DNR order has been entered. B. if there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately .C. If a DNR order has been entered (and this has been verified by checking the resident's chart), CPR will not be administered. All normal comfort measures will be administered and the attending physician must be called. If the order required withholding life support measures such as respirators, or IV or tube feeding, the order is in accordance with his best medical judgement, that the resident is in a terminal condition and that he has considered the resident's wishes as expressed by the resident or through the appropriate substitute decision - maker (s) or the resident's next-of-kin. Staff must also notify the attending physician and the Administrator if a resident verbally expresses a desire to change or revoke his/her advance directives. Record review of the facility's Director of Resident and Family Services I and II, not dated, revealed the primary purpose of your job position is plan, organize, develop and direct the overall operation of the Social Services department in accordance with current federal, state and local standards, guidelines and regulations our established policies and procedures, and as may be directed by the Executive Director, to ensure that the medically related emotional and social needs of the residents are met/maintained on an individual basis. As part of the admission process, meet with the resident and family to review policies on advance directives, resident rights, and non-discrimination. Conduct and document a social services evaluation, including identification of resident problem/needs. Provide / arrange for social work services as indicated by resident / family needs. Keep the residents' family informed of resident problems, personal needs, transfers, and changes of level assignment. Meet with the appropriate facility staff concerning resident issues. Record review of facility's policy, Social Services, dated [DATE] revealed medically - related social services will be provided to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Social Service personnel will identify the medically related social and emotional needs of residents and their families and provide for those needs by assisting residents with decisions concerning issuing /not issuing advanced directives and/or naming a health care proxy, DNR's and the ramifications of such decisions. 3. During an interview on [DATE] at 6:20 a.m. Staff H, Certified Nursing Assistant (CNA), stated that she was working the night Resident #3 passed away. She stated she was not the resident's aide, but when the code was called, she went to the resident's room. She stated that she witnessed Staff A, LPN, Staff B, RN and Staff G, RN in the resident's room. She stated that they were performing CPR on the resident. When asked the time of the incident, she stated it was between 2 and 3 a.m. During an interview on [DATE] at 6:22 a.m. Staff I, CNA stated that she was working the night of the incident. She stated that she did not have the resident on her assignment but went to the resident's room when the code was called. She stated that she observed the resident lying in the bed and CPR being performed. She stated that Staff A, LPN, Staff G, RN and Staff B, RN were the nurses in the room. She stated that Staff A, LPN drew the curtain in her face and she walked out and went back to her unit. When asked why she thought Staff A, LPN, pulled the curtain in her face, she shrugged and stated because they didn't want me to see them doing CPR. She stated that there were no aides in the room at that time. She stated that Staff A, LPN, was on the right side of the bed, Staff B, RN, was at the foot of the bed and Staff G, RN was on the left side of the bed. During an interview on [DATE] at 3:35 p.m. Staff B, RN, stated that the ,[DATE] shift nurses had received a report that the Resident #3 was declining from Staff D, LPN. Staff D told her they were trying to retrieve the State of Florida DNR order yellow form. Staff D told Staff B that Staff A, LPN was looking for the yellow form in the resident's old chart. Staff B stated that she was told verbally from Staff D that he was a DNR. Staff B stated that the resident did not have a yellow form in his chart nor a physician's DNR order in the clinical record. Staff B stated that she went to Staff A as she was also working that night, staffing a medication cart. Staff A, LPN, said that she would go check on the yellow form. Staff B, RN told Staff A, LPN, that she would have to do CPR if she had not physically seen the yellow form. Staff B stated that an aide came and got her, stating that the resident was unresponsive. She called Staff A and another nurse for assistance. Staff B stated that she started performing CPR on the resident due to absence of pulse and respirations. She stated that she called 911. Staff B stated that she called the healthcare proxy also. Staff B stated that the Emergency Medical Services (EMS) came into the room and began the CPR for the facility staff. She stated that EMS tried to revive the resident but could not revive and the EMS pronounced him expired. She stated that the funeral home came to the facility to pick up the resident. Staff B stated that she did not see a State of Florida DNR order yellow form or a physician's DNR order in the clinical record. Staff B stated that she was looking for the yellow form regarding the resident's DNR status. During a second interview on [DATE] at 5:42 p.m., Staff B, RN, was asked if she called the Healthcare Proxy about the passing of Resident #3. She stated that, yes she was the one that called the Healthcare Proxy, while they were performing CPR. She stated that she told the Healthcare Proxy that they had called 911 and that the response team had pronounced the resident dead. She stated that she was under the impression the Healthcare Proxy had made funeral home arrangements. She stated that she was unable to locate funeral home arrangements on the clinical record so she had to ask the Healthcare Proxy what he wanted to do. The Healthcare Proxy stated that he would have to call back. She stated that the Healthcare Proxy called back later about the funeral home arrangements. When asked again, if she had told the Healthcare Proxy about starting CPR on Resident #3, she stated that she told him the resident had passed, that EMS had pronounced him dead, and she needed the funeral home arrangements. She stated that it happened about a month ago and she does not remember word for word. She stated that she remembered speaking to the Healthcare Proxy. Staff B, RN was asked at least three times if she had told the Healthcare Proxy that the facility had performed CPR on Resident #3 and all three times, she did not give a definitive answer. Staff B, RN stated that she followed the policy that she had been taught, look for the yellow paper in the clinical record. She stated that obviously you are asking questions about CPR because we are not supposed to do it that way. During an interview on [DATE] at 4:45 p.m. Staff A, LPN, Minimum Data Set (MDS) coordinator, stated that an aide advised her that Resident #3 was not breathing. She stated that she went to his room and verified he did not have a pulse and was not breathing. Staff A stated that she went to the clinical record and verified the resident did not have a DNR order and started CPR. She stated that she was looking for the yellow form on his clinical record. Staff A stated that she did not look for a physician's DNR order on the chart, only the yellow form. She stated that after reviewing the clinical record and not finding a yellow form, she activated 911. She then stated that she went to the resident's room to perform CPR. She stated that the aide stayed in the room with the resident while she was looking in the clinical record for the yellow form. Staff A stated that EMS came about ,[DATE] minutes later. She stated that EMS took over performing CPR on Resident #3. She stated that EMS staff pronounced the resident expired. Staff A stated that another nurse called the family and physician. Staff A stated that on this night she was looking for the State of Florida DNR order yellow form. She stated that she has been in-serviced that they were to look for a physician's DNR order in the clinical record instead of the yellow form. During an interview on [DATE] at 10:54 a.m., the attending physician stated that he did not remember the details regarding Resident #3 specifically. He stated that the resident did have a DNR order. He asked the surveyor if the facility had the yellow form on the clinical record. The surveyor stated that the facility policy showed the facility was to follow the physician's DNR order, not the yellow form. He stated that the facility had to abide by their policy. He stated that actually the yellow form was for transfers to a hospital anyway. He stated that he was not necessarily on call when it occurred, but normally the facility just calls and says the resident passed away and can they release the body. He stated that if the resident had a physician's DNR order, the facility was not to perform CPR. He stated that Resident #3 did not survive and end up on a respirator but it was still not right that the facility performed CPR and attempted resuscitation. An interview on [DATE] at 3:54 p.m. with the Medical Director, M.D., she stated that they discussed the incident regarding Resident #3 in the Quality Assurance (QA) meeting. She stated that the facility needed to reinforce with the nurses that they need to follow the physician's orders [REDACTED].#3 that had a DNR order in place. She stated that if there is a physician order, and it had been verified with the resident or family that they wanted a DNR, and no one in the family had changed their mind, then the facility should follow the physician's orders [REDACTED]. The SSD should have already assessed for any changes, if the family wanted any. She stated that during the QA meeting it was decided that we wanted to get all of us on the same page and educate the staff. She stated that the facility needed to educate the physicians also. She stated that as Medical Director she could send a letter to the doctors to educate them on DNR orders. She stated that her expectation was for the facility not to put the family or resident through that (CPR for a DNR resident). She stated that they were going to educate the staff and new hires. She stated that it was mainly the need for education. The facility has had many new hires and has a high turnover rate. She stated that she hoped the new hires stayed and it settled down. 4. A review of the clinical record revealed Resident #3 was admitted on [DATE], readmitted on [DATE] and discharged /deceased on [DATE]. The Face sheet showed [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE], quarterly assessment, showed a Brief Interview for Mental Status score of 01 (severe impairment). Review of Resident #3's admission agreement dated [DATE] signed and initialed by the resident's son revealed The Center will provide the Patient with 24 hour nursing and personal care. The care will be what is needed for Patient's health, safety, and well-being as required by the Center's License. The facility also had a Consent to Treatment document signed by the resident and dated [DATE] that stated, The Resident and Responsible Party consent to the administration of such care, treatment, services, and medical nursing procedures to the Resident, as the Facility and the Resident's attending physician or nurse practitioner deem appropriate . Further review of the monthly orders present on the clinical record showed a Do Not Resuscitate physician's orders [REDACTED]. Record review of the Nursing Progress notes showed the following: On [DATE] at 5:11 p.m. Staff C, RN and Staff D, Licensed Practical Nurse (LPN), as a witness, discussed Advanced Directive with Healthcare Proxy. The Healthcare Proxy agreed to a DNR order and comfort measures only. On [DATE] at 11:30 p.m., Resident #3 was lying in his bed with a temperature of 103.5 degrees. Tylenol was given at 10:45 p.m. when his temperature was 104 degrees per Staff B, RN. On [DATE] at about 1:30 a.m., the resident observed lying in his bed responsive, Staff B, RN. On [DATE] at 2 PM (Documented in nursing progress note as 2 p.m.) A nursing assistant observed that the resident was not responsive. The resident had no pulse. 911 (EMS) was called and CPR started, per Staff B, RN. On [DATE] at 2:20 a.m., documented that the resident did not have a DNR on his clinical record at this time, per Staff A, LPN. On [DATE] at 2:20 a.m., advised by the aide that the resident was unresponsive and not breathing. Upon arrival to the resident's room it was noted an absence of vital signs. Respirations were zero. Blood pressure was zero. CPR initiated with the assistance of the aide and second nurse (Staff G, RN), per Staff A, LPN. On [DATE] at 2:25 a.m., CPR continued with vital signs absent. 911 (EMS - Emergency Medical Services) was activated at 02:20 and awaiting their arrival to the facility, per Staff A, LPN. On [DATE] at 2:35 a.m., EMS was on site. CPR continued by EMS. Resident intubated by EMS. Vital signs remain absent per Staff A, LPN. On [DATE] at 2:40 a.m., CPR continued by EMS. Vital signs remain absent. Staff A, LPN. On [DATE] at 3:12 a.m., contacted Healthcare Proxy. Provided funeral home. Per Staff B, RN. Medical Dictionary definition of intubation is the insertion of a tubular device into a canal, hollow organ, or cavity; specifically, passage of a tube for control of [MEDICAL CONDITION] ventilation or anesthesia. Reference for intubation definition: http://medical-dictionary.thefreedictionary.com/intubation Record review of Code Blue Documentation, dated [DATE] revealed Staff A, LPN, called Code Blue at 2:20 a.m. Staff A, LPN, started CPR at 2:22 a.m. An AMBU (Artificial Manual Breathing Unit; ventilation) /mask used for ventilation. Vital signs were absent at 2:25 a.m., 2:30 a.m., and 2:40 a.m. Blood glucose drawn at 2:20 a.m. was 72. Documentation showed resuscitation terminated at 2:55 a.m. Code team that was present was Staff A, LPN, Staff F, CNA and Staff G, RN. Recorder documented as Staff A, LPN. Record review of Record of Death dated [DATE] showed cessation of vital signs. Pronounced by EMS at 2:50 a.m., physician notified at 3:00 a.m. Record review of the facility form titled Designation of Health Care Proxy / Acceptance of Designation showed this facility may designate an individual who shall be responsible for making healthcare decisions on behalf of Resident #3. The form documented that the attending physician for this resident has conducted a physical examination and has determined that he/she is incapacitated and incapable of making his/her own healthcare decisions. This facility wishes to designate you as the Healthcare Proxy. The form was signed and dated by Resident #3's son on [DATE]. Further review of Resident #3's clinical record included a form titled Certificate of Incapacity, which showed that the physician had examined this resident. My examination includes a review of all medical records in the resident's medical chart. Based on my physical examination and review on the above mentioned records, I find that this resident is unable to make health care decisions for himself or provide informed consent to medical treatment. It is my medical opinion that there is no reasonable probability that the resident will recover competency to make healthcare decisions. The form was signed and dated by a physician on [DATE]. Record review showed another Certificate of Incapacity form was signed and dated by a physician on [DATE]. 5. On [DATE] at 4:40 p.m. Regional Director of Clinical Services, provided a list of 30 residents that were identified to have current Do Not Resuscitate (DNR) physician's orders [REDACTED]. She stated that these orders were in accordance with the resident's or their health care surrogate's choices for healthcare and medical interventions at the end of life. She stated that these residents would not receive CPR if they were found to be unresponsive and without pulse or respiratory effort. She stated that the facility was reviewing all the residents in the facility's medical record and filing the physician's written DNR order on the medical record. She stated that they had completed a 100% clinical record audit of all residents to ensure DNR / Full code status was correct. She stated that that they had reviewed all thirty residents having current DNR physician orders [REDACTED]. She stated that they had begun re-educating the licensed nursing staff regarding the facility's policy, Advance Directive-Nursing. Regional Director of Clinical Services stated that they had re-educated both the ,[DATE] shift and ,[DATE] shift. She also stated that they were calling the licensed staff at home and re-educating them on the facility's policy, Advance Directive-Nursing. She stated the nursing staff would not be able to work their assigned shift until after they had been re-educated on the Advance Directive - Nursing policy. 6. Surveyors performed interviews on [DATE] regarding the facility's Advance Directive policy. Five out of 16 nurses gave conflicting information regarding the facility policy. During an interview on [DATE] at 3:40 p.m., Staff Q, RN, was asked what she would do if she found an unresponsive resident. She stated, First I stay with the patient, then I send a co-worker for the chart. I look in the front of the chart. The DNR is yellow, but full code is regular paper. After checking the front of the chart, I call 911 if there is a DNR or full code. If the patient is full code, then I start CPR with 911 coming. When asked if she had recent training. She stated, Yes, in orientation they said to check in the chart if DNR or full code, it will be in the front of the chart. About ,[DATE] weeks ago there was a paper to sign about CPR. I read and I review CPR. The DON brought an in-service talk with me, and then another, and another. Refresh about CPR. She said to review the chart for DNR or full code on the first page of the chart. DNR is yellow and full code is regular paper. During an interview on [DATE] at 3:16 p.m., Staff P, RN evening supervisor, was asked what she would do if she found a resident non-responsive. She stated, Going to assess patient first, and call out for someone to bring the chart physically. Then look to see if doctor signed and dated the yellow/orange DNR form. If it's signed and dated, then it's valid and not going to perform CPR. If you don't see a yellow paper, then the patient is considered full code, then call code blue, page 3 times overhead consistently with room number and bed, and the crash cart comes, and assignments are given. When asked if she had training recently. She stated she had received a verbal call at home on Monday. The procedure to get a doctors order if there isn't the yellow/orange paper yet. To go to the computer and see the doctor's order for the advance directive. They were explaining that if caught in the in-between time where the doctor's order was given, and in the computer, but no yellow paper, that finding that order in that computer is valid. During an interview on [DATE] at 9:40 a.m., Staff N, LPN, when asked what she would do if she found a resident unresponsive and without a pulse. She stated The first thing, I'll check to see if breathing, take pulse, if not, then I'll say code blue and call out for help, and then I'll go check the chart to see what status they are because I'm not going to start CPR without checking their status. When asked how she would identify the resident's Code status, she stated, Look all over their chart to see if there is an order. First, I'll look for the yellow paper, if I don't find the yellow paper, then I'll look for the doctor's orders. If I find a yellow paper, then I check to see if it's signed. If it's signed, then it's all legal. If the yellow paper is all signed like it's supposed to be, then I'll go to the patient and check to see if no pulse and breathing and heartbeat. When asked if she had had any recent training. She stated, Yes, it was just last year, my CPR training. The facility did a training on DNR's a couple of months ago, and sometimes they'll do a simulation--they have someone appear non-responsive and then they'll call the code and see what people do next. No more recent training than that. When asked what was discussed in this training? She stated, What was done wrong, what could be done better. To check the pulse and respirations, then leave CNA with resident, then we go to see their status, bring crash cart just in case. We check the chart book, and we find the status in their DNR and their physician's orders [REDACTED]. If I don't find it, then I look in the orders. If it's not in one place, it will be in the other. During an interview on [DATE] at 4:04 p.m., Staff R, RN, was asked what she would do if she found an unresponsive resident. She stated, First run to chart which would be under the doctor's orders in the chart. The DNR form, the DNR itself is in the doctor order section of the patients chart--it's yellow. The DNR on the yellow paper is the doctor's order. The signature and date make it official. When asked if she had any recent training. She stated, A couple of days ago. Where we need to keep the DNR. We don't keep it in the front of the chart--we keep it in chart under the doctor's orders section. The yellow paper is now kept in the doctor order section. During an interview on [DATE] at 9:57 a.m., Staff O, RN unit manager for long term, was asked what she would do if she found a resident unresponsive and without a pulse. She stated, I check not responsive, I start CPR, then I get someone to call 911, and then I verify in the record for DNR or advance direction, and notify the doctor. If I'm doing CPR and they find DNR, then I continue CPR and the doctor is called to say client found non responsive, started CPR and found a DNR order, does he want me to continue with CPR or stop. When asked if she had any recent training. She stated, No, my CPR certification is about one year old, and there hasn't been any facility training regarding DNRs. I was on vacation the last 12 days and this is my first day back. They would notify me of any training while I was gone by email. I arrived here at 8 a.m. and then had a staff meeting with the administrator and DON, discussing what's new in 24 hours. They discussed that now we need a doctor order for DNR on the record. It doesn't matter if there is a yellow form, we need a doctor order that specifies DNR or other advanced direction. After being told this, if I found someone non-responsive, I would verify doctor order before I start CPR. I just got the orientation changes a few minutes ago, and I know that for a non-responsive client that I have to verify orders. Specifically a doctor order or advance direction. During an interview on [DATE] at 4:50 p.m., Regional Director of Clinical Services, NHA, and Regional Vice President acknowledged that 5 out of 16 nurses that had been interviewed had given conflicting information regarding the Advance Directive policy regarding following the physician's orders [REDACTED]. They stated that the five nurses would be re-educated regarding the policy. On ,[DATE] and [DATE], the 5 nurses were re-interviewed, and were able to verbalize the facility policy. Seventy-three percent of the nursing staff was interviewed and able to voice the Advanced Directive Policy. 7. During an interview on [DATE] at 2:15 p.m., Regional Director of Clinical Services, stated that they had an ad hoc meeting on [DATE] regarding the Advance Directive issue. She provided the agenda. The Nursing Home Administrator (NHA) and Regional Director of Clinical Services, stated that they had the meeting to address DNRs. The attendees included the NHA, Regional Director of Clinical Services, Medical Director, ADON / interim DON and rehab director. The ad hoc meeting occurred because of the complaint survey, which alerted them to the problem with performing CPR on Resident #3. It was to put a plan into place from [DATE]. The plan included checking the advance directive status of the residents weekly, for the SSD to be educated on the process, to educate the nursing staff on the advance directive policy, to print out all DNR orders from electronic chart system and file into clinical record for easy access during an incident. When asked, the NHA and Regional Director of Clinical Services stated that they had not self-identified the DNR issue prior to the complaint survey. Regional Director of Clinical Services stated that she had looked at death records. She stated that they needed to improve on documentation of DNR but they had not noticed any serious issues. The NHA stated that our self-identifying at morning meetings should capture the issues. The morning meeting will identify residents with current physician DNR orders and any change in physician DNR orders will be discussed. Also, any change in a resident's or family wishes regarding advance directives will be discussed in morning meetings. The prior DON did not look at discharge records. The nurses did the discharge form only; they did not do a discharge progress note on discharge. A lot of documentation education is needed, regarding discharges also. An interview on [DATE] at 3:54 p.m. with the Medical Director, M.D., revealed she had been medical director at the facility for three years. She stated that this was her first time as a medical director. She was an Infectious Disease Specialist (TRUNCATED)

Based on clinical record review, facility record review and interviews the facility failed to provide oversight supervision to prevent injury for one (#1) of six residents who were reviewed for accidents and supervision. Documentation for Resident #1, an elderly resident with [DIAGNOSES REDACTED]. Documentation for Resident #1 detailed the resident's lack of safety awareness and the need for supervision to ensure the resident was safe and free from harm beginning [DATE] at 12:00 p.m. Though the documentation clearly demonstrated Resident #1 displayed poor safety awareness and restlessness throughout the day, the facility chose not to provide adequate supervision from [DATE] to [DATE]. Consequently, at approximately 10:00 a.m. on [DATE], the resident stood up from her wheelchair at the nursing station / day room without supervision and fell , hit her head on the couch and suffered a catastrophic left subdural hematoma (bleeding in the brain). Resident #1 was transferred to the hospital where she required intubation and was placed on a ventilator (breathing for resident). The resident was diagnosed by CT scan with an acute massive left subdural hematoma with brain herniation and cerebral compression (brain squeezed across structures inside the skull due to very high pressure causing displacement of brain tissue), acute obstructive [DIAGNOSES REDACTED] (normal drainage of spinal fluid out of the brain blocked causing increased pressure in the brain). In addition, she was diagnosed with [REDACTED]. The resident's prognosis was extremely poor, survival was not likely, the family had to make the decision to remove the breathing tube from the resident, and she expired on [DATE] at approximately 1:00 p.m. The facility's failure to provide oversight supervision to prevent injury and ensure that staff were knowledgeable of the Fall Prevention protocol, resulted in findings of Immediate Jeopardy, which was removed on [DATE] at 3:25 p.m. and the severity reduced to a D. The Nursing Home Administrator, the Regional Director of Clinical Services and the Director of Nursing were notified of the findings on [DATE]. Findings included: 1. Resident #1 was admitted to the facility on [DATE]. A review of the Face sheet showed [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 (indicating severe cognitive impairment). The resident required extensive assistance for bed mobility, transfers and walking. Record review of the 3008 hospital transfer form dated [DATE] showed the primary [DIAGNOSES REDACTED]. Resident was sent to the Emergency Department (ED) from her Assisted Living Facility after an unwitnessed fall event with evolution of lethargy during transport. The patient was evaluated in the ED without acute CT head findings, notation of acute kidney injury. Record review of physician orders showed, chair alarm on at all times when in wheelchair dated [DATE] and check placement and functioning of chair alarm every shift. Review of Haldol orders were as follows: Haldol 2mg / ml intramuscular (IM) every 4 hours as needed for agitation related to bipolar starting [DATE] and ending [DATE]. Haldol 5 mg / ml IM every 6 hours as needed for agitation for 2 days starting [DATE] and ending [DATE]. Haldol 10 mg every 12 hours for bipolar starting [DATE] and ending [DATE]. Haldol 10 mg at bedtime for bipolar disorder starting [DATE] and ending [DATE]. Haldol 5 mg in the morning for bipolar starting [DATE] and ending [DATE]. Haldol 5 mg at bedtime for bipolar starting [DATE] and ending [DATE]. Haldol 5 mg twice a day for bipolar starting [DATE] and ending [DATE]. Record review of Resident #1's care plans revealed the resident had the potential for injury related to history of falls, decreased mobility, gait / balance problems, poor safety awareness and psychoactive drugs use, initiated on [DATE] and last revised on [DATE]. The care plan showed the following [DIAGNOSES REDACTED]. Goals included the resident will not injure themselves in a fall through next review, initiated on [DATE], with a revision date of [DATE] and a target date of [DATE]. Interventions included: the resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach, date initiated [DATE] with a revision on [DATE]. Next intervention was anticipate and meet the residents needs initiated on [DATE]. Avoid repositioning furniture on [DATE]. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, initiated on [DATE]. Chair alarm in place at all times. Check placement and functioning every shift, initiated [DATE]. Investigate each fall to determine root cause as of [DATE]. Keep needed items, water, etc. in reach as of [DATE]. Medication review as of [DATE]. OT to evaluate (transfers, wheelchair mobility) and PT evaluate and treat as of [DATE]. Record review of the Admission /Readmission Data Collection with an effective date of [DATE] at 12:00 p.m. showed admission information date and time of admission as of [DATE] at 6:00 p.m. Admission form showed Section H. Functional Status as resident requiring total assistance of one for bed mobility and transfers. Section N. Safety, resident unaware of safety limitations or resistant. Fall Risk Evaluation performed showed Mental Status as 2. Disoriented times three at all times; History of falls as 2. ,[DATE] falls in the past 3 months; Ambulation / Elimination status as 2. Chair bound; Vision status as 0. Adequate; Gait Balance as 1. Unable to stand; Systolic Blood Pressure as 1. Unable to stand; Medications as 4. Takes ,[DATE] of these medications currently and / or within last 7 days; Predisposing Diseases as 2. ,[DATE] present. Total score of 10 or above deems resident at risk. Is the score of 10 or above? Answered No. Fall Risk Evaluation Form directs to total the corresponding numbers for a score, when added the resident was a score of 14 which deems the resident a Fall Risk. Interventions included frequent staff monitoring at night and visual and verbal reminders to use call light, side rails are indicated and serve as an enabler to promote independence. Writer Staff M, RN. Record review of SBAR (Situation, Background, Assessment and Recommendation) and progress notes showed: On [DATE] at 12:00 p.m., resident fell . The resident was confused. Resident had been sitting in her wheelchair or walking with it down the hallways. Resident was confused, and far away from the wall. She fell trying to stand up. Resident sent to the hospital for open wound on the right eyebrow, and said that she hurt all over. Family and physician notified. On [DATE] at 1:04 a.m., 8-hour note showed vital signs. Resident returned from hospital at 5:50 p.m. Resident had fallen on the floor [DATE] in the morning, and 911 was called and resident was sent to the hospital. Resident had a wound over her eyebrow with ,[DATE] stitches. Observed for edema in right eye and a hematoma. She required assistance in Activities of Daily Living (ADL's). Monitoring her closely for any change in condition. No complaints of referred pain. On [DATE], an Interdisciplinary Team (IDT) meeting progress note with Staff S, RN/Assistant Director of Nursing (ADON), MDS coordinator, and Unit Manager (UM), showed resident had numerous falls this past week. Resident tries to ambulate from wheelchair to hallway. Resident did have a fall in the hallway that resulted in a laceration to the right eye, and required stitches. Resident sent to the emergency room (ER). Written as a late entry on [DATE] by Staff M, RN. Record review of ARNP's nursing home progress note dated [DATE] revealed patient sustained a mechanic ground level fall on [DATE], landed on her right side and hit her head on the ground, sustaining a laceration to the right eyebrow. She was sent to the ER for evaluation. CT head was negative for acute changes. She received wound care to the right eyebrow with stitches and was returned to the nursing home. Patient does report pain, but she is unable to specify any location, she stated all over and is unable to describe the pain or give pain level. She just responds, Yes. Assessment / Plan included fall from ground level: fall precautions, transfer with assist and alert mate at all times while in bed and in wheelchair. Pt manic with psychomotor agitation, frequently trying to get out of bed on her own. Elderly resident who is restless and anxious appearing. On [DATE] at 7:47 a.m. per the SBAR, the resident was observed sitting on the floor. The physician notified. resident had a history of [REDACTED]. Resident had no apparent injury. Resident has decreased safety awareness. On [DATE], 8-hour note showed vital signs. Patient is stand up in few occasion from wheelchair put your Haldol IV. Bring all meds. She is high risk of fall observe closely. She is assists in ADLs. Continue with hematoma in right eye with stitches. (Review of Physician orders does not show Haldol as ordered IV). Record review of progress note for [DATE] at 11:15 a.m. showed Staff B, RN, spoke with the Advanced Registered Nurse Practitioner (ARNP) regarding recent fall ([DATE]) and resident's inability to sit still. ARNP ordered Haldol 5mg/1ml Intramuscular (IM) and stated that the resident's condition did not require the resident to be sent out (to ER). Record review of progress note for [DATE] at 12:40 p.m. Staff M, RN, unit manager per Staff S, RN, ADON's request spoke with ARNP and attending physician, about resident's numerous falls and to see if resident could be evaluated at hospital for a medical evaluation. ARNP stated that resident did not need to go out unless needed, and ARNP and physician would be in to see resident. Record review of progress note for [DATE] at 12:50 p.m. Staff M, RN, documented per ARNP, resident did not have an injury, so it was unnecessary to send to ER as she did not have an injury related to the recent fall. The fall was not justification for an emergency visit. SBAR on [DATE] at 10:41 a.m. showed found resident on the floor. Showed treatment for [REDACTED]. Other relevant information showed, multiple falls. Section C. Background showed resident had fallen multiple times in the last week. Most recent blood pressure on [DATE] at 9:16 a.m. was ,[DATE]. Assessment by the LPN revealed resident observed on the floor. She has had multiple falls and seems to not understand safety (BIMS score of 05 or severe impairment). Request included monitoring vital signs. Nursing Notes showed reported to RN that resident fell multiple times this weekend. Resident put into chair with chair alarm on, and placed into sitting area near nurses' desk. During medication pass, heard chair alarm sounding, and found resident on the floor. Resident did not have any external bleeding or bruising. Attending physician called on [DATE] at 10:00 a.m. and daughter-in-law called on [DATE] at 11:00 a.m. per Staff K, RN SBAR on [DATE] at 11:45 a.m. documented by Staff K, RN, revealed in Situation Section: reason calling was about resident falls, resident continuously getting out of chair despite alarm, and has a decrease in level of consciousness, which started on [DATE]. Since this started this has gotten worse. Things that make the condition worse are a decrease in level of consciousness. This condition has not occurred before. Other relevant information included resident had multiple falls, and fell this a.m. Background section revealed resident had a history of [REDACTED]. LPN Assessment showed resident appeared more confused and started shaking. Documented under requested orders, resident did not lose consciousness after fall. Nursing Note showed after fall this a.m. kept resident in wheelchair next to Staff K, RN during medication pass. Showed resident tried to get up twice after fall this a.m. Noticed bruising/edema on the left side of face. Per attending physician, send to hospital for a full work up / CT via non-emergency transport (BLS). While on the phone with non-emergency transport, resident started shaking and no longer responsive. Blood pressure taken and at first was ,[DATE] with pulse of 88, followed by ,[DATE] and pulse 83, and lastly ,[DATE] with pulse 84. Resident's oxygen saturation level was 97% so oxygen added for comfort. Non-emergency transport was canceled and 911/emergency transport was called. Family called on [DATE] at 11:24 a.m. attending physician was present on [DATE] at 11:15 a.m. On [DATE] at 12:27 p.m., Staff M, RN, unit manager spoke with nearest Hospital ER in regards to Resident #1's condition. Hospital stated that resident had a brain bleed and resident being intubated. Hospital wanted to know the contact information for resident's family. Writer provided family information to hospital. Staff M, notified Staff S/ADON, NHA, and attending physician who was here at the facility of the update. Record review of the fall Root Cause Investigation Report dated [DATE] provided by Staff S, ADON showed a date of occurrence of [DATE]. (Record review of clinical record does not show a fall occurrence on [DATE].) Details showed Resident #1 had both short term and long term memory loss; the resident was ambulatory with use of a walker and required assistance with transfers. Resident had multiple falls. Evaluation of Resident's environment showed chair alarm and slipper socks. What event was resident engaged in prior to fall, repeated attempts to get out of chair. Resident contributing factors were continued falls, sun-downing, anxiety, agitation, and restlessness and non-compliance with plan cannot educate. Identified patterns of Behaviors: repeatedly got up out of chair. Changes in dosages of medication revealed Haldol 2 mg every 4 hours as needed for agitation. Other factors and [DIAGNOSES REDACTED]. The summary included altered mental status. Resolution / Intervention for minimizing future occurrences: send out to hospital. The Five Whys Tool for Root Cause Analysis showed, problem statement as fell multiple times. Why, while walking. Why, wanted to go to bed/bathroom/no direct reason given. Why, chair alarm was on. Why, needs constant supervisor and/or alarm. Root Cause (s) were wanted to go to bed/bathroom and constantly trying to get up. 2. During an interview on [DATE] at 2:30 p.m., Staff K, RN, Resident #1's assigned nurse stated that on [DATE], the resident had been trying to get up. She stated the resident was sitting at the nursing station area. She stated that her chair alarm went off and she had an unwitnessed fall. She called the attending physician. She stated that she asked the physician if she wanted her to send the resident out for evaluation. She stated that the physician said, no, she was coming in and would evaluate her then at the facility. Staff K stated that she kept the resident with her for her whole medication pass. The physician came in and assessed the resident. Staff K stated that after a little bit (does not know how much time) her face started swelling and bruising. She stated that the physician was here in the facility and saw the bruising on her face. The physician stated to send her out non-emergency for evaluation. She stated the physician said she was stable and was singing, etc. While calling non-emergency transport, the resident started shaking and having seizure like movements. She stated that she hung up with non-emergency transport and called 911. She stated that she and the physician took the blood pressure three times. The resident was moved to her bed on request of the physician. She stated that both she and the physician waited with the resident until EMS / 911 came. When asked what she normally does when a resident falls, she stated that she would call the physician for orders, check the skin, provide first aid if needed, and if the resident was bleeding would send them out to the ER. When asked if she would perform neurological checks on a resident with an un-witnessed fall like Resident #1's fall, she stated that Resident #1's eyes were responsive. When asked where the neurological checks were documented in the clinical record, she stated that she did not know whether she documented them or not. During an interview on [DATE] at 4:55 p.m. with the NHA, Staff S/ADON, and Regional Director of Clinical Services it was revealed that the resident's attending physician and ARNP come together every day to the facility. They stated that the ARNP saw the resident prior to the [DATE] fall. They stated that the attending physician was with the resident after the [DATE] fall. Staff S/ADON and the Regional Director of Clinical Services verified a Fall Risk Assessment was to be done post every fall and verified one was not done after Resident #1's falls on [DATE] or [DATE]. They also verified the nurse was to perform neuro checks after an unwitnessed fall or a fall where the resident hit their head. They verified no documentation of neuro checks after the falls was found in the clinical record. During an interview on [DATE] at 11:55 a.m., the resident's ARNP for her attending physician stated that the resident was elderly and admitted to the facility for deconditioning (had multiple, potentially reversible changes in body systems brought on by physical inactivity and disuse. Commonly occurs in a sedentary lifestyle or bed or chair rest during an acute illness and can lead to disastrously rapid physical decline), skilled nursing, physical therapy and occupational therapy. The ARNP stated that the resident had advanced dementia, restlessness, and they had made reductions in her psychotropic medications due to drowsiness. He stated that they had reduced the Haldol but it had increased her restlessness. He stated that over the weekend she had some falls. He stated that the attending physician was here after the fall on [DATE]. He stated that the resident had some neurological changes of drowsiness and hypertension. He stated he understood she had swelling on the side of her face also. He stated that she had psychomotor agitation (a series of unintentional and purposeless motions that stem from mental tension and anxiety of an individual) due to medication changes and not due to the prior fall ([DATE]). He stated that she had a long history of psychiatric disorders. During an interview on [DATE] at 1:40 p.m. Staff L, CNA stated that she had Resident #1 on [DATE] She stated that she was on one-on-one in the TV room (unable to verify through interview with Staff S/ADON, schedules or documentation). She stated that when she got here that morning the resident was with therapy. She stated that they were not letting her stay in her room because she kept trying to get up. She stated that she did not see her fall, only heard about it. She stated that she saw another aide, Staff J, CNA taking the resident's blood pressure. She stated she knew the blood pressure was taken three times and kept getting higher. She stated they brought the resident back to her bed to lie down after she became stiff and shaking. The facility wanted her in the bed so when the EMS arrived they could transfer her to the gurney faster and easier. She stated that was the only day she had her, because she used to be on the other hallway. (on review of schedule, Staff L, worked [DATE] but was not assigned to Resident #1) Record review of the nursing staffing sheet dated, Tuesday, [DATE] revealed there was not a staff member assigned to provide one-on-one supervision on the 7 a.m. to 3 p.m. shift. During an interview on [DATE] at 2:10 p.m., Staff S/ADON when asked to clarify the statement by Staff L, CNA regarding the resident being on one-on-one in the TV room, she stated that Resident #1 was not on one-on-one supervision [DATE]. She stated that the nurses would bring the resident down to the nursing station / TV area to sit. She stated that the staff told her that the resident was sitting on the couch. She reviewed the schedule for [DATE] and stated that the resident had no one assigned to her for one-on-one supervision. She stated that the aide Staff L, CNA was referring to was working after the Resident #1 fall incident. She stated that all the aides on the schedule that day had room assignments. When asked if the facility provided one-on-one supervision for a resident, she stated for residents with behavior issues only. She stated that the facility does not provide one-on-one supervision as a fall prevention. When asked even if the facility was aware the resident was trying to get up and a high fall risk, she stated that they only provided one-on-one supervision for residents with behavior issues. When asked who makes the decision to put a resident on one-on-one supervision, she stated that the DON and NHA make those decisions. She stated that at the time of the falls, they had an acting DON, who is a Regional DON for the company. During an interview on [DATE] at 9:35 a.m. Staff J, CNA stated that she had Resident #1 on her assignment, [DATE]. She stated that she was already up and dressed for the day when she came on shift at 7:00 a.m. She stated that after breakfast she wheeled the resident to the nurses' station / TV area while she took care of her other residents. She stated that the resident fell around 10 a.m. She stated that a staff member told her the resident had fallen. She asked Staff K, RN, who told her the resident had fallen next to the couch trying to transfer from the wheelchair to the couch. Staff J, CNA stated that she took the resident's blood pressure and it was 148 over something, in the normal range. She stated that Staff K, RN called the physician and the physician told Staff K, RN, she would be in to check on her. Staff K, RN had her beside her while she was calling non-emergency transport. She stated that she saw the resident begin to shake and informed Staff K, RN. Staff K, RN looked to see if the resident had a seizure diagnoses. The resident by that time was non-verbal but her eyes were open. She had been laughing and joking about having a scar on one side of her head and a bump on the other prior. The attending physician was in the building and came over to the resident. She stated that the attending physician asked Staff J, CNA to take the resident's blood pressure, which was 199 over something. The physician asked Staff J what it was and when she told her, the physician asked her to repeat it. It was 2--- / 1--- (could not remember exact numbers). The physician told Staff K, RN, to send her out 911. Staff K, RN, called 911. She stated that the physician said it was something with the brain. Staff J, CNA, took the blood pressure again and it was 220 / 124. The physician asked the resident to squeeze her hands. Staff J, CNA, stated that at this point she was still trying to respond. While Staff K, RN, was on with 911, the physician said for us to lay her down in her bed. Staff K, RN, Staff L, CNA, and Staff J, CNA took her to her room in her wheelchair and transferred her to the bed. She was in and out of consciousness at this point. 911/ EMS was here within ,[DATE] minutes. When asked about her face swelling she stated that she had the stitches on the right side and a bruised quarter size swelling on the left side. She stated that she had a dent above her temple area, from hitting the couch she thought. She stated that the staff felt she hit her head on the corner of the couch because her head was toward the couch after the fall. She stated that she fell around 10 a.m. and sent out to the hospital around 11:30ish, before lunch. An interview on [DATE] at 11:45 a.m. with Resident #1's attending physician and ARNP revealed that they had been coming to the facility since [DATE]. They stated that they were hospital employees that come to the facility to see their residents that discharge from their hospital. The physician stated that she got a call that day ([DATE]), saying the resident had fallen. She stated that the resident had already fallen, hitting her head, and needed stitches. A CT was done at that time and she had no injuries and only needed stitches. The ARNP stated that the resident had psychomotor agitation and wanted to stand up and was restless. She had a long-standing psychiatric history and they were changing her medications due to her being drowsy. She had been admitted on Haldol 10 mg twice a day and it was being adjusted due to the drowsiness. The decrease in Haldol caused her to be more awake but also more restless. They stated that she was never aggressive. The ARNP stated that the facility called him over the weekend when she had fallen ([DATE]). He stated that her behavior issues were not a reason to send her to the hospital. The Physician stated that after the fall ([DATE]), they called her and the resident's blood pressure was very high, 200 over something. When she got to the facility, the resident was awake and talking to her. She stated that she told Staff K, RN to call non-emergency to transfer her to the hospital. She observed a bruise on the side of her head. After about 5 minutes, the resident started becoming unresponsive. The physician stated that she changed the order to calling 911/ EMS instead. She stated that the staff asked about giving her blood pressure medications, but she told them no due to it was most likely a brain bleed post the fall. The physician stated that she had them lie her down. The physician stated that her expectations were, the residents just need care, need attention; they don't always have the right staff or enough staff here. The ARNP stated that they had an alarm on the chair but obviously, the chair alarm was not enough. The physician stated that the resident probably needed one-to-one, but they do not usually do it even if requested by the physician. The physician stated that they have to have the judgement to make that call here at the facility (regarding one-on-one). The ARNP stated that he would like to see them use lap belts or lap buddies or something to help the ones that are fall risks as a reminder to not stand. During an interview on [DATE] at 12:18 p.m., the ARNP, stated that My understanding is that they do allow lap belts and lap buddies here but require consent from the POA. I would have been happy for them to do one-on-one. I was not asked. 4. Record review of the Fire Rescue Report dated [DATE] at 11:26 a.m. showed upon arrival, found resident lying supine on a hospital-type bed in care of nursing facility staff who reported that the resident had a fall this morning around 8 a.m. They also reported that the resident had a history of [REDACTED]. Resident was responsive to pain only. Resident had an older hematoma on the right temple and eye area with sutures in her right eyebrow. There was swelling and bruising in her left temple and eye area. Eyes non-reactive, nose, ears and throat within normal limits. Resident had a strong regular radial pulse and showed some minor movement of her hands and arms. No bleeding or abnormal masses noted other than the aforementioned injuries to her head. Blood pressure was very elevated. Stroke Alert called. At 11:44 a.m. blood pressure 247 /123, at 11:57 a.m. blood pressure ,[DATE]. Record review of hospital records dated [DATE] at 1:09 p.m. for Resident #1 reflected resident admitted post fall. Principal Discharge [DIAGNOSES REDACTED]. Resident admitted to the hospital with [REDACTED]. Resident seen by Neurosurgery. No intervention indicated. Resident seen by palliative care medicine. Patient was electively extubated and comfort measures only. Resident discharged on [DATE] at 1:13 p.m. Hospital Record review of History and Physical dated [DATE] at 2:52 p.m. showed resident found unresponsive on the scene. She had one episode of emesis. She only responded to painful stimuli. Resident's CT scan showed a massive subdural hematoma and placed on a ventilator. Hospital Record review of Admission Documents showed Final Impression of CT Head/Brain without contrast on [DATE] at 12:12 p.m., showed acute pan-hemispheric left subdural hemorrhage measuring 2.2 cm in maximal thickness. Mass effect on the left cerebral hemisphere and left lateral ventricle with entrapment and dilation of the right lateral ventricle. Plan showed extremely poor prognosis, survival not likely, improvement not anticipated, and needs palliative care medicine consultation. Hospital Emergency record showed on [DATE] at 11:55 a.m., resident presented with altered mental status. The onset was 4 hours ago and last unknown well 4 hours ago. Risk factors consisted of diabetes and hypertension. Presented to the ER for evaluation of altered mental status onset of 4 hours ago, that has progressively worsened. Last known well 4 hours ago. Per EMS, resident was well and at baseline per family this morning, and then fell at approximately 8:00 a.m. and she then had gradual decreasing mentation since, family called EMS. Resident unresponsive per EMS, posturing with some response to pain. One episode of vomiting on arrival to ER. Resident evaluated at this facility, status [REDACTED]. ER caveat secondary to altered mental status. Stroke alert paged from field. Hospital record review of Progress Note dated [DATE] at 12:54 p.m. showed had meeting with family explaining resident suffered a catastrophic brain bleed that has a poor outcome. She had a poor functional status at baseline. Discussed with the family the fact that was a minimal hope for recovery and they have requested withdrawal of care and terminally extubate her. Code status updated in record. Hospital progress note showed on [DATE] at 12:44 p.m. physician agreed with comfort measures only. Agreed with terminal extubation. Resident had no chance of recovery from this massive subdural hemorrhage. Hospice care. 5. Record review of the facility's policy, Fall Risk, effective [DATE] reflected to identify risk factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevent falls to the extent possible, residents will have a fall risk evaluation completed on admission/readmission and quarterly. Fall risk evaluation will be completed by licensed nurses on admission/readmission, quarterly, with significant change, and as needed. A resident wi

Based on clinical record review, policy and procedure review, job description review for the Executive Director I (Administrator) and interviews with staff, family and physicians, it was determined that the facility failed to be managed in a manner that enabled it to use its resources effectively. The administration did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and failed to ensure end-of-life health care choices were met for one (#3) of thirty residents with Do Not Resuscitate (DNR) orders and failed to provide oversight supervision to prevent injury and subsequent death from a fall for one (#1) of six residents reviewed for accidents and supervision. The clinical record for Resident #3 contained a physician's orders [REDACTED].#3 received CPR (Cardio [MEDICAL CONDITION] Resuscitation) as well as intubation, which were against the wishes of the HealthCare Proxy for a peaceful death with comfort measures only. The administration's failure to ensure that the expressed wishes related to advance directives, DNR orders, and the right to refuse treatment were honored and protected led to findings of Immediate Jeopardy, which was removed on [DATE] at 8:10 p.m. and the severity reduced to a D. The Nursing Home Administrator, the Regional Director of Clinical Services and the Director of Nursing were notified of findings on [DATE]. In addition, the clinical record for Resident #1 showed an elderly resident with [DIAGNOSES REDACTED]. The resident had decreased safety awareness, a high risk for falls, was known to stand up frequently from her wheelchair and was unable to protect herself from harm. Though the documentation clearly demonstrated Resident #1 displayed poor safety awareness and restlessness throughout the day, the facility administration did not ensure a safe environment and did not provide needed supervision for Resident #1 from [DATE] to [DATE]. Consequently, at approximately 10:00 a.m. on [DATE], the resident stood up from her wheelchair at the nursing station / day room without supervision and fell , hit her head on the couch and suffered a catastrophic left subdural hematoma (bleeding in the brain). Resident #1 was transferred to the hospital where she required intubation and was placed on a ventilator (breathing for resident) and later expired on [DATE] at approximately 1:00 p.m. from her injuries. The failure of the facility's administration to provide oversight supervision to prevent injury, ensure that staff were knowledgeable of the Fall Prevention protocol, and ensure the safety and well-being of residents resulted in findings of Immediate Jeopardy, which was removed on [DATE] at 3:25 p.m. and the severity reduced to a D. The Nursing Home Administrator, the Regional Director of Clinical Services and the Director of Nursing were notified of the findings on [DATE]. Findings included: 1. Record review of the facility's Executive Director I (Administrator), job description, not dated, showed 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 regulations that govern nursing facilities to ensure that the highest degree of quality can be provided to our residents at all times. Job Function: Responsible for day-to-day clinical and administrative activities of the facility, including ensures compliance with all state and federal regulations. You will also provide leadership to all facility staff in meeting goal of providing quality resident care. Duties and Responsibilities included: recruit, hire, and provide orientation / training for a sufficient number of qualified staff to carry out facility programs and services. Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal and other regulatory guidelines. Support and guide the facility's quality improvement process. Ensure a safe, clean and comfortable environment for residents, visitors and staff. Maintain a file for and monitor incident reports. Attend and / or conduct facility meetings, as required, to carry out responsibilities. Adhere to facility policies and procedures and participate in facility quality improvement and safety program. Attend to overall operation of the facility. Resident Rights included to ensure the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights are well established and maintained at all times. A review of the facility's policy, Advanced Directives-Nursing, dated [DATE] revealed the facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with Federal and State regulations. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident. Medical records must contain the Advance Directives discussion document and a copy of the proxy, living will, or power of attorney if they are available. Social Services will provide these for the clinical record. Follow these steps in an emergency situation: A. if a resident stops breathing or there is an absence of pulse or heartbeat, staff will check to determine whether a DNR order has been entered. B. if there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately .C. If a DNR order has been entered (and this has been verified by checking the resident's chart), CPR will not be administered. All normal comfort measures will be administered and the attending physician must be called. If the order required withholding life support measures such as respirators, or IV or tube feeding, the order is in accordance with his best medical judgement, that the resident is in a terminal condition and that he has considered the resident's wishes as expressed by the resident or through the appropriate substitute decision - maker (s) or the resident's next-of-kin. Staff must also notify the attending physician and the Administrator if a resident verbally expresses a desire to change or revoke his/her advance directives. Record review of the facility's policy, Fall Risk, effective [DATE] reflected to identify risk factors which place the resident at risk for falls and to facilitate the development of interventions to minimize or prevent falls to the extent possible, residents will have a fall risk evaluation completed on admission/readmission and quarterly. Fall risk evaluation will be completed by licensed nurses on admission/readmission, quarterly, with significant change, and as needed. A resident with a fall risk score of ten or more should be considered a risk for falls. Residents identified as risk for falls will have individualized prevention interventions added to the resident's care plan. Initiate appropriate intervention to reduce risk. Documented identified risk and intervention (s) in the resident's plan of care. 2. On [DATE] at 4:40 p.m. Regional Director of Clinical Services provided a list of 30 residents that were identified to have current Do Not Resuscitate (DNR) physician's orders [REDACTED]. She stated that these orders were in accordance with the resident's or their health care surrogate's choices for healthcare and medical interventions at the end of life. She stated that these residents would not receive CPR if they were found to be unresponsive and without pulse or respiratory effort. She stated that the facility was reviewing all the residents in the facility's medical record and filing the physician's written DNR order on the medical record. She stated that they had completed a 100% clinical record audit of all residents to ensure DNR / Full code status was correct. She stated that that they had reviewed all thirty residents having current DNR physician orders [REDACTED]. She stated that they had begun re-educating the licensed nursing staff regarding the facility's policy, Advance Directive-Nursing. Regional Director of Clinical Services stated that they had re-educated both the ,[DATE] shift and ,[DATE] shift. She also stated that they were calling the licensed staff at home and re-educating them on the facility's policy, Advance Directive-Nursing. She stated the nursing staff would not be able to work their assigned shift until after they had been re-educated on the Advance Directive - Nursing policy. Resident #3 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. The Face sheet showed [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE], quarterly, showed a Brief Interview for Mental Status score of 01 (severe impairment). Further review of the monthly orders present on the clinical record showed a Do Not Resuscitate physician's orders [REDACTED]. Record review of the facility form titled Designation of Health Care Proxy / Acceptance of Designation showed this facility may designate an individual who shall be responsible for making healthcare decisions on behalf of Resident #3. The form documented that the attending physician for this resident has conducted a physical examination and has determined that he/she is incapacitated and incapable of making his/her own healthcare decisions. This facility wishes to designate you as the Healthcare Proxy. The form was signed and dated by Resident #3's son on [DATE]. Further review of Resident #3's clinical record included a form titled Certificate of Incapacity, which showed that the physician had examined this resident. My examination includes a review of all medical records in the resident's medical chart. Based on my physical examination and review on the above mentioned records, I find that this resident is unable to make health care decisions for himself or provide informed consent to medical treatment. It is my medical opinion that there is no reasonable probability that the resident will recover competency to make healthcare decisions. The form was signed and dated by a physician on [DATE]. Record review showed another Certificate of Incapacity form was signed and dated by a physician on [DATE]. Record review of the Nursing Progress notes showed the following: On [DATE] at 5:11 p.m. Staff C, RN and Staff D, Licensed Practical Nurse (LPN), as a witness, discussed Advanced Directive with Healthcare Proxy. The Healthcare Proxy agreed to a DNR order and comfort measures only. On [DATE] at 11:30 p.m., Resident #3 was lying in his bed with a temperature of 103.5 degrees. Tylenol was given at 10:45 p.m. when his temperature was 104 degrees per Staff B, RN. On [DATE] at about 1:30 a.m., the resident observed lying in his bed responsive, Staff B, RN. On [DATE] at 2 PM (Documented in nursing progress note as 2 p.m.) A nursing assistant observed that the resident was not responsive. The resident had no pulse. 911 (EMS) was called and CPR started, per Staff B, RN. On [DATE] at 2:20 a.m., documented that the resident did not have a DNR on his clinical record at this time, per Staff A, LPN. On [DATE] at 2:20 a.m., advised by the aide that the resident was unresponsive and not breathing. Upon arrival to the resident's room it was noted an absence of vital signs. Respirations were zero. Blood pressure was zero. CPR initiated with the assistance of the aide and second nurse (Staff G, RN), per Staff A, LPN. On [DATE] at 2:25 a.m., CPR continued with vital signs absent. 911 (EMS - Emergency Medical Services) was activated at 02:20 and awaiting their arrival to the facility, per Staff A, LPN. On [DATE] at 2:35 a.m., EMS was on site. CPR continued by EMS. Resident intubated by EMS. Vital signs remain absent per Staff A, LPN. On [DATE] at 2:40 a.m., CPR continued by EMS. Vital signs remain absent. Staff A, LPN. On [DATE] at 3:12 a.m., contacted Healthcare Proxy. Provided funeral home. Per Staff B, RN. Record review of Code Blue Documentation, dated [DATE] revealed Staff A, LPN, called Code Blue at 2:20 a.m. Staff A, LPN, started CPR at 2:22 a.m. An AMBU (Artificial Manual Breathing Unit; ventilation) /mask used for ventilation. Vital signs were absent at 2:25 a.m., 2:30 a.m., and 2:40 a.m. Blood glucose drawn at 2:20 a.m. was 72. Documentation showed resuscitation terminated at 2:55 a.m. Code team that was present was Staff A, LPN, Staff F, CNA and Staff G, RN. Recorder documented as Staff A, LPN. Record review of Record of Death dated [DATE] showed cessation of vital signs. Pronounced by EMS at 2:50 a.m., physician notified at 3:00 a.m. During an interview on [DATE] at 3:35 p.m. Staff B, RN, stated that the ,[DATE] shift nurses had received a report that the Resident #3 was declining from Staff D, LPN. Staff D told her they were trying to retrieve the State of Florida DNR order yellow form. Staff D told Staff B that Staff A, LPN was looking for the yellow form in the resident's old chart. Staff B stated that she was told verbally from Staff D that he was a DNR. Staff B stated that the resident did not have a yellow form in his chart nor a physician's DNR order in the clinical record. Staff B stated that she went to Staff A as she was also working that night, staffing a medication cart. Staff A, LPN, said that she would go check on the yellow form. Staff B, RN told Staff A, LPN, that she would have to do CPR if she had not physically seen the yellow form. Staff B stated that an aide came and got her, stating that the resident was unresponsive. She called Staff A and another nurse for assistance. Staff B stated that she started performing CPR on the resident due to absence of pulse and respirations. She stated that she called 911. Staff B stated that she called the healthcare proxy also. Staff B stated that the Emergency Medical Services (EMS) came into the room and began the CPR for the facility staff. She stated that EMS tried to revive the resident but could not revive and the EMS pronounced him expired. She stated that the funeral home came to the facility to pick up the resident. Staff B stated that she did not see a State of Florida DNR order yellow form or a physician's DNR order in the clinical record. Staff B stated that she was looking for the yellow form regarding the resident's DNR status. During an interview on [DATE] at 4:45 p.m. Staff A, LPN, MDS coordinator, stated that an aide advised her that Resident #3 was not breathing. She stated that she went to his room and verified he did not have a pulse and was not breathing. Staff A stated that she went to the clinical record and verified the resident did not have a DNR order and started CPR. She stated that she was looking for the yellow form on his clinical record. Staff A stated that she did not look for a physician's DNR order on the chart, only the yellow form. She stated that after reviewing the clinical record and not finding a yellow form, she activated 911. She then stated that she went to the resident's room to perform CPR. She stated that the aide stayed in the room with the resident while she was looking in the clinical record for the yellow form. Staff A stated that EMS came about ,[DATE] minutes later. She stated that EMS took over performing CPR on Resident #3. She stated that EMS staff pronounced the resident expired. Staff A stated that another nurse called the family and physician. Staff A stated that on this night she was looking for the State of Florida DNR order yellow form. She stated that she has been in-serviced that they were to look for a physician's DNR order in the clinical record instead of the yellow form. During an interview on [DATE] at 1:45 p.m., Healthcare Proxy / family member for Resident #3 stated that his end of life wishes for his father was for comfort measures only. He stated that he did not want him resuscitated or CPR done. He stated that he only had days to go after coming home from the hospital. He stated that he passed in his sleep, he just quit breathing. When asked if the facility had done CPR on his dad he stated, No. When asked if the facility staff had called an ambulance for his dad, he said, No, they have people there at the facility at night to watch after him. When asked again if the facility had performed CPR on his dad, he said, No. when asked again regarding the calling of an ambulance, he again stated, No, he just passed in his sleep. During an interview on [DATE] at 10:54 a.m., the attending physician stated that he did not remember the details regarding Resident #3 specifically. He stated that the resident did have a DNR order. He asked the surveyor if the facility had the yellow form on the clinical record. The surveyor stated that the facility policy showed the facility was to follow the physician's DNR order, not the yellow form. He stated that the facility had to abide by their policy. He stated that actually the yellow form was for transfers to a hospital anyway. He stated that he was not necessarily on call when it occurred, but normally the facility just calls and says the resident passed away and can they release the body. He stated that if the resident had a physician's DNR order, the facility was not to perform CPR. He stated that Resident #3 did not survive and end up on a respirator but it was still not right that the facility performed CPR and attempted resuscitation. During a second interview on [DATE] at 5:42 p.m., Staff B, RN, was asked if she called the Healthcare Proxy about the passing of Resident #3. She stated that, yes she was the one that called the Healthcare Proxy, while they were performing CPR. She stated that she told the Healthcare Proxy that they had called 911 and that the response team had pronounced the resident dead. She stated that she was under the impression the Healthcare Proxy had made funeral home arrangements. She stated that she was unable to locate funeral home arrangements on the clinical record so she had to ask the Healthcare Proxy what he wanted to do. The Healthcare Proxy stated that he would have to call back. She stated that the Healthcare Proxy called back later about the funeral home arrangements. When asked again, if she had told the Healthcare Proxy about starting CPR on Resident #3, she stated that she told him the resident had passed, that EMS had pronounced him dead, and she needed the funeral home arrangements. She stated that it happened about a month ago and she does not remember word for word. She stated that she remembered speaking to the Healthcare Proxy. Staff B, RN was asked at least three times if she had told the Healthcare Proxy that the facility had performed CPR on Resident #3 and all three times, she did not give a definitive answer. Staff B, RN stated that she followed the policy that she had been taught, look for the yellow paper in the clinical record. She stated that obviously you are asking questions about CPR because we are not supposed to do it that way. During an interview on [DATE] at 6:20 a.m. Staff H, Certified Nursing Assistant (CNA), stated that she was working the night Resident #3 passed away. She stated she was not the resident's aide, but when the code was called, she went to the resident's room. She stated that she witnessed Staff A, LPN, Staff B, RN and Staff G, RN in the resident's room. She stated that they were performing CPR on resident. When asked the time of the incident, she stated it was between 2 and 3 a.m. During an interview on [DATE] at 6:22 a.m. Staff I, CNA stated that she was working the night of the incident. She stated that she did not have the resident but went to the resident's room when the code was called. She stated that she observed the resident lying in the bed and CPR being performed. She stated that Staff A, LPN, Staff G, RN and Staff B, RN were the nurses in the room. She stated that Staff A, LPN drew the curtain in her face and she walked out and went back to her unit. When asked why she thought Staff A, LPN, pulled the curtain in her face, she shrugged and stated because they didn't want me to see them doing CPR. She stated that there were no aides in the room at that time. She stated that Staff A, LPN, was on the right side of the bed, Staff B, RN, was at the foot of the bed and Staff G, RN was on the left side of the bed. During an interview on [DATE] at 8:12 a.m. the Social Service Director (SSD), stated that upon admission or within 72 hours she speaks with the family and/or resident regarding all the options they have regarding advance directives and provides them with resources. She stated that she assists them with making those choices and assists with their needs, notarizing, etc. She stated that usually they come from the hospital with the advance directive in place and the facility just verifies them. She stated that she performs an audit weekly reviewing the resident's advanced directives to ensure something was in place or if nothing was in place, that was still their wishes. If they do not have anything in place, we call them quarterly to see if anything had changed. She stated that this usually occurs at the quarterly care planning meeting or if they are not there, she will reach out to the family to ensure that was still their wish. She stated that it was documented in the quarterly assessment / SS progress review. She stated that she had only been here a little over a month. She stated that the prior SSD went to another building. She stated that the staff was educated in advance directives during orientation. She stated that part of the orientation that the SSD performs, was to go over the advance directives, resident rights, abuse and neglect with the new orientees. When asked if the the SSD monitors the system of ensuring resident's choice regarding advance directives are honored, she stated yes, on admission, and at least quarterly with care plan meetings and by review of the clinical records weekly. She stated that she also attends the Resident Council Meetings quarterly to review advance directives with them, that they have the right to choose. When asked about SSD documenting in the chart that Resident #3 was DNR and comfort measures only in February 2017, she stated that she was not here, but will look into it. The SSD never brought documentation to verify this statement in the SS progress notes from February 2017. 3. Surveyors performed interviews on [DATE] regarding the facility's Advance Directive policy. Five out of 16 nurses gave conflicting information regarding the facility policy. During an interview on [DATE] at 4:04 p.m., Staff R, RN, was asked what she would do if she found an unresponsive resident. She stated, First run to chart which would be under the doctor's orders in the chart. The DNR form, the DNR itself is in the doctor order section of the patients chart--it's yellow. The DNR on the yellow paper is the doctor's order. The signature and date make it official. When asked if she had any recent training. She stated, A couple of days ago. Where we need to keep the DNR. We don't keep it in the front of the chart--we keep it in chart under the doctor's orders section. The yellow paper is now kept in the doctor order section. During an interview on [DATE] at 9:57 a.m., Staff O, RN unit manager for long term, was asked what she would do if she found a resident unresponsive and without a pulse. She stated, I check not responsive, I start CPR, then I get someone to call 911, and then I verify in the record for DNR or advance direction, and notify the doctor. If I'm doing CPR and they find DNR, then I continue CPR and the doctor is called to say client found non responsive, started CPR and found a DNR order, does he want me to continue with CPR or stop. When asked if she had any recent training. She stated, No, my CPR certification is about one year old, and there hasn't been any facility training regarding DNRs. I was on vacation the last 12 days and this is my first day back. They would notify me of any training while I was gone by email. I arrived here at 8 a.m. and then had a staff meeting with the administrator and DON, discussing what's new in 24 hours. They discussed that now we need a doctor order for DNR on the record. It doesn't matter if there is a yellow form, we need a doctor order that specifies DNR or other advanced direction. After being told this, if I found someone non-responsive, I would verify doctor order before I start CPR. I just got the orientation changes a few minutes ago, and I know that for a non-responsive client that I have to verify orders. Specifically a doctor order or advance direction. During an interview on [DATE] at 3:16 p.m., Staff P, RN evening supervisor, was asked what she would do if she found a resident non-responsive. She stated, Going to assess patient first, and call out for someone to bring the chart physically. Then look to see if doctor signed and dated the yellow/orange DNR form. If it's signed and dated, then it's valid and not going to perform CPR. If you don't see a yellow paper, then the patient is considered full code, then call code blue, page 3 times overhead consistently with room number and bed, and the crash cart comes, and assignments are given. When asked if she had training recently. She stated she had received a verbal call at home on Monday. The procedure to get a doctors order if there isn't the yellow/orange paper yet. To go to the computer and see the doctor's order for the advance directive. They were explaining that if caught in the in-between time where the doctor's order was given, and in the computer, but no yellow paper, that finding that order in that computer is valid. During an interview on [DATE] at 3:40 p.m., Staff Q, RN, was asked what she would do if she found an unresponsive resident. She stated, First I stay with the patient, then I send a co-worker for the chart. I look in the front of the chart. The DNR is yellow, but full code is regular paper. After checking the front of the chart, I call 911 if there is a DNR or full code. If the patient is full code, then I start CPR with 911 coming. When asked if she had recent training. She stated, Yes, in orientation they said to check in the chart if DNR or full code, it will be in the front of the chart. About ,[DATE] weeks ago there was a paper to sign about CPR. I read and I review CPR. The DON brought an in-service talk with me, and then another, and another. Refresh about CPR. She said to review the chart for DNR or full code on the first page of the chart. DNR is yellow and full code is regular paper. During an interview on [DATE] at 9:40 a.m., Staff N, LPN, when asked what she would do if she found a resident unresponsive and without a pulse. She stated The first thing, I'll check to see if breathing, take pulse, if not, then I'll say code blue and call out for help, and then I'll go check the chart to see what status they are because I'm not going to start CPR without checking their status. When asked how she would identify the resident's Code status, she stated, Look all over their chart to see if there is an order. First, I'll look for the yellow paper, if I don't find the yellow paper, then I'll look for the doctor's orders. If I find a yellow paper, then I check to see if it's signed. If it's signed, then it's all legal. If the yellow paper is all signed like it's supposed to be, then I'll go to the patient and check to see if no pulse and breathing and heartbeat. When asked if she had had any recent training. She stated, Yes, it was just last year, my CPR training. The facility did a training on DNR's a couple of months ago, and sometimes they'll do a simulation--they have someone appear non-responsive and then they'll call the code and see what people do next. No more recent training than that. When asked what was discussed in this training? She stated, What was done wrong, what could be done better. To check the pulse and respirations, then leave CNA with resident, then we go to see their status, bring crash cart just in case. We check the chart book, and we find the status in their DNR and their physician's orders [REDACTED]. If I don't find it, then I look in the orders. If it's not in one place, it will be in the other. During an interview on [DATE] at 4:50 p.m., Regional Director of Clinical Services, NHA, and Regional Vice President acknowledged that 5 out of 16 nurses that had been interviewed had given conflicting information regarding the Advance Directive policy regarding following the physician's orders [REDACTED]. They stated that the five nurses would be re-educated regarding the policy. On ,[DATE] and [DATE], the 5 nurses were re-interviewed, and were able to verbalize the facility policy. Seventy-three percent of the nursing staff was interviewed and able to voice the Advanced Directive Policy. During an interview on [DATE] at 2:15 p.m., Regional Director of Clinical Services, stated that they had an ad hoc meeting on [DATE] regarding the Advance Directive issue. She provided the agenda. The Nursing Home Administrator (NHA) and Regional Director of Clinical Services, RN stated that they had the meeting to address DNRs. Regional Director of Clinical Services stated the meeting lasted approximately 30 minutes. The attendees included the NHA, Regional Director of Clinical Services, Medical Director, ADON / interim DON and rehab director. The ad hoc meeting occurred because of the complaint survey, which alerted them to the problem with performing CPR on Resident #3. It was to put a plan into place from [DATE]. The plan included checking the advance directive status of the residents weekly, for the SSD to be educated on the process, to educate the nursing staff on the advance directive policy, to print out all DNR orders from electronic chart system and file into clinical record for easy access during an incident. When asked, the NHA and Regional Director of Clinical Services stated that they had not self-identified the DNR issue prior to the complaint survey. Regional Director of Clinical Services stated that she had looked at death records. She stated that they needed to improve on documentation of DNR but they had not noticed any serious issues. The NHA stated that our self-identifying at morning meetings should capture the issues. The morning meeting will identify residents with current physician DNR orders and any change in physician DNR orders will be discussed. Also, any change in a resident's or family wishes regarding advance directives will be discussed in morning meetings. The prior DON did not look at discharge records. The nurses did the discharge form only; they did not do a discharge progress note on discharge. A lot of documentation education is needed, regarding discharges also. An interview on [DATE] at 3:54 p.m. with the Medical Director, M.D., revealed she has been medical director at the facility for three years. She stated that this was her first time as a medical director. She was an Infectious Disease Specialist and was chief of IDD at a local hospital. She stated that she was the Medical Director due to her affiliation with the college, she thought. She stated that if a resident were to be admitted at midnight, the nurse would call and verify orders including the DNR status. She stated that she felt the staff was confused about the yellow paper versus a physician order. She stated that they do verify all the orders on admission. She stated that the last Social Services Director (SSD) was very obsessive-compulsive about the yellow papers. She stated that the prior SSD said the yellow paper confirmed that the doctor had a conversation with the resident or family about the DNR status, so the facility wanted the yellow form. She stated that(TRUNCATED)