Every finding on record at Aviata at Grand Oaks

Based on record review, interview, and facility policy and procedure review, the facility failed to ensure residents' refunds were refunded within 30 days after discharge for 1 (Resident #1) of 4 residents sampled for timely discharge refunds. The findings include:Record review for Resident #1 showed the resident was discharged /deceased on [DATE].Record review of the Transaction Report by effective date [DATE] through [DATE] (printed on [DATE]) for Resident #1 showed a total due from Resident Liability of ($2,853.16). (Copy obtained)On [DATE] at 10:35 AM, the Business Office Coordinator stated she had been at the facility for only a few weeks and was unaware Resident #1 had not received a refund. During the interview, the Administrator stated he has worked at the facility since [DATE]. He acknowledged that he was aware of two separate families unrelated to Resident #1, that were due refunds and have now been paid. The Administrator stated he was not familiar with a letter sent about Resident #1 refund but confirmed that the refund was not yet verified or issued. The facility has accounts for deceased residents still showing money. The plan is to contact the beneficiaries of these residents to issue the checks. The payment timeline would take 7-10 days to get the regional office involved and process checks.Review of an email from Director of Business Office Services to Administrator dated [DATE] at 12:32 pm, revealed the facility planned to issue a refund to Resident #1's son in the amount of $2,853.16 with an anticipated date of [DATE]. (Copy obtained)Review of the facility's FL admission Packet/admission Agreement (no date) section 5. Refunds: revealed: The Center will refund any overpayment due to the Patient within state and or federal guidelines. In the event of the Patient's death or discharge, refunds and any of the Patient's personal property remaining in the Center will be returned to the Patient, Patient's estate, or other person authorized by law pursuant to state and federal law. (Copy obtained)Review of the facility's policy and procedures titled: Refunds - Accounts Receivables revision date: 2/2022, revealed Policy: Upon confirmation that an overpayment was made on a resident's A/R account, the Business Office shall process a refund according to state regulations or according to payer guidelines. Procedure: After refund balances are verified, the Business Office shall begin the refund workflow process. Private Pay: Once a refund has been confirmed with supporting documentation and account notes, a check or electronic retraction will be issued. If a refund check is needed, the Business Office should submit a request on the A/R Refund Workflow for processing; located on the Company Intranet portal> My Apps>AR Refund Workflow. 1. The Business Office initiates the original request through the AR Refund Workflow with supporting documentation. 2. The AR Refund Workflow system then prompts an email notification to the next authorized approver that a refund request is pending review. (Copy obtained)

Based on resident and staff interviews, review of facility and resident records, and a review of the manufacturer's instructions for Resident #1's rolling walker, the facility failed to ensure that Resident #1 received adequate supervision and sufficient safeguards to prevent an avoidable accident. Staff failed to understand the proper use of the resident's rollator which resulted in Resident #1, one of seven residents reviewed for accidents, falling backwards and striking his head on the cement sidewalk. This failure resulted in a traumatic subarachnoid hemorrhage requiring three days of monitoring in the Intensive Care Unit (ICU) at an acute care hospital.On 04/06/2026 at approximately 10:35 AM while on a group nature walk/resident outing, Resident #1 was walking on the sidewalk using his four-wheeled walker (FWW)/rollator with oversight/assistance from the Social Services Director (SSD). Resident #1 became tired and sat down on the seat of his walker. The SSD began pushing him down the sidewalk toward the facility while he was sitting on the walker facing her. The wheels of the walker caught on a gap in the sidewalk, the walker stopped abruptly, and the resident fell backwards, striking the back of his head against the cement sidewalk. This resulted in a traumatic subarachnoid hemorrhage requiring hospitalization from 04/06/2026 through 04/09/2026 with monitoring in the intensive care unit due to the risk of neurological deterioration. The SSD had not been trained on resident safety regarding the use of resident mobility devices. The facility's therapy department and the Administrator stated non-clinical staff members were not provided any training on resident safety, yet these employees were escorting/supervising residents during facility outings.Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on 05/11/2025 at 1:25 PM.On 04/06/2026, Immediate Jeopardy began.On 05/13/2026 at 3:30 PM, the Administrator was notified of the IJ determination. An IJ template was provided, and Immediate Jeopardy was ongoing as of the survey exit on 05/13/2026.The findings include:A review of Resident #1's medical record revealed an admission date of 05/29/2024 with a transfer to an acute care hospital on [DATE] and a re-entry on 04/09/2026. His diagnoses included traumatic subarachnoid hemorrhage (bleeding between the brain and the tissues covering it, caused by a physical head injury such as a fall) without loss of consciousness, type II diabetes, dementia, muscle weakness, hypertension (high blood pressure), and generalized anxiety disorder. A review of the resident's active physician's orders revealed:-Acetaminophen (over-the-counter pain reliever for mild to moderate pain) Oral Tablet 325 mg (milligrams), two tabs every six hours as needed for pain/temp (temperature), start date: 04/10/2026-Assess for pain every shift, start date: 04/10/2026-Norvasc Oral Tablet 10 MG (Amlodipine Besylate - a prescription medication that widens and relaxes blood vessels, making it easier for the heart to pump blood). Give one tablet by mouth QD (daily) hold for HR <60 (heartrate of less than 60 beats per minute (BPM) related to hypertension, start date: 04/11/2026A review of the active care plan (revised 9/15/2025) revealed that the resident was at risk for falls related to gait/balance problems and general weakness. Interventions included anticipating and meeting the resident's needs. There were no care plans addressing mobility needs, assistance required from staff or mobility devices used. A review of the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/09/2026, revealed that the resident was usually understood by others, usually understood others and had a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment. He used a rolling walker for assistance during mobility and required supervision or touching assistance from staff while walking.A review of the resident's most recent Transfer Mobility Status assessment, dated 12/08/2025, revealed that the resident required oversight, encouragement or cueing with a gait belt (a belt worn by resident and used by staff as a secure handhold to safely support a resident with mobility or balance issues) used for mobility.A nursing progress note dated 04/06/2026 read, Resident #1 had a fall while returning from the activity at the park at approximately 10:30 AM, when the resident became tired on the walk back and decided to sit on his rollator, the rollator flipped over. Vital signs reviewed, Neuro (nervous system) WNL (within normal limits), Full ROM (range of motion) of all extremity, no open areas were observed, hematoma (severe bruise with a lumpy texture) to the back of the head was noted, Resident got himself up and proceeded to walk to the facility, with the provider notified and new orders to send to ER (emergency room) for CT (imaging test that creates cross-sectional images of the inside of the body) scan.A nursing progress note dated 04/07/2026 revealed that Resident #1 was kept at the hospital for observation and was noted to have a three-centimeter (about 1.5 inches) bleed.A nursing progress note dated 04/09/2026 revealed that Resident #1 returned to the facility post-acute care due to a fall and had a subarachnoid hemorrhage.A review of the hospital's Critical Care Discharge summary, dated [DATE], revealed that Resident #1 was admitted to the hospital's emergency department on 04/06/2026 after a fall while out on a nature walk where he was being pushed backwards. This fall resulted in traumatic brain injury/subarachnoid hemorrhage which required monitoring in the ICU for neurological deterioration and advanced age. During his hospital stay he demonstrated decreased safety awareness, impaired judgement, decreased balance and endurance, and required prompting and supervision for activities of daily living (ADLs). Hospital Occupational and Physical Therapy evaluations revealed the resident was moderately disabled and required contact guard (touching the resident without bearing their weight) or supervision for transfers, ambulation and ADLs due to decreased balance and endurance. The resident was able to ambulate 85 feet with a front-wheeled walker and contact guard assistance, but he exhibited global weakness (generalized weakness), impaired mobility and confusion regarding the reason for his admission and the events surrounding the incident.In an interview with the Social Services Director (SSD) on 05/11/2026 at 12:10 PM, she stated she had been working in her role as the SSD since February of 2025. She and the Social Services Assistant volunteered to assist with resident activities including community outings. She said recently they had a picnic at the park, and before that they went on a nature walk. She denied having received training on resident safety and/or assistance with mobility devices. She was unaware of the facility's procedure for locating resident mobility and safety care needs, specifically while escorting them out in the community. She could not explain what the facility's policy was for community outings, or whether the facility had a policy, even though she volunteered for the resident's nature walk to the park on 04/06/2026 and was assigned oversight of Resident #1. She reported that towards the end of their walk Resident #1 became tired, so she had him sit on his rollator walker. She stated she began pushing him and was not thinking. She probably should have gotten a wheelchair, but she continued to push him along the sidewalk. The rollator hit an uneven part of the sidewalk pavement and Resident #1 tipped backwards and fell hitting his head on the sidewalk. In an interview with the Activities Director on 05/11/2026 at 12:52 PM, she stated she had been employed by the facility for two and a half years. She planned the activities calendar for each month. The facility usually had one community outing scheduled per month. Most recently she reported they wheeled residents to the park up the street for a picnic, and the month prior they went on a nature walk. The management team assisted with pushing the residents down to the park, and when they needed to come back, the managers were texted to assist getting them back to the facility. During the nature walk last month (April), there was an incident that she did not witness because she was all the way in the front of the group, but a resident was walking with one of the managers, got tired, sat on his walker and fell, but that's all she could say about the event. She confirmed that prior to this incident, she never received training on resident safety, assistance with resident mobility or proper use of mobility equipment, but that after this incident, training rolled out educating staff not to sit a resident on the walker facing them and push them on the walker. This was dangerous and there should always be a wheelchair available.On 05/11/2026 at 3:35 PM, Resident #1 was observed seated in a dining room chair in the dining/activities room. He was alone and was dressed in shirt, sweatpants, socks and house slippers. He had his blue, four-wheeled rollator walker positioned off to his left side. He smiled when greeted and stated he was unable to recall how long he had been living at the facility. He could not recall having had any falls or hospitalizations. When he was asked if he went out on walks to the park, he reported that he did not know and he could not remember.In an interview with the Director of Rehabilitation on 05/11/2026 at 4:42 PM, she reported that she had been employed by the facility for almost two years. She confirmed that the therapy department did not participate in or provide staff education or training, including new employee orientation or post-incident training. She further stated the therapy department provided no specific information to staff about resident safety, mobility or transfers. She confirmed that the therapy department was currently working with Resident #1 since his return to the facility after his fall incident on 04/06/2026 during a resident outing.In an interview with the Assistant Director of Nursing/Staff Educator on 05/12/2026 at 9:04 AM, she reported working in her current role for under two years. She said she was responsible for new employee/staff orientation, annual training and nursing competencies. She reported that all staff went through dementia training, elopement training, and bloodborne pathogens. The certified nursing assistants (CNAs) had their own competencies, and non-clinical staff such as the Social Services Department and Human Resources Department participated in training about hand hygiene, dawning and doffing PPE and infection control, and fall prevention that included keeping things within the residents' reach, keeping resident rooms clutter free, and cleaning up spills on the floor. Safe mobility techniques were discussed only with the clinical staff. She denied providing any training to staff (clinical or non-clinical) about mobility and safety during resident community outings prior to the recent incident involving Resident #1.In an interview with the Administrator in Training (AIT) on 05/12/2026 at 10:10 AM, he reported starting his AIT program at a different facility/location with the same company and then transferred to this facility with the current Administrator in December of 2025. He stated training he received during new employee orientation did not include fall prevention education. He stated he shadowed the activities department in the first facility he worked in and they trained him on resident transfers; however, this facility had not. He stated he could not recall what the procedures were for resident community outings; however, he did volunteer for both community outings, the nature walk (April 2026) and the picnic in the park (May 2026), where he was assigned his own resident to supervise while on each outing. He confirmed that no discussion took place prior to the outing, and no coordination of resident care needs took place. He confirmed that he witnessed Resident #1's fall on 04/06/2026. It was toward the end of the nature walk when he saw the SSD unsafely pushing Resident #1 on his walker. The AIT was approximately 20 feet away and noticed they were slowing down, so he waited but said nothing. When he reached the facility on the sidewalk, he saw the SSD hit a gap/bump in the sidewalk and Resident #1 started falling backwards. The SSD tried to break his fall, but it happened too fast and the resident fell to the ground. The Administrator came to make sure Resident #1 was okay and saw that his head was on the ground. Nursing was contacted, they came and assessed Resident #1 prior to getting him up and asked him questions. He responded well and was ready to get up and walk back to the building, though he had a bruise on the top of his head. The AIT confirmed that no training was offered to staff regarding safety during community outings and stated he felt better coordination for the activity should have occurred. The length of the walk was too long; someone should have done some recon (reconnaissance - gathering of information about the target area prior to the event) of the walk with a plan discussed prior to the outing, but that didn't happen. No one walked the route to see what the walk would even be like. On 5/12/2026 at 11:04 AM, an interview was conducted with the Business Office Manager who stated she had been in her position a little over a year. Upon hire, she received abuse and neglect training but denied receiving any fall/accident prevention training or safe mobility/transfer assistance training in her current role. She said she had volunteered when there was a resident activity or event. She said she was asked at the last minute to assist with the nature walk in April because there weren't enough staff for the event. She did not know the resident she was assigned to supervise during the walk; all of the residents going on the activity were gathered in the front foyer of the facility and she was asked to just pick someone, so she did. The walk was approximately 15-20 minutes long and almost one full mile. They completed a scavenger hunt, they stopped at the picnic tables, went over the scavenger hunt paper, then turned back toward the facility. She reported not being familiar with her assigned resident's specific care needs or any information about their mobility care needs or assistance required. She said she did not witness the incident with Resident #1 and his walker, but if she saw someone getting pushed on a walker that way she would say something because it's not safe and the incident involving Resident #1 could have been avoided if the walker was being used safely and appropriately. On 05/12/2026 at 12:12 PM, an interview was conducted with the facility's Administrator, who reported that he attended the nature walk as a volunteer on 04/06/2026. It was the first outing since his arrival at the facility in November of 2025. Extra staff were needed for the outing at the last minute, so he was assigned to supervise a resident while on the walk. He did not witness the incident involving Resident #1, but he did assist after the fall. He reported that there was no facility policy for them to follow for external resident outings, so this was a lesson learned and little changes were made but nothing in writing. This would be discussed in the next QAPI (quality assurance and performance improvement) meeting. His said his expectation for staff leaving the facility with residents was that they were properly supervised with safety measures maintained throughout the event. He said this was not in place prior to the 04/06/2026 event with Resident #1, so going forward, once it was determined that residents needed special or different interventions or care, staff would be educated about the best way to manage their care/safety while out on the event; wheelchairs would also be brought along. This was the first event, and we don't have a strong policy on this. He further reported that all staff attending and assisting during the nature walk would mostly be department heads/management. Some would be clinical, and he was okay with that. He confirmed that emergency Ad-Hoc meetings were held on 04/16/2026 and 4/20/2026 and the Medical Director was not in attendance, but he did brief them on the incident. He stated the Medical Director did not state one could not push a resident on a walker, only that the resident could only be pushed in one direction and that was with the resident facing staff (sitting backwards). Moving forward, wheelchairs would be used. He stated staff were not prepared and no one walked the nature walk prior to the scheduled outing to determine the length and time it would take the residents to make the round trip or the supplies/equipment needed. On 05/12/2026 at 1:13 PM, a telephone interview was conducted with the Medical Director. He confirmed having been made aware of the 04/06/2026 incident involving Resident #1 immediately. He said he was told that the resident fell backwards from a rolling walker and hit his head, so we sent him to the hospital for further evaluation. He reported attending the facility's QAPI meeting but couldn't recall the date. He further stated that if he did not attend in person, he joined via telephone. When he was asked if having a resident pushed while seated on a four-wheeled walker was considered safe practice, he replied, If a patient needs to sit down in the facility to rest, but outside, I don't think it's safe to do that. Small wheels would hit every nook and cranny, and if on a sidewalk, the walker would go right over.In an interview with the Director of Nursing (DON) on 05/12/2026 at 2:38 PM, she said she recalled having been notified that Resident #1 had fallen. She said she responded immediately with a team and assessed him, then the Unit Manager called to inform the family, and EMS (emergency medical services) was contacted for a transfer to the hospital for a CT scan because he hit his head. She reported that prior to the incident, the resident used a walker independently for mobility. She further stated it was dangerous for a resident to be pushed while seated on a wheeled walker, but she was never educated not to push a resident on one, and she had never seen a policy or education regarding the use of walkers. She said the nature walk was poorly planned, and she was made aware of the event 10 minutes prior to the residents leaving the facility when they were asking department heads to volunteer. She confirmed she was aware that none of the non-clinical staff had received training on resident safety and mobility assistance, even though they were escorting the residents during the outing. In a follow-up interview with the Administrator and DON on 05/12/2026 at 5:15 PM, they confirmed that after the 04/06/2026 event involving Resident #1, education was provided to the staff about residents who used wheelchairs/rollators and was ongoing. The Administrator reported that aside from the Ad-Hoc meetings and the education provided to staff, nothing else had been done/implemented. They were unable to produce documented verification of the interventions they described. Initially, they were focused on the incident as a fall, and only a fall, not that the fall could have been prevented. They said that now they saw issues with their planning and process for activity outings, or any outings including medical appointments, home visits, etc. The DON confirmed that they continued to educate staff about mobility transfers and safety for external activities, but they could not produce documented evidence.A review of the Guardian, Medline Industries. Basic Steel Rollator With 6 Rolling [NAME] User Instructions and Warranty at https://www.medline.com/media/catolog/Docs/MKT/MAN, (revised 10/13/2017 and accessed on 05/13/2026 at 1:00 PM), Page 2 read: Not to be used as a wheelchair. Seat Cautions: Do not use the seat to transport people or objects.The facility was unable to produce policies and procedures to review for resident supervision and assistance with mobility devices, or resident supervision and assistance while on community outings.

Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system for its current census of 103 residents. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. The findings include: An interview was conducted on 5/07/25 at 2:39 p.m. with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated she had been in this position for ten (10) months. She further stated Maintenance was responsible for the facility's water management program. She provided a policy on Legionella along with education that was provided to the nursing department staff. An interview was conducted on 5/8/25 at 1:20 p.m. with Employee A, Regional Plant Operations. He stated the Legionella policy that the ADON/IP provided was only for the clinical side. He stated the Water Management policy was what was needed for the facility's Infection Control (IC). He was asked about the facility's measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility's water system, as well as a way to monitor the measures they had in place and established ways to intervene when control limits were not met. He stated there were no logs or measures. He stated they would test if there was a suspected concern. He then contacted Employee B by telephone (speaker), who he identified as the facility's Infection Control Plant Supervisor. Employee B immediately stated there was no requirement for the facility to test water temperatures. He stated there was nothing in the American Society of Heating and Air-Conditioning Engineers (ASHRAE) nationally accepted standards that stated it had to be done. He was asked for evidence that the facility was doing/monitoring what was outlined in their policy and procedure titled Water Management Program Document Name: S-314 effective 9/18/2018, Revision Date: 2/23/2020. He was asked how the facility monitored the measures they had in place and established ways to intervene when control limits were not met. Employee B confirmed there were no tests. He again stated this was not an ASHRAE requirement. Employee A also confirmed that there was no evidence of control measures i.e., visible inspections, disinfectants, temperature controls, etc. A review of the facility's policy and procedure titled Water Management Program Document Name: S-314 effective 9/18/2018, Revision Date: 2/23/2020, revealed the following: Procedures included: B.) Assess potential problems before they endanger the domestic water supply system through a preventive maintenance process (TELS). TELS preventive maintenance program consists of the following items designed to maintain the domestic water system: 1. Daily temperature checks for hot water in the resident care areas, kitchen, and laundry areas. 2. Routine preventive maintenance of all mixing values used to provide proper hot water temperature used within the facility. 3. Routine operational checks for all water circulation pumps used to provide water throughout the facility. 4. Routine preventive maintenance for cleaning of A/C drain lines and condensation pans to ensure they remain clean. 5. Routine maintenance on all roof drains including any pitch pans. 6. Routine maintenance on all facility installed drinking fountains. Fountains are to be disinfected daily by housekeeping services. 7. Routine maintenance of domestic in-line water filters, water softener systems, including ice machine filters. 8. Routine maintenance of any decorative water fountain, including proper chlorination of the water supply. 9. Routine maintenance of all wells supplying domestic water to a facility. 10. Routine maintenance of any facility that utilizes a cooling tower to generate HVAC within a facility. D.) Establish water safety control limits (ex. temperature and disinfectant levels) and where control limits should be applied. Develop responses and ways to intervene when measurements are outside the established limits. The following NSPIRE policies or protocols apply: a. Safety and Facilities Management Hot Water Temperature Policy b. Dietary Policy for disinfection of three-compartment sinks c. Housekeeping disinfection policy for water fountains d. Housekeeping policies for disinfecting shower rooms, including tubs and showers e. Testing of decorative water fountains for water chlorine levels as required f. Notifying management whenever any of the control limits fall outside the parameters of safe operating conditions.

Based on record review, interviews, and a review of facility policies and procedures, the facility failed to ensure that residents with mental disorders were appropriately assessed on admission or as needed to determine the need for specialized services for four (Residents #21, #32, #89, and #42) of five residents reviewed for Preadmission Screening and Resident Review (PASRR). The findings include: 1. A review of the medical record revealed that Resident #21 was admitted to the facility on [DATE] with diagnoses including bipolar disorder and depression. A review of the quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 2/1/25, revealed that active psychiatric disorders were noted as depression and bipolar disorder. A review of the Level I PASRR dated 3/1/22, revealed that Section #1 was not completed to indicate the resident's diagnoses. (Copy obtained) 2. A review of the medical record revealed that Resident #32 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, major depressive disorder, schizophrenia and dementia. A review of the quarterly MDS with an ARD of 4/11/25 revealed that the resident's active psychiatric disorders were noted as anxiety disorder, major depressive disorder, schizophrenia and dementia. A review of the resident's Level I PASRR, dated 8/6/15, revealed that it did not include the resident's diagnoses of schizophrenia, depressive disorder, or anxiety disorder. (Copy obtained) 3. A review of the medical record revealed that Resident #89 was admitted to the facility on [DATE] with diagnoses including schizophrenia and depression. A review of the resident's Level I PASRR, dated 3/13/25, revealed that it did not include the resident's diagnosis of schizophrenia. An interview was conducted on 5/6/25 at 10:43 a.m. with the social services director who stated PASRRs were reviewed upon admission to ensure availability and accuracy. She further stated they were discussed during the clinical meetings held each morning to ensure that the resident had a PASRR that was accurate based on the resident's diagnoses. She stated they made sure it was uploaded into the resident's electronic chart, and that if there was a change or additional information was obtained, then they determined whether or not a Level II PASRR was required. 3. A review of the medical record revealed that Resident #42 was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder, persistent mood disorder, anxiety disorder, psychosis and dementia. A review of the resident's active physician's orders revealed the following orders: Depakote 125 milligrams (mg), give 2 capsules two times a day (BID) for mood disorder (3/28/25). Trazadone 50 mg, give half a tablet for major depressive disorder (4/14/25). Alprazolam 0.25 mg for anxiety (4/25/25). A review of the resident's Level I PASRR, dated 2/5/24, revealed that Section I had the following diagnoses checked off: Depression and anxiety. Under Section II #3 b. Concentration, persistence and pace: The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks was marked Yes. Section IV of the PASRR screen completion indicated that the resident was admitted to the facility with serious mental illness. During a 5/7/25 interview with the Care Liaison at 3:54 p.m., he stated he had been employed by the facility for a year and half. He stated he reviewed the PASRRs upon residents' admissions to ensure that they did not trigger for a PASRR Level 2 and to ensure that all PASRRs were completed. If there were concerns with PASRRs, he notified the clinical team. He stated when a resident experienced a change while at the facility, the clinical team reviewed the PASRR and updated it accordingly. During a 5/7/25 interview with the Director of Nursing (DON) at 4:13 p.m., she stated PASRRs were reviewed the next business day following a resident's admission during the clinical meeting and as needed if a resident had a change in diagnoses or behaviors that might trigger a Level II PASRR. When asked if there was a protocol/process in place to review (and revise asneeded) current residents' PASRRs for accuracy, she replied that when she started working at the facility, the corporate team and the social worker reviewed the PASRRs for all residents in the facility. She was then asked to provide the PASRRs for the residents identified with concerns. On 5/8/25 at 10:17 a.m., the regional director of social services stated during her audit, she identified concerns with the PASRRs and was working out a process to review all PASRRs. She confirmed that the PASRRs for Residents #21,#32, #89 and #42 were inaccurate. A review of the facility's policy and procedure titled Preadmission Screening and Resident Review (PASRR) Document Name: SS-402 Revision Date: 11/08/2021 Original Date: 11/08/2021, revealed: Policy: The Center will assure that all Serious Mentally III (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 2. If an individual is declared exempt from a PASRR screening, the Center should make sure that appropriate documentation is on the chart upon admission. Individuals who are exempted from this assessment include: a. Those who are admitted after a release from an acute care hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery. b. Those who are certified by a physician as to be terminally ill with a 6-month prognosis, and are not a danger to self or others. c.Those who are comatose, ventilator dependent, functions at significantly disabling Parkinson's Disease, Huntington's Disease, Amyotrophic Lateral Sclerosis, CHF or COPD. d.Those with a diagnosis of dementia or its related disorders with detailed documentation supporting this diagnosis. 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. 6. Recommendations will be incorporated in the individual resident's plan of care and approaches/interventions developed to meet the identified needs of the individual. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records.

Based on a review of resident records, facility reports, staff interviews, and the facility's policies and procedures titled Advance Directives and Florida Cardiopulmonary Resuscitation (CPR), the facility failed to act in accordance with the resident's Advance Directives and his Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to honor Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:34 p.m. on [DATE]. On [DATE], at 7:35 a.m., Immediate Jeopardy began. On [DATE], at 5:30 p.m., the Interim Administrator/Associate Regional [NAME] President of Operations (ARVPO) was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and after verification of the removal of immediate jeopardy, the scope and severity were reduced to D, no actual harm, with a potential for no more than minimal harm, due to the facility's nursing staff failing to provide cardiopulmonary resuscitation (CPR) to a resident with a CPR order. The findings include: Cross Reference F678 A closed record review for Resident #1 found he was admitted to the facility from an acute care hospital on [DATE] for short-term skilled care, with an expected discharge home with his spouse. He had diagnoses including acute systolic congestive heart failure (the left ventricle cannot contract normally), chronic respiratory failure with hypercapnia (the body has too much carbon dioxide in the blood and cannot rid itself of the excess), acute pulmonary edema (fluid buildup in the lungs making it difficult to breathe), chronic obstructive pulmonary disease (COPD, lung disease causing restricted airflow and breathing problems), and atherosclerotic heart disease of the native coronary artery without angina pectoris (a buildup of plaque on the inner walls of the heart arteries, causing narrowing and blocking blood flow, without chest pain). A review of the Death in Facility Minimum Data Set (MDS) assessment with a reference date of [DATE], revealed that Resident #1 expired on [DATE]. A review of the resident's medical record revealed physician's orders dated [DATE] for Full Code Status and a plan to discharge home. (Photographic evidence obtained) A review of the medical record's nursing progress notes revealed the following: On [DATE] at 10:04 a.m., Registered Nurse (RN) A/Weekend Supervisor (in training) charted that at approximately 7:35 a.m., a code (Code Blue - used to announce a resident is unresponsive) and 911 were called for Resident #1. RN A immediately responded and assessed the resident to be pulseless, apneic (involuntarily and temporarily stopped breathing), unresponsive, and cool to the touch. It was noted that CPR was performed for approximately 15 minutes. Code called by this RN. Calls placed to ADON (Assistant Director of Nursing) and DON (Director of Nursing). EMS (Emergency Medical Services) entered the building at approximately 8:15 a.m . at 8:20 a.m. as deceased (sentence incomplete). Call placed to wife. (Photographic evidence obtained) On [DATE] at 5:15 p.m., Licensed Practical Nurse (LPN) B noted that the CNA (Certified Nursing Assistant A) for Resident #1 entered his room and found the resident unresponsive. CNA A advised LPN B, who immediately checked the chart for a Do Not Resuscitate (DNR) status while the nurse on the 200 hall, LPN A, called the Code Blue and 911. The resident did not have a DNRO (do not resuscitate order). CPR was started and continued for five rounds, for approximately 15 minutes until 7:50 a.m. Patient's body was stiff and rigid. Cold to touch. Registered Nurse (RN) on duty notified the ADON and Administrator. Re-started CPR at 7:54 AM. EMS re-called; patient pronounced deceased 8:20 a.m. (Photographic evidence obtained) A review of a facility report generated by the Nursing Home Administrator (NHA) on [DATE] at 6:48 p.m. alleging neglect, declared that on [DATE] at approximately 7:35 a.m., Resident #1 was observed by CNA A to be unresponsive. CNA A notified LPN B, who immediately retrieved Resident #1's medical record and discovered the resident was a Full Code. LPN A verified the Full Code status, paged Code Blue on the overhead speaker and notified 911. LPN B went to the room and RN A arrived with the crash cart. RN A assessed the resident as cool to the touch, pulseless, and apneic. His digits were blue. CPR was immediately initiated and performed for approximately five rounds/15 minutes. RN A then stopped CPR to notify the NHA of the incident but was instructed to continue CPR. The CPR was stopped for approximately ,d+[DATE] minutes, then resumed. EMS (emergency medical services) arrived at the facility and placed leads on the resident, who was found to be without a pulse. EMS pronounced the resident deceased at 8:20 a.m. An update to the report on [DATE] at 9:56 p.m. revealed that from [DATE] to [DATE] between the hours of 11:00 p.m. and 6:00 a.m., CNA B stated Resident #1 was seen at 11:00 p.m., then called for assistance at 12:30 a.m. and again at 3:00 a.m. At 6:00 a.m., the resident was noted to be sleeping in his bed. On [DATE] at 5:00 a.m., LPN F stated I was in there often throughout the night. He kept taking his CPAP off. His O2 (oxygen) sat (saturation) was ,d+[DATE]%, but he kept taking it off, and I kept redirecting him. At 5:00 a.m., I gave him meds (medications) and he was fine. He wasn't wearing the mask, but he was awake. (Photographic evidence obtained) As part of the facility's investigation, written statements from licensed staff on duty the morning of [DATE] were obtained. A review of the statements revealed the following: CNA A noted that she started passing drinks at 7:30 a.m. in room [ROOM NUMBER]. When she got to [Resident #1's] room, she tapped his foot, called his name and shook his arm, but got no response. She told LPN B he was not responding. By the time she got back to the room, RN A entered. CNA A waited outside until ordered by RN A to start post-mortem (after death) care. RN A noted that Resident #1 was pulseless, apneic, unresponsive, and cool to touch. CPR was performed for approximately 15 minutes. RN A called the code, and the ADON and DON were called immediately. EMS entered the building at approximately 8:15 a.m. and pronounced the patient deceased at 8:20 a.m. In a second written statement by RN A, also on [DATE], she added that Resident #1 was apneic, pulseless, cool to the touch, and with blue lips, fingers, toes and ears. CPR was performed per protocol and despite the RN's assessment, for approximately 15 minutes. Resident #1's oxygen was running but the nasal cannula was not on his face. RN A pronounced the resident deceased secondary to no life response. She turned EMS away the first time they arrived, as she was unaware that she was not permitted per facility protocol to pronounce a resident deceased . She dispatched EMS again, and they returned at 8:15 a.m. EMS assessed the resident as deceased and pronounced his death at 8:20 a.m. In a second written statement on this day by RN A, she added that she conducted CPR for 15 minutes, then pronounced the resident's death. LPN B wrote that CNA A advised her that Resident #1 was unresponsive. LPN B checked the chart while LPN A called 911. The resident did not have a Do Not Resuscitate Order (DNRO). CPR was started for five rounds for approximately 15 minutes until 7:50 a.m. The resident's body was stiff and cold to the touch. RN A notified the ADON and NHA. CPR was restarted at 7:54 a.m. EMS was called and pronounced the resident's death at 8:20 a.m. LPN A wrote that while passing medication on the 200 hall, the 500 hall nurse told her a CNA advised that the Resident #1 was expired. She immediately ran to check the chart for the resident's code status, then called 911. While on the phone with 911, the nurse supervisor (RN A) came and told her she had it handled. LPN D wrote that when she responded to the hall for the Code Blue call, the RN supervisor told her she was not needed. LPN C noted that she heard the overhead page and ran to check the resident's chart, but they were already checking. Then the nurse supervisor stated they had it handled. The NHA noted that she called the county's Emergency Medical Services to request reports. She was advised that they were dispatched at 7:50 a.m. for CPR in progress but were made aware that the resident had rigor and the nurse had called it, so they left. They were called back 15 minutes later as CPR had been resumed, since they (the nurse) were unable to pronounce the resident's death. When EMS arrived, they placed two leads on the resident and pronounced him deceased at 8:20 a.m. LPN E wrote that she heard the Code Blue announced and walked toward 500 East. Her partner nurse was coming back and said, they don't need us. She then noticed the 911 truck and went to see what happened. The RN supervisor (RN A) was walking out of the room and told East Wing staff to cancel 911, he is already cold. (Photographic evidence of all statements obtained) On [DATE], additional statements from follow-up interviews were noted by the ADON and revealed the following: RN A explained that her new employee orientation Friday ([DATE]) was fast because the facility needed her. She got no training, just a stack of papers to sign, and then was sent with LPN A to shadow her on the medication cart. On Sunday ([DATE]), she heard the Code Blue called and responded, finding Resident #1 lifeless. She sent responding nurses away because there was nothing to code. No one wanted to take charge, and everyone was looking at her for what to do. She did the best she knew how to do. RN A said she had pronounced bodies 100 times. After turning EMS away, the other nurses told her she shouldn't have done that. RN A asked why not, pointing out the fact that the resident was expired. RN A left the room and texted the NHA, DON and ADON. When they arrived, everyone started taking statements. LPN B told RN A the NHA said they had to lie and say they did CPR, or they could lose their licenses. CPR was never done, not once. RN A said, I wouldn't do that to a dead body; you wouldn't want that done to your loved one. LPN B admitted everything she said in her previous statement was true but added that she was told by the NHA to say they did CPR, or she would lose her license. LPN B admitted they never performed CPR, as the resident had been dead for a long time. RN A pronounced his death and said it would be defiling a body to do CPR. LPN B wrote that EMS said the resident had to have been dead for two to three hours. RN A pronounced his death at around 7:48 a.m. LPN D explained that she was the 400 hall nurse and responded to the Code Blue overhead page. She went to the resident's room and RN A reported the patient died , nothing could be done, and LPN D wasn't needed. LPN D asked, Don't we have to do CPR? RN A advised, He's been dead for a while and there's nothing we can do. I pronounced him. LPN D returned to her unit. CNA C stated she heard the Code Blue and responded. There were five CNAs outside of the resident's door and two nurses were in the room; one was the RN supervisor (RN A). CNA C asked, Are we doing anything? No one responded. The RN supervisor came out of the room and said there was nothing they could do; he'd been gone too long. (Photographic evidence of all statements obtained) On [DATE], the Regional [NAME] President of Operations (RVPO) generated a follow-up facility report that included an analysis of the event and detailed the findings of the facility's investigation. In the summary of interviews conducted, the newly identified discrepancies from the original witness statements were noted. They were summarized as follows: LPN B now stated that on [DATE] at 7:30 a.m., after responding to the resident's room, the RN on duty was in the room and said the resident was expired, had been dead, and there was nothing to code. LPN B told the RN the resident was a full code. The RN said, There is nothing to code.; that (performing CPR) would be defiling a body. The RN directed the CNAs to start post-mortem care and stated she would notify everyone and had it handled. RN A heard a Code Blue called and ran to the resident's room. The resident's oxygen tubing was on the floor with the oxygen concentrator running. The resident was lying supine (on his back) with no pulse, no respirations, no response, stiff, cold to touch, lips, ears, fingers and feet were all blue. RN A applied a stethoscope for apical pulse; none was noted for one minute and still no respirations. RN A stayed in the room until EMS arrived for the first code. She stopped them to report the resident was deceased . Nurses were responding to the room, but RN A sent them away because there was nothing to code. CPR was never done, not once. (Photographic evidence of both statements obtained) The report's conclusion was that as a result of the investigation which had been conducted by the Regional Nurse Consultant (RNC), the allegation of neglect was substantiated. (Photographic evidence obtained) A review of the facility's policy and procedure for Advanced Directives (document SS-124, effective [DATE] and revised [DATE]) revealed: Policy: The center will abide by state and federal laws regarding Advance Directives. The center will honor all properly executed Advance Directives that have been provided by the resident and/or resident representative. Process: 1. Upon admission, Social Service Director or Business Development Coordinator/designee will: a) Communicate to resident and/or resident representative his or her right to make choices concerning health care and treatments, including life sustaining treatments. 4. Upon completion of the Advanced Directives Discussion Document, Social Services or nurse will notify the Physician of the resident ' s wishes and procure a state approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record. 5. Advanced Directives will be reviewed: - Quarterly - Hospice Admission - 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 or modify approaches. Any changes to Advanced Directives will require a new Advanced Directives Discussion Document to be completed and placed in the medical record. The previous document to be filed in the thinned record. (Photographic evidence obtained) The facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR) (document N-301 effective [DATE], revised [DATE]) revealed: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 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. (Photographic evidence obtained) An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:05 p.m. She advised that she was not present the day of the event but said RN A was supposed to be in orientation. She chose to take herself off orientation and help out on the floor. Company policy when finding a resident unresponsive is to check the code status, call Code Blue, and perform CPR (if full code) until EMS arrives, even if there are apparent signs of death. EMS will put the leads on and make that call. Nurses are not allowed to pronounce residents' deaths. An interview with CNA A on [DATE] at 7:10 a.m., revealed that on [DATE], she was assigned to rooms 504 to 509 and began her shift with passing drinks. At approximately 7:30 a.m., upon arriving at room [ROOM NUMBER], she greeted Resident #1, but there was no response. He appeared to be sleeping, but when she lifted his hand it just dropped, and he felt cold. She alerted CNA D, who confirmed Resident #1 appeared deceased , and together they notified LPN B. When CNA A, CNA D, and LPN B arrived back at Resident #1's room, RN A was already there. LPN B announced that the resident was a full code, however RN A refused to perform CPR and ordered CNA A and CNA D to start post-mortem care. EMS was seen outside the door but was leaving without entering the room. While providing post-mortem care, RN A announced, CPR should've been performed and EMS allowed in. She then stood over Resident #1 and performed pretend CPR with hand movements over his body. EMS returned and were informed by the nursing staff that CPR was performed for three minutes, however, CPR was never performed. Later, CNA A reported she was approached by LPN B, who stated they needed to keep their stories straight, and say CPR was performed for three minutes. The NHA was interviewed on [DATE] at 11:25 a.m. She recalled being asleep that Sunday morning when RN A called her to report finding Resident #1 deceased . The NHA asked if the resident was a full code. When told, yes, she instructed RN A go start CPR now. When she arrived at the facility, she approached LPN B, the resident's assigned nurse, and asked what happened. LPN B did not respond. LPN B then said RN A stopped it. The NHA asked, What do you mean? This is your patient, right? LPN B then said the resident was deceased ; that she ran in and started CPR, then RN A called it and called the NHA. RN A went back into the room and re-started CPR. The NHA thought to herself, Ok, well at least CPR was done. The NHA started writing her facility report while the ADON interviewed staff, including LPN B and RN A. Those statements were all she had to write in the first report. Corporate then asked for the statements to be amended to include Resident #1 being cold, blue and rigorous when found. The following Monday ([DATE]), the ADON came to her and said the timeline wasn't adding up; that her gut was telling her the nurses were not telling the truth about starting CPR. The Regional Nurse Consultant (RNC) came in the next day and took over the investigation. The NHA never spoke with anyone else after that. On Wednesday, the RNC told her CPR was not, in fact, started. The NHA responded, What the f*** are you talking about? The RNC explained the CNA came forward and admitted LPN B had called them all together and told them they needed to have a plan and come up with a statement before the NHA and the ADON got to the facility. Then, LPN B and RN A stood over the body and pretended to perform CPR. LPN B then blamed the NHA for saying they had to come up with the false statement. That did not happen! The NHA explained that she thought, after reminding LPN B that Resident #1 was her resident and her responsibility, LPN B may have panicked and told this whole story about starting CPR. CNA A was the only one who told the truth about LPN B saying, We've got to come up with a statement, make up a story. I worked hard for that license. The RNC was interviewed on [DATE] at 12:00 p.m. After reiterating the findings in the facility reports as above, he stated the only thing they knew for sure was that CPR was not started. He called it a series of unfortunate events. The Medical Director (MD) was interviewed on [DATE] at 2:10 p.m. He said the NHA advised him of the situation on the day of the event. There was now a question about whether the CPR was performed. Resident #1 was diagnosed with COPD and CHF. His chances of recovery were minimal, but he was a full code. CPR should have been initiated. The nurse acted on her own. The MD stated a nurse like this could damage a building for years. It was a mistake by this nurse that affected the whole building. He said, This is a setback. It is so sad. On [DATE] at 2:13 p.m., an interview with CNA D revealed that on [DATE], she was approached by CNA A regarding Resident #1. She went with CNA A to room [ROOM NUMBER] where she agreed that Resident #1 appeared deceased , and she notified LPN B. Upon returning to the room, RN A was already there, turning staff away telling them that he was gone already and she was calling it. LPN A, LPN C, LPN E and RN A began arguing back and forth because the resident was a full code. No one initiated CPR. RN A initiated not real CPR while LPN A, LPN B, LPN C and LPN E stood watching at the door. CNA D again stated, CPR was never initiated for [Resident #1]. When the Administrator arrived, she was pressuring CNA D for a statement while the ADON tried to come up with a story to cover things up. LPN C was interviewed on [DATE] at 3:09 p.m. She stated when she responded to the Code Blue call for Resident #1, the supervisor lady (RN A) was in the room with her phone in hand. Lots of people were at the door. The supervisor (RN A) said, Don't worry about it, we got it. An interview conducted on [DATE] at approximately 3:15 p.m. with CNA C revealed that on [DATE], she responded to a Code Blue call for room [ROOM NUMBER]. Upon arrival, she observed multiple nurses and CNAs in the room, but nothing was being done. CNA C asked if anyone was going to do anything because the resident was a full code, but she was informed by RN A that there was nothing they could do. EMS showed up but got turned away by RN A before seeing Resident #1. LPN G was interviewed on [DATE] at 3:25 p.m. She stated the facility protocol when finding anyone unresponsive was to first check the resident's chart to see if a DNRO was in place. Two nurses must verify the code status for anyone discovered with cardiac/respiratory arrest. If the resident was a full code, staff were to start chest compressions. Someone grabbed the crash cart and called 911. Even in the presence of obvious signs of death, CPR was to be initiated. CPR could never be stopped until medics or a doctor arrived. She was not, as a nurse, permitted to pronounce anyone's death. RN B/Unit Manager was interviewed on [DATE] at 3:32 p.m. The facility policy if a resident codes is to get help. Two nurses check the chart and if a full code, someone calls 911, and someone gets the crash cart. Don't stop CPR until paramedics get there and take over or pronounce. You are absolutely not allowed to pronounce a resident death as a nurse. Even with obvious signs of death, if the resident is a full code, CPR is started. During the survey, the facility volunteered its Quality Assurance Performance Improvement (QAPI) plan and Performance Improvement Plan (PIP) developed in response to the incident. The plan was reviewed with the RVPO, ARVPO, DON and RNC on [DATE] at 4:30 p.m. The DON explained that the QAPI committee met monthly and included the Medical Director and all department heads. Departmental surveillance and data were used to identify trends that might need improvement plans. Floor staff, resident grievances and resident council meetings were also used to identify concerns. Once identified, concerns were delegated to appropriate departments and a performance improvement plan (PIP) was developed. Depending on the issue, the situation was monitored until compliance was achieved, preferably total compliance. The RNC contributed, explaining that following the incident, an Ad Hoc QAPI meeting was conducted on [DATE] and the PIP was developed. The data was gathered, and a root cause analysis was determined. Initially, the root cause analysis focused on a lack of orientation training for RN A, the new supervisor. This was the primary focus. RN A was oriented on Friday and was supposed to be orienting that Sunday but ran off on her own. That is where they felt maybe they could have done something differently. In response, all resident code statuses were checked and found to be accurate. The initiation of the Code Blue response the day of the incident was also deemed correct. But then, the false information presented and forced a revisit. Another Ad Hoc QAPI meeting was conducted on [DATE] with the discovery of false information. False documentation was also identified. A separate plan was developed to focus on ethics and compliance; how to now address unethical behavior and staff response. Being the only RN in the building on the day of the event, staff felt it would be insubordination to reject her directives. They were re-educated on that. Staff were trained on Advance Directives (AD), and they made sure all licensed staff were aware of what that meant, as well as the situations during which Advance Directives should be honored. Staff were trained in the facility's CPR policy, including when to start CPR. An audit of CPR certifications for nurses was performed and now all nurses were American Heart Association (AHA) certified. Abuse and neglect training was provided building wide. Scheduled deviations were covered too, since RN A had effectively removed herself from facility orientation. The ARVPO added the focus was currently on policing themselves and resulted in another root cause analysis and evaluation of processes. The second QAPI was conducted about the corporate compliance program with a focus on staff notification (of non-compliance) and filing concerns without fear of retaliation. It also included what to do if someone asked a staff member to do something unethical. Code blue drills were still being conducted with all licensed staff participating. Staff had been retrained, or received the information packet, on Code Blue response and drills. There was a QAPI meeting scheduled for tomorrow ([DATE]), and the PIP would be re-evaluated. Weekly Advance Directive audits were being conducted, and the facility would continue reviewing nurses' CPR status and licensure. This was all added to the orientation process. Classroom training for new nurses would be audited to ensure completion. CPR tests were provided to validate the nurses' understanding of policies with 100% of nurses passing. On [DATE] at 1:03 p.m., LPN B was interviewed and explained that on the day of the event, RN A was training with her. The CNA came and told her that Resident #1 was deceased and stiff. One nurse called the Code Blue, and someone called EMS. LPN B went to the room after RN A ran in. The resident was in full 100% rigor, stiff as a board, and had been dead for a while. RN A decided there was nothing they could do. Nothing would have brought him back; they would have broken all the bones in his body (had they initiated CPR). It was too late. LPN B admitted they did not perform CPR. She told RN A that facility protocol was to provide CPR. RN A called the NHA who instructed her to call medics and get back in the room and perform CPR. It had been 30 minutes since they had discovered the body at this point. The NHA was more concerned about what was going to happen to the facility and wanted RN A to lie. When the NHA arrived at the facility that day, she told LPN B, You know, this could affect your license. She threatened LPN B that she would lose her nursing license. The NHA insinuated that they had to lie and was asking pointed questions such as, This happened, right? LPN B said she felt cornered and threatened, as though she had no choice but to do what the NHA wanted her to do. Then the NHA would not let LPN B leave until she went over her documentation to make sure it included everything the NHA wanted it to include. She stated again that no one ever started CPR. The resident was in full rigor. When EMS came back, they said he had been dead for at least three hours. LPN B told the truth when she talked to the RNC. She stated, Was it wrong for me to document what I did? Yes, it was. LPN B concluded, saying she was afraid not to follow the NHA's instructions. The ADON was interviewed on [DATE] at 2:25 p.m. She recalled being in bed the morning of the event and receiving a message from RN A. RN A reported finding Resident #1 and pronouncing his death. The ADON and NHA arrived at the facility around 9:00 a.m. and interviewed LPN B. LPN B was initially vague about what happened, then the NHA said, This is your resident, he was your responsibility, you need to explain what happened. LPN B then said after CNA A found Resident #1 deceased , RN A went to the room. LPN B went for the chart and LPN A paged the Code Blue. LPN B said they then performed the required five rounds/15 minutes of CPR on Resident #1. The ADON had never heard of this required 5 rounds of CPR, but LPN B repeated this several times. LPN B said due to obvious signs of death, RN A pronounced the resident. RN A called the NHA and was advised to resume CPR, so she returned to the room. They reportedly resumed compressions until paramedics arrived. The ADON and NHA interviewed RN A, who told the same story about the required five rounds/15 minutes of CPR before pronouncing Resident #1's death. After going home that evening and thinking about the timelines more closely, the ADON realized they did not line up. The CNA's testimony did not line up with 15 rounds of CPR being performed and the time the phone call came from RN A that she had pronounced the resident's death. There was no way five rounds could have been performed. On Monday ([DATE]), the ADON reported this to the NHA, and they called corporate and reported their suspicion that CPR had not been performed. The RNC arrived on Tuesday to take over the investigation. Upon speaking with the CNA, she admitted CPR was not performed. Instead, the nurses stood over the body arguing. LPN B and RN A eventually admitted this too in subsequent interviews. RN A was interviewed on [DATE] at 3:45 p.m. She said this was the first time she had experienced anything like this. Her background was in hospitals, home health and acute care settings, and she had been a nurse for [AGE] years. RN A said she was hired as a nursing supervisor and oriented with LPN A on a medication cart on Friday ([DATE]). They had 20 residents and she had never experienced that. A lot of the residents required a lot of care but did not get it because there were not enough staff. She felt unsafe right away. The second day she came in there were not enough nurses. She and an LPN had 60 residents and they were on the medication cart. She was given no administrative orientation. She did not know anyone's name, role, or facility guidelines. RN A did what she did in the hospital or would have done at home that day. She did what she was trained to do. She was the highest licensed position in the building but was expected to act in a supervisory role even though she was in orientation. When she entered Resident #1's room, he was supine with his oxygen tubing on the floor and the concentrator running. His bipap/cpap machine was on the bedside table. It was off and the mask was on the table. His hands, fingertips, lips, face and feet were blue, and the body was cold, rigid, and firm to the touch. RN A said she had pronounced hundreds of people. A lot! People responded to the Code

Based on a review of resident records, facility reports, staff interviews, and the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR), the facility failed to provide CPR for one resident who was a Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to provide CPR according to Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:34 p.m. on [DATE]. On [DATE], at 7:35 a.m., Immediate Jeopardy began. On [DATE], at 5:30 p.m., the Interim Administrator/Associate Regional [NAME] President of Operations (ARVPO) was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was removed, effective [DATE]. The facility remained out of compliance, and after verification of the removal of immediate jeopardy, the scope and severity were reduced to D, no actual harm, with a potential for no more than minimal harm, due to the facility's nursing staff failing to provide cardiopulmonary resuscitation (CPR) to a resident with a CPR order. The findings include: Cross Reference F578 A closed record review for Resident #1 found he was admitted to the facility from an acute care hospital on [DATE] for short-term skilled care, with an expected discharge home with his spouse. He had diagnoses including acute systolic congestive heart failure (the left ventricle cannot contract normally), chronic respiratory failure with hypercapnia (the body has too much carbon dioxide in the blood and cannot rid itself of the excess), acute pulmonary edema (fluid buildup in the lungs making it difficult to breathe), chronic obstructive pulmonary disease (COPD, lung disease causing restricted airflow and breathing problems), and atherosclerotic heart disease of the native coronary artery without angina pectoris (a buildup of plaque on the inner walls of the heart arteries, causing narrowing and blocking blood flow, without chest pain). A review of the Death in Facility Minimum Data Set (MDS) assessment with a reference date of [DATE], revealed that Resident #1 expired on [DATE]. A review of the resident's medical record revealed physician's orders dated [DATE] for Full Code Status and a plan to discharge home. (Photographic evidence obtained) A review of the medical record's nursing progress notes revealed the following: On [DATE] at 10:04 a.m., Registered Nurse (RN) A/Weekend Supervisor (in training) charted that at approximately 7:35 a.m., a code (Code Blue - used to announce a resident is unresponsive) and 911 were called for Resident #1. RN A immediately responded and assessed the resident to be pulseless, apneic (involuntarily and temporarily stopped breathing), unresponsive, and cool to the touch. It was noted that CPR was performed for approximately 15 minutes. Code called by this RN. Calls placed to ADON (Assistant Director of Nursing) and DON (Director of Nursing). EMS (Emergency Medical Services) entered the building at approximately 8:15 a.m . at 8:20 a.m. as deceased (sentence incomplete). Call placed to wife. (Photographic evidence obtained) On [DATE] at 5:15 p.m., Licensed Practical Nurse (LPN) B noted that the CNA (Certified Nursing Assistant A) for Resident #1 entered his room and found the resident unresponsive. CNA A advised LPN B, who immediately checked the chart for a Do Not Resuscitate (DNR) status while the nurse on the 200 hall, LPN A, called the Code Blue and 911. The resident did not have a DNRO (do not resuscitate order). CPR was started and continued for five rounds, for approximately 15 minutes until 7:50 a.m. Patient's body was stiff and rigid. Cold to touch. Registered Nurse (RN) on duty notified the ADON and Administrator. Re-started CPR at 7:54 AM. EMS re-called; patient pronounced deceased 8:20 a.m. (Photographic evidence obtained) A review of a facility report generated by the Nursing Home Administrator (NHA) on [DATE] at 6:48 p.m. alleging neglect, declared that on [DATE] at approximately 7:35 a.m., Resident #1 was observed by CNA A to be unresponsive. CNA A notified LPN B, who immediately retrieved Resident #1's medical record and discovered the resident was a Full Code. LPN A verified the Full Code status, paged Code Blue on the overhead speaker and notified 911. LPN B went to the room and RN A arrived with the crash cart. RN A assessed the resident as cool to the touch, pulseless, and apneic. His digits were blue. CPR was immediately initiated and performed for approximately five rounds/15 minutes. RN A then stopped CPR to notify the NHA of the incident but was instructed to continue CPR. The CPR was stopped for approximately ,d+[DATE] minutes, then resumed. EMS (emergency medical services) arrived at the facility and placed leads on the resident, who was found to be without a pulse. EMS pronounced the resident deceased at 8:20 a.m. An update to the report on [DATE] at 9:56 p.m. revealed that from [DATE] to [DATE] between the hours of 11:00 p.m. and 6:00 a.m., CNA B stated Resident #1 was seen at 11:00 p.m., then called for assistance at 12:30 a.m. and again at 3:00 a.m. At 6:00 a.m., the resident was noted to be sleeping in his bed. On [DATE] at 5:00 a.m., LPN F stated I was in there often throughout the night. He kept taking his CPAP off. His O2 (oxygen) sat (saturation) was ,d+[DATE]%, but he kept taking it off, and I kept redirecting him. At 5:00 a.m., I gave him meds (medications) and he was fine. He wasn't wearing the mask, but he was awake. (Photographic evidence obtained) As part of the facility's investigation, written statements from licensed staff on duty the morning of [DATE] were obtained. A review of the statements revealed the following: CNA A noted that she started passing drinks at 7:30 a.m. in room [ROOM NUMBER]. When she got to [Resident #1's] room, she tapped his foot, called his name and shook his arm, but got no response. She told LPN B he was not responding. By the time she got back to the room, RN A entered. CNA A waited outside until ordered by RN A to start post-mortem (after death) care. RN A noted that Resident #1 was pulseless, apneic, unresponsive, and cool to touch. CPR was performed for approximately 15 minutes. RN A called the code, and the ADON and DON were called immediately. EMS entered the building at approximately 8:15 a.m. and pronounced the patient deceased at 8:20 a.m. In a second written statement by RN A, also on [DATE], she added that Resident #1 was apneic, pulseless, cool to the touch, and with blue lips, fingers, toes and ears. CPR was performed per protocol and despite the RN's assessment, for approximately 15 minutes. Resident #1's oxygen was running but the nasal cannula was not on his face. RN A pronounced the resident deceased secondary to no life response. She turned EMS away the first time they arrived, as she was unaware that she was not permitted per facility protocol to pronounce a resident deceased . She dispatched EMS again, and they returned at 8:15 a.m. EMS assessed the resident as deceased and pronounced his death at 8:20 a.m. In a second written statement on this day by RN A, she added that she conducted CPR for 15 minutes, then pronounced the resident's death. LPN B wrote that CNA A advised her that Resident #1 was unresponsive. LPN B checked the chart while LPN A called 911. The resident did not have a Do Not Resuscitate Order (DNRO). CPR was started for five rounds for approximately 15 minutes until 7:50 a.m. The resident's body was stiff and cold to the touch. RN A notified the ADON and NHA. CPR was restarted at 7:54 a.m. EMS was called and pronounced the resident's death at 8:20 a.m. LPN A wrote that while passing medication on the 200 hall, the 500 hall nurse told her a CNA advised that Resident #1 was expired. She immediately ran to check the chart for the resident's code status, then called 911. While on the phone with 911, the nurse supervisor (RN A) came and told her she had it handled. LPN D wrote that when she responded to the hall for the Code Blue call, the RN supervisor told her she was not needed. LPN C noted that she heard the overhead page and ran to check the resident's chart, but they were already checking. Then the nurse supervisor stated they had it handled. The NHA noted that she called the county's Emergency Medical Services to request reports. She was advised that they were dispatched at 7:50 a.m. for CPR in progress but were made aware that the resident had rigor and the nurse had called it, so they left. They were called back 15 minutes later as CPR had been resumed, since they (the nurse) were unable to pronounce the resident's death. When EMS arrived, they placed two leads on the resident and pronounced him deceased at 8:20 a.m. LPN E wrote that she heard the Code Blue announced and walked toward 500 East. Her partner nurse was coming back and said, they don't need us. She then noticed the 911 truck and went to see what happened. The RN supervisor (RN A) was walking out of the room and told East Wing staff to cancel 911, he is already cold. (Photographic evidence of all statements obtained) On [DATE], additional statements from follow-up interviews were noted by the ADON and revealed the following: RN A explained that her new employee orientation Friday ([DATE]) was fast because the facility needed her. She got no training, just a stack of papers to sign, and then was sent with LPN A to shadow her on the medication cart. On Sunday ([DATE]), she heard the Code Blue called and responded, finding Resident #1 lifeless. She sent responding nurses away because there was nothing to code. No one wanted to take charge, and everyone was looking at her for what to do. She did the best she knew how to do. RN A said she had pronounced bodies 100 times. After turning EMS away, the other nurses told her she shouldn't have done that. RN A asked why not, pointing out the fact that the resident was expired. RN A left the room and texted the NHA, DON and ADON. When they arrived, everyone started taking statements. LPN B told RN A the NHA said they had to lie and say they did CPR, or they could lose their licenses. CPR was never done, not once. RN A said, I wouldn't do that to a dead body; you wouldn't want that done to your loved one. LPN B admitted everything she said in her previous statement was true but added that she was told by the NHA to say they did CPR, or she would lose her license. LPN B admitted they never performed CPR, as the resident had been dead for a long time. RN A pronounced his death and said it would be defiling a body to do CPR. LPN B wrote that EMS said the resident had to have been dead for two to three hours. RN A pronounced his death at around 7:48 a.m. LPN D explained that she was the 400 hall nurse and responded to the Code Blue overhead page. She went to the resident's room and RN A reported the patient died , nothing could be done, and LPN D wasn't needed. LPN D asked, Don't we have to do CPR? RN A advised, He's been dead for a while and there's nothing we can do. I pronounced him. LPN D returned to her unit. CNA C stated she heard the Code Blue and responded. There were five CNAs outside of the resident's door and two nurses were in the room; one was the RN supervisor (RN A). CNA C asked, Are we doing anything? No one responded. The RN supervisor came out of the room and said there was nothing they could do; he'd been gone too long. (Photographic evidence of all statements obtained) On [DATE], the Regional [NAME] President of Operations (RVPO) generated a follow-up facility report that included an analysis of the event and detailed the findings of the facility's investigation. In the summary of interviews conducted, the newly identified discrepancies from the original witness statements were noted. They were summarized as follows: LPN B now stated that on [DATE] at 7:30 a.m., after responding to the resident's room, the RN on duty was in the room and said the resident was expired, had been dead, and there was nothing to code. LPN B told the RN the resident was a full code. The RN said, There is nothing to code.; that (performing CPR) would be defiling a body. The RN directed the CNAs to start post-mortem care and stated she would notify everyone and had it handled. RN A heard a Code Blue called and ran to the resident's room. The resident's oxygen tubing was on the floor with the oxygen concentrator running. The resident was lying supine (on his back) with no pulse, no respirations, no response, stiff, cold to touch, lips, ears, fingers and feet were all blue. RN A applied a stethoscope for apical pulse; none was noted for one minute and still no respirations. RN A stayed in the room until EMS arrived for the first code. She stopped them to report the resident was deceased . Nurses were responding to the room, but RN A sent them away because there was nothing to code. CPR was never done, not once. (Photographic evidence of both statements obtained) The report's conclusion was that as a result of the investigation which had been conducted by the Regional Nurse Consultant (RNC), the allegation of neglect was substantiated. (Photographic evidence obtained) The facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR) (document N-301 effective [DATE], revised [DATE]) revealed: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure: 1. In the event of cardiac arrest, immediately call for assistance. 2. Two licensed nurses are to verify: - Resident identification - Fully executed Florida Do Not Resuscitate order (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. (Photographic evidence obtained) An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:05 p.m. She advised that she was not present the day of the event but said RN A was supposed to be in orientation. She chose to take herself off orientation and help out on the floor. Company policy when finding a resident unresponsive is to check the code status, call Code Blue, and perform CPR (if full code) until EMS arrives, even if there are apparent signs of death. EMS will put the leads on and make that call. Nurses are not allowed to pronounce residents' deaths. An interview with CNA A on [DATE] at 7:10 a.m., revealed that on [DATE], she was assigned to rooms 504 to 509 and began her shift with passing drinks. At approximately 7:30 a.m., upon arriving at room [ROOM NUMBER], she greeted Resident #1, but there was no response. He appeared to be sleeping, but when she lifted his hand it just dropped, and he felt cold. She alerted CNA D, who confirmed Resident #1 appeared deceased , and together they notified LPN B. When CNA A, CNA D, and LPN B arrived back at Resident #1's room, RN A was already there. LPN B announced that the resident was a full code, however RN A refused to perform CPR and ordered CNA A and CNA D to start post-mortem care. EMS was seen outside the door but was leaving without entering the room. While providing post-mortem care, RN A announced, CPR should've been performed and EMS allowed in. She then stood over Resident #1 and performed pretend CPR with hand movements over his body. EMS returned and were informed by the nursing staff that CPR was performed for three minutes, however, CPR was never performed. Later, CNA A reported she was approached by LPN B, who stated they needed to keep their stories straight, and say CPR was performed for three minutes. The NHA was interviewed on [DATE] at 11:25 a.m. She recalled being asleep that Sunday morning when RN A called her to report finding Resident #1 deceased . The NHA asked if the resident was a full code. When told, yes, she instructed RN A go start CPR now. When she arrived at the facility, she approached LPN B, the resident's assigned nurse, and asked what happened. LPN B did not respond. LPN B then said RN A stopped it. The NHA asked, What do you mean? This is your patient, right? LPN B then said the resident was deceased ; that she ran in and started CPR, then RN A called it and called the NHA. RN A went back into the room and re-started CPR. The NHA thought to herself, Ok, well at least CPR was done. The NHA started writing her facility report while the ADON interviewed staff, including LPN B and RN A. Those statements were all she had to write in the first report. Corporate then asked for the statements to be amended to include Resident #1 being cold, blue and rigorous when found. The following Monday ([DATE]), the ADON came to her and said the timeline wasn't adding up; that her gut was telling her the nurses were not telling the truth about starting CPR. The Regional Nurse Consultant (RNC) came in the next day and took over the investigation. The NHA never spoke with anyone else after that. On Wednesday, the RNC told her CPR was not, in fact, started. The NHA responded, What the f*** are you talking about? The RNC explained the CNA came forward and admitted LPN B had called them all together and told them they needed to have a plan and come up with a statement before the NHA and the ADON got to the facility. Then, LPN B and RN A stood over the body and pretended to perform CPR. LPN B then blamed the NHA for saying they had to come up with the false statement. That did not happen! The NHA explained that she thought, after reminding LPN B that Resident #1 was her resident and her responsibility, LPN B may have panicked and told this whole story about starting CPR. CNA A was the only one who told the truth about LPN B saying, We've got to come up with a statement, make up a story. I worked hard for that license. The RNC was interviewed on [DATE] at 12:00 p.m. After reiterating the findings in the facility reports as above, he stated the only thing they knew for sure was that CPR was not started. He called it a series of unfortunate events. The Medical Director (MD) was interviewed on [DATE] at 2:10 p.m. He said the NHA advised him of the situation on the day of the event. There was now a question about whether the CPR was performed. Resident #1 was diagnosed with COPD and CHF. His chances of recovery were minimal, but he was a full code. CPR should have been initiated. The nurse acted on her own. The MD stated a nurse like this could damage a building for years. It was a mistake by this nurse that affected the whole building. He said, This is a setback. It is so sad. On [DATE] at 2:13 p.m., an interview with CNA D revealed that on [DATE], she was approached by CNA A regarding Resident #1. She went with CNA A to room [ROOM NUMBER] where she agreed that Resident #1 appeared deceased , and she notified LPN B. Upon returning to the room, RN A was already there, turning staff away telling them that he was gone already and she was calling it. LPN A, LPN C, LPN E and RN A began arguing back and forth because the resident was a full code. No one initiated CPR. RN A initiated not real CPR while LPN A, LPN B, LPN C and LPN E stood watching at the door. CNA D again stated, CPR was never initiated for [Resident #1]. When the Administrator arrived, she was pressuring CNA D for a statement while the ADON tried to come up with a story to cover things up. LPN C was interviewed on [DATE] at 3:09 p.m. She stated when she responded to the Code Blue call for Resident #1, the supervisor lady (RN A) was in the room with her phone in hand. Lots of people were at the door. The supervisor (RN A) said, Don't worry about it, we got it. An interview conducted on [DATE] at approximately 3:15 p.m. with CNA C revealed that on [DATE], she responded to a Code Blue call for room [ROOM NUMBER]. Upon arrival, she observed multiple nurses and CNAs in the room, but nothing was being done. CNA C asked if anyone was going to do anything because the resident was a full code, but she was informed by RN A that there was nothing they could do. EMS showed up but got turned away by RN A before seeing Resident #1. LPN G was interviewed on [DATE] at 3:25 p.m. She stated the facility protocol when finding anyone unresponsive was to first check the resident's chart to see if a DNRO was in place. Two nurses must verify the code status for anyone discovered with cardiac/respiratory arrest. If the resident was a full code, staff were to start chest compressions. Someone grabbed the crash cart and called 911. Even in the presence of obvious signs of death, CPR was to be initiated. CPR could never be stopped until medics or a doctor arrived. She was not, as a nurse, permitted to pronounce anyone's death. RN B/Unit Manager was interviewed on [DATE] at 3:32 p.m. The facility policy if a resident codes is to get help. Two nurses check the chart and if a full code, someone calls 911, and someone gets the crash cart. Don't stop CPR until paramedics get there and take over or pronounce. You are absolutely not allowed to pronounce a resident death as a nurse. Even with obvious signs of death, if the resident is a full code, CPR is started. During the survey, the facility volunteered its Quality Assurance Performance Improvement (QAPI) plan and Performance Improvement Plan (PIP) developed in response to the incident. The plan was reviewed with the RVPO, ARVPO, DON and RNC on [DATE] at 4:30 p.m. The DON explained that the QAPI committee met monthly and included the Medical Director and all department heads. Departmental surveillance and data were used to identify trends that might need improvement plans. Floor staff, resident grievances and resident council meetings were also used to identify concerns. Once identified, concerns were delegated to appropriate departments and a performance improvement plan (PIP) was developed. Depending on the issue, the situation was monitored until compliance was achieved, preferably total compliance. The RNC contributed, explaining that following the incident, an Ad Hoc QAPI meeting was conducted on [DATE] and the PIP was developed. The data was gathered, and a root cause analysis was determined. Initially, the root cause analysis focused on a lack of orientation training for RN A, the new supervisor. This was the primary focus. RN A was oriented on Friday and was supposed to be orienting that Sunday but ran off on her own. That is where they felt maybe they could have done something differently. In response, all resident code statuses were checked and found to be accurate. The initiation of the Code Blue response the day of the incident was also deemed correct. But then, the false information presented and forced a revisit. Another Ad Hoc QAPI meeting was conducted on [DATE] with the discovery of false information. False documentation was also identified. A separate plan was developed to focus on ethics and compliance; how to now address unethical behavior and staff response. Being the only RN in the building on the day of the event, staff felt it would be insubordination to reject her directives. They were re-educated on that. Staff were trained on Advance Directives (AD), and they made sure all licensed staff were aware of what that meant, as well as the situations during which Advance Directives should be honored. Staff were trained in the facility's CPR policy, including when to start CPR. An audit of CPR certifications for nurses was performed and now all nurses were American Heart Association (AHA) certified. Abuse and neglect training was provided building wide. Scheduled deviations were covered too, since RN A had effectively removed herself from facility orientation. The ARVPO added the focus was currently on policing themselves and resulted in another root cause analysis and evaluation of processes. The second QAPI was conducted about the corporate compliance program with a focus on staff notification (of non-compliance) and filing concerns without fear of retaliation. It also included what to do if someone asked a staff member to do something unethical. Code blue drills were still being conducted with all licensed staff participating. Staff had been retrained, or received the information packet, on Code Blue response and drills. There was a QAPI meeting scheduled for tomorrow ([DATE]), and the PIP would be re-evaluated. Weekly Advance Directive audits were being conducted, and the facility would continue reviewing nurses' CPR status and licensure. This was all added to the orientation process. Classroom training for new nurses would be audited to ensure completion. CPR tests were provided to validate the nurses' understanding of policies with 100% of nurses passing. On [DATE] at 1:03 p.m., LPN B was interviewed and explained that on the day of the event, RN A was training with her. The CNA came and told her that Resident #1 was deceased and stiff. One nurse called the Code Blue, and someone called EMS. LPN B went to the room after RN A ran in. The resident was in full 100% rigor, stiff as a board, and had been dead for a while. RN A decided there was nothing they could do. Nothing would have brought him back; they would have broken all the bones in his body (had they initiated CPR). It was too late. LPN B admitted they did not perform CPR. She told RN A that facility protocol was to provide CPR. RN A called the NHA who instructed her to call medics and get back in the room and perform CPR. It had been 30 minutes since they had discovered the body at this point. The NHA was more concerned about what was going to happen to the facility and wanted RN A to lie. When the NHA arrived at the facility that day, she told LPN B, You know, this could affect your license. She threatened LPN B that she would lose her nursing license. The NHA insinuated that they had to lie and was asking pointed questions such as, This happened, right? LPN B said she felt cornered and threatened, as though she had no choice but to do what the NHA wanted her to do. Then the NHA would not let LPN B leave until she went over her documentation to make sure it included everything the NHA wanted it to include. She stated again that no one ever started CPR. The resident was in full rigor. When EMS came back, they said he had been dead for at least three hours. LPN B told the truth when she talked to the RNC. She stated, Was it wrong for me to document what I did? Yes, it was. LPN B concluded, saying she was afraid not to follow the NHA's instructions. The ADON was interviewed on [DATE] at 2:25 p.m. She recalled being in bed the morning of the event and receiving a message from RN A. RN A reported finding Resident #1 and pronouncing his death. The ADON and NHA arrived at the facility around 9:00 a.m. and interviewed LPN B. LPN B was initially vague about what happened, then the NHA said, This is your resident, he was your responsibility, you need to explain what happened. LPN B then said after CNA A found Resident #1 deceased , RN A went to the room. LPN B went for the chart and LPN A paged the Code Blue. LPN B said they then performed the required five rounds/15 minutes of CPR on Resident #1. The ADON had never heard of this required 5 rounds of CPR, but LPN B repeated this several times. LPN B said due to obvious signs of death, RN A pronounced the resident. RN A called the NHA and was advised to resume CPR, so she returned to the room. They reportedly resumed compressions until paramedics arrived. The ADON and NHA interviewed RN A, who told the same story about the required five rounds/15 minutes of CPR before pronouncing Resident #1's death. After going home that evening and thinking about the timelines more closely, the ADON realized they did not line up. The CNA's testimony did not line up with 15 rounds of CPR being performed and the time the phone call came from RN A that she had pronounced the resident's death. There was no way five rounds could have been performed. On Monday ([DATE]), the ADON reported this to the NHA, and they called corporate and reported their suspicion that CPR had not been performed. The RNC arrived on Tuesday to take over the investigation. Upon speaking with the CNA, she admitted CPR was not performed. Instead, the nurses stood over the body arguing. LPN B and RN A eventually admitted this too in subsequent interviews. RN A was interviewed on [DATE] at 3:45 p.m. She said this was the first time she had experienced anything like this. Her background was in hospitals, home health and acute care settings, and she had been a nurse for [AGE] years. RN A said she was hired as a nursing supervisor and oriented with LPN A on a medication cart on Friday ([DATE]). They had 20 residents and she had never experienced that. A lot of the residents required a lot of care but did not get it because there were not enough staff. She felt unsafe right away. The second day she came in there were not enough nurses. She and an LPN had 60 residents and they were on the medication cart. She was given no administrative orientation. She did not know anyone's name, role, or facility guidelines. RN A did what she did in the hospital or would have done at home that day. She did what she was trained to do. She was the highest licensed position in the building but was expected to act in a supervisory role even though she was in orientation. When she entered Resident #1's room, he was supine with his oxygen tubing on the floor and the concentrator running. His bipap/cpap machine was on the bedside table. It was off and the mask was on the table. His hands, fingertips, lips, face and feet were blue, and the body was cold, rigid, and firm to the touch. RN A said she had pronounced hundreds of people. A lot! People responded to the Code Blue call for Resident #1, but no one helped. A second Code Blue was called elsewhere shortly after finding Resident #1, so she shifted her attention to that. She felt that to be appropriate, as Resident #1 was deceased . She did not know at the time that they were supposed to do pretend CPR. It was chaos. This resident died on the night shift. She did not know if the facility was trying to cover that up. She told LPN B that she was not going to perform CPR on a dead body. RN A confirmed that she sent EMS away. Earlier that morning she had called the NHA, DON and ADON but no one told her what to do. The NHA told her she had to say she performed CPR even though she had not. The NHA also instructed her to document that CPR was performed per Corporate, but they knew the truth as they had her text message (saying she had pronounced Resident #1's death). When RN A told the NHA that this was not what had happened, she was told this was all corporate knew had happened; so that was what we knew happened. RN A was told the facility would be in trouble, could be shut down, and she could lose her license, so this was the story; this was what had to be done. The NHA instructed her to write it in a simple statement and put it in the computer. RN A thought to herself, This is so bad, this is not good. Perhaps the culture of fear existed, because LPN B wrote the same thing in her notes. RN A thought by telling the truth everything would be ok. Instead, she was told what to writ [TRUNCATED]

Based on observations, staff interviews, and facility policy and procedure review, the facility failed to equip corridors with firmly secured and intact handrails. The facility staff failed to report/service the handrails outside of resident rooms #205 and #511, handrails next to the clean utility linen closet located on the 200 hallways, and handrails located around the 400 hallways' nursing station. Handrails in these locations were observed with jagged ends and sharp edges, posing a risk of injury to residents, staff and other building occupants. Daily facility rounds are important to ensure handrails are firmly secured and in good condition to prevent resident injury. The findings include: On 02/05/2024 at 1:10 PM, an observation was made of the handrails located outside of rooms #205 and #511, which were missing end caps. (Photographic evidence obtained) An interview was conducted with Certified Nursing Assistant (CNA) J on 02/07/2024 at 1:05 PM. He stated residents usually reported maintenance requests to the first staff member they saw. Any staff member could report maintenance requests either verbally to someone in the maintenance department or electronically in the TELS system (electronic building management platform). A tour and an interview were conducted with the Maintenance Director on 02/08/2024 at 12:07 PM. During the tour, three handrail end caps were observed missing on the 200 hallways, two handrail end caps were observed missing around the nursing station on the 400 hallways, and one handrail end cap was missing outside of room [ROOM NUMBER]. The Maintenance Director confirmed the end caps were missing and stated he was not aware of this issue. He stated maintenance requests were reported in the TELS system and that it was his to-do list daily. There was a new maintenance department assistant expected to start at the facility soon. The Maintenance Director stated again that he took care of all requests received the same day. Staff reported maintenance requests to him in person or he received maintenance requests from TELS. An interview was conducted with Registered Nurse (RN)/Unit Manager (UM) D on 02/08/2024 at 12:31 PM. She stated, There is a system called TELS. You log in and report the issue or concern. You can also report to him (Maintenance Director) verbally. The Maintenance Director repairs things the same day. CNAs and nurses report verbally or in TELS. Maintenance requests reported included pest sightings, broken equipment, non-working lights, stopped-up toilets, or anything that needed repair. An interview was conducted with the Administrator on 02/08/2024 at 12:45 PM. She stated there was no capital improvement plan but she had been replacing equipment and items as needed. On 02/08/2024 at 4:08 PM, another observation was made of missing end caps on handrails located outside of rooms #205 and #511. Missing end caps were also observed on the handrails next to the clean utility linen closet located on the 200 hallways and around the 400 hallways' nursing station. (Photographic evidence obtained) A review of the facility's policy and procedure titled Maintenance (effective 11/30/2014), revealed: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will follow all policies regarding routine periodic maintenance. The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. All employees will report physical plant areas or equipment in need of repair or service to their supervisor . (Copy obtained)

Based on observations, staff interviews, and a review of the facility's Maintenance policy and procedure, the facility failed to ensure maintenance was provided to maintain a safe, clean, and comfortable environment for two (Rooms #502 and #508) of 70 rooms in the facility. The air conditioners' electrical covers were broken, and parts of the covers were missing and had become detached from the units in these two rooms. The findings include: A facility tour was conducted on 2/6/24 at 11:00 a.m., and two air conditioning units were observed in need of repair in rooms #502 and #508. The electrical covers for the air conditioners were broken with parts of the covers missing and detached from the units. The units were observed daily on 2/7/24 and 2/8/24. (Photographic evidence obtained) A tour and interview were conducted with the Maintenance Director on 2/8/24 at 12:07 p.m. He reported being unaware of the concerns with the two air conditioning units in rooms #502 and #508. He confirmed that the electrical covers were not attached securely, parts were missing and parts of the covers were broken. The Maintenance Director stated he was the only one working and another individual was expected to be hired. He stated the staff went into TELS (electronic building management platform) and reported maintenance issues or told him about concerns verbally. An interview was conducted with the Registered Nurse (RN)/Unit Manager at 12:31 p.m. on 2/8/24. She stated staff could access the TELS system on the computer to report any maintenance concerns or they could speak with Maintenance about the problems. The RN/Unit Manager stated Maintenance completed the repairs the same day. Pests, broken equipment, non-working lights, stopped up toilets, leaking sinks, anything that needed repair could be reported. An interview was conducted with Certified Nursing Assistant (CNA) H on 2/8/24 at 4:35 p.m. She reported having been employed by the facility for three months, and if there were concerns with facility maintenance, she would report it to the nurse and tell the Maintenance Director. An interview was conducted with CNA I on 2/8/24 at 4:40 p.m. She stated maintenance concerns were reported in the electronic TELS system. Staff logged in and entered their concern in the system. You could also make Maintenance aware of concerns verbally. A review of the Policy and Procedure for Maintenance (effective 11/30/2014 with no revision date) revealed that the facility's physical plant and equipment would be maintained through a program of preventive maintenance and prompt action to identify area/items in need of repair. All employees would report physical plant areas or equipment in need of repair or service to their supervisor. All items needing maintenance assistance would be reported to Maintenance.

Based on record reviews and staff interviews, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every three months for three (Residents #11, #68, and #226) of three residents reviewed, from 34 residents in the total sample. Failure to complete resident minimum data set (MDS) assessments could result in a failure to provide needed care, contributing to residents' inability to maintain their highest practicable physical, mental, and psychosocial well-being. The findings include: A review of the medical record for Resident #11 revealed that the required quarterly assessment, due by 12/10/2023, was not documented as having been completed. A review of the medical record for Resident #68 revealed that the required quarterly assessment, due by 12/7/2023, was not documented as having been completed. A review of the medical record for Resident #226 revealed that the required quarterly assessment, due by 12/10/2023, was not documented as having been completed. During an interview with the Regional Director on 02/08/2024 at 10:43 AM, she confirmed that the required quarterly assessments for Residents #11, #68, and #226 were not completed by the facility.

Based on observations, record review, interviews, and a review of the facility's Oxygen Therapy policy and procedure, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for one (Resident #54) of one resident reviewed for oxygen therapy from a total of 34 residents in the sample. The findings include: An observation and interview was conducted with Resident #54 in her room on 2/5/24 at 11:00 a.m. She reported that her oxygen flow rate was set at 2 liters per minute via nasal cannula. The oxygen flow rate was observed to be set at 2.5 liters per minute. A review of the resident's medical record revealed a re-entry to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, emphysema, congestive heart failure and atrial fibrillation. The resident's active physician's orders were reviewed which noted: Respiratory: oxygen at 2 liters via nasal cannula continuous. The care plan was reviewed, which was updated on 1/25/24. Resident has oxygen therapy related to respiratory illness and receives oxygen via nasal prongs at 2 liters per minute. An observation was made in the resident's room on 2/6/24 at 11:55 a.m. The oxygen flow rate on the oxygen concentrator was set at 2.5 liters per minute. An observation was conducted in the resident's room on 2/7/24 at 8:55 a.m. The oxygen flow rate was set at 2.5 liters per minute. An observation was conducted in the resident's room on 2/7/24 at 4:34 p.m. The oxygen flow rate was set at 2.5 liters per minute. An interview was conducted with Registered Nurse (RN) A at 4:35 p.m. on 2/7/24. She was asked what Resident #54's oxygen flow rate should be per the physician's order, and she replied 2 liters per minute. She was accompanied to the resident's room to observe the oxygen concentrator and flow rate setting. She confirmed that the oxygen was not set at 2 liters per minute as ordered. A review of the policy and procedure for Oxygen Therapy (revised 8/28/17), noted under procedure to review the physician's order and start the oxygen flow rate at the prescribed liter for the administration device.

Based on observations, resident and staff interviews, medical record review, and a review of facility policies and procedures, the facility failed to maintain and implement its infection control program to prevent the development and transmission of communicable diseases and infections, when three employees (Employees C, E, and F) were observed failing to use personal protective equipment (PPE) in transmission base precaution (TBP)/isolation rooms. Supplies for hand hygiene were not provided in the soiled utility room, PPE was not readily available and convenient to the staff for use in TBP rooms, and employees failed to perform hand hygiene when leaving a TBP room. Failure to follow infection control protocols and procedures could leave vulnerable nursing home residents at risk of contracting infections that could be detrimental to their health. The findings include: On 02/05/2024 at 10:25 AM, Certified Nursing Assistant (CNA) C was observed donning PPE appropriately. He then entered room [ROOM NUMBER] to deliver a cup of tea to Resident #171who was under TBP. He donned a gown, an N95 respirator mask, a face shield and disposable gloves. After putting the cup on the tray table, he came out of the room and proceeded to doff the PPE. He stepped into the hallway to doff the PPE. When asked if there was a trash can in the resident's room, he stated Yes, but it did not have a garbage bag in it. He called out to the CNA in the room across the hall to have her bring him a trash bag. After she did, he took the bag and put his PPE in it with his bare hands. He then took the trash can inside the resident's room and put all of the trash (several PPE gowns, gloves, etc.) into the bag. He then put a new trash bag in the can and placed the can back in the room. He tied up the trash bag and set it on the floor. At that point, a CNA came to the room with Resident #171's meal tray and asked CNA C if he could deliver the tray to the resident. He took the tray and went back into the room without donning PPE. He put the tray down on the tray table and spoke to the resident briefly, then walked back out of the room. He then picked up the trash bag on the floor in the hallway and walked down to the soiled utility room approximately 60 feet from the resident's room. He open the door with his bare hand and walked in. He disposed of the bag of trash (including used PPE items) and proceeded to walk out of the soiled utility room. When asked if he washed his hands with soap and water in the soiled utility room, he stated he did not because there were no paper towels in the dispenser. The soiled utility room was then observed and no paper towels were available at the handwashing sink. CNA C stated he was not supposed to wash his hands in the resident's restroom prior to leaving the TBP room. He then walked away back to his assigned area. He did not perform hand hygiene. During an interview with Registered Nurse (RN)/Unit Manager (UM) D on 02/05/2024 at 11:17 AM, she stated Resident #171 was due to be taken off of TBP on 02/08/2024. She confirmed that Resident #171 was on isolation precautions. During an interview with Resident #171 on 02/05/2024 at 3:46 PM, she stated the staff tested her yesterday (Sunday 02/04/2024) to determine whether she still needed to be on isolation precautions. She was not sure if the staff were wearing appropriate PPE when they entered her room. She confirmed that they were not using her restroom to wash their hands prior to leaving her room. On 02/07/2024 at 11:55 AM, CNA E was observed donning PPE appropriately, then entering TBP room [ROOM NUMBER] with a meal tray for Resident #171. When she exited the room, she did not wash her hands with soap and water in the restroom. She came out and used hand sanitizer she had in her pocket. She then went across the hall and donned new PPE appropriately and took the meal tray into TBP room [ROOM NUMBER]. After she left room [ROOM NUMBER], she did not wash her hands in the restroom with soap and water or use hand sanitizer. She walked down the hallway to her next task. On 02/07/2024 at 12:29 PM, CNA F was observed coming out of room [ROOM NUMBER], the TBP room for Resident #171. She was not wearing PPE. The storage bin in the hallway outside the room did not have any PPE gowns in the drawer. During an interview with CNA F on 02/07/2024 at 12:38 PM, she confirmed that she did not wear PPE in TBP room [ROOM NUMBER]. She stated she was supposed to wear the PPE when she went into an isolation room. She was supposed to wear the appropriate PPE that was on the signage posted on the outside of the door to the room. She did not know why there was no PPE in the bin outside of the door. She did not know who was responsible for refilling it. She did not go to obtain more PPE to refill the bin. During an interview with CNA J on 02/07/2024 at 1:11 PM, he stated there should be caution signs on the door if the room was a TBP room. The staff member entering the room should have all PPE on before he/she entered the room. He stated he thought the blue gowns were reusable and could be hung up inside the resident's room to be worn again. Staff were trained to use the resident's restroom to wash their hands prior to leaving the room. They were supposed to wash their hands using soap and water. If there were soiled linens to drop off, he delivered them to the soiled utility room and washed his hands again prior to leaving the soiled utility room. He stated it was not acceptable to use hand sanitizer only. During an interview with CNA G on 02/07/2024 at 2:00 PM, she stated they (CNAs) had been trained to wash their hands with soap and water after they left an isolation room. Hand sanitizer gel alone was not acceptable. During an interview with CNA E on 02/07/2024 at 2:08 PM, she had just exited TBP room [ROOM NUMBER]. She had been providing direct incontinence care for Resident #178. She stated she was supposed to wash her hands with soap and water before exiting an isolation room. Hand sanitizer gel was not enough. During an interview with the Director of Nursing (DON) on 02/08/2024 at 2:55 PM, she stated it was not acceptable for the staff to walk through the hall to the soiled utility room after leaving a TBP room before performing hand hygiene. During an interview with the Administrator on 02/08/2024 at 3:00 PM, she stated staff should wash their hands prior to leaving an isolation room. They were to use the facilities in the resident's bathroom. Walking from the isolation room to the soiled utility room to wash their hands was not acceptable. Hand sanitizer alone was not acceptable. She confirmed that all required PPE should be donned prior to entering an isolation room. She was unaware that the PPE bins were empty and needed refilling. A review of Resident #171's physician's order, dated 02/02/2024, confirmed that she should be on isolation. (Copy obtained) A review of Resident #178's physician's order, dated 02/06/2024, confirmed that he should be on isolation. (Copy obtained) A review of the facility's policy and procedure titled Handwashing/Hand Hygiene (revised 08/2019), revealed: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 3. Hand hygiene products and supplies (sinks, soaps, towels, alcohol-base hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled and b. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. Difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; before donning sterile gloves; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after removing gloves; before and after entering isolation precautions settings; before and after assisting a resident with meals. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: c. when in contact with a resident or the equipment or environment of a resident who is on contact precautions. Equipment and Supplies: 1. The following equipment and supplies are necessary for hand hygiene: b. running water, c. soap, d. paper towels, g. sterile gloves. (Copy obtained) A review of the facility's policy and procedure titled Isolation - Initiating Transmission-Based Precautions (revised 08/2019), revealed: 3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): e. Ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. G. Ensures that an appropriate linen/barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room (Copy obtained).

Based on record review, staff interview, and policy review, the facility failed to ensure pneumococcal immunizations were offered to 1 of 5 sampled residents who consented to receive the immunization. (Resident 4) The findings include: A record review for Resident #4 revealed an admitted [DATE], and readmitted [DATE]. Resident #4's record contained an Informed Consent for Pneumococcal Vaccine form signed by the resident's representative on 11/30/2021 indicating she accepted and gave the facility permission to administer the vaccine. (Photographic evidence was obtained) Further record review for Resident #4 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date was 12/4/2021 and the end date was 12/5/2021. Review of December 2021's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The corresponding signature box on the eMOR was initialed by a nurse on this date, but marked with a 9 meaning, See nurses note. Review of the corresponding eMOR progress note dated 12/4/2021 found the [MEDICATION(S)] Suspension was Unavailable. There was no further explanation. Review of the eMARs between December 2021 and July 2022 found the vaccination was never administered. (Photographic evidence was obtained) An interview was conducted with the Director of Nursing (DON) on 7/6/2022 at 12:35 pm. She reviewed Resident #4's records and exclaimed, OH SHOOT! in acknowledgement the vaccination was not provided, as requested. Review of the facility's Pneumococcal Vaccine policy version 2.1 revised October 2019 revealed: Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: 1. Prior to or on admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series . 3. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine . 4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given or refused) per our facility's physician-approved pneumococcal vaccination protocol. (Photocopy was obtained)

Based on record review, staff interview, and policy review, the facility failed to ensure COVID-19 immunizations were offered to 1 of 7 sampled residents who consented to receive the immunization. (Resident #4) The findings include: A record review for Resident #4 revealed an admitted [DATE], and readmitted [DATE]. Resident #4's record contained a COVID-19 Information and Consent Form- 5.11.21 signed by the resident's representative on 11/30/2021 accepting and giving the facility permission to administer the vaccine. (Photographic evidence was obtained) Futher record review of Resident #4 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Director of Nursing (DON) in presence of the Regional Registered Nurse on 7/6/2022 at 12:50 pm. She was advised of the findings. The DON responded by stating Resident #4 had refused the vaccination, and produced a refusal dated August 2021. The DON was informed Resident #4 had been offered the vaccine again and consented on 11/30/2021. The Regional Nurse confirmed this, explaining to the DON a more recent consent form was executed. Both acknowledged the oversight. A review of the facility's COVID-19 Pandemic Plan, dated 3/2/2020 and revised 3/11/2022 revealed, Residents will be offered the COVID-19 vaccine when the vaccine supplies are available to the center. Vaccine emergency use authorization fact sheet will be provided and reviewed with the resident/resident representative, including the risk/benefit and potential side effects). Consent (including the screening questions) will be obtained. Obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence was obtained)

Based on observations, interviews, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to 1) Ensure wet nesting did not occur, 2) Maintain safe food temperatures, 3) Label and date food items in the West Wing nourishment room refrigerator/freezer, 4) Dispose of outdated and unlabeled/undated foods items properly, 5) Maintain thermometers in the East and West Wing nourishment room freezers, 6) Ensure hot water was available in the kitchen handwashing sinks, and 7) Ensure the kitchen trashcan pedal, which opened the trashcan lid, was functional. These failures had the potential to negatively impact all residents who received food from the facility kitchen and nourishment rooms. The findings include: An observation of the kitchen was made on [DATE] at 3:25 p.m. Neither of the two hand washing stations had hot water. The trash can foot pedal was not working at the hand washing station nearest to the kitchen entrance. At 3:45 p.m., a dietary aide was observed putting ice in a bin filled with milk and drinks for dinner service with a dinner start time of 4:45 p.m. The dinner start time was confirmed by the cook. On [DATE] at 11:41 a.m., an observation was made of the kitchen. The Certified Dietary Manager (CDM) was on the tray line with two other employees who were observed wearing face masks under their noses. Wet nesting of plastic domes was observed. The CDM was asked about them and reported, They don't have enough time to dry because its too humid in kitchen. At 11: 45 p.m., two different thermometers in the walk-in refrigerator were observed; one at 40 °F and one at 45 °F. At the time of the observation, Cook Q was asked to check the temperature of a random milk carton. The temperature was 43 °F. Due to the high temperature reading, Cook Q was asked to pull another milk carton to check for temperature. It was also higher than the 40°F maximum. The District Dietary Manager (DDM), who was present at the time, reported having just received a milk delivery and stated that was the reason for the high temperature of the milk cartons. A copy of the milk delivery slip with a time stamp was requested, but it was never received. On [DATE] at 12:17 p.m., an observation was made of the beverage cart on the 500 Hall. A metal container of milk cartons was observed. The DDM was asked to bring a thermometer to the floor to check the milk cartons for temperature. The temperature of one of the milk cartons was 45 °F. The DDM was asked what temperature the milk should be. He stated, I don't know, 45 °F? He was asked to pull another milk carton from the metal container. The temperature was 40 °F. The ice in the metal milk container was nearly completely melted at the time of food delivery. The DDM took the container of milk back to the kitchen and stated he would get new milk. At 12:20 p.m., the CDM was asked to come to the floor. She was asked to test the temperature of the milk cartons on a different beverage cart on other side of the 500 Hall. The temperature of the milk in that cart was 43 °F. The CDM was asked what temperature the milk should be. She stated, less than 40 degrees, but no more than 40 °F when served. She stated, We didn't put enough ice in the beverage bath. When she was asked about the milk on other halls, the CDM stated, We will pull them. Kitchen staff puts drinks out early and the ice melts. The 500 Hall is the last hall served. The beverage carts for the other halls had already been distributed and beverages on them had been pulled for use by this time. On [DATE] at 3:10 p.m., another observation was made of the two kitchen hand sinks. Neither had hot water and the pedal on the trash can was still not working. Another observation was made of wet nesting of plastic serving platters. (Photographic evidence obtained) Cook Q entered the kitchen two times without a mask during this time. The CDM was interviewed at 3:15 p.m. on [DATE] and was asked about the lack of hot water at the hand washing sinks. She stated, Yes, there should be hot water. She stated she had spoken with Maintenance but didn't know why there was no hot water. On [DATE] at 4:00 p.m., the Maintenance Director was interviewed and reported the hand-washing sinks had been without hot water for at least two months. He stated he expected a needed replacement in a couple of days and the sinks were expected to be repaired soon. On [DATE] at 9:56 a.m., an observation of the West Wing nourishment room was made. There was no thermometer in the freezer. Although there was no thermometer, a temperature had been logged for both the refrigerator and freezer areas. The date on refrigerator/freezer temperature log was observed as being incomplete and unclear. The log appeared to be for February 2022. The [DATE] log appeared to be missing. The freezer was observed with several food items in it. One item was apple slices with a use by date of ,d+[DATE]. (Photographic evidence obtained) Other food items were observed in bags with names on them, but not all of the bags were dated. (Photographic evidence obtained) The refrigerator contained a box of what appeared to be fried chicken with no date or name on it. Additionally, a bag of fast food items with no name or room number was observed in the freezer, as was a container of yogurt with an expiration date of [DATE]. The freezer also contained an undated, green plastic bag with what appeared to be takeout food inside, and an unsealed plastic bag containing cheese was observed with a hand-written date of [DATE]. An interview was conducted with Registered Nurse (RN) A on [DATE] at 10:30 a.m. He reported that the night nurses (7:00 p.m. through 7:00 a.m. shift) checked the refrigerator/freezer temperatures in the nourishment rooms. He reported that they also checked the food items and after two days threw them away. An interview with the Director of Nursing (DON) was conducted on [DATE] 10:35 a.m. She reported that the night nurses were responsible for the nourishment rooms, disposing of expired foods, and ensuring the refrigerator/freezer temperatures were accurate. The Unit Manager was expected to follow up. The DON was asked for the thermometer for the East Wing nourishment room at this time. She stated she didn't see one and would get one. Certified Nursing Assistant (CNA) Z was interviewed on [DATE] at 10:49 a.m. She reported that as far as she knew, the CNAs had no nourishment room duties. An interview with Licensed Practical Nurse (LPN)/Unit Manager N, was conducted on [DATE] at 11:08 a.m. She reported that both night shift nurses should be checking the temperatures in nourishment room refrigerator as it was a group effort. The food in the refrigerator should be discarded within three days. When asked if there should be two thermometers, one in the refrigerator and another in the freezer, LPN N replied, yes, there should be. The facility policy titled Safe Handling for Foods from Visitors (HCSG Policy 031, effective ,d+[DATE]) stated, Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: * Equipped with thermometers * Have temperature monitored daily for refrigeration of less than or equal to 41 degrees Fahrenheit and freezer of less than or equal to 10 degrees Fahrenheit * Daily monitoring for refrigerated storage duration and discard any food items that have been stored for 7 or more days When food items are intended for later consumption, the responsible facility staff member will: * Ensure that foods are in a sealed container to prevent cross contamination * Label foods with the resident name and the current date .

Based on observations during four of four days, record reviews, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for eleven (Residents #14, #65, #57, #100, #30, #1, #7, #27, #32, #45, and #252) of 46 residents in the sample. Specifically, the facility failed to maintain housekeeping and maintenance services in resident rooms and common areas. The findings include: On 2/27/22 at 12:20 p.m., Resident #1's bathroom was observed with a soap dispenser bag lying on the toilet tank. Grab bars were discolored, the floor was soiled, and the air conditioning vent was covered in grey debris. (Photographic evidence obtained) On 2/27/22 at 12:24 p.m., Resident #7's bathroom was observed with a toilet that was soiled above the water line. (Photographic evidence obtained) On 2/27/22 at 12:40 p.m., Resident #100's bathroom was observed with a vent covered in grey, thickened debris. The drain cover under the sink was broken. Grab bars had a rusted appearance, and the sink faucet was encrusted with calcification (buildup of calcium/minerals from hard water). (Photographic evidence obtained) On 2/27/22 at 12:50 p.m., Resident #14's bathroom was observed with a vent covered in grey, thickened debris. The drain cover under the sink was broken. Grab bars had a rusted appearance, and the sink faucet was encrusted with calcification. On 2/27/22 at 1:00 p.m., Resident #65's bathroom was observed with a calcium-encrusted faucet on the sink and brown rust on the grab bars. The ceiling vent was covered in grey, thickened debris. (Photographic evidence obtained) On 2/27/22 at 2:00 p.m., Resident #57's room was observed. The air conditioner was covered with a thick, dark brown substance all over the outside of the casing and inside the vents. The resident reported the air conditioner had not been cleaned in a year. (Photographic evidence obtained) On 2/27/22 at 3:16 p.m., Resident #30's bathroom was observed. A toilet plunger was lying on the floor with a handle covered in brown debris. Pest droppings and dead pests were observed behind the toilet. (Photographic evidence obtained) On 2/28/22 at 9:15 a.m., Resident #1's bathroom was observed. The soap dispenser bag remained on the toilet tank, the floor remained stained and discolored, and the seal around the base of the toilet was soiled. (Photographic evidence obtained) On 2/28/22 at 9:15 a.m., Resident #27's bathroom was observed. The floors were covered with a black substance, brown splatter was observed on the wall behind the toilet, and clean linen, stacked on the toilet tank, was touching the splattered substance. The sink faucet was calcium-encrusted, the grab bars were rusted, and the air conditioning vent was covered with grey, thickened debris. (Photographic evidence obtained) On 2/28/22 at 9:30 a.m., Resident #100's bathroom was observed to be unchanged since the 2/27 observation at 12:40 p.m. (Photographic evidence obtained) On 2/28/22 at 9:30am in Resident #14's bathroom was observed to be unchanged since the 2/27 observation at 12:50 p.m. On 2/28/22 at 9:45 a.m., Resident #65's bathroom was observed to be unchanged since the 2/27 observation at 1:00 p.m. (Photographic evidence obtained) On 2/28/22 at 12:28 p.m., Resident #30's bathroom was observed. Pest droppings and dead pests remained behind the toilet and the floor was soiled. (Photographic evidence obtained) On 3/2/22 at 9:20 a.m., Resident #57's air conditioner was rechecked after having conducted multiple observations on 2/28/22, and 3/1/22. The air condiitoner had not been cleaned and remained with a brown substance coating the surface of the casing and vents. Housekeeper EE was mopping the floor in the resident's room. When she was asked who was responsible for cleaning the air conditioning unit, she stated maintenance cleans them. She confirmed that the casing on the air conditioning unit was covered with a dark, soiled substance, and she started wiping it with her white cloth and spray. After she sprayed the air conditioner and wiped an area, the white cloth became black. She reported the vents were soiled and needed to be cleaned. On 3/3/22 at 2:00 p.m., the 800 hallway was observed. Hand sanitizer dispensers had dripped sanitizer down the walls onto the grab bars and the floor. Significant buildup was observed. Ceiling grates had a black substance on them. On 3/3/22 at 2:05 p.m., Resident #32's room was observed with patches in the wall. The resident stated it had been that way for the last six months. (Photographic evidence obtained) On 3/3/22 at 2:15 p.m., Resident #45's bathroom was observed with a calcium-encrusted sink faucet and rusted grab bars. The ceiling vent was covered in grey, thickened debris, and the walls and floor were soiled. (Photographic evidence obtained) On 3/3/22 at 2:15 p.m., Resident #252's bathroom was observed with a calcium-encrusted sink faucet and a rusted toilet paper holder and grab bars. The ceiling vent was covered in grey, thickened debris, and the walls and floor were soiled. (Photographic evidence obtained) On 3/3/22 at 2:30 p.m., the 500 hallway was observed. Hand sanitizer dispensers had dripped sanitizer down the walls onto the grab bars and the floor. Significant buildup was observed. On 3/3/22 at 3:00 p.m., the 400 hallway was observed. Hand sanitizer dispensers had dripped sanitizer down the walls onto the grab bars and the floor. Significant buildup was observed. On 3/3/22 at 3:15 p.m., the 700 hallway shower room was observed with a kickplate falling off the door. The Environmental Services Director (ESD) was interviewed on 3/3/22 at 10:30 a.m. He was asked about the cleaning of the air conditioners and he stated maintenance replaced the filters, and housekeeping was responsible for cleaning the casing and outside covering. If the covering was really bad, it could be replaced. The ESD walked into room 810 and observed the air conditioning unit. He confirmed it was soiled even after housekeeping had cleaned it. He stated it needed cleaning and spoke with the resident in the room about taking the cover off at 2:00 p.m. and trying to clean it. The resident was agreeable. The ESD stated, If it is not cleanable, we will replace the cover. The Housekeeping Manager was interviewed on 3/3/22 at 1:40 p.m. She stated she had worked in the facility for four years. She was the person responsible for stripping and waxing the floors, her Tech was mainly responsible for emptying trash and cleaning baseboards, and housekeeping staff were responsible for light cleaning. They were not permitted to use bleach or harsher chemicals to deep clean. The approved chemicals were Virex (one-step disinfectant/deodorizer cleaner concentrate) and [NAME] (nonhazardous wash solvent that removes wax, grease, oil and silicone). He stated all facility hallways were being cleaned and disinfected according to facility practices. They cleaned the outside of the ceiling vents and the outside casing of the air conditioning units with a duster. Things like caulking around the toilets, descaling the faucets, grab bars and inside air conditioning vents and equipment were addressed by Maintenance/Environmental Services. The Housekeeping Manager stated it was the Maintenance Manager's responsibility to discover problems with the air conditioning units in resident rooms. According to the Housekeeping Manager, the maintenance department did not rely on housekeeping to inform them. The Activities Director was interviewed on 3/3/22 at 1:45 p.m. She stated she had worked in the facility since October 2021. She further stated the activities room and refrigerator did not get the attention from housekeeping as often as she would like. She did her best to clean up herself. The activities room floors were sticky and soiled. The refrigerator had a brown substance all over the exterior, and the ceiling vents were covered with grey, thickened debris. Two vents had a black substance in the center of them. Housekeeper U was interviewed on 3/3/22 at 2:45 p.m. She stated she had worked in the facility for two years. She usually did the basics, which included bathroom sanitation, floor sweeping with an adjuster tool, and dusting over the bed tables. The window blinds and air conditioning covers were cleaned once weekly. She was also responsible for changing out soiled privacy curtains. The ESD was interviewed on 3/3/22 at 3:20 p.m. during a tour of the facility. He stated he had been working there for one month and had one technician working under him. He further stated he was doing his best and acknowledged that the building (including resident rooms) had many issues that needed repair. The ESD toured the 500 and 800 hallways including resident rooms. He stated he would replace hallway ceiling grates throughout the facility, as well as bathroom faucets and grab bars. He had plans to replace all hand sanitizer stations in the facility, so the product did not drip on the floor, walls and handrails. He stated it was the housekeeping staff's responsibility to notify him when air conditioning units needed repair and filter cleaning. The units were cleaned monthly. The job descriptions for Environmental Director I and II and Environmental Technician were reviewed. The job descriptions revealed that the Director of Environmental Services Is delegated the administrative authority, responsibility and accountability necessary for carrying out assigned duties. Responsibilities included upkeep of the facility, building, building systems and grounds. A review of Environmental Technician job description revealed the job duties included Replace burned out light bulbs to include exit lights, over head lights . and to perform cleaning duties wherever necessary. Service heating and cooling units/systems . (Copies obtained) A review of the facility's policy for Maintenance Service (Revised December 2009) revealed: The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free of hazards. d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. f. Establishing priorities in providing repair service. i. Providing routinely scheduled maintenance service to all areas. The Maintenance Director is responsible for maintaining the following records/reports: b. Work order requests c. Maintenance schedules A review of the facility's 5 & 7 Steps of Cleaning revealed the following: * 7 Step (Resident Bathroom) 3. Dust mop floor. Corn broom tough to reach areas i.e. corners, edges and behind the commode. 5. Clean sink and plumbing. Work high to low. Sink should be cleaned with Virex solution. 6. Clean commode and/or urinal areas. use toilet bowl cleaner and Johnny mop to properly sanitize area. 7. Wet mop floor.

Based on observations, interviews, and facility policy review, the facility failed to treat one (Resident #1) of 46 sampled residents with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, by failing to ensure the resident's urinary drainage bag was covered for privacy. The findings include: On 2/27/22 at 12:20 p.m., Resident #1 was observed awake and lying in bed. A urinary catheter bag was observed on the right side of her bed facing the door. The catheter bag was not covered with a privacy/dignity bag and urine was visible in the bag from the hallway. On 2/27/22 at 2:07 p.m., Resident #1 was observed in her room from the hallway. Her door was open and her urinary catheter bag was hanging from the right side of her bed. It was not covered with a privacy/dignity bag. On 2/28/22 at 9:15 a.m., Resident #1 was observed lying in bed. Her urinary catheter bag was not covered with a privacy/dignity bag. Urine was visible in the bag. On 3/1/22 at 8:22 a.m., Resident #1 was observed lying in bed. Her door was open and her urinary catheter bag was visible from the hallway. It was not covered with a privacy/dignity bag and urine was visible in the bag. Observations of Resident #1 were made on 3/1/22 at 11:38 a.m. and 3:09 p.m. Her urinary catheter bag was not covered with a privacy/dignity bag and urine was visible in the bag. On 3/2/22 at 8:21 a.m., Resident #1 was observed in bed from her doorway. Her urinary catheter bag was not covered with a privacy/dignity bag and urine was visible in the bag. On 3/2/22 at 11:15 a.m., an observation of Resident #1 was made from the hallway. Her door was open and her urinary catheter bag was not covered with a privacy/dignity bag. Urine was visible in the bag. On 3/2/22 at 11:50 a.m. Certified Nursing Assistant (CNA) H, who had been assigned to Resident #1 for three of five days of the survey, was interviewed. When she was asked about privacy/dignity bags for urinary catheter drainage bags, she stated she did not know whether the facility had any, but sometimes she would use a pillowcase. On 3/2/22 at 11:56 a.m., the Director of Nursing (DON) and the Regional Nurse were interviewed regarding expectations of the clinical staff for urinary catheter care and care of urinary drainage bags. They stated a privacy/dignity bag should be in place if the resident was out of their room. A review of the facility's policy and procedure for Catheterization (initiated 11/30/2014 and last revised on 9/19/2017), revealed: Foley bag (urinary catheter drainage bag) to be covered by a privacy bag to preserve dignity of resident.

Based on a review of resident records and interviews with staff, the facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASARR) in order to determine appropriateness of placement in a nursing facility and to provide the most appropriate setting and support for one (Resident #34) of five residents identified with serious mental disorders requiring a Level 2 screen, from a total of 45 residents in the sample. The findings include: 1. A medical record review for Resident #34 found she was admitted to the facility on [DATE], with a re-entry date of 2/16/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34 had a Level I PASRR dated 11/18/21. The screening tool indicated under section I.A. Mental Illness (MI) or Suspected MI, that Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section II. question 2.a. was marked Yes, indicating Resident #34 experienced functioning limitations in major life activities that would otherwise be appropriate for the individual's developmental stage. The form instructed that the completion of a Level II PASARR screening was required prior to admission to the nursing facility if any box in section I.A or 1.B (MI or Suspected MI) was checked, and there was a Yes checked in Section II.1, II.2 or II.3, unless the individual met the definition of a provisional admission or a hospital discharge exemption. Section III, PASARR Screen Provisional Determination noted Resident #34 did have a hospital discharge exemption. The instructions stated that should the resident be admitted under the 3-day exemption, and the stay in the nursing facility (NF) was anticipated to exceed 30 days, the NF must notify the Level I screener on the 25th day of the resident's stay, and the Level II evaluation must be completed no later than the 40th day after admission. The discharge exemption statement was signed by the attending physician on 11/18/21. Further review of the clinical record found no Level II screening was completed within 40 days of the residents admission, as required. An interview was conducted with the Director of Admissions on 3/3/22 at 10:10 a.m. She reported that new admission PASARRs were received from the hospital and Social Services would obtain a Level II if needed. A Level II had to be completed within 30 days after admission. She reviewed Resident #34's PASARR and stated a Level II was needed. I will go look in her closed chart to see if there is a Level II. The Social Services Director is not in the building. Kepro was called via telephone on 3/3/22 at 11:12 a.m., and a staff member was asked to review 5 PASARRs for a Level II. The employee at Kepro reviewed the 5 PASARRs and reported that Resident #34 indicated a need for a Level II from the latest date of the PASARR, which was 11/18/21. An interview was conducted with the Admissions Director on 3/3/22 at 11:21 a.m. She confirmed that a Level II PASARR was indicated but was not done.

Based on observations and interviews, the facility failed to provide personal grooming for one (Resident #30) of a sample of 46 residents. Resident #30 was dependent on staff for care, and his fingernails were long with a thick black substance underneath, which could have resulted in scratches and a potential infection. The findings include: Resident #30 was observed in his room on 2/28/2022 at 9:15 a.m. He was lying in bed with an indwelling urinary catheter, which was hanging on the bed rail covered by a privacy bag. He pulled his covers down and his fingernails were approximately an inch long with a thick black substance underneath them. The resident was observed in his room lying in bed on 3/1/2022 at 8:58 a.m. His nails are still long and unclean. He acknowledged that they were long and stated he would allow staff to cut them. The resident was observed in his room lying in bed on 3/2/2022 at 9:00 a.m. He reported that no one had cut his fingernails or cleaned them. They were still long and filled with a black substance underneath. A medical record review was conducted, which noted an admitted [DATE]. Resident #30's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, dated 12/16/2021, noted that Resident #30 required extensive assistance from staff with personal hygiene and grooming. The resident's comprehensive care plan was reviewed. It had been updated on 12/23/2021. Resident #30 had a focus area of Activities of Daily Living (ADL)/Self-Care Performance Deficit related to impaired mobility and weakness. One of the care plan interventions was to check nail length and trim and clean on bath day as necessary. An interview was conducted with Certified Nursing Assistant (CNA) GG on 3/3/2022 at 1:15 p.m. He reported that residents' nails are cut by CNAs on bath/shower days. He stated he floated to different areas of the facility and did not work with Resident #30 on a consistent basis. Today he was relieving a staff member (for lunch) who was doing one-to-one supervision with a another resident. CNA GG was asked to come to Resident #30's room when the staff member he was covering for returned. An interview was conducted with CNA GG at 2:40 p.m. on 3/3/2022. He reported that Resident #30's nails were cut by another CNA, but the black substance underneath them was hard and grown into the skin and was unable to be removed. The resident's hand would have to be soaked to loosen and remove the black substance.

Based on record review, observation and interviews, the facility failed to ensure provision of care and treatment in accordance with professional standards of practice for one (Resident #256) of 46 residents reviewed, by failing to obtain orders for the care and monitoring of a peripherally inserted central catheter (PICC) line. Resident #256 was admitted from the hospital with a PICC line for antibiotic therapy to treat a urinary tract infection ([CONDITION(S)]). The facility was administering intravenous (IV) antibiotics and flushing the PICC line without a physician's order. There was no physician's order for PICC line dressing changes, and no dressing change occurred for 11 days, despite the facility's policy for catheter site dressing regimens. The findings include: A review of Resident #256's medical record revealed he was admitted to the facility from an acute care hospital on 2/18/2022 with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was receiving antibiotics that required intravenous access. No physician's orders were found in the resident's record for assessment, monitoring, flushing, or dressing changes related to the intravenous (IV) access. A review of the resident's February 2022 electronic medication administration and treatment administration records (eMAR and eTAR) revealed no orders to change or monitor the IV dressing or to flush the IV line. On 2/27/2022 at 4:00 p.m., Resident #256 was observed in bed. A PICC line was observed in his right upper arm. The dressing was dated 2/18/2022. On 2/28/2022 at 8:35 a.m., Resident #256 was observed in bed. A PICC line was observed in his right upper arm. The dressing was dated 2/18/2022. On 2/28/2022 at 1:00 p.m., during an interview with Resident #256, he was asked if his PICC line dressing, located on his right upper arm, had been changed since he arrived at the facility. He stated no. He was asked if he recalled what day he was admitted to the facility. He replied, Yes, it's been ten days. He was asked if he recalled what day the PICC line was placed in his right upper arm. He replied, The same day I came to this facility, ten days ago. They put it in at the hospital before I came here. On 3/1/2022 at 2:10 p.m., during an interview with Registered Nurse (RN) A, he was asked if he was caring for Resident #256 today. He replied yes. He was asked if he was the nurse who hung the resident's 2:00 p.m. IV antibiotic, and he replied yes. He was asked how often PICC line dressings were changed, and he stated, Every two to three days, so every 48 to 72 hours. RN A was observed taking down the resident's IV antibiotic upon completion at 2:20 p.m. He was observed flushing the IV with 10 cc (cubic centimeters) of normal saline. The nurse was asked for the date on the IV dressing. He lifted the resident's sleeve and stated, Oh, the date on the dressing is February 18th. On 3/1/2022 at 2:25 p.m. during an interview with LPN L, she was asked how often midline IV dressings should be changed. She stated, once a week. On 3/1/2022 at 2:45 p.m., an interview was conducted with the Regional Corporate Coordinator. She was asked how often midline IV dressings should be changed. She stated, I can go pull the policy for you, but it should have been changed on admission to our facility, every seven days from that date, and as needed. On 3/3/2022 at 4:05 p.m., during an interview with LPN/Unit Manager N, she stated, Anyone can put the orders in. She was asked whether this resident's orders for the care and monitoring of the PICC line, the PICC line dressing changes and the IV flushes should be on the eMAR/aTAR. She stated, Yes, they should be. She was asked if there was a system check in place to ensure orders were put in the eMAR/eTAR. She stated, If a resident is admitted in the evening, the DON (Director of Nursing) and I review the orders the next day. When asked why there were no orders for the care and monitoring of the PICC line, she stated, Human error. It's my job to update the orders and I got behind. A review of the facility's policy titled Guideline for Preventing Intravenous Catheter-Related Infections (revised April 2014) section Catheter Site Dressing Regimens revealed: 1. Change initial dressing after catheter placement within 24 hours. 8. Replace transparent dressings on tunneled or implanted CVCs (central venous catheters) every 5-7 days unless the dressing is loose or soiled. According to MedlinePlus at https://medlineplus.gov (accessed on 3/25/22 at 2:50 p.m.), A peripherally inserted central catheter (PICC) is a long, thin tube that goes into your body through a vein in your upper arm. The end of this catheter goes into a large vein near your heart. The PICC carries nutrients and medicines into your body. A dressing is a special bandage that blocks germs and keeps your catheter site dry and clean. You should change the dressing about once a week. You need to change it sooner if it becomes loose or gets wet or dirty. .

Based on interviews and record review, the facility failed to ensure that residents with limited range of motion received the appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #89) resident reviewed, out of 14 residents with contractures, from a total of 46 residents in the sample. Specifically, the facility failed to apply and remove Resident #89's left wrist splint as ordered, which could result in the worsening of her contracture. The findings include: An interview was conducted with Resident #89 and her family representative on 2/28/2022 at 1:00 p.m. During the interview, the family representative stated the resident had a splint that she was supposed to wear on her left wrist at night. The family representative stated she came to visit and put the splint on Resident #89 every night around 6:00 p.m., because the staff either did not know how to put it on, or they just did not put it on. A review of Resident #89's medical record revealed an admitted [DATE]. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Minimum Data Set (MDS) assessment, dated 11/5/2021, revealed that she did not ambulate (walk), and she required extensive assistance or was totally dependent with activities of daily living (ADLs). A functional limitation in range of motion (ROM) to both the upper and lower extremities on her left side was noted. The resident's brief interview for mental status (BIMS) score was documented as 15 out of a possible 15 points, indicating intact cognition. During the MDS look-back period, occupational therapy was documented as having been provided for 85 minutes, and physical therapy was provided for 160 minutes, however no restorative nursing (including splint or brace assistance) was documented as having been provided. A review of the 5-day MDS assessment dated [DATE], revealed documented therapy minutes as follows during the look-back period: Physical therapy totaled 155 minutes Occupation therapy totaled 165 minutes Restorative nursing, including splint or brace assistance was not provided A review of the quarterly MDS assessment dated [DATE], revealed documented therapy minutes as follows during the look-back period: Physical therapy was not provided Occupation therapy totaled 105 minutes Restorative nursing, including splint or brace assistance was not provided The resident's BIMS score was documented as 10 out of a possible 15 points, indicating moderate cognitive impairment. According to the therapy department's Notification of Discharge, the resident was discharged from physical therapy and occupational therapy services to the LTC (long-term care) Restorative/ Functional Management Program (FMP). The last date of treatment in therapy was noted as 1/29/2022, and the therapy communication to the Restorative Nursing Program was also dated 1/29/2022. It recommended to Continue gentle range of motion for Left Upper Extremity (LUE) and donning Left (L) hand/wrist orthotic (splint) 4-5 hours at night. A review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's active comprehensive care plan was reviewed. She was not care planned for therapy services, restorative nursing services, or for the use of a wrist splint. The resident's certified nursing assistant (CNA) task list was reviewed, but the application/removal of a left wrist splint was not documented. During an interview with the resident's Unit Manager (UM) on 3/3/2022 at 1:10 p.m., the UM reviewed the resident's medical file and the restorative order. The therapy recommendation for the splint was communicated to nursing via the therapy discharge form, but it was not transcribed to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with the Occupational Therapist (OT) was conducted on 3/3/2022 at 1:33 p.m. During the interview, the OT stated, The FMP (Functional Maintenance Program) is communicated to nursing either before or at the time of discharge from therapy. It is given to the nurses. It is then communicated, and staff is trained. The FMP is posted in the resident's room, preferably on the inside of the closet door for the resident's privacy. If it isn't in the closet, there is a copy at the nurses' station. The Unit Manager is responsible for ensuring the staff is trained according to the FMP. The Director of Nursing (DON) also receives a copy of the FMP. During an observation of the resident's room at 1:50 p.m. on 3/3/2022, the FMP was not posted on the inside of the closet door or in any location within the room. The Unit Manager was interviewed at 1:53 p.m. on 3/3/2022. During the interview, the UM was asked about the process for communication between Therapy and the Nursing Restorative Program. The UM could not verbalize the process, stating she did not know, because she had not received a restorative communication since she began working in the facility. An interview with Certified Nursing Assistants (CNAs) BB, Z, and Y, at 2:50 p.m. on 3/3/2022, revealed that they were not aware of a Functional Maintenance Program or a Restorative Therapy Program. They are not aware of any residents who required functional maintenance, splinting, or restorative care. An interview was conducted with the Regional Director of Clinical Services (RDCS) at 3:30 p.m. on 3/3/2022. During the interview, the RDCS stated, The FMP is communicated to the floor staff. Therapy communicates the FMP to the CNAs directly. Therapy ensures the CNA staff is trained. If there is a restorative program, the restorative aide will train the CNAs. All staff CNAs are trained on restorative. Staff CC is the 3:00 p.m. to 11:00 p.m. therapy aide. An interview was conducted with CNA CC at 4:15 p.m. on 3/3/2022. During the interview, CNA CC stated she was not aware of a Functional Maintenance Program (FMP) or a Nursing Restorative Program. She further stated she was a CNA and the therapy coordinator. CNA CC confirmed that she did not do any splinting, restorative care, or care pertaining to functional maintenance for the residents. .

Based on resident interviews, observation, staff interviews and facility policy and procedure review, the facility failed to ensure one resident (#46) out of two residents sampled for dignity concerns from 50 total sampled residents, was treated with respect and dignity in a manner that promoted maintenance or enhancement of his quality of life recognizing his individuality. Failure to treat Resident #46 with dignity and respect had a negative impact on his psychosocial wellbeing. The findings include: Resident #46 was observed on 02/25/2020 at 10:10 AM lying in bed with his eyes closed and appeared asleep. The resident granted permission to enter his room and stated he has a pressure ulcer on his sacrum that is not healing. He stated that wound care was not being done every day. He went on to say that the staff are demanding and harsh during incontinence care. He identified Employee J, CNA, as very demanding. He stated that the staff think he is capable of turning on his side while in bed and grabbing hold of the bed rail to assist when he requires incontinence care. He is not able to do this and has to be physically turned on his side. He stated, They don't believe me. He explained he has very limited use of his left hand and not much better in his right. He tells staff it is very painful to be turned on his sides. He has complained in the past about the staff not being respectful to him. There was a Certified Nursing Assistant (CNA) that he reported a few months ago that was moved to another assignment after the resident complained about her. Since then, there are several CNAs that are disrespectful, demanding and harsh to him. He thinks these staff are friends with the CNA he complained about and they might be trying to get back at him for her. He stated he is afraid of retribution by some of the staff, but he did not know if what they were doing was deliberate. He stated he has told at least three staff members of his concerns, but nothing changes. Review of the clinical record for Resident #46 revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #46's care plan revealed focus areas that included activities of daily living (ADL) self-care performance deficit related to activity intolerance, disease process ([MEDICAL CONDITION]), fatigue, bilateral hands with limited range of motion. The goal was for Resident #46 to receive appropriate staff support with bed mobility, transfer, toileting, grooming and hygiene through the next review. Interventions included: Bed Mobility: The resident is totally dependent on 1-2 staff for repositioning and turning in bed as necessary. Bedfast: The resident is bedfast all or most of the time. Toilet Use: The resident is totally dependent on (1) staff for toilet use. Focus area: The resident has [MEDICAL CONDITION] affecting mobility and self-care. The goal was for Resident #46 to remain free of further signs or symptoms of discomfort or complications related to [MEDICAL CONDITION] through the next review. Interventions included: Monitor for signs and symptoms of depression. Provide emotional support, encouragement. Encourage resident to vent feelings about disease. Review of the facility grievance log from December 2019 through February 2020 revealed no grievances filed by or on behalf of Resident #46. On 02/27/2020 at 12:22 AM, an observation of ADL care and an assessment of skin integrity was conducted for Resident #46. The ADL care was provided by Employee I, CNA. The CNA was observed walking into the resident's room while simultaneously saying loudly knock, knock, but he did not knock on the door or request permission to enter the room. Upon entering, the CNA began conversing with the surveyor stating, I need you to stand on the other side of the bed because when I roll him, he likes to pee, so I have to put this towel down or he'll wet the bed. The surveyor explained to the resident that ADL care and an assessment of his skin integrity would be performed with his permission. The resident stated yes, and the CNA proceeded to quickly pull the resident's blankets off him and lift up the resident's hospital gown exposing the resident's incontinence brief. The surveyor closed the room door and the privacy curtains around the resident's bed. The CNA stated Oh yeah. Thank you. The CNA unfastened the resident's brief on one side, placed his hand on top of the brief, squeezed the brief and stated, Oh and he's wet too so I'll just change him after we do this. The surveyor explained to the resident that his brief would need to be removed and that the CNA planned to change it after his skin was assessed. The resident stated ok and care continued. The resident was then rolled onto his left side. A partial thickness wound with no dressing or treatment was observed to the resident's left buttock. The resident explained that the area was painful and described the pain as a burning sensation. The CNA was asked whether he knew what treatments were being applied to the area. He explained that sometimes the nurses come and put some kind of cream on it but was not sure of the treatment schedule. ADL care was then rendered, and the resident was assisted back to a supine position. There were no pillows or positioning devices offered to the resident in an effort to offload the area. Resident #46 was interviewed on 02/27/2020 at 4:12 PM. The resident remembered the incontinence care provided during the overnight shift by Employee I. He stated, (Employee I) was being rough with me. I'm not sure if it was deliberate or not. He jammed my face into the rail. He stated he felt scared. He has a fear of retribution from some of the staff. He identified Employee I as one of the staff members that are disrespectful to him. He felt that he is not being included in his own care. He had been complaining for a week about the wound on his sacral area being painful, but it seems no one is paying attention. He feels the wound has gotten worse because the wound care is not being done. He stated on one occasion, the wound care nurse came in to provide treatment but when she rolled him on his side, she observed that he had a bowel movement. According to Resident #46 she stated, Oh my God, I don't have to put up with this! She then left the room. He stated when the nurse said that, he felt sad and angry. He is not able to always know when he has a bowel movement and did not know he needed to be cleaned up. He stated other staff make comments like that and it makes him feel bad. When the staff provide ADL care to him, they talk to each other instead of him. He described it as non-stop talking with each other. He stated that when Employee I provides incontinence care and the sheets get soiled, the CNA pitches a fit because he has to change the sheets too. They do not acknowledge him. He stated, It costs a lot of money to live here and I expect to be treated with respect. He stated that the staff will stop what they are doing if he tells them to stop, but he knows he needs to be clean because that is what is causing the wounds on his sacrum. When he tells them to stop, they do, but they scold him and he feels he deserves better treatment. At that point, the resident started to cry. He stated it makes him feel angry and sad afterward. During the entrance conference, all Quality Assurance data was requested for any projects that were ongoing. No data was provided. During the Quality Assurance (QA) meeting on 02/27/2020 at 6:10 PM with the Administrator and the Director of Nursing (DON), the Administrator stated that she gathers information through mock survey data and grievances. Mock surveys are conducted daily for each resident. No data was provided regarding the mock surveys during the survey for Resident #46. She confirmed that Resident #46 had filed a complaint a couple of months ago about a CNA and they moved her to another assignment. After describing Resident #46's statements and the ADL care observation, the Administrator and DON expressed surprise and did not know about his feelings. The Administrator stated she thought she would need to conduct an investigation. A meeting was requested by the Regional Nurse Consultant (RNC). On 02/27/2020 at 8:45 PM, upon approach to the Administrator's office, Employee J, CNA, was observed seated in a chair across from the administrator's desk. The Administrator, DON and RNC were in the office with him. The Administrator dismissed Employee J before the meeting. During the meeting, the Administrator asked why Resident #46's concerns were not reported to her when he first voiced them. She stated that the facility needed to file a report to the State, and she needed to start an investigation. It was explained to her that the resident did not voice concerns about being abused - only the fear of retribution, being treated with disrespect and lack of wound care. His concerns needed to be investigated first. The resident did not describe his feelings in detail until 02/27/2020 during the interview at 4:12 PM. She was informed during the QA meeting on 02/27/2020 at 6:10 PM. She confirmed that no staff had reported any concerns to her voiced by Resident #46. She was asked if any staff had interviewed Resident #46 after the information was shared with her during the QA meeting at 6:10 PM. She stated, Not yet. She confirmed that she was interviewing Employee J regarding Resident #46's concerns when the surveyors approached her office at 8:45 PM. She and the RNC acknowledged that obtaining the resident's statement would be an important first step in beginning an investigation. Review of the facility policy and procedure entitled Perineal Care effective date 11/30/2014 and revised on 09/05/2017 revealed it read: Explain procedure to resident and provide privacy, perform hand hygiene, leave the resident comfortable with signal cord in reach. Review of the facility employee handbook and policy and procedure entitled Core Values revealed it read: (Facility Name) is committed in our efforts to provide a high standard of resident /patient care and excellent customer service, and also in the communication that takes place during the workday. You are expected to approach residents and families in a professional, courteous and efficient manner. A caring attitude and a smile are the first steps toward providing service. The residents of (Facility Name) have rights that are enforced by federal and state laws which are designed to ensure that our residents are able to maintain their dignity and self-respect. You and (Facility Name) have a moral and legal responsibility to communicate and preserve these rights. You are expected to treat all residents and patients with [MEDICATION NAME], honesty, respect, integrity and [MEDICATION NAME].

Based on record review and staff interview, the facility nurses failed to provide care that met professional standards of quality for one resident's (Resident #1) abdominal wound and [DEVICE] therapy (promotes wound healing through negative pressure), out of 3 residents reviewed for wound care. The nurses did not administer the following treatments as indicated or authorized by a duly licensed practitioner, according to the Florida Nurse's Practice Act and Lippincott Manual of Nursing Practice 10th Edition: Did not assess the abdominal surgical wound for 20 days. Did not change the dressing to the abdominal surgical wound for 20 days. Did not obtain physician orders for management of the abdominal [DEVICE] for 13 days. Did not ensure the [DEVICE] was plugged in as prescribed on the 3-11 shift on 2 days. The resident did not receive any abdominal wound care from the day of admission to the facility, 1/20/15, until 2/9/15, 20 days, resulting in actual harm. When the [DEVICE] was removed on the 20th day, the dressing was imbedded in the wound tissue and could not be removed. As a result, the resident was hosptalized on [DATE] for extensive debridement of the wound bed. Resident #1 was 1 out of 3 residents reviewed for wound care. The facility practices of not providing care, which did not meet professional standards of quality, resulted in actual harm to Resident #1. The facility's failure to provide care for Resident #1's abdominal wound resulted in complications of the dressing becoming imbedded in the wound, hospital readmission, and need for extensive debridement. The facility's census was 118, with 10 residents receiving wound care. See also F309. The findings include: The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, and evaluation of care; health teaching and counseling of the ill, injured and infirm; and the promotion of wellness, maintenance of heath, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. Additionally, the Act states that the "practice of practical nursing" means "the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing." According to Lippincott Standards of Care Guidelines Preventing and Recognizing Postoperative Complications, postoperative complications may interfere with the expected outcome of the surgery and may extend the patient's hospitalization and convalescence. The nurse plays a critical role in attempting to prevent complications and in recognizing their signs and symptoms immediately. Care of the patient after surgery should include the following, until risk of complication has passed: Observe the wound site for drainage, odor, swelling, and redness, which could indicate infection. Observe the wound for stage of healing. Sandra M. Nettina. (2014). Lippincott Manual of Nursing Practice (10th ed.) Lippincott. According to Mosby's wound management teaching, Negative Pressure Wound Treatment (NPWT) perform most favorably in complicated deep wounds. Acute wound healing guidelines advocate NPWT to oppose distractive soft tissue vectors that may act to delay healing and keep an acute wound, especially an open abdominal wound. Application essentials include assessment of the wound and periwound, wound bed preparation, and measurement of wound. Typically change entire dressing, including wound filler, every 48 hours or three times per week. Document ease of removal of dressing, and number of wound fillers. Ruth A. Bryant. (2012). Acute and Chronic Wounds: Current Management Concepts (4th ed.) Mosby. Review of Resident #1's history and physical dated 1/21/15 revealed a [AGE] year old who was admitted to the facility on [DATE] from the hospital, after abdominal surgery on 12/31/14 for small bowel obstruction, with perforation (hole through the bowel) and sacral abdominal wall wound (the resident's abdominal surgical wound had become infected and opened up). A [DEVICE] (wound vac) was in place on admission to the facility, and the wound care service was following the resident (wound service does not manage the wound vac however). Record review revealed that other [DIAGNOSES REDACTED]. Review of Resident #1's hospital "Wound Care Progress Note" dated 1/9/15 revealed open incision of the abdomen midline with mixed pink-yellow slough (dead tissue) tissue present, santyl (wound cleaning ointment) applied to wound base, negative pressure wound treatment (NPWT) black foam dressing applied. Review of Resident #1's "Pressure Ulcer Record" dated 1/20/15 revealed a surgical incision right abdomen measuring 19.0 x 2.0 x 1.0 (no increment), wound bed [MEDICATION NAME] (outer layer of skin tissue), pink; wound edges rolled; drainage small amount, clear. Review of Resident #1's admission nursing assessment dated [DATE] revealed abdominal wound cleansed with normal saline and wound vac applied (admitting nurse was no longer employed at the facility, unavailable for interview). Review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed an unstageable wound on admission to the coccyx (base of the spine) with eschar (thick crust of dead tissue). Surgical wound present on admission. Treatments included surgical wound care and application of nonsurgical dressings. Review of Resident #1's Skin/Wound care plan dated 1/27/15 revealed status [REDACTED]. Record review of Resident #1's physician orders revealed no documentation of surgical wound or wound vac orders for the pressure setting of the device, frequency of dressing changes, or alternative method of care if the seal to the dressing or the pump failed. Review of a physician order for [REDACTED]. Further record review revealed a fax sent to Resident #1's physician on 2/1/15 which stated that the resident's family was concerned regarding the resident's post-operative appointment with the surgeon. The family also wanted to know who was following the resident's abdominal wound and wound vac. Record review of a nursing note for Resident #1 dated 2/9/15 at 9:00 am read wound vac noted mid abdomen. Wound dressing is intact, drainage is green in color, minimal output noted. At 2:30 pm wound vac change attempted by the Registered Nurse (RN). Black foam pad (a component of the wound vac dressing) noted in wound bed and unable to remove. The physician's office was called and an order was obtained to soak the foam dressing and attempt to remove with force if needed. If unable to remove notify surgeon's office for further orders. The resident was sent to the physician's office on 2/10/15. Interview with the hospital case manager on 3/25/15 at 12:29 pm revealed that the resident went to the hospital from the physician's office on 2/10/15 for debridement of the abdominal wound. The case manager stated that the wound required extensive debridement due to the foam dressing being imbeded in the resident's tissue. The case manager stated that the resident's family said the resident's abdominal dressing was not changed during his stay in the facility. Complete record review of Resident #1's nursing notes revealed no documentation regarding Resident #1's abdominal wound status, or any wound vac dressing changes prior to 2/9/15. Review of Resident #1's "Weekly Skin Integrity Review" dated 1/20/15 revealed abdominal surgical wound with wound vac treatment in place. The next skin review was dated 2/2/15 and marked "Other," with no mention of the abdominal wound or wound vac treatment. The skin review dated 2/9/15 was marked "Open Area," with no mention of the abdominal wound or wound vac treatment. Record review of Resident #1's January, 2015 Treatment Administration Record (TAR) revealed no documentation of abdominal wound vac care or dressing changes. Record review of Resident #1's February, 2015 TAR revealed an order dated 2/2/15 to apply wound vac to mid abdomen, cleanse wound with normal saline, apply santyl to wound bed, cover with black foam dressing and [MEDICATION NAME], skin prep around wound. Maintain negative pressure at 125mmhg. Change Tuesday, Thursday and Saturday on evening shift. The box designated for the prescribed wound treatment on Tuesday 2/3/15 was marked with a dash, signifying "Not documented." The box designated for the wound treatment on Thursday 2/5/15 was marked with an asterick, signifying "Not administered (explanation given was "supplies ordered"). The box designated for the wound treatment on Saturday 2/7/15 was marked with Employee F's initials, signifying that the wound care was done. All other boxes for wound care in the month of February, 2015 were marked with an "X," signifying "Not scheduled." Record review of the nursing staffing schedule for the 3 pm-11 pm shift and the 11 pm-7 am shift on 02/07/15 revealed that Employee F, Licensed Practical Nurse (LPN) was the charge nurse on the 700 hall on that date. During a telephone interview on 02/23/15 at 3:00 pm with Employee F, she stated that she did not recall doing a wound vac change for Resident #1 on the 3-11 or 11-7 am shift on 2/7/14. Further review of Resident #1's February, 2015 TAR revealed orders dated 2/2/15 to ensure that the wound vac was plugged in each shift and charging. The box designated for the 3-11 shift on 2/3/15 and 2/4/15 was marked with a dash, signifying "Not documented." During an interview on 02/23/15 at 12:55 pm with Employee D, Registered Nurse (RN), she stated that Resident #1's wound care should have been documented on the TAR if done. She confirmed that there was no documentation on the resident's January, 2015 TAR that the wound vac dressing had been changed. She confirmed that there was no documentation on the February, 2015 TAR that the wound vac dressing had been changed prior to 2/7/15. She confirmed that the admitting nurse had not communicated with the resident's physician upon admission for wound vac orders. Employee D stated that Resident #1 was moved to the 700 hall on 1/26/15. She confirmed that there were no orders for the wound vac treatment at that time, and she notified the physician for orders. She confirmed that an order for [REDACTED]. " She stated that the resident's skin review should have been completed weekly. She reviewed the resident's record and confirmed that there was no documentation of the condition of the resident's abdominal wound or wound vac dressing changes from admission on 1/20/15 until 2/7/15. During an interview on 02/23/15 at 1:00 pm with the Director of Nursing (DON) she confirmed that Resident #1's skin/wound care plan had not been followed regarding the wound vac treatment. During an interview with the DON on 02/23/15 at 3:10 pm she stated that the facility policy was to assess residents' skin weekly and document on the "Weekly Skin Integrity Review" forms. She confirmed that this had not been done for Resident #1's abdominal wound. She stated that the facility recognized that "their systems were not in place (regarding wound care), and they were in the process of correcting that." Review of the facility policy titled "Non-Pressure Skin Condition Record" revealed instructions to document the presence of skin impairment/ new skin impairment not related to pressure when first observed and weekly thereafter. This includes skin tears and surgical sites. Each week the non-pressure ulcer skin condition is to be assessed and the following information collected on this form until the area heals (refers to form that captures data on wound location, size, drainage, wound edges, and periwound area). Review of the facility provided NPWT Recommended Guidelines for Treating Wound Types, revised 01/11, revealed instructions to monitor characteristics of wound drainage and report any significant changes to the physician. It is extremely important during the entire course of NPWT therapy to keep the therapy on continuously and clean the wound thoroughly at each dressing change.

Based on observation and interview the facility failed to provide necessary care and services for abdominal surgical wound and [DEVICE] therapy (promotes wound healing through negative pressure) for one resident (Resident #1), out of 3 sampled residents reviewed for wound care. The nurses did not administer the following surgical wound care: Did not assess the abdominal surgical wound for 20 days. Did not change the dressing to the abdominal surgical wound for 20 days. Did not obtain physician orders for management of the abdominal [DEVICE] for 13 days. Did not ensure the [DEVICE] was plugged in as prescribed on the 3-11 shift on 2 days. The resident did not receive any abdominal wound care from the day of admission to the facility, 1/20/15, until 2/9/15, 20 days, resulting in actual harm. When the [DEVICE] was removed on the 20th day, the dressing was imbedded in the wound tissue and could not be removed. As a result, the resident was hosptalized on [DATE] for extensive debridement of the wound bed. Resident #1 was 1 out of 3 residents reviewed for wound care. The facility practices of not providing care, which did not meet professional standards of quality, resulted in actual harm to Resident #1. The facility's failure to provide care for Resident #1's abdominal wound resulted in complications of the dressing becoming imbedded in the wound, hospital readmission, and need for extensive debridement. The facility's census was 118, with 10 residents receiving wound care. See also F281. The findings include: Review of Resident #1's history and physical dated 1/21/15 revealed a [AGE] year old who was admitted to the facility on [DATE] from the hospital, after abdominal surgery on 12/31/14 for small bowel obstruction, with perforation (hole through the bowel) and sacral abdominal wall wound (the resident's abdominal surgical wound had become infected and opened up). A [DEVICE] (wound vac) was in place on admission to the facility, and the wound care service was following the resident (wound service does not manage the wound vac however). Record review revealed that other [DIAGNOSES REDACTED]. Review of Resident #1's "Pressure Ulcer Record" dated 1/20/15 revealed a surgical incision right abdomen measuring 19.0 x 2.0 x 1.0 (no increment), wound bed [MEDICATION NAME] (outer layer of skin tissue), pink; wound edges rolled; drainage small amount, clear. Review of Resident #1's admission nursing assessment dated [DATE] revealed abdominal wound cleansed with normal saline and wound vac applied (admitting nurse was no longer employed at the facility, unavailable for interview). Review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed surgical wound present on admission. Treatments included surgical wound care and application of nonsurgical dressings. Review of Resident #1's Skin/Wound care plan dated 1/27/15 revealed status [REDACTED]. Record review of Resident #1's physician orders revealed no documentation of surgical wound or wound vac orders for the pressure setting of the device, frequency of dressing changes, or alternative method of care if the seal to the dressing or the pump failed. Review of a physician order for [REDACTED]. Further record review revealed a fax sent to Resident #1's physician on 2/1/15 which stated that the resident's family was concerned regarding the resident's post-operative appointment with the surgeon. The family also wanted to know who was following the resident's abdominal wound and wound vac. Record review of a nursing note for Resident #1 dated 2/9/15 at 9:00 am read wound vac noted mid abdomen. Wound dressing is intact, drainage is green in color, minimal output noted. At 2:30 pm wound vac change attempted by the Registered Nurse (RN). Black foam pad (a component of the wound vac dressing) noted in wound bed and unable to remove. The physician's office was called and an order was obtained to soak the foam dressing and attempt to remove with force if needed. If unable to remove notify surgeon's office for further orders. The resident was sent to the physician's office on 2/10/15. Interview with the hospital case manager on 3/25/15 at 12:29 pm revealed that the resident went to the hospital from the physician's office on 2/10/15 for debridement of the abdominal wound. The case manager stated that the wound required extensive debridement due to the foam dressing being imbedded in the resident's tissue. The case manager stated that the resident's family said the resident's abdominal dressing was not changed during his stay in the facility. Complete record review of Resident #1's nursing notes revealed no documentation regarding Resident #1's abdominal wound status, or any wound vac dressing changes prior to 2/9/15. Review of Resident #1's "Weekly Skin Integrity Review" dated 1/20/15 revealed abdominal surgical wound with wound vac treatment in place. The next skin review was dated 2/2/15 and marked "Other," with no mention of the abdominal wound or wound vac treatment. The skin review dated 2/9/15 was marked " Open Area," with no mention of the abdominal wound or wound vac treatment. Record review of Resident #1's January, 2015 Treatment Administration Record (TAR) revealed no documentation of abdominal wound vac care or dressing changes. Record review of Resident #1's February, 2015 TAR revealed an order dated 2/2/15 to apply wound vac to mid abdomen, cleanse wound with normal saline, apply santyl to wound bed, cover with black foam dressing and [MEDICATION NAME], skin prep around wound. Maintain negative pressure at 125mmhg. Change Tuesday, Thursday and Saturday on evening shift. The box designated for the prescribed wound treatment on Tuesday 2/3/15 was marked with a dash, signifying "Not documented." The box designated for the wound treatment on Thursday 2/5/15 was marked with an asterisk, signifying "Not administered (explanation given was "supplies ordered"). The box designated for the wound treatment on Saturday 2/7/15 was marked with Employee F's initials, signifying that the wound care was done. All other boxes for wound care in the month of February, 2015 were marked with an "X," signifying "Not scheduled." Record review of the nursing staffing schedule for the 3 pm-11 pm shift and the 11 pm-7 am shift on 02/07/15 revealed that Employee F, Licensed Practical Nurse (LPN) was the charge nurse on the 700 hall on that date. During a telephone interview on 02/23/15 at 3:00 pm with Employee F, she stated that she did not recall doing a wound vac change for Resident #1 on the 3-11 or 11-7 am shift on 2/7/14. Further review of Resident #1's February, 2015 TAR revealed orders dated 2/2/15 to ensure that the wound vac was plugged in each shift and charging. The box designated for the 3-11 shift on 2/3/15 and 2/4/15 was marked with a dash, signifying "Not documented." During an interview on 02/23/15 at 12:55 pm with Employee D, Registered Nurse (RN), she stated that Resident #1's wound care should have been documented on the TAR if done. She confirmed that there was no documentation on the resident's January, 2015 TAR that the wound vac dressing had been changed. She confirmed that there was no documentation on the February, 2015 TAR that the wound vac dressing had been changed prior to 2/7/15. She confirmed that the admitting nurse had not communicated with the resident's physician upon admission for wound vac orders. Employee D stated that Resident #1 was moved to the 700 hall on 1/26/15. She confirmed that there were no orders for the wound vac treatment at that time, and she notified the physician for orders. She confirmed that an order for [REDACTED]. " She stated that the resident's skin review should have been completed weekly. She reviewed the resident's record and confirmed that there was no documentation of the condition of the resident's abdominal wound or wound vac dressing changes from admission on 1/20/15 until 2/7/15. During an interview on 02/23/15 at 1:00 pm with the Director of Nursing (DON) she confirmed that Resident #1's skin/wound care plan had not been followed regarding the wound vac treatment. During an interview with the DON on 02/23/15 at 3:10 pm she stated that the facility policy was to assess residents' skin weekly and document on the "Weekly Skin Integrity Review " forms. She confirmed that this had not been done for Resident #1's abdominal wound. She stated that the facility recognized that "their systems were not in place (regarding wound care), and they were in the process of correcting that." Review of the facility policy titled "Non-Pressure Skin Condition Record" revealed instructions to document the presence of skin impairment/ new skin impairment not related to pressure when first observed and weekly thereafter. This includes skin tears and surgical sites. Each week the non-pressure ulcer skin condition is to be assessed and the following information collected on this form until the area heals (refers to form that captures data on wound location, size, drainage, wound edges, and periwound area). Review of the facility provided NPWT Recommended Guidelines for Treating Wound Types, revised 01/11, revealed instructions to monitor characteristics of wound drainage and report any significant changes to the physician. It is extremely important during the entire course of NPWT therapy to keep the therapy on continuously and clean the wound thoroughly at each dressing change.