Every finding on record at Aviata at Lakeside Oaks

Based on observation, interview, and record review, the facility did not maintain dignity during a meal service for one resident (#84) out of six residents reviewed for dining, and did not ensure residents' rights to self determination regarding leave of absence (LOA) for two residents (#60 and #12) out of four residents reviewed. These failures resulted in Resident #84 not receiving a timely lunch meal and Residents #60 and #12 being restricted from leaving the facility. Findings include: On 7/27/26 at 12:25 p.m., an observation showed Resident #84's roommate received a lunch tray and began eating in their shared room. At 12:48 p.m., Resident #84 walked into the hallway and asked Staff A, Certified Nursing Assistant (CNA), where his lunch was. Staff A checked the meal cart in the hallway and told the resident the tray was not present, then left the area. Resident #84 asked Staff B, CNA, if coffee was available. Staff B stated in an interview that all residents in the unit were provided a lunch tray. An observation showed Resident #84's roommate had finished their meal. At 12:53 p.m., Staff A returned to the hallway and asked Resident #84 if he wanted a grilled cheese or peanut butter and jelly sandwich. Staff A stated the kitchen had run out of stir fry. A review of Resident #84's admission record revealed an admission on [DATE]. A review of Resident #84's physician orders revealed dietary orders for a regular diet with regular texture and thin liquids. A review of Resident #84's quarterly minimum data set (MDS) assessment, dated 5/20/26, revealed a brief interview for mental status (BIMS) score of 15, indicating intact condition and Resident #84 eats independently, without the assistance of staff. A review of the lunch menu, on 7/27/26, revealed the main entree was chicken stir fry with vegetables, steamed rice, dinner roll/bread, dessert, and tea of choice. The other meal option was pork chop, egg noodles, and braised cabbage. A review of the Always Offered Menu, revealed the following food options: chicken tenders, grilled cheese sandwich, egg salad sandwich, chef's salad and soup of the day. A review of Resident #84's meal ticket for lunch, on 7/27/26, revealed the following to include: chicken stir fry with vegetables, steam rice, dinner roll/bread, assorted pudding, whole milk and sugar free fruit punch. During an interview on 7/29/26 at 3:22 p.m., the Dietary Manager stated resident information is maintained in a meal tracker system and meal tickets are printed and matched to trays during tray line. The manager said two residents transferred from another facility on 7/27/26 and were not yet added to the meal system, which caused two missing trays. The manager said they were aware another resident did not like the entree and received an alternate meal, but the kitchen did not run out of the main entree on 7/27/26. The manager said Resident #84 should have received a tray or the alternate pork chop meal. The manager did not recall what Resident #84 received and did not know how the tray or ticket became missing.On 7/30/26 at 11:52 a.m., Staff A, CNA, stated she spoke with the cook and Dietary Manager on 7/27/26 and was told they did not have more stir fry available. Staff A stated they instructed her to ask Resident #84 if he wanted a grilled cheese or peanut butter and jelly sandwich.On 7/30/26 at 4:19 p.m., the Director of Nursing (DON) stated meal tickets contain resident information and help ensure trays are delivered accurately. The DON said nursing staff should obtain a tray from the kitchen if one was missed. The DON stated meal trays should be delivered at the same time to avoid one resident watching another eat, and that this expectation applies both in rooms and dining rooms. The DON said they were not aware Resident #84 did not receive a lunch tray on 7/27/26.A review of the facility's policy titled Meal Distribution, revised 2/2023, revealed the following, Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Further review of the policy revealed the following, Procedures . 4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients.On 7/27/26 at 11:00 a.m., an interview and observation was conducted with Resident #60. Resident #60 was observed sitting up in bed and stated he was not allowed to leave the facility. Resident #60 said he was interested in leaving the facility to go to the store but was told by facility staff he could not. A review of Resident #60's admission record revealed an admission date on 2/3/26 and a re-admission on [DATE], with diagnoses to include psychoactive substance abuse, major depressive disorder, bipolar disorder, and brief psychotic disorder.A review of Resident #60's physician orders revealed the following, May not go out on LOA, with an order date on 2/3/26. A review of Resident #60's care plan revealed the following:- [Resident #60] is at risk for leaving the center against medical advice R/T [related to] drug or alcohol use due to substance use disorder. Created date: 2/20/2026.- [Resident #60] is at risk for leaving the center without notifying staff R/T drug or alcohol seeking due to substance use disorder.Educate [sic] resident on LOA procedure ---NO LOA'S AT THIS TIME Created date: 2/20/2026.- [Resident #60] is at risk for a psychosocial well-being problem r/t little interest in doing things he is able to make his own decisions. Created date: 2/20/2026. A review of Resident #60's psychiatry (psych) notes, dated 6/29/26 and 7/2/26, revealed the resident reported no additive substance cravings, and no other psychiatric symptoms were observed and Resident #60 with a BIMS score of 14, indicating intact cognition. A list of the residents' LOA orders was requested and provided by the facility. A review of the current orders showed thirty-five residents may not go out on LOA. On 7/28/26 at 9:58 a.m., an interview was conducted with Staff Q, receptionist and the Staffing Coordinator. Staff Q, receptionist said she had a list, dated 12/19/25, for residents who are incapacitated. Staff Q stated being instructed the list was current, Until told otherwise. There was another list observed in the receptionist area with names of residents who cannot go on LOA. The Staffing Coordinator and Staff Q, receptionist both said they also checked in the electronic health record for the residents' LOA orders and consulted with the DON. The Staffing Coordinator said LOA orders are based on cognition and if they needed a responsible party to accompany them. The Staffing Coordinator said there are several residents who are not able to leave the facility because they have not asked or do not have family. On 7/28/26 at 12:20 p.m., an interview was conducted with the DON. The DON stated LOA orders marked May not go out on LOA were old and not up to date, and that orders could be changed if a resident requested to leave.On 7/30/26 at 4:04 p.m., an interview was conducted with the DON. The DON stated the May not go out on LOA order was a batch order used for all residents upon admission. The DON said individual orders would be updated only if a resident asked to leave and the provider approved it. The DON stated Resident #60 had not asked to leave and that the resident's LOA restriction dated 2/3/26 remained in place. On 7/28/26 at 10:49 a.m., an interview was conducted with Resident #12. Resident #12 said he was not allowed to leave the facility. Resident #12 said he would ask friends to pick him up, but he was told by facility staff that he was not allowed to go out. Resident #12 said he wanted to go shopping and visit with his outside friends. A review of Resident #12's admission record revealed an admission date on 5/4/26, with diagnoses to include cerebral infarction, need for assistance with personal care, muscle weakness (generalized), adjustment disorder with depressed mood, end stage renal disease, unsteadiness on feet, and acquired absence of left leg below knee. A review of Resident #12's physician orders revealed the following, May not go out on LOA, with an order date on 5/4/26. A review of psych notes, dated 6/22/26 and 7/30/26, revealed no psychiatric symptoms observed. Further review of the psych note, dated 6/22/26, revealed a BIMS score of 11, indicating moderately impaired cognition. On 7/30/26 at 4:17 p.m., an interview was conducted with the DON. The DON said Resident #12 had current orders for, May not go out on LOA. The DON stated Resident #12's LOA order had not been addressed because the resident had not requested to go anywhere and that a physician would determine the need for supervision.A review of the facility's policy titled Leave of Absence, dated 6/14/21, revealed the following, A patient/resident is allowed a leave of absence (LOA) from the center in accordance with safe medical practice and state and federal regulations. During admission process patient/residents receive information regarding the leave of absence procedure. Further review of the policy revealed the following, Procedure: 1. Obtain a physician's order for the patient/resident to leave the center. 7. If the physician determines that the patient/resident should not leave the center and the patient/resident and/or resident representative does not agree refer to the Against Medical Advice procedure.

Based on observations, interviews, and record reviews, the facility did not ensure each resident's person centered comprehensive care plan was revised in a timely manner for two of four residents reviewed (Residents #3 and #12). This deficient practice resulted in care plans that did not reflect current diagnoses, orders, conditions, or code status, which could lead to unmet needs or delayed interventions.Findings include: A record review of Resident #3 admission Record showed an original admit date of 4/29/2025 with a readmission date of 5/03/2026 and diagnoses to include but not limited to cerebral infarction due to embolism of bilateral posterior cerebral arteries. A review of Resident #3's physician orders showed a Do Not Resuscitate (DNR)order dated 6/18/2026. Review of Resident #3's care plan for the focus area of advance directives showed the resident was listed as choosing to remain Full Code. This care plan was initiated and last revised on May 15, 2025, and had not been updated to reflect the current DNR order. A record review of Resident #12's admission Record showed an admit date of 5/04/2026 with diagnoses to include but not limited to Type 2 diabetes mellitus with other diabetic kidney complication, need assistance with personal care, independence on renal dialysis. A review of Resident #12's physician orders showed an order for the following:Cleanse right hip with normal saline, apply honey fiber, cover with silicone super absorbent bordered dressing every night shift for wound care, ordered 6/26/2026.Paint right heel with betadine and leave open to air every shift ordered 7/03/2026 Review of Resident #12's care plan showed the resident was identified as being at risk for pressure injury related to impaired mobility, non ambulatory status, incontinence, dialysis, and diabetes mellitus. The care plan, initiated May 20, 2026, did not include the resident's actual wounds or their locations, and did not include interventions related to the right hip or right heel wounds. On 7/30/2026 at 10:50 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN)/traveling Minimum Data Set (MDS) coordinator, and the Regional Director of Clinical Reimbursement. Staff H, LPN/ MDS coordinator stated her process would be to check the dashboard for new admissions, discharges and transfers, run an order list from the night before and update care plans accordingly. Staff H stated a review would also be conducted weekly with a team consisting of the Director of Nursing (DON), Director of Rehab, Nursing Home Administrator, Business Office Manager, Unit Manager and Social Service Manager to discuss their managed care residents. Staff H stated upon admission, the nurse will place a basic care plan and then within 14 days a more person-centered care plan will be developed. Staff H stated care plans are updated quarterly during review and if there would be a change in condition or diagnosis (s). Staff H stated the advanced directive section of the care plan would be relegated to the Social Services department. Staff H as well as the Regional Director of Clinical Reimbursement agreed Resident #3's care plan for Advance Directives was incorrect. Staff H and the Regional Director of Clinical Reimbursement agreed Resident #12's care plan should reflect an actual wound and its location with appropriate interventions. Staff H stated the nursing staff can update the care plan but stated usually the Unit Manager (UM) Assistant Director of Nursing (ADON) or the DON update the information. On 7/30/2026 at 12:07 p.m., an interview was conducted with Staff D, LPN/Unit Manager (LPN/UM). Staff D, LPN/UM stated she would provide the former MDS coordinator with her wound list every Friday. Staff D, LPN/UM stated she does not know how to initiate or revise a care plan in the electronic medical records. On 7/30/2026 at 2:59 p.m., an interview was conducted with the Social Service Manager who stated the advance directive section would be a team effort but agreed Resident #3's care plan needed to be updated to reflect his code status as a DNR. On 7/30/2026 at 3:10 p.m., an interview was conducted with the DON. The DON stated he was aware of the concerns and acknowledged revisions were warranted for Resident #3's advanced directives and Resident #12's current wound status. A review of the facilities policy titled, Plans of Care revised on 9/25/2017, showed the following policy statement: An individualized person -centered plan of care will be established by the interdisciplinary team (IDT) with the resident and or/ resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record.Procedure: .Review, update and or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessment) and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Based on observations, interviews and record review, the facility did not ensure one resident (#12) out of one resident reviewed received services for dialysis consistent with professional standards of practice.Findings include:On 7/28/2026 at 10:49 a.m., an interview was conducted with Resident #12 in his room. Resident #12 stated he refused dialysis today and stated he did not want to continue with dialysis anymore. Resident stated he did not go to dialysis last Saturday as well. On 7/28/2026 at 11:02 a.m., Resident #12's assigned nurse, Staff C, Registered Nurse (RN) stated she was unaware the resident did not go for his dialysis treatment today. Staff C, RN stated the resident has an early start dialysis time and assumed he had gone to dialysis before her shift started. Staff C, RN denied she was told in her oncoming shift report he refused his dialysis treatment today. On 7/28/2026 at 11:23 a.m., an interview was conducted with Staff D, Licensed Practical Nurse/Unit Manger (LPN/UM). Staff D, LPN/UM stated she had thought the resident had gone to dialysis as well and stated she would bring the concern to the Director of Nursing and the primary physician. Staff D, LPN/UM provided Resident #12's dialysis communication book. Resident #12's dialysis communication book contained the following dialysis communication record: 6/04, 6/11, 6/18, 6/20, 6/23, 7/04, 7/16 and 7/18/2026. The dialysis communication book also contained Fluid and blood pressure (BP) Management from the dialysis facility from 5/28, 5/30, 6/04, 6/09, 7/04, 7/07, 7/09, 7/ 11, 7/14, 7/16, and 7/23/26. An observation was made of these dialysis communication records for the section for the facility to fill upon return from the dialysis center. Dialysis communication record sheets showed 6/18/ and 6/11/2026 as completed for documentation of post vital signs and assessment of the access site and for pain. The remainder of the dialysis communication record sheets were blank as well as opportunities for other dialysis treatment records were missing altogether. A record review of Resident #12's admission Sheet showed an admit date of 5/04/2026 with diagnoses to include by not limited to type 2 diabetes mellitus with other diabetic kidney complication, end stage renal disease, and dependence on renal dialysis. A review of Resident #12's physician orders showed the following:Hemodialysis -medication may be given on dialysis days prior to dialysis every shift every Tues, Thursday and Saturday, ordered 5/01/2026Dry weight from dialysis center every day shift every Tuesday, Thursday and Saturday. ordered 5/01/2026Check AV (arteriovenous) shunt each shift assess for bruit and thrill every shift for monitoring, ordered 5/01/2026Hemodialysis - assess site left arm fistula and dialysis catheter for bruising/bleeding/symptoms of infection every shift, ordered 5/01/2026.Midodrine - Send 2 tabs of 5 mg (milligrams) with resident to dialysis every Tuesday, Thursday, Saturday once daily every Tuesday, Thursday and Saturdays, ordered 5/04/2026Hemodialysis dialysis [center] transport pick up 5:50 a.m.-6:10 a.m., chair time 6:45 a.m., pick up for return 10:45 a.m., stretcher, patient (pt) is on 2 liters of oxygen., ordered 7/29/2026A record review of Resident #12's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 12, which indicted moderate cognition impairment (some memory loss or confusion).On 7/30/2026 at 8:03 a.m., a telephone interview was conducted with the charge nurse at Resident #12's dialysis center. The charge nurse stated their facility was not notified either last Saturday or Tuesday of Resident #12's refusal for dialysis. The charge nurse stated they would contact the facility by 6:30 a.m. if the resident had not shown up. The charge nurse stated she did not know the resident refused this morning until she called and stated they had everything ready for him to start a dialysis treatment today. The charge nurse stated she had a telephone conversation with the facility and informed the facility because the resident had missed three treatments in a row and/or seven days he will have to be sent to the hospital for new labs and further higher level of care. The charge nurse stated the dialysis center will always try to accommodate residents if they are having a bad day and cannot make dialysis. She stated we would try to reschedule the following day if needed. On 7/30/2026 at 8:50 a.m., a telephone interview was conducted with Resident #12's nephrologist at the dialysis center. The nephrologist stated she had not approved twice dialysis sessions and no communication was had between herself and the primary physician. The nephrologist stated Resident #12 needs dialysis three times a week and at this point may need to go to the hospital for higher level of careOn 7/30/2026 at 11:52 a.m., an interview was conducted with Staff D, LPN/UM. Staff D stated the nurse should fill out the Dialysis communication record each time a resident return from dialysis. Staff D, LPN/UM stated she does not routinely check the dialysis communication binder. Staff D, LPN/UM stated the nurse would be expected to check for vital signs, assess either the catheter or fistula for signs of infection. Staff C, RN stated she would also check for bruit/thrills for the AV fistula as well as for bleeding. Staff C, RN and Staff D, LPN/UM stated they both were unaware Resident #12 missed dialysis Tuesday the 28th. Staff D, LPN/UM stated she was the on-call manager on Saturday the 25th and did not receive a call informing her of Resident #12's refusal for dialysis. A review of Resident #12's progress note dated 7/21/2026 at 7:48 a.m., showed the following: Resident refused to go to scheduled dialysis treatment despite education regarding the importance of treatment and potential risks associated with missing dialysis treatment. Resident verbalized understanding and continued to refuse, Staff E, LPNA review of a progress note entry dated 7/25/2026 at 11:38 a.m. showed the following statement: Resident refused dialysis. Staff F, RNA review of progress note entry date 7/28/2026 at 5:53 a.m., showed the following: Resident refused to attend scheduled dialysis treatment. Writer educated the resident on the importance of dialysis and the potential risks of missing treatment including fluid overload, electrolyte imbalance, and worsening renal function. Resident verbalized understanding but continued to refuse transport. Resident remains in the facility at this time. Medical Doctor (MD) will be notified of refusal. Staff G, LPN.A review of progress note entry date 7/28/2026 at 6:42 a.m., showed the following: Resident refused to attend scheduled dialysis treatment. Writer educated the resident on the importance of dialysis and the potential risks of missing treatment including fluid overload, electrolyte imbalance, and worsening renal function. Resident verbalized understanding but continued to refuse transport. Resident remains in the facility at this time. MD will be notified of refusal. Staff G, LPNA review of progress note entry date 7/28/2026 at 11:10 a.m., showed the following: MD notified with on call due to resident refused to go to dialysis this morning before my shift started; he said he just did not want to go; Contacted MD to see if his meds can be provided late due to resident refused med earlier; he said he will take them now, MD said this is ok & ok to continue with other meds as ordered. Staff C, RNOn 7/30/2026 at 12:21 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated he would expect an assessment and vital signs would be done within half an hour of a post dialysis resident upon arrival to the facility. The DON acknowledged missed opportunities for the nursing staff to notify the physician when the resident had refused on 7/21, 7/25 and 7/28/2026. The DON reviewed Resident #12's dialysis communication binder and acknowledged the missed opportunities for better documentation post dialysis upon arrival back to the facility. On 7/30/2026 at 4:59 p.m., a telephone interview was conducted with Resident #12's primary physician. The physician stated he was aware of refusals from medication, treatments to dialysis but could not specify dates of refusals for dialysis. The physician stated he had ordered stat lab work for the resident to determine if he had to send the resident out to the hospital today or to seek treatment this Saturday.

Based on record review and interviews, the facility did not develop a person centered care plan that addressed Post Traumatic Stress Disorder (PTSD) for one resident (Resident #6) out of one resident reviewed, which had the potential to affect the resident's psychosocial well being.Findings include: A review of Resident #6's admission record revealed an admission date of 7/07/2026 with diagnoses that included PTSD, alcohol dependence, anxiety disorder, and bipolar disorder. Review of Resident #6's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) summary score of 15/15, indicating cognition was intact. Review of Resident #6's psychosocial history and assessment dated [DATE] showed Resident #6 is a patient with a past psychiatric history of bipolar disorder, PTSD, depression, anxiety, and alcohol abuse. Review of Resident #6's Care Plan revealed Resident #6 did not have a focus area, goal, or interventions related to PTSD or trauma informed care. During an interview on 7/30/2026 at 5:46 p.m., the Regional Director of Clinical Reimbursement stated that psychosocial conditions such as anxiety, depression, PTSD, and trauma should be included in a resident's care plan. After reviewing Resident #6's diagnosis and care plan, the Regional Director stated PTSD was not included and should have been addressed with trauma informed care. On 7/30/26 at 6:50 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated if Resident #6 has a diagnosis of PTSD, a trauma informed care plan should be included in the resident's care plan. Review of the facility's policy titled, Plans of Care revised on 9/25/2017 revealed the following: Policy: An individualized person -centered plan of care will be established by the interdisciplinary team (IDT) with the resident and or/ resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record.Procedure: The Individualized Person Centered plan of care may include but is not limited to the following:-Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements.-Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals

Based on interviews and record review, the facility failed to ensure medications were refilled timely, when needed or requested, for two residents (#4 and #6) out of two residents sampled.Findings Included: 1.During a tour of the facility on 07/27/2026 at 10:24 AM, Resident #4 stated he had the right receive morphine an hour ahead or an hour behind. The resident stated he experienced a lot of pain when he didn't receive his morphine when he needed it. While speaking, Resident #4 stated aahhh, twice, and grimaced while turning his head and clenching his hands. During an interview on 07/28/2026 at 04:56 PM, Staff T Nurse Practitioner (NP), stated medication could be given to residents an hour before or after the scheduled time according to facility policy, but certainly not to exceed that. Staff T stated if pain medication time frames were exceeded or missed, it could cause a resident pain. During an interview on 07/30/2026 at 11:36 AM, Staff U Licensed Practical Nurse (LPN), stated Resident #4 told her his medication was ineffective a few weeks prior. Staff U stated hospice was notified on 06/22/2026. During an interview on 07/30/2026 at 11:58 AM the hospice provider Registered Nurse (RN) for Resident #4. The hospice provider RN stated hospice started seeing Resident #4 on 03/26/2026. The hospice RN stated Resident #4 has two different narcotics orders for pain;Morphine 100milligram (mg)/5 milliliter (ml) - give 0.5 ml, routinely every four hoursOxycodone 5mg - give two tablets, routinely every six hoursMorphine 100mg/5 ml - give 0.25 ml, as needed every three hoursTylenol 325mg - give two tablets, as needed every four hours Record Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Resident #4's medical diagnosis included chronic obstructive pulmonary disease, muscle weakness, need of assistance with personal care, dysphagia, panic disorder, heart disease, depressive disorder, arthritis, and heart failure. Review of Resident #4's orders revealed: morphine sulfate (concentrate) oral solution 100 MG/5ML (morphine sulfate) give 0.5 ml by mouth four times a day for pain, with a start date of 04/22/2026 and an end date of 06/24/2026. Resident #4 orders revealed Oxycodone HCI Oral Tablet 5 MG (Oxycodone HCI) give 2 tablets by mouth every 6 hours for pain, with a start date of 04/02/2026 and no end date.Review of Resident #4's Medication Administration Record (MAR), revealed morphine sulfate (concentrate) oral solution 100 MG/5ML (morphine sulfate) give 0.5 ml by mouth four times a day for pain, with a start date of 04/22/2026 and an end date of 06/24/2026 had not been administered from the 09:00 PM administration time on 04/25/2026 through the 09:00 PM administration time on 04/26/2026. Resident #4's MAR revealed Oxycodone HCI Oral Tablet 5 MG (Oxycodone HCI) give 2 tablets by mouth every 6 hours for pain, with a start date of 04/02/2026 and no end date, was not administered on 04/27/2026 during the scheduled times of 06:00 AM and 06:00 PM. Review of Resident #4's Minimum Data Set, dated [DATE] Section C, revealed Resident #4 had a Brief Interview Mental Status of 14, which meant cognition was intact. Review of Resident #4's progress notes revealed on 04/25/2026 at 09:31 PM, morphine had been ordered. Progress notes revealed on 04/26/2026 at 10:00 AM, delivery was pending with no new orders. Progress notes revealed on 04/26/2026 at 12:09 PM, delivery was pending with no new orders. Progress notes revealed on 04/26/2026 at 04:25 PM, delivery was pending with no new orders. Progress notes revealed on 04/27/2026 at 06:34 AM, oxycodone had been ordered. Progress notes revealed on 04/27/2026 at 11:05 AM, Resident #4 had a change in condition and was lethargic and had a decreased appetite. Review of Resident #4's care plan, revealed a focus: Resident #4 is at risk for complaint of pain related to history of heavy drinking, underweight generalized discomfort, dated 03/06/2023. The goal was for Resident #4 to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through review date, revised 07/08/2026. The interventions included: evaluate for effectiveness of pain interventions when given; review for compliance, alleviating of symptoms, dosing schedules, and resident satisfaction with results, impact on functional ability and impact on cognition, revised 12/04/2023. Interventions included: observe/record/report to nurse resident complaints of pain or request for pain medication treatment, revised 12/04/2023. Interventions included pain management as indicated, initiated 05/28/2025. Interventions included: the resident is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain, revised 12/04/026. During an interview on 07/30/2026 at 04:36 PM, the Director of Nurses (DON) stated a 14 day stop date is a requirement for narcotics. The DON stated the staff should reach out for new orders, prior to the medication going completely out. The DON stated a resident's primary nurse or facility leadership ensures medication is maintained by getting refills prior to medications going completely out. The DON stated if a resident misses a medication for pain, obviously they would have increased pain. The DON stated on 04/25/2026 Resident #4's morphine got to the point where it needed to be ordered. The DON stated staff should have called the physician and had a script ordered through the pharmacy. The DON stated for the morphine it should have happened prior to it running out on the 25th. The DON stated on 04/26/2026, morphine was pending delivery. The DON stated Resident #4 not receiving morphine could have caused the resident pain. The DON stated, I would assume yes, the pain medication running completely out could have been avoided. 2.On 07/27/2026 at 11:02 AM, an interview was conducted with Resident #6. She stated she has not received her Lorazepam tablet since Friday, 07/24/2026. She stated when she would ask for her medication, she was told by staff they did not have her medication on hand. The resident stated she had been experiencing a lot of anxiety and began to cry. A review of Resident #6's admission record revealed an admission date of 07/07/2026. Diagnoses included Post- Traumatic Stress Disorder (PTSD), alcohol dependence, anxiety disorder, and bipolar disorder. Review of Resident #6's quarterly Minimum Data Set (MDS) Section C Cognition, dated 07/14/2026, revealed a Brief Interview for Mental Status (BIMS) summary score of 15/15, indicating cognition was intact. Review of Resident #6's active orders revealed the following:-Lorazepam Oral Tablet: Give 1 tablet by mouth every 8 hours as needed for increased anxiety for 14 days. Review of Resident #6's Care Plan revealed the following:The resident uses anti-anxiety medication related to anxiety disorder, with an intervention to administer anti-anxiety medications as ordered by a physician and monitor for side effects and effectiveness every shift. Review of Resident #6's progress notes revealed a note from the facility's medical provider dated 07/27/2026: Patient is resting in bed today on exam.She tells me that she had a rough weekend as her psychiatric and pain medications were not renewed in time. Review of Resident #6's Medication Administration Record (MAR) dated July 2026, revealed Lorazepam Oral Tablet, with a start date of 07/09/2026 and a discontinue date of 07/23/2026, was administered daily from 07/10/2026-07/12/2026 and from 07/14/2026-07/23/2026. Review of the Medication Monitoring/Control Record for Resident #6 revealed the resident had 11 tablets remaining after the Lorazepam order was discontinued on 07/23/2026. On 07/29/2026 at 12:47 PM, an interview was conducted with Staff R, LPN. He stated Resident #6 becomes anxious easily and panics. He stated she receives one tablet of Lorazepam for her anxiety. He stated the order is discontinued every two weeks. Staff must notify the psychiatrist, so the order is refilled. On 07/30/2026 at 8:45 AM, an interview was conducted with Staff C, RN. She stated the resident can be emotional and has anxiety. She stated the resident has orders for Lorazepam, administered as needed for her anxiety. She stated when she sees Resident #6 is experiencing anxiety, she will offer her anti-anxiety medication. The order is for 14 days, then is discontinued unless staff notifies the psychiatrist. She stated she was aware the resident's order was getting low and she should have notified the physician and asked if the order should be refilled. She stated she was off over the weekend, but when she came in on Tuesday 07/28/2026, she saw the resident did not have any more of her medication and she contacted the psychiatric provider for a refill. She stated the process should be when staff is aware the order is getting low; they should notify the physician before the medication runs out and is discontinued. On 07/30/2026 at 11:35 a.m., an interview was conducted with Staff S, RN. She stated as needed psychiatric mediations are discontinued every 14 days, and staff must notify the psychiatric provider to get the order refilled. She closely monitors these types of order and will notify the provider when the order is getting low so they can either refill it or discontinue the order. She stated she notifies the provider before the order is discontinued. On 07/30/2026 at 9:47 a.m., an interview was conducted with the facility's Psychiatric Advanced Registered Nurse Practitioner (ARNP). She stated she comes to the facility on Monday and Thursday and tries to ask the nurses if they need prescriptions and reminds them if they run out of prescription over the weekend, they can call the on call provider. She stated she was notified on Tuesday 07/28/2026 that the resident needed a refill of her medication. She was not aware that the resident's original order was discontinued on 07/23/2026. On 07/30/2026 at 3:30 PM, an interview was conducted with Staff D, LPN, Unit Manger. She stated her expectation for nurses are for them to reach out to the provider who ordered the medication to let them know that the medication will be discontinued. She stated if staff notice there are two tablets left in the order, she expects staff to contact the provider before the order is discontinued. On 07/30/2026 at 4:36 PM, an interview was conducted with the Director of Nursing. He stated if a medication stop date is on day 14, his expectation is for staff to ask the physician prior to the 14 days discontinue date if the physician would like for the order to be refilled. If staff notice the medication is running low, staff should be contacting the physician. Review of the facility's policy titled Administering Medications with a revision date of April 2019, revealed the following:Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation4. Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy titled Physician Orders, with a revision date of 3/3/21, revealed the following:Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record.Procedure: Routine Orders:A nurse may accept a telephone order from the Physician, Physician Assistant or Nurse Practitioner (as permitted by state law).

Based on observation, record review, and interviews, the facility did not ensure the care plan was updated and individualized interventions were in place after a reportable adverse event, that resulted in re-traumatization, for one resident (#1) out of one resident reviewed.Findings included: On 10/21/25 at 10:58 a.m., an interview was conducted with Resident #1. She said an event occurred at the facility on 9/4/25. She said she had a bowel movement and relied on the staff to change her. She said around 5:00 or 6:00 p.m., on 9/4/25, she requested a female staff to assist with changing her. Resident #1 said she was told by a male staff the female staff member was busy, and she could wait until about 7:30 p.m. She said she was not comfortable with a male staff member changing her. Resident #1 said her response was she was not waiting for two hours to be changed. She said Staff I, Certified Nursing Assistant (CNA) was the only person available to assisting with changing her soiled brief. She said she ambulated in the wheelchair to her room and waited. Resident #1 said Staff I, CNA came in and assisted her into bed. She said she rolled to the side to be changed. Resident #1 said she has a catheter and when Staff I, CNA was cleaning that area she felt a lot of pressure towards her anus. She said she asked him what he was doing and continued to feel more pressure. Resident #1 said she felt Staff I, CNA's fingers enter her genital area. She stated, I swatted him and told him to get me dressed. She said she felt embarrassed afterwards and called her family members. Resident #1 stated, I didn't want to do anything, and I wanted to act like it didn't happen. She said she felt she did not have anyone to talk to. She said she told Staff J, Licensed Practical Nurse (LPN) about the incident on 9/6/25 and the nurse reported it. A review of Resident #1's admission record revealed an admission date of 8/15/25 with diagnoses to include intraspinal abscess and granuloma, other bipolar disorder, need for assistance with personal care, muscle weakness (generalized), neuromuscular dysfunction of bladder, unspecified, other psychoactive substance use, unspecified, uncomplicated, other specified anxiety disorders, other recurrent depressive disorders, and chronic post-traumatic stress disorder (PTSD).A review of Resident #1's comprehensive minimum data set (MDS), section C-cognitive patterns, dated 8/18/25 revealed a brief interview for mental status (BIMS) score of 15, meaning cognitively intact.A review of Resident #1's care plan initiated on 9/2/2025 revealed the following a focus - [Resident name] has potential for re-traumatization due to past history of trauma kidnapped and raped by [family member], multiple family suicide, trigger---loud noise, Date Initiated: 09/02/2025, with a goal of, [Resident name] triggers will be avoided, and resident will not be re-traumatized. Date Initiated: 09/02/2025 . Target Date: 12/01/2025. Interventions to include, Announcing self before entering, avoiding sudden movements Date Initiated: 09/02/2025. Avoiding noises/noisy environment Date Initiated: 09/02/2025. Do not talk about the event unless the resident wants to/initiates the conversation about the event, Date Initiated: 09/02/2025 . Giving resident control and choices, Date initiated 09/02/2025. Other: Psych services as indicated Date Initiated: 09/02/2025.Another focus in the same care plan revealed - [Resident name] is at risk for behaviors r/t [related to] use of psychoactive medication, Bipolar, PTSD, history of drug abuse Date Initiated: 09/02/2025.Another focus in the same care plan revealed - [Resident name] has a mood problem r/t Admission/bipolar, PTSD Date Initiated: 09/02/2025 Revision on: 09/02/2025.Review of the care plan and the electronic medical record (EMR) revealed no documentation about Resident #1's preference of no male caregivers. A review of Resident #1's progress note dated 8/21/25 revealed, encounter, Date of Service: 08/21/2025 . Psychiatry Evaluation Note . Chief Complaint: Depression, anxiety, Bipolar and PTSD. Reason for Today's Evaluation: I was consulted for psychiatric evaluation and treatment of depressed mood. History of Present Illness: . Past psychiatric history of depression, anxiety, Bipolar and PTSD . Patient reports she's a little depressed and having intermittent trouble sleeping. She has been having mood swings and outburst with the staff. Patient does not want to change or adjust any medications at this time, however she is open to psychotherapy. According to PHQ9 [patient heath questionnaire-9] score is 11 that is moderate depression and BIMS score of 15, which is cognitively intact. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 . Assessment and plan for trauma: History of trauma: Kidnapped and raped by [family member], multiple family suicide. Current triggers if any: Loud noise, PTSD status: No PTSD diagnosis Care plan if trauma and triggers present: Continue ability, refer to psychotherapy . Added PTSD dx [diagnosis] and care plan in the chart: As pt. (patient) has active symptoms of PTSD such as flashbacks, nightmares, hypervigilance causing distress, .A review of Resident #1's nursing progress note dated 9/7/25 revealed - Writer knocked on resident door & introduced herself & resident said come in; Writer asked how she is doing and she got a little teary and said she is still quite emotional & said she should have spoken up sooner; provided her comfort and reassurance that staff are here to support her and make her stay here pleasant & safe. Reminded her not to blame herself but to focus on her healing & therapy & recovery so she can go home when ready; Reminded her if she wants to talk anytime just let me know and I will be right there.A review of Resident #1's nursing progress note dated 9/7/25 revealed, When writer went into resident's room to give resident IV [intravenous] writer asked how she was feeling resident stated, emotional that it was a long day resident started to cry very upset. Writer assured resident that she was safe resident applied for waiting so long to report the situation and started to cry again writer tried to comfort resident, stating that it is understandable due to situation. Resident is in good spirits to see [family member] in morning.A review of Resident #1's nursing progress note dated 9/8/25 revealed a medication administration note, 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress notes . 5 resident crying off and on.A review of Resident #1's progress note dated 9/9/25 revealed an encounter note, Date of Service: 09/09/2025 . Today, I saw patient as it was reported to me that patient is unstable requiring psychiatric assessment. Due to acuity of the situation, I saw patient using Telepsych [telehealth psychiatry] . The facility requested a psychiatric assessment to evaluate for trauma following an abuse allegation involving a staff member. The resident was cooperative and engaged during interview. She endorsed a history of PTSD related to prior kidnapping and sexual assault and stated that the recent incident was triggering for her. She prefers to manage her reactions independently at this time and declined both medication changes and initiation of psychotherapy. Recommend documenting the allegation per facility policy, offering trauma-informed supports and crisis resources, and arranging supportive check-ins with the option to re-evaluate if symptoms emerge or worsen. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .A review of Resident #1's progress note dated 9/11/25 revealed an encounter note, Date of Service: 09/11/2025 . Psychiatry Subsequent Note . Reason for Today's Encounter: Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment . past psychiatric history of depression, anxiety, Bipolar and PTSD. Prior to last visit, patient was at baseline. The patient reported feeling a little depressed and having intermittent trouble sleeping. She was having mood swings and outbursts with the staff. During last visit, patient endorsed a history of PTSD related to a prior kidnapping and sexual assault. She stated that the recent incident was triggering her PTSD symptoms. No medication changes were done. As per collected information, observed patient lying in bed resting. Patient reports that she is still feeling depressed about the alleged incident with a staff member. She is not open to psychotherapy as she has her own therapist outside. She reports that she is journaling and that it is helping her cope. Patient is not experiencing anxiety. No mood swings and behavioral outbursts noted. Patient has fair sleep and appetite. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .On 10/21/25 at 3:55 p.m., an interview was conducted with Staff S, LPN. She said she had not recently been the nurse assigned to Resident #1 as she, Floats all over the place. She said she was not aware of where to look for the resident's PTSD triggers. She said the nurse that is usually assigned to Resident #1 was not working today.On 10/21/25 at 4:00 p.m., an interview was conducted with Staff E, CNA. She said she floats and does not have a set assignment. Staff E, CNA said she had not worked with Resident #1 long enough to determine what her PTSD triggers were. She said Resident #1 showed signs of frustration if care was not done her way and could seem overwhelmed at times. Staff E, CNA said she was not aware if Resident #1 preferred a male or female to care for her. She said there was a place to document behaviors in the electronic health record.On 10/21/25 at 4:59 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON said there were changes made as a result of the investigation of Resident #1's allegation of sexual abuse made on 9/6/25. He said the change they made was to make sure Resident #1 did not have a male caregiver, per her request. He said nursing staff were made aware of the change. The DON stated, It's not written down anywhere, it's verbal. He said he was not sure if changes or updates were made to Resident #1's care plan.A review of Resident #1's nurse aide reference information, known as the Kardex, dated 10/21/25, revealed no information about a preference for a female caregiver or no male care givers. On 10/21/25 at 6:28 p.m., the DON provided an assignment sheet for the east back hall that had handwritten documentation of, no male caregivers. review of other documents revealed no documented reference of the resident's caregiver preferences.A review of the facility's, trauma-informed care, dated 10/24/22, revealed the following, Residents will be evaluated to identify a history of trauma, triggers and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization. Further review of the policy, under procedure, revealed the following, .3. Develop a care plan and add interventions to the nurse aid Kardex.

Based on interviews and record review, the facility did not ensure two allegations of abuse were investigated thoroughly for two residents (#1 and #2) out of four residents with reportable incidents reviewed.Findings included: 1.) On 10/21/25 at 10:58 a.m., an interview was conducted with Resident #1. She said an event occurred at the facility on 9/4/25. She said she had a bowel movement and relied on the staff to change her. She said around 5:00 or 6:00 p.m., on 9/4/25, she requested a female staff to assist with changing her. Resident #1 said she was told by a male staff the female staff member was busy, and she could wait until about 7:30 p.m. She said she was not comfortable with a male staff member changing her. Resident #1 said her response was she was not waiting for two hours to be changed. She said Staff I, Certified Nursing Assistant (CNA) was the only person available to assisting with changing her soiled brief. She said she ambulated in the wheelchair to her room and waited. Resident #1 said Staff I, CNA came in and assisted her into bed. She said she rolled to the side to be changed. Resident #1 said she has a catheter and when Staff I, CNA was cleaning that area she felt a lot of pressure towards her anus. She said she asked him what he was doing and continued to feel more pressure. Resident #1 said she felt Staff I, CNA's fingers enter her genital area. She stated, I swatted him and told him to get me dressed. She said she felt embarrassed afterwards and called her family members. Resident #1 stated, I didn't want to do anything, and I wanted to act like it didn't happen. She said she felt she did not have anyone to talk to. She said she told Staff J, Licensed Practical Nurse (LPN) about the incident on 9/6/25 and the nurse reported it. A review of Resident #1's admission record revealed an admission date of 8/15/25 with diagnoses to include intraspinal abscess and granuloma, other bipolar disorder, need for assistance with personal care, muscle weakness (generalized), neuromuscular dysfunction of bladder, unspecified, other psychoactive substance use, unspecified, uncomplicated, other specified anxiety disorders, other recurrent depressive disorders, and chronic post-traumatic stress disorder (PTSD).A review of Resident #1's comprehensive minimum data set (MDS), section C-cognitive patterns, dated 8/18/25 revealed a brief interview for mental status (BIMS) score of 15, meaning cognitively intact.A review of Resident #1's care plan initiated on 9/2/2025 revealed the following a focus - [Resident name] has potential for re-traumatization due to past history of trauma kidnapped and raped by [family member], multiple family suicide, trigger---loud noise, Date Initiated: 09/02/2025, with a goal of, [Resident name] triggers will be avoided, and resident will not be re-traumatized. Date Initiated: 09/02/2025 . Target Date: 12/01/2025. Interventions to include, Announcing self before entering, avoiding sudden movements Date Initiated: 09/02/2025. Avoiding noises/noisy environment Date Initiated: 09/02/2025. Do not talk about the event unless the resident wants to/initiates the conversation about the event, Date Initiated: 09/02/2025 . Giving resident control and choices, Date initiated 09/02/2025. Other: Psych services as indicated Date Initiated: 09/02/2025. A review of Resident #1's nursing progress note dated 9/7/25 revealed - Writer knocked on resident door & introduced herself & resident said come in; Writer asked how she is doing and she got a little teary and said she is still quite emotional & said she should have spoken up sooner; provided her comfort and reassurance that staff are here to support her and make her stay here pleasant & safe. Reminded her not to blame herself but to focus on her healing & therapy & recovery so she can go home when ready; Reminded her if she wants to talk anytime just let me know and I will be right there.A review of Resident #1's nursing progress note dated 9/7/25 revealed, When writer went into resident's room to give resident IV [intravenous] writer asked how she was feeling resident stated, emotional that it was a long day resident started to cry very upset. Writer assured resident that she was safe resident applied for waiting so long to report the situation and started to cry again writer tried to comfort resident, stating that it is understandable due to situation. Resident is in good spirits to see [family member] in morning.A review of Resident #1's nursing progress note dated 9/8/25 revealed a medication administration note, 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress notes . 5 resident crying off and on.A review of Resident #1's progress note dated 9/9/25 revealed an encounter note, Date of Service: 09/09/2025 . Today, I saw patient as it was reported to me that patient is unstable requiring psychiatric assessment. Due to acuity of the situation, I saw patient using Telepsych [telehealth psychiatry] . The facility requested a psychiatric assessment to evaluate for trauma following an abuse allegation involving a staff member. The resident was cooperative and engaged during interview. She endorsed a history of PTSD related to prior kidnapping and sexual assault and stated that the recent incident was triggering for her. She prefers to manage her reactions independently at this time and declined both medication changes and initiation of psychotherapy. Recommend documenting the allegation per facility policy, offering trauma-informed supports and crisis resources, and arranging supportive check-ins with the option to re-evaluate if symptoms emerge or worsen. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .A review of Resident #1's progress note dated 9/11/25 revealed an encounter note, Date of Service: 09/11/2025 . Psychiatry Subsequent Note . Reason for Today's Encounter: Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment . past psychiatric history of depression, anxiety, Bipolar and PTSD. Prior to last visit, patient was at baseline. The patient reported feeling a little depressed and having intermittent trouble sleeping. She was having mood swings and outbursts with the staff. During last visit, patient endorsed a history of PTSD related to a prior kidnapping and sexual assault. She stated that the recent incident was triggering her PTSD symptoms. No medication changes were done. As per collected information, observed patient lying in bed resting. Patient reports that she is still feeling depressed about the alleged incident with a staff member. She is not open to psychotherapy as she has her own therapist outside. She reports that she is journaling and that it is helping her cope. Patient is not experiencing anxiety. No mood swings and behavioral outbursts noted. Patient has fair sleep and appetite. Insight and Judgement: Intact Orientation: Alert, Oriented X 3 .A review of Resident #1's pain management note dated 9/9/25 revealed, Plan . per nrsg [nursing] she had verbal altercation w/ [with] male CNAs out of proportion w/ event. she can stand short period of time; she is able to move upper body freely and is now self-propelling WC [wheelchair] . A review of Resident #1's primary provider's note dated 9/8/2025 revealed, . Follow up with sexual harassment and abuse allegation - patient expresses of being violated - police already seen the patient and made their report 3. Patient expresses feeling fine at this time - no further report of abuse . Patient report to have abuse while being take care off with her personal care. Unable to tell specific time of event. Assessment and interaction with patient is limited and cut off. When patient verbalizes already that police already made the report and assessment was done, and she is feeling fine at this time. Unable to do thorough assessment at this time - will do if patient allows us. Patient is pretty much dependent with nursing care and services for personal care and ADLs. [activities of daily living] . 4. Physical abuse of adult, initial encounter Notes: Police report already filed Psychiatry consult to evaluate and manage patient's psychiatric needs No physical assessment done - patient done - She has already been assessed and done with it. Police already took pictures and filed report - we will conduct a thorough assessment with nurse as witness if needed or warranted - patient denies any complaints or discomfort at this time.On 10/21/25 at 4:27 p.m., an interview was conducted with the Director of Nursing (DON). The DON said on 9/6/25 he was notified by Staff J, LPN, who was the resident's nurse that day, that an allegation was made about a staff member being sexually inappropriate with Resident #1. He said the incident date was 9/4/25 according to Resident #1. He said law enforcement, the Department of Children and Families (DCF), and the abuse hotline was contacted on 9/6/25. The DON said the statement from Resident #1 was that Staff I, CNA did incontinence care and put his finger in her genital area. He said Staff I, CNA was suspended pending their investigation. The DON stated a skin assessment was conducted on Resident #1 and, Found issue on backside, nothing else reported. He said the sexual assault nurse examiner (SANE) came on 9/7/25 to evaluate Resident #1. The DON said he found out about the results from the SANE evaluation from DCF after they completed their investigation on 9/30/25 and told them there were no findings. The DON said skin checks were completed on residents with a BIMS score of 9 and below. He said Resident #1 had a psych consult scheduled, but she declined. Staff statements were reviewed to include the following, Staff J, LPN (dated 10/6/25, however, the DON said it was an error), Staff I, CNA (dated 9/6/25), Staff K, CNA (dated 9/6/25), Staff L, Registered Nurse (RN) (dated 9/6/25), Staff M, CNA (dated 9/6/25), and Staff R, CNA (dated 9/6/25). The DON confirmed the staff who worked on 9/4/25, during the shift where the alleged incident occurred, were interviewed but the facility did not have documentation of their statements. The DON said he typically documented the staff's interviews during an investigation. The DON provided documentation of four residents that were interviewed on 9/7/25, regarding being treated with respect, abuse and neglect, feeling safe/comfortable and knowing who the NHA, DON, and ombudsman are. He said Resident #1's roommate was interviewed and said she was unaware of what happened. The DON said he did not have documentation of the roommate's statement, except for documented responses to questions that were not specific to the incident. When asked what changes were made after the investigation, for Resident #1, the DON said they made sure the resident does not have a male caregiver per her request. He stated it is not documented as it is, Verbal between nursing staff. He said he was not sure if changes had been made to her care plan to reflect her wishes of a male caregiver. When asked about documentation of skin assessments completed on the resident the DON confirmed the facility did not have documentation in the investigation file. He said the skin checks would have been completed under the weekly skin checks in their electronic health record. On 10/21/25 at 4:47 p.m., an interview with the Nursing Home Administrator (NHA) was conducted regarding the investigation for Resident #1. A review of the NHA's handwritten notes that were in the investigation file revealed, on 9/8/25 at 2 p.m., the DCF staff member told her, with the DON present, that Resident #1 had a new complaint, . stated new complaint received 9/8 re: anal penetration on Saturday. The NHA said she is not sure where that statement came from. The DON said he did not recall the DCF staff member saying that. The NHA said she did not do anything with the information, but she thinks the DCF staff member may have asked about it. The NHA said Resident #1 did not mention that information to her directly. 2.) A review of Resident #2's admission record revealed an original admission date of 3/7/24 and a re-admission date of 6/25/24. Further review of the admission record revealed diagnoses to include other cervical disc degeneration, unspecified cervical region, major depressive disorder, recurrent moderate, generalized anxiety disorder, other chronic pain, and post-traumatic stress disorder unspecified.A review of Resident #2's care plan revealed the following:- [Resident name] has potential for re-traumatization due to past history of trauma . Triggers---Nightmares, loud noises, flashbacks, gunshots, certain TV [television] shows Date Initiated: 07/04/2024 Revision on: 05/21/2025 . A review of the facility's investigation with the NHA and the DON on 10/21/25 at 5:13 p.m., revealed the following, [Resident #2] reported that several weeks ago, [staff member] made a personal comment regarding his reproductive health in relation to [family member]. Resident denies physical contact. She remains at her psychosocial baseline. Resident states that she feels safe in facility. Psych eval [evaluation] completed on 7/3/25. Abuse, neglect, and exploitation education initiated. Staff statements initiated. Interviewed Res [residents] with BIMS of 10 or greater. Skin sweeps of residents with BIMS of 9 or below. Witness statements initiated. Employee suspended pending investigation. A review of witness statements provided by the facility revealed a statement from Staff Q, RN, with no date documented. No other witness statements, from staff and residents, were provided by the facility regarding the investigation of Resident #2's allegation of a sexual/verbal adverse event. The NHA and DON said they did not interview other residents as it was a conversation between a staff member and one resident. The NHA said she felt it was an isolated event, and no other residents were present. The NHA and DON said no other staff members were present except for Staff Q, RN. The DON said no skin sweeps were completed because of the delay in reporting and confirmed there was no documentation in the investigation file about skin sweeps that were completed. He confirmed the FEDREP information included the facility conducted skin sweeps on residents with a BIMS of 9 and below as part of their investigation. The DON confirmed skin checks are typically done weekly at the facility and the unit manager is expected to ensure they are being completed. He said the wound care provider documents in the non-pressure versus (vs) pressure assessment. He confirmed the wound care provider is not completing the weekly skin evaluations during their wound care, as it is specific to the wound for that resident. Review of the facility's policy titled abuse, neglect, exploitation and misappropriation, dated 11/16/22, revealed the following under investigation, The Abuse Coordinator and/ or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Further review of the policy, under reporting/response, revealed the following, . The Abuse Coordinator will endeavor to protect the rights of resident and employees. The Administration recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened.

Based on interviews and record review, the facility did not ensure the grievance process was followed by failing to document a grievance for one resident (#4) out of three residents reviewed. Findings included: Review of Resident #4's admission record revealed an admission date of 10/29/24 with diagnoses to include type 2 diabetes, muscle weakness, seizures, paranoid schizophrenia, bipolar disorder, major depressive disorder, brief psychotic disorder, and anxiety disorder. A review of Resident #4's Minimum Data Set (MDS) dated [DATE], section C revealed a brief interview for mental status (BIMS) score of 13, meaning cognitively intact. A review of a statement completed by Staff A, Registered Nurse (RN) on 9/7/25 with Resident #4, related to a reportable incident, revealed the resident expressed they do not always feel safe or comfortable at the facility due to Certified Nursing Assisting (CNA) staff mishandling and being rough with her. A review of the facility's grievance log revealed there was no grievance initiated for Resident #4 regarding her concern expressed to Staff A, RN on 9/7/25. A review of Resident #4's progress notes revealed there was no documentation regarding the resident's statement on 9/7/25. Review of the training records revealed a grievance training was conducted on 8/5/25. Out of eighty-six (86) total staff members, thirty-six (36) staff members did not attend the training including the Activities Director; Staff A, CNA; Staff E, CNA; Staff F, CNA; Staff G, CNA; Staff H, CNA; Staff I, CNA; and Staff J, CNA. An interview with Staff C, CNA on 10/20/25 at 10:36 a.m., revealed she completes a voiced concern by a resident only if she feels like one needs to be filled out. She said she did not complete a grievance for every concern that is voiced to her. An interview with Staff C, CNA on 10/20/25 at 10:36 a.m., revealed having never received grievance training before, for at least eight years. Staff C said she had never written a grievance before. An interview with the Nursing Home Administrator (NHA) on 10/20/25 at 4:50 p.m. revealed Resident #4 was typically easily gets upset, and is, Usually very dramatic when needing something. The NHA expressed she did ask Resident #4 about the complaint made during the investigation from 9/7/25 but did not complete an investigation or document anything about the concern that was voiced by Resident #4. On 10/20/25 at 5:50 p.m., an interview with the Social Services Director (SSD) revealed any voiced concern should be documented as a grievance. The SSD stated there are no parameters in what should be considered a grievance or not. The SSD expressed that he regularly goes around asking the CNA's if they have heard of any recent concerns, and he will write up the grievance himself if the nurse or CNA does not want to themselves. The SSD explained a nurse or CNA might not write up a grievance on their own due to lack of education on grievances or if the individual might feel like they cannot or should not write the grievance. When the SSD was asked if completing grievances should be based on an employee's discretion, the SSD stated the grievance would matter more on the concern rather than the individual's discretion. The SSD explained the only time discretion should be made is if the nurse or CNA came to him and let him make the determination on whether a grievance should be made or not. The SSD stated that he, doesn't really know who does or does not know about the grievance process. When asked if a grievance is filed when there is an allegation of abuse, the SSD explained that a grievance and reportable should be completed in reference to the allegation, as the situation needs to be rectified. The SSD explained that any concerns about residents being handled roughly during care should be addressed with the nursing department, and a grievance should be made and processed. A review of the facility's grievance policy revealed: The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The resident should have reasonable expectations of care and services, and the center should address those expectations in a timely, reasonable, and consistent manner. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. Original grievance forms are then submitted to the Grievance Officer/designee for further action. The Grievance Officer/designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame, this should not exceed 14 days. The Grievance Officer will log complaints/grievances in Monthly Grievance Log. The individual voicing the grievance will receive follow-up communication with the resolution, a copy of the grievance will be provided to the resident upon request.

Based on record review and interview, the facility failed to ensure a safe and orderly discharge for one residents (#1) and failed to follow up post discharge for two residents (#1 and #10) out of three residents sampled.Findings included:1. Review of Resident #1's admission record showed he was admitted on [DATE] and discharged on 6/20/25 to Private home/apt.(apartment) with no home health services: Home. Resident #1's medical diagnoses including the following: Stage 3 pressure ulcer of sacral region, paraplegia, chronic pain and osteomyelitis of the spine. Review of Resident #1's physician order dated 6/20/25 revealed Resident to discharge 6/20/25, DME [durable medical equipment]: 18 in (inch) W/C (wheelchair) with leg rests; shower chair, bedside commode; hospital bed; slide board; recliner chair; large briefs; wound care; physical therapy/ occupational therapy eval (evaluation) and treat (treatment).Review of Resident #1's physician order summary report, showed orders including:An order dated 6/19/25 revealed, discharge on [DATE], send all non-controlled medications. Send three days of narcotics.Order dated 6/11/25, apply zinc [ointment] to left ischium daily and as needed.Order dated 6/1/25, Cleanse left ischium wound with Dakins sol 0.125%, apply collagen powder, Cal Alginate and cover with superabsorbent dressing daily and as needed.Order dated 4/11/25, Oxycodone 15mg every 4 hours as needed for non-acute pain.Review of Resident #1's Medication Administration Record (MAR) dated 6/1/25-6/30/25 showed Oxycodone 15mg every 4 hours as needed for non-acute pain was given 43 out of 56 opportunities, between five to six dosages daily. Review of Resident #1's wound care provider note, dated 6/18/25 showed the reason for the visit was a stage four sacral pressure ulcer follow-up. Treatment clean wound with Dankins solution 0.125%, cover with collagen, alginate, super absorbent and bordered dressing daily. Recommendations include off load wound, turn and reposition per facility policy. Review of Resident #1's pain management provider note, dated 6/19/25 showed current regimen is reported reasonable effective to maintain comfort and motivation with person Activities of Daily Living [ADL's] . Plan he had dc [discharge] plans in place; .will ok 3 days of opiates to go home with patient .he is concerned in regard to quantity of PRN meds; oxycodone 15 mg every 4 hours; have discussed with nursing/ADON.Review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section C, cognitive patterns revealed a Brief Interview for Mental Status (BIMS) summary score of 15 out of 15 indicating intact cognition. Section GG, Functional Abilities showed Resident #1 had impairments to bilateral lower extremities, uses a manual wheelchair for mobility, requires substantial to maximal assistance to get in and out of a tub or shower and needs full assistance with shower/bathe. Resident #1 requires partial to moderate assistance when positioned from sitting on the side of the bed to lying down, transferring from a bed to a chair and getting on and off the commode. Review of Resident #1's Social Service Progress notes showed the following:A note dated 6/16/25, Resident said he would like to be discharged from the current facility by 6/20/25. Social Service staff faxed a request for DME and Home Health (HH) and will request the resident's discharge address prior to facility discharge.A note dated 6/17/25 showed the facility called Resident #1's home care service provider and told the name of the home health provider and was informed DME had not been established with a vendor. The facility's social service staff will follow up with the home care service provider to see when a DME provider is chosen.A note created on 6/20/25, dated 6/19/25 showed, call placed to the home care service provider to inquire about the DME for Resident #1's 18 (inch) W/C (wheelchair). The home care provider services representative has not received insurance authorization.A note dated 6/20/25, Social Service staff was contacted that authorization for wheelchair had not been obtained and a request for the facility's social services to reach out to Resident #1's insurance to find out when authorization and be established. A review of Resident #1 Primary Care Physician (PCP) note dated 6/17/25 showed continue oxycodone for pain, on Naloxone (antidote) as directed . continue wound care management for pressure ulcers, .fall precautions and use of safety devices A review of Resident #1's discharge plans and instructions, with an effective date of 6/18/25, showed the following:The name of who will accompany Resident #1 was not listed. The disposition was home by car. Part 2; Physician information: Section E- Home Health Services: Receiving Home Health Services is not marked, Section F- Medical Equipment Supplier: receiving medical equipment is not marked and Section K- Wound Care: Receiving Wound Care Services is not marked. Part 4- Functional Status Evaluation discharge: Section 3- shows Resident #1 usually needs setup or clean up assistance before and after voiding or having a bowel movement. The helper does all the task when transferring from a bed to a chair. The ability to transfer in and out of a car was not attempted. Resident #1 requires a helper to do all the task to get on and off the toilet or commode. Review of the Social Services Discharge Summary note revealed a Home Health Care agency was provided, and DME provided. The Medication Summary shows prescriptions and mediations were sent with Resident #1. The section to document the number for the president's post discharge follow-up phone call is not completed. The discharge disposition shows Resident #1 was discharged with home health services. Documentation regarding post discharge follow-up phone call is blank. Review of the medical record did not reveal evidence the facility followed up with Resident #1 after discharge.During an interview on 8/27/25 at 4:34 PM the Social Services Director (SSD) said his responsibilities include faxing referral orders to home health services (HHS) and Durable Medical Equipment (DME) providers. He said he has an established relationship with Resident #1's HHS provider. Regarding the process to verify HHS services had started, the SSD says he does not always know and relies on the HHS providers to contact him.During a telephone interview on 8/28/25 at 9:47 AM with Resident #1's Primary Care Physician (PCP) said the resident had chronic pain, he is also his patient in the community, and he knew him well. HHS providers are involved; they are the ones who help us deal with making sure that the patient receives the care they need. He said, I expect my orders to be followed. During a telephone interview on 8/28/ 25 at 9:10 AM with Resident #1's documented HHS provider. The HHS representative said there is no file [current record] for Resident #1 the last referral for services was on 7/19/24. On 8/28/25 at 9:30 AM during a telephone conversation with Resident #1's home care benefits manager company, a company representative said on 6/20/25 the facility was notified the home care benefits provider did not accept Resident #1's insurance for home care services. On 6/27/25 Resident #1 was notified the company could not process orders for shower chair. On 8/5/25 the home care benefits manager closed out orders for the commode and transfer device due to missing documentation from Resident #1's insurance company. The representative said according to Resident #1's records the referral needed to be sent directly to [Insurance Company] for authorization.2. Review of Resident #10's admission record showed an admission date of 7/1/25 and a discharge date of 8/18/2025 to a private home/apartment with home health services. Resident #10's diagnoses including diabetes mellitus with foot ulcer, cognitive communication deficit, difficulty walking, and need for assistance with personal care and chronic pain.Review of Resident #10's physician order dated 7/29/25 showed Resident to discharge with 20 in wheelchair and PT/OT [Physical Therapy/Occupational Therapy] eval and treatReview of Resident #10 Discharge Plan and Instructions, signed on 8/1/25 revealed Resident #10 discharged to home with family member. The care plan goal is continue wound care is documented. Skin condition is described Right planter [NAME] 3.8 cm x1.5cm x 0.3 cm collagen, calcium alginate. The social service discharge summary .resident will receive HHS (home health services) for wound and PT/OT (physical therapy/occupational therapy). Discharge home with home health is selected for Resident #10. Resident #10's discharge plan and instructions did not list the name or contact phone number for HHS provider. Documentation regarding post discharge follow-up phone call is blank.Review of the medical record did not reveal discharge follow up communication was performed, and the facility did not provide documentation after two requests.During an interview on 8/27/25 at 10:51 AM Staff O, RN said the SSD starts the discharge documentation and notifies the nurses. Regarding discharging residents with controlled medications Staff O, RN said sometimes they will send the resident's remaining controlled medications and/or a prescription for the medication. She said depending on the provider orders for controlled medications they send enough for three days or what is on hand.During an interview on 8/27/25 at 12:03 PM, Staff U, Licensed Practical Nurse (LPN) for discharges the DON gives him the resident's packet. He checks the residents' orders, review the discharge packet with the resident and if ordered, gives the remaining medications to the resident. Staff U, LPN said the resident signs the paperwork. He is told in advance of DME delivery for the resident and wheelchairs are usually delivered to the facility before discharged . If the provider approves controlled medications to be sent with the resident he verifies with the DON. He sends whatever [number of pills] is on the card.During an interview on 8/27/25 at 12:58 PM, the DON said the facility follows physician orders. If a resident is discharging with controlled medications and does not have the number of pills ordered a prescription will be sent at the time of discharge. During an interview on 8/28/25 at approximately 1:30 PM with the SSD and the Regional SSD (RSSD), the RSSD said it is the company's policy to call the resident within three days of facility discharge to confirm HHS providers showed up and DME was delivered. He confirmed the three-day post discharge phone calls were not completed for Resident #1 or Resident #10.Review of facility's policy and procedure, titled Discharge of Resident to Home or Other Center, revised 8/3/2018 showed Procedure: 1. Upon determination by the Interdisciplinary team that resident is appropriate for discharge, the Nurse will obtain a physician's order for discharge to include:-Place of discharge-Community resources or referrals required-Status of medications on discharge (i.e. May discharge home with med)2. Complete the Discharge Plan.3. The list of medications may be printed from pharmacy for resident or legal representative review and signature. Signed copy of the pharmacy discharged Resident Medication Transfer Record is to be faxed to the number indicated on the discharge resident medication transfer record printed from the pharmacy and filed in the clinical record.5.Provide resident a copy of the Discharge Plan, and the pharmacy Medication list.6. Document final disposition in the resident's clinical record.-Resident's goals for admission and desired outcomes, as well as preferences and potential for future discharge- Individualized interventions that honor the resident's preferences and promote achievement of the resident's goal-Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths and desired outcomes.

Based on interview and record review, the facility failed to maintain accurate records of controlled substances and ensure narcotics were reconciled as required for three residents (#2, #3, and #4) out of three sampled residents.Findings included:On 8/27/2025 at 10:03 a.m., an interview was conducted with Resident #3. Over a week ago the resident did not receive the prescribed oxycodone 10 mg during an evening shift. The resident stated the pain medication was due at 6:00 p.m. Staff U, Licensed Practical Nurse (LPN), was asked several times to administer the medication. The resident did not receive the medication until the next shift. Review of the Medication Administration Record (MAR) and the Medication Monitoring/Control Record, the Narc log, revealed administrations were present in the Narc log but the corresponding administrations were not documented in the MAR. The following findings detail the volume of administration not documented in the MAR:Review of the Medication Administration Record dated 7/1/2025 through 7/31/2025, revealed Resident #3's MAR was missing nine out of 56 doses of Oxycodone 10 mg recorded on the Narc log. Resident #2's MAR was missing five out of the 90 doses of Norco (hydrocodone / acetaminophen) 325 mg recorded on the Narc log. Resident #4's MAR was missing 10 out of the 62 doses of Oxycodone 10 mg recorded on the Narc log.Review of 8/1/2025 through 8/15/2025 MAR records, revealed Resident #3's MAR was missing 10 out of 31 doses of Oxycodone 10 mg recorded on the Narc log. Resident #4's MAR was missing 2 out of the 13 doses of Oxycodone 10 mg recorded on the Narc log.On 8/28/2025 at 9:25 a.m., an interview was conducted with Resident #4. The resident began to use pain medications when physical therapy started. Resident #4 said medication is required to improve the residents' pain tolerance during the physical therapy sessions. The pain medication is scheduled for every 4 hours now. The resident will request the medication before physical therapy and would like it to be coordinated with physical therapy more often.On 8/28/2025 at 10:11 a.m., an interview was conducted with Staff H, LPN. She described the facility's process for receiving and documenting controlled substances. The pharmacy brings the medications to the facility, and two nurses must sign to receive the medications. They record the medication information in the Narc book. She stated when the medications are scheduled then they are administered during that scheduled time. If the medication is PRN, as needed, then it is administered if the resident asks for it. The medications are supposed to be recorded in the MAR and on the narcotic count sheet. She revealed that if you forget to record a medication, then the medication can be back dated. She was unsure of a certain amount of time allowed to back date a medication, but she knows that documentation should be done immediately. She stated that if the narcotic count does not match the documentation, then they are required to flag it. They must then let the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) know about the error. She has received some training on the facility's controlled substance reconciliation policy. She was unsure about the date the training occurred. Her most recent training was in June 2025 regarding the facility's two-nurse system. The narcotics are stored in the medication carts, with a two-lock system. She has never encountered a narcotic discrepancy. During shift-to-shift narcotic count verification, the nurses look at the number of medications on the Narc Sheet and count it all together. If medication is not available in the cart, then the nurse must retrieve the medication from a medication dispensing system. They must call the Pharmacy Consultant and are given a code to retrieve the medication out of the medication dispensing system. A pharmacy representative performs monthly checks of the medication dispensing system.On 8/28/2025 at 10:23 a.m., an interview was conducted with the Director of Nursing (DON). The DON said the narcotic medications come from the pharmacy with a manifest slip. Two nurses are required to sign for the medications and log them into the Narc book. The medications are placed in the locked medication cart and counted every shift. Narcotics are reviewed at the management level at least every week. An audit is performed 10 times a month. If a discrepancy is reported, then he will try to figure out how it happened. If there was a diversion found, then one of the regional supervisors would be involved in the investigation. The DON revealed that there have not been any investigations into narcotic discrepancies in the last six months. He also has never reported narcotic discrepancies to the state board, Drug Enforcement Administration (DEA), or law enforcement. He related that training is completed during the narcotic auditing and during employee onboarding training. Discontinued medications are placed in a two-drawer locked file cabinet until destruction. Destruction of narcotics is completed with the Pharmacy Consultant during the monthly review. On 8/28/2025 at 10:35 a.m., an interview was conducted with the Pharmacy Consultant. He stated that he monitors the controlled substances in this facility. He tracks what is coming into the facility, checks the logs, and ensures there are two nurses' signatures. He disposes of the pulled narcotics with the DON every month. The audit review and disposals usually occur on the first Thursday of the month. He provides a monthly report for the facility that includes any discrepancies. He notes discrepancies such as scratch marks, missing numbers, and missing signatures. When discrepancies are identified, he also talks to the DON. He is not aware of any diversion during narcotic handling. His last audit and report was on August 1, 2025.On 8/28/2025 at 10:50 a.m., a follow up interview was conducted with Resident #3. The resident confirmed that she only had an issue with not receiving pain medication on that one day. Resident #3 takes pain medication every eight hours. The resident stressed that the medication is never refused because it is needed. The night nurses may run late with medications, but the resident usually gets it sooner or later.On 8/28/2025 at 11:43 a.m. an interview with the DON was conducted. The discrepancies found in the sampled residents records were discussed. The DON stated that the staff should be signing the medication narcotics sheet and the MAR. The staff did not sign them out as given, and that is an error. He provided a copy of the monthly report. He stated actions would be planned in reference to the monthly report and education would be provided for the staff.A review of the Monthly Medication Unit Review completed on 8/1/2025 by the Consultant Pharmacist revealed a no under sections titled: Controlled substance documentation is accurate and complete, and Controlled substance inventory is reconciled according to facility procedures.A review of the facility policy and procedure titled Medication-Oral Administration of with a revision date of 08/15/2019, revealed: on page 2, when documenting in the EMAR, the nurse will document immediately prior to administration and immediately post administration based on individual professional practice of the nurse.A review of the facility pharmacy policy and procedure titled 4.0 Schedule II Controlled Substance Medication with no listed effective date, revealed: on page 4-8, Section H (5), When a controlled dangerous substance medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials.

Based on observations, record review and interviews, the facility failed to ensure treatment and care were provided after an upper extremity fracture in accordance with professional standards of practice for one resident (#2) of three sampled residents.Findings included:On 8/27/25 at 10:05 a.m., Resident #2 was observed sitting up in bed wearing a hospital gown. Resident #2's left arm was observed to be without movement and laid straight at his side. He was not wearing a left arm sling. Review of Resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses to include: cerebral infarction due to thrombosis of right middle cerebral artery; muscle weakness (generalized); spastic hemiplegia affecting left nondominant side; other symptoms and signs involving cognitive functions and awareness; aphasia following cerebral infarction; other schizoaffective disorders and was updated to include unspecified fracture of upper end of left humerus on 7/23/25.Review of Resident #2's medical record showed he had a designated healthcare proxy.On 8/21/2025 Resident #2 had a Brief Interview for Mental Status (BIMS) score, of 15 indicating intact cognition. Review of Resident #2's Emergency Department (ED) Discharge (DC) instructions from an acute care facility dated 7/22/25 at 5:24 p.m. shows: See Orthopedic surgery within 3-5 days. Please call to arrange an appointment for your left humerus fracture. Review of Resident #2's facility orders on 7/23/25 showed: sling to left arm as allowed and tolerated every shift related to unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. There were no orders found for orthopedic surgery follow-up. Review of Resident #2's Treatment Administration Record (TAR) shows sling to left arm as allowed and tolerated every shift was checked off as performed for 8 of 9 days in July and 26 of 27 days in August. Review of Resident #2's progress notes dated 7/24/25 and 8/6/25 by the Resident's Primary Care Physician (PCP) stated: Plan includes: left arm sling, continue to monitor. Physician Progress notes dated 8/14/25 8:17 p.m. by the Resident's Nurse Practitioner stated: Left humerus fracture: continue immobilization and orthopedic follow-up per protocol. There were no progress notes stating the resident refused the left arm sling. Review of Resident #2's care plan initiated on 9/9/24 and revised on 5/15/25 shows: Alteration in usual functional performance in self-care related to CVA, use of psychoactive medication, communication impairment with a goal that stated the resident's functional performance in self-care will maintain at current functioning level through the next review target date of 11/26/25. The most recent intervention included: Apply sling to left arm as allowed and tolerated (initiated 7/23/25). There were no other interventions initiated since 7/23/25 including in other focus areas of the care plan. An interview was conducted with Resident #2 on 8/27/25 at 11:15 a.m. Resident #2 stated they put my arm in a sling after my injury. I don't need it anymore. My arm is better. During a phone interview on 8/27/25 at 1:24 pm with Resident #2's healthcare proxy, the healthcare proxy stated: He won't wear the sling for the left arm. The hospital ED said Resident #2 needed to see a bone doctor, but I was told by nursing at the facility that it was not recommended. During an interview on 8/27/25 at 2:00 p.m. with Staff Q, LPN, Staff Q stated if the staff makes a check mark in the TAR for an arm sling it means the sling is on. If the resident didn't have it on, I would chart ‘No' and then make a note about it. Or we can use the number codes to say ‘Other, refused', but I would make a note. During an interview on 8/27/25 at 2:20 p.m. with Staff P, CNA, Staff P stated I usually get Resident #2 out of bed every day. I know he used to have a left arm sling, but the resident is not wearing it anymore. The CNAs can put that on, but I haven't for a while. An interview was conducted with Staff O, RN on 8/27/25 at 2:25 p.m. Staff O said the left arm sling order is when needed (PRN). If there is a checkmark in the chart, it probably means it is on. Resident #2 hasn't been wanting to wear it. I don't even know if Resident #2 still needs it. Therapy or the doctor would make that decision. I haven't been able to discuss this with the doctor because I am only here once a week. An interview was conducted with the Medical Records Coordinator (MRC) on 8/27/25 at 4:20 p.m. The MRC said she schedules all residents' physician appointments. She says Resident #2 doesn't have any appointments coming up and hasn't had an appointment outside the building since March. A telephone interview was conducted with Resident #2's PCP on 8/28/25 at 9:50 a.m. The PCP stated treatment of this comminuted fracture often does not include surgery, but the orthopedic surgeon would make that determination. The PCP was not aware that the resident has not seen orthopedic surgery yet. The PCP said treatment with a sling is mainly for comfort, but it may continue to be used until the arm is re-X rayed. The orthopedic surgeon would need to re-Xray to determine healing even if surgery is not performed. During an interview on 8/28/25 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that post injury, Resident # 2, was placed in a sling and with instructions to follow up with orthopedics. The resident has not seen orthopedics yet. I will have to check with the MRC about an appointment. The resident refuses the sling often and will not wear it. At this point, there is no follow up about his refusal. The normal process on post-acute care orders is that the primary nurse admitting the patient back from the hospital would put the orders in or the DON or Assistant Director of Nursing could place the orders. The facility staff would verify the orders with our physician as well. Review of a Facility Policy titled 'Admissions Procedure' revised 8/19/18 revealed: Any new information or changes noted during the collection of data from resident and/or Responsible Party will be communicated as necessary.

Based on record review, staff interview, and policy review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) was issued to 1 of 2 sampled residents reviewed for beneficiary notices. (Resident #136) The findings include: A review of Resident #136's record revealed a Medicare Part A Skilled Services start date of 11/23/23, with the last covered day of Part A services listed as 12/13/23. The record did not contain the required SNF-ABN form. An interview was conducted with the Social Services Director on 1/24/24 at 12:01 PM. He stated the facility did not issue a SNF-ABN to Resident #136 because he was not aware of the requirement. A review of the facility policy SNF Advance Beneficiary Notification (ABN) & Notice of Medicare Provider Non-Coverage (BO-510 revised 5/1/18) revealed that the Care Center is responsible for delivering the Notice of Medicare Provider Non-Coverage and the SNF ABN to all beneficiaries not later than 2 days, before their covered services end and for delivering the Detailed Notice to the Quality Improvement Organization and the beneficiary by close of business of the day the beneficiary requests a review (if a review is requested).

Based on interview, record review, and policy review, the facility failed to obtain and/or act upon pharmacy recommendations in July and December 2023 for 4 of 5 sampled residents. (Residents #26, #46, #60, #70) The findings included: Resident #26 On 1/25/24, a review of a Consultant Pharmacist Medication Regimen Review to Psychiatry dated 12/18/23 for Resident #26 was conducted. The review stated, .the resident is due for a gradual dose reduction in an attempt to find the lowest effective dose. If the medication cannot be reduced at this time please check the appropriate rationale below related to the gradual dose reduction being clinically contraindicated at this time and make a brief clinical rational note that the benefits outweigh the risks. The form was not completed or signed by a medical practitioner or psychiatrist at the time of the survey. A review of the order summary report dated 1/24/24 for Resident #26 was conducted. Resident #26 had a diagnosis of Schizoaffective disorder and Alzheimer's Disease. The resident had an order dated 8/8/23 to take Seroquel (an antipsychotic medication) 50 mg 1 tablet by mouth twice daily. The last psychiatric assessment for Resident #26 was completed on 12/29/23. The assessment did not provide any information or statement regarding a gradual dose reduction for the Seroquel 50 mg twice daily for Resident #26. Resident #46 On 1/25/24 a review of two Consultant Pharmacist Medication Regimen Reviews dated 12/18/23 for Resident #46 was conducted. The first medication regimen review to the physician for Resident #46 was regarding guaifenesin oral tablet 400 mg give 1 tablet by mouth two times daily for seasonal allergies. This order was started on 10/10/23. The order stated that the medication may be used for an acute illness/symptoms for a defined duration and the stopped or may be of a chronic nature and that the medical staff should indicate if chronic or acute and discontinue if appropriate. The review will help reduce overmedication. The form was not completed or signed by a medical practitioner at the time of the survey. A review of the order summary report dated 1/24/24 for Resident #46 was conducted. Resident #46 had an order dated 10/10/23 to take guaifenesin oral tablet 400mg tablet by mouth two times daily for seasonal allergies. The second medication regimen review to the nurse for Resident #46 was regarding Midodrine HCL oral tablet 10 mg 1 tablet by mouth three times daily for Hypertension (HTN). The recommendation asked the nurse to please evaluate the indication of hypertension vs hypotension. At the time of the survey, the form was not signed or updated by a nurse or physician. A review of the order summary report dated 1/24/24 for Resident #46 was conducted. The summary noted that Resident #46 had a diagnosis of Essential Hypertension and had an order for Midodrine HCL 10 mg 1 tablet by mouth three times daily for Hypertension (HTN). On 1/25/23, a review of the Consultant Pharmacist Services Agreement effective 12/1/2023 was conducted. The agreement indicated that the consultant pharmacy would provide general supervision of clients pharmaceutical services including medication regimen reviews. These reports would be provided for each resident of the facility at least once each month. The consultant pharmacy agreement indicated that an electronic copy of the report would be sent within 3 business days to facility leadership. 41185 Resident #60 On 01/25/2024 during a record review for Resident #60, the 12 month Pharmacy Review revealed that the December 2023 review had not been received by the facility or requested by the facility, and was only discovered by facility staff after the survey team requested the Pharmacy Review for Resident #60. The December 2023 pharmacist review recommended an antidepressant to be reviewed for a possible Gradual Dose Reduction in an effort to find the lowest effective dose, which had not been followed up. (Photographic evidence obtained) Resident #44 On 01/25/2024, during record review for resident #44, the 12 month Pharmacy Review revealed the December 2023 review had not been received by the facility or requested by the facility, and was only discovered by facility staff after the survey team requested the Pharmacy Review for Resident #44. The pharmacist had recommended a dose reduction for an antihistamine prescribed for Resident #44, which had not been followed up. (Photographic evidence obtained) 28603 Resident #70 Review of Resident #70's record revealed a consultant pharmacist recommendation dated 7/10/23, which indicated the resident had a diagnosis of diabetes, but a hemoglobin A1C (a blood test that measures the individuals average blood sugar levels over the past 3 months) was not available in the medical record in the past 6 months. The pharmacist recommended monitoring the hemoglobin A1C on the next convenient lab day and every 6 months if meeting treatment goals, or every 3 months if therapy has changed or goals are not being met. The pharmacist recommendation form contained a hand written telephone order by the Director of Nursing (DON) dated 7/20/23 stating, okay to do lab draw. A review of Resident #70's record revealed no hemoglobin A1C blood test on file. An interview was conducted with the DON on 1/24/24 at 11:48 AM. She stated the hemoglobin A1C was missed and not obtained. She and the Assistant DON were responsible for ensuring the pharmacy recommendations were acted upon. She may have been interrupted during the process. On 1/24/24, the survey team requested the pharmacy recommendations from December 2023. The review of the consultant pharmacist for Resident #70, dated 12/18/23, revealed a recommendation to consider adding an as needed parameter for the Glucagon injection as needed for hypoglycemia on when to administer the medication, for example blood sugar less than 60. A review of the record revealed the recommendation had not been acted upon by the facility. An interview was conducted with the DON on 1/24/24 at 3:15 PM. The DON stated the facility changed pharmacy consultants in December 2023 and the new pharmacist emailed some reports in December 2023. She did not realize she did not receive all of the reviews until the survey team requested specific pharmacy reviews for December 2023 and she did not have them. She stated the facility expects the reports on all residents to be provided in the same month of the review. Review of the facility policy for Monthly Drug Regimen Review (N-866 revised 10/10/18) revealed, During the drug regimen review, the consultant pharmacist is to identify drug regimen irregularities. Drug regimen irregularities are to be communicated to the attending physician, the Medical Director, and the DON/designee to complete follow up as indicated. Routine recommendations to be communicated to the DON/designee, attending physician, and Medical Director for response and resolution, after the completion of the Monthly Drug Regimen Review. Drug regimen irregularities identified by the consultant pharmacist that require urgent action are to be communicated to the DON/designee for resolution with the attending physician and/or Medical Director.

Based on observations, record review, and interviews, the facility failed to follow its grievance procedure and accurately conduct its investigation for one (Resident #1) of three sampled residents for a voiced grievance. Findings included: On 12/6/2022 at 11:07 a.m., during an interview with Resident #1, she was asked if she had ever filed a grievance. She confirmed she had but did not know the outcome of the grievance. She reported she filed several grievances in October, specifically one on the length of time she had to wait for staff to answer her call light on the 11:00 p.m. to 7:00 a.m. shift. She confirmed no one had come to explain what they were going to do or to discuss the findings. Resident #1 had a roommate who was alert and oriented, she also confirmed no one had come to talk to Resident #1 regarding the outcomes for the grievances. Resident #1 was asked specifically if the Nursing Home Administrator (NHA) had notified her of any resolution to her grievances particularly the one regarding not answering call lights on the 11:00 p.m. to 7:00 a.m. shift. Resident #1 confirmed she had not received any findings for this grievance. A review was conducted of the Grievance Log for October 2022. Resident #1 had filed three grievances in October. On 10/24/22, the resident had a grievance related to the length of time it took for staff to answer call lights. The grievance which was investigated by the NHA with a date of 10/24/22, with findings documented on 10/25/22, read as follows: Resident stating it took too long for her call light to be answered. Resident stated this happens usually during the 11:00 p.m.-7:00 a.m. shift. Resolution dated 10/25/22- call light audits conducted - [Audits were not on the 11:00 p.m. to-7:00 a.m. shift]. Nursing reported resident turned on light right after (unreadable) comes in. Part of the written resolution was 1. Apologized to the resident, 2. Call light audits 3. Education staff aware to answer call lights after leaving the room and resident turned back on 4. Spoke to resident regarding audits and education. During a second interview conducted with Resident #1 on 12/6/22 at 2:15 p.m., the resolution was read to her, and she confirmed this was the first time anyone had given her a response to her grievance. She denied the NHA came to talk to her. An interview with the NHA was conducted on 12/6/22 2:18 p.m., regarding her resolution to the resident's grievances and regarding her audits for the resident's voiced concern timeframe. Review of the audits revealed they were not within the timeframe of 11:00 p.m. to 7:00 a.m. shift. The audits were conducted between 11:30 a.m. through 6:00 p.m. The NHA confirmed the audits should have been done within the time range that was in the complaint. The NHA was made aware Resident #1 denied having heard back with a resolution to her grievance, the NHA responded of course she did. A facility policy dated 11/30/2014 with a revision date of 8/9/2018 titled Complaint/Grievance, read as follows- Under the heading Purpose: To support each resident's right to voice grievances; resulting in a follow up and resolution while keeping the resident apprised of its progress toward resolution. The individual voicing the grievance shall receive follow up communication with the resolution.

Based on observations, record reviews, and interviews, the facility failed to thoroughly investigate an allegation of drug misappropriation for one (Resident #2) of one sampled resident with an allegation of drug diversion. Findings included: Resident #2 was admitted on [DATE] and readmitted on [DATE]. The Admission Record included diagnoses not limited to unspecified paraplegia, sequelae of unspecified injury to unspecified level of lumbar spinal cord, and unspecified hereditary and idiopathic neuropathy. The Quarterly Minimum Data Set (MDS) dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS indicated the resident had answered having occasional pain in the last 5 days with the worse pain of 6 out of 10. A review of the facility's Reportable Events Logs from September 2022 to December 2022 identified an allegation in October 2022 regarding misappropriation involving Resident #2 on 10/1/22. The log indicated notifications to law enforcement (LE) and to the state and federal oversight agencies were done. An interview was conducted, on 12/6/22 at 1:08 p.m., with the Nursing Home Administrator (NHA). The NHA reported a blister card containing the narcotic, Oxycodone 30 milligram (mg) was missing on 10/1/22. She stated when the nurse went to re-order Resident #2's Oxycodone, they could not re-order because it was to early. The pharmacy informed the facility they had delivered four blister cards, the facility could only account for three cards, and the facility could not find the Controlled Medication Utilization Record (a record of narcotic medication administration) for the Oxycodone from 9/17 to 9/23/22. The NHA reported on 9/9/22, four blister cards that contained 30 tablets each were delivered for Resident #2 who received the medication per schedule. She stated the physician was notified and an audit of narcotics was done, the previous Assistant Director of Nursing (ADON) looked through the medication cart, the Director of Nursing (DON) came in the next day and looked through the medication carts and the shredder bins. The NHA stated the count of blister cards and narcotic pills was correct. The NHA stated she could not answer why the count of cards was not correct when counted during on-off going shifts. The NHA stated staff should have re-ordered and noticed the count was wrong prior to this incident. The NHA reported on 9/20/22 a vital records company had removed eight bins for shredding. The NHA reported the facility conducted an ad hoc Quality Assurance meeting on 10/3/22 (two days after the incident) and did education with the two oncoming and off-going nurses who had not signed the counting of narcotics on 9/28 and 9/29/22. She stated 100% of the nurses were educated on the policy and procedure for shift to shift narcotic count. The NHA confirmed staff had signed on 9/9/22 for the delivery of four cards of 30 mg Oxycodone. The NHA stated the root cause was that staff were not counting cards or pills correctly. A review of the Ad Hoc Quality Assurance was conducted during the interview with the NHA. The ad hoc meeting notes on 10/3/22 indicated the reason for Ad Hoc was to Immediately correct and maintain compliance with medication administration and controlled substance reconciliation center wide. The data indicated that 1. Unable to re-order narcotic (NARC) and 2. Controlled substance cared and sheet missing for 9/27/22. The root cause analysis identified that Nurse NARC shift to shift count was not being completed per policy. The plan was as follows: - 1. Follow Policy and Procedure for shift to shift NARC count. See Attached. - 2. Education to follow Policy and Procedure. - 3. Full House Audit of NARC received from pharmacy. - 4. Weekly Audit by Director of Clinical Service (DCS) on each unit. The Quality Review identified a Controlled Substance Reconciliation was conducted on 10/3/22 by the Director of Clinical Services (DCS). The review indicated, Quality Review will be conducted by the Director of Nursing/designee monthly (A minimum of 15 Patients/Residents will be reviewed). Results of the Quality Review to be reviewed in the monthly Quality Assurance/Performance Improvement (QAPI) meeting. During the interview on 12/6/22 at 1:08 p.m., the NHA stated the Quality Review was not ongoing as the facility had found no other discrepancies and she would have to ask nursing when the audits were completed. The NHA did not produce any weekly audits following the full house narcotic audit. She stated that Resident #2 was okay, the facility had done a pain assessment, and had received as needed pain medication. On 12/6/22 at 2:01 p.m., the NHA confirmed she had only one audit which was 100% of the residents receiving narcotics done on 10/3/22. The facility provided a pain evaluation, dated at 10:15 a.m. on 10/2/22, for Resident #2. The pain evaluation was conducted approximately 34 hours after Resident #2 did not receive the scheduled dose of Oxycodone 30 mg due to unavailability. The NHA stated on 12/6/22 at 1:08 p.m., the nurse did not document the assessment right away and it should have been a late entry. The evaluation was signed and locked at 10:20 a.m. on 10/3/22 (three days after the incident). During an interview, on 12/6/22 at 2:53 p.m., the Director of Nursing (DON) stated she did not recall how many audits were completed, remembered only the one (10/3/22). She stated she remembered doing audits on all the carts, then stated we (herself and the previous ADON) did weekly audits on Monday and Thursday to make sure medications were available before and after the weekend but did not document them (audits). She stated the previous ADON left at the end of October, did not know why the ADON did not document, and that she did not follow up on the ADON documentation. The DON related that weekly means more than one and the Ad Hoc was a plan of correction and would be more than one (audit). She identified the audit completed on 10/3/22 was not the weekly audit but the full house audit of narcotics from the pharmacy. A review of the Shift Change Controlled Substance Inventory Count Sheet for the West wing, identified on 9/13/22 at 7:00 a.m., one card was removed and the card count was 26, at 7:00 p.m. The facility added four cards and subtracted one to equal 29. The facility documented again for 9/13/22 at 7:00 a.m., to add one card and remove three for a total of 27 cards. There was no documentation for 9/14/22 however, the next total cards for 9/15/22 for 7:00 a.m. to 7:00 p.m., was 23. The record did not account for the disposition of the narcotic cards (from 9/13 to 9/15/22). The Shift Change Sheet for the West wing identified on 9/13, 9/20, and 9/21/22 the oncoming nurse at 7:00 p.m. did not sign the log and the off-going staff had not signed the count log on 9/5/22 or 9/23/22. The policy and procedure - Abuse, Neglect, Exploitation and Misappropriation, effective 11/30/2014, and revised 11/28/2017, indicated it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The policy defined Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent. The definition included Diversion of resident's medication(s), including, but not limited to, controlled substances for staff use or personal gain. The procedure revealed that investigations would include the following: - The nurse of Director of Clinical Services shall perform and document a thorough nursing evaluation, and notify the attending physician. - The Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. The policy and procedure - Controlled Drug Count, effective 11/30/2014 and revised 10/30/2020, identified 'the process for counting and documention of controlled substance chain of custody from off going nurse to on coming nurse and additional steps to take if a discrepancy is discovered. The procedure indicated that The oncoming and the off-going shift nurses assigned to the controlled drug cart are responsible for ensuring the accuracy of the controlled drug count.

Based on observation, medical record review, facility policy review, and interviews, the facility failed to ensure one (Resident #1) of eight sampled residents received ordered treatment and services to prevent further decrease in range of motion. Findings included: During an interview with Resident#1 on 12/6/22 at 11:07 a.m., she reported she had not received restorative services but had an order to receive ROM (range of motion) at least three times a week. A review of the resident's medical record revealed the resident was originally admitted to the facility on [DATE] with a re-admitted [DATE]. Resident #1 had multiple diagnoses but not limited to quadriplegia, anxiety, muscle weakness, chronic pain and depression. Resident#1 was alert, oriented, and able to make her needs known with a BIMS of 15, which indicated intact cognition. A review of a restorative order by her physician dated 8/3/2022 read: Restorative: Gentle PROM (passive range of motion) on BLE (bilateral lower extremities) flex/extend/ABD (abduction) for one set of 20 reps without using weights. PROM to bilateral feet dorsiflexion for 1 set of 20 reps. AROM (active range of motion) on BUE (bilateral upper extremities) for 2 sets of 20 reps with modified technique using trapeze and bands, hook system using moderate to heavy bands. A review was conducted of Resident #1's care plans dated 5/24/22, with an intervention dated 8/4/22, and read as follows: Name of resident, requires assistance with all her ADLs (activities of daily living) related to quadriplegia, impaired balance/transfers, non-ambulatory, unable to feed self or assist with any ADLs. She is alert and able to express her wants and needs. She has a urostomy. An intervention was: Restorative program as written. Dated 8/4/22. Further record review revealed no documentation regarding the resident receiving this service from 8/3/22 through 10/25/22 the date she voiced her grievance. On 12/7/2022 at 9:30 a.m., the Director of Nursing was asked to provide documented evidence the resident was being provided with restorative services as ordered on 8/3/2022. A second request was made to the corporate nurse at 1:16 p.m. on 12/7/2022. She confirmed there was no documentation to the effect that Resident#1 received restorative services from 8/3/22 through 10/25/22 when she filed a grievance. During this interview, the Director of Nursing was present and stated the resident did receive restorative services, we just did not document it. They were advised the resident who was alert, oriented, and able to make her needs known denied receiving restorative services. Policies and procedures were reviewed for the facility's restorative nursing program dated 2/1/2016 with a revision date of April 15th, 2022. Under the heading of Documentation, #7 indicates restorative nurse or designee to document in the medical record the initiation of a restorative program. #8 RNA will document residents' participation actual number of minutes participating in the restorative intervention. #9 restorative nurse or designee will review RNA (restorative nurse aide) documentation weekly during standard of care meeting. Restorative nurse or designee will document residents' response to intervention and progress towards goals. Modify goals and intervention is appropriate. Revised care plan is needed and is program changes and #10- the restorative nurse or designee will review restorative programs monthly and document a summary note. Documentation should include but is not limited to, and evaluation of the continued appropriateness of the current restorative nursing program, reflect functional progress made during the entire month, and any teaching.

Based on observations, staff and resident interview, and medical record review, the facility failed to ensure one resident (#15) of thirty-two sampled residents received services to maintain or promote further range of motion for a contracture related to not applying a hand splint for three (12/20/2021, 12/21/2021, and 12/22/2021) of three days. Findings included: On 12/20/2021 at 2:12 p.m. Resident #15 was observed in his room, lying in bed. Resident #15 was interviewable but had verbal difficulties. Further observation revealed Resident#15's right hand appeared contracted and was placed/positioned on his stomach area. Resident #15 was not wearing a hand splint on his right hand during the observation. However, a blue and black splint was observed placed on the left side of the bed on a dresser, out from his reach. On 12/21/2021 at 12:10 p.m. Resident #15 was observed lying in bed and under the covers. Resident #15 was noted not wearing a right-hand splint and it was observed positioned on the left side of the bed on a dresser. On 12/22/2021 at 10:13 a.m. Resident #15 was observed in his room, lying in bed with his hands positioned on top of the covers. He again was noted not to be wearing his right hand splint. He confirmed it was not on by nodding his head and lifted his head to point at the hand splint on the dresser at bedside which was placed out of his reach. On 12/22/2021 at 12:15 p.m. Resident #15 was observed in his room and was eating his lunch meal. He was using his left hand to eat, by using built up adaptive eating utensils. He was asked about his right hand but he had some verbal communication deficit. However, he was able to shake his head yes and no to questions about his splint. He was able to confirm that he needs help putting on his right hand splint, and it had been left in the same place on his dresser for over one week without receiving assistance to put it on. He was able to confirm he would wear it if staff would help him put it on. He confirmed that no staff has helped him with putting it on during the day or night. Resident #15 also confirmed, by nodding his head up and down, that his right hand does feel better when the splint was on. Review of Resident #15's Admission Record revealed he was admitted initially on 05/26/20 and the most recent readmission on 12/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Minimum Data Set (MDS) assessment, Section G: Functional Status, dated 12/09/21, revealed Resident #15 required at minimum, extensive assistance of one person for activities of daily living and was impaired on one side of both upper and lower extremities. Section O - Special Treatments and Programs showed for Restorative Nursing Programs under Technique a 0 for Splint or brace assistance. Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *Right hand splint to be placed for up to 6 hours and removed. Skin checks prior to putting splint on and following the removal of splint, ordered 06/02/21. *Restorative passive range of motion, right upper extremities all planes 10 repetitions times 3 sets, ordered 09/18/21. On 12/22/2021 at 12:26 p.m. an interview with the Staff B, Restorative Aide revealed she was the restorative aide and normally if she has a resident on her case load, she would be the person who assisted the resident with applying (donning/doffing) of splints and braces. She confirmed Resident #15 had gone to the hospital and she felt that he was no longer on her restorative case load when he returned to the facility. She was unaware he currently had an order to receive restorative care. She was aware that Resident #15 had a right-hand splint and it was normally kept in his room. Staff B also revealed when not on her case load, direct care floor aides are supposed to help residents with donning and doffing of the splints/braces. Staff B confirmed Resident #15 had a contracture of his right hand and again confirmed he was not currently wearing the brace/splint, and confirmed it was currently placed on the dresser behind him. She again confirmed she does not currently have him on her workload. On 12/22/2201 at 1:28 p.m. an interview with the Rehabilitation Therapy Director (Director) revealed Resident #15 has been on their work load many times since his first admission back in 2018. The Director confirmed Resident #15 does have a right-hand contracture and does utilize a splint/brace on his right hand and there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When the Director was told that Staff B, Restorative Aide stated she no longer had Resident #15 on her workload, she didn't understand because there was still a current order for restorative services. The Director also confirmed the resident would benefit from daily use of the right-hand brace/splint. She revealed the order interpretation for six hours on and as tolerated would mean during the 7 (a.m.) -3 (p.m.) shift, as that was when the Restorative Aide (Staff B) normally works. Review of the Restorative Nursing Progress Notes revealed: *6/02/21 - Right hand splint was to be placed on for up to 6 hours and removed. Skin checks prior to putting on splint and following removal of splint. *06/28/21 - Continued order for right hand splint. *07/22/21 - Splint was to be placed to the right hand daily for comfort as tolerated per resident. Restorative was to continue until all goals were met. *08/03/21 - [Resident #15] continued with restorative services for splint placement to the right hand. Tolerated well. Continued current plan of care related to restorative services. Review of the Occupational Therapy Rehabilitation assessment dated [DATE] revealed under the section titled Long-term goals: [Resident #15] would tolerate four hours of right resting hand splint to inhibit any further contractures and caregivers would demonstrate 100 percent compliance with proper resting hand splint application and skin inspection. [Resident #15] was discharged to the Restorative Nursing program with recommended equipment to include right wrist/hand splint. Review of the current care plan initiated on 11/13/18 with the next review date of 12/27/21, revealed a focus area: [Resident #15] has an ADL self-care performance deficit r/t (related to) [CONDITION(S)] ([CONDITION(S)] accident [stroke]), impaired balance, [CONDITION(S)], incontinent, not able to ambulate, he is alert and able to propel himself, feed self. Interventions included resting right hand splint to be worn daily as tolerated, and restorative nursing program as written. On 12/22/2021 at 4:00 p.m. an interview with the Director of Nursing confirmed Resident #15 had a right-hand contracture and that he utilized a right-hand splint daily and as tolerated. She could not provide any documented evidence that Resident #15 had ever refused the use of the splint and confirmed Resident #15 was supposed to receive restorative aide services to apply the splint/brace daily. She could not provide any documentation to show for the past two months of 11/2021 and 12/2021, that Resident #15 was ever offered and or assisted with his donning or applying of the right hand splint.

F812 Based on observations, record reviews, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety related to male staff members not wearing hair restraints to cover beards, expired and undated food in the walk-in cooler, and black build up and condensation leaking from vents above the serving line and food prep table in one of one kitchen, and undated food and spillage in the nourishment refrigerator on one wing (East), and an uncovered ice scoop stored in one nourishment room on one wing (West) out of a total of two nourishment rooms. Findings included: On [DATE] at 9:04 a.m., an initial tour of the kitchen was conducted. The Certified Dietary Manager (CDM) was observed wearing a surgical mask and no beard guard to cover facial hair. Facial hair was exposed at the bottom of the surgical mask and on both sides of the mask. Two containers of Fresh Salsa were observed in the walk-in cooler with an expiration date of [DATE] and [DATE] (photographic evidence obtained). A peanut butter and jelly sandwich was observed in the walk-in cooler on a tray without a date. The CDM was asked when the sandwich was made, he stated he did not know, and immediately removed the sandwich from the tray. Following the initial tour of the kitchen an observation of the nourishment room on the East Wing revealed: the lid to the ice cooler was open and stored next to a bedside commode, a tray with five bowls of fruit was observed in the homestyle nourishment refrigerator without a date, spillage was observed in the top and bottom of the refrigerator, and strands of hair were observed in the top of the refrigerator. Following this observation an observation of the nourishment room on the West Wing revealed an uncovered ice scoop was observed on the shelf above the ice cooler (photographic evidence obtained). On [DATE] at 11:25 a.m., the vents above the serving table and food preparation table were observed with black buildup and condensation leaking from the vents (photographic evidence obtained). The Account Manager stated, It's condensation and it leaks every once in a while. She stated they had not submitted a work order for the vents. One male staff member assisting with plating the trays for lunch was observed wearing a surgical mask and no beard guard to cover exposed facial hair. On [DATE] at 11:29 a.m., the CDM reported he and the Account Manager were responsible for ensuring there were no expired foods in the walk-in cooler and that all foods were labeled and dated in the walk-in cooler. He reported that housekeeping was responsible for cleaning the nourishment refrigerators once per month and kitchen staff was responsible for cleaning the refrigerator as needed. The CDM stated he only wears a beard guard while he is prepping food. Surveyor pointed out the male staff member assisting with plating the trays for lunch and the CDM stated he would get him a beard guard. A policy was requested at this time related to beard guards and was not provided. The policy provided by the facility titled, Equipment, dated [DATE] revealed the following: Policy Statement It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. Action Steps 1. The Food Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials. 2. The Food Service Direction will ensure that all staff members are properly trained in the cleaning and maintenance of all equipment. 3. The Food Services Director ensures that all food contact equipment is cleaned and sanitized after every use. 4. The Food Services Director ensures that all non-food contact equipment is clean. 5. The Food Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Food Services Director will notify the administrator when repairs are complete. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly. The policy provided by the facility titled, Food Storage: Cold, dated [DATE], revealed the following: Policy Statement It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the USDA [United States Department of Agriculture) Food Code. Action Steps 5. The Food Services Director/ Cook ensures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the FDA Food Code - 2017 revealed, Hair Restraints ,d+[DATE].11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. A general cleaning schedule was requested and not provided.

Based on observations, record reviews, and interviews, the facility failed to ensure that its Quality Assurance plan was effective related to 1. Failure to prepare, distribute, and serve food in accordance with professional standards for food service safety related to a staff member not wearing hair restraints, condensation leaking from vents above the serving line and food prep table in one of one kitchen, and an uncovered ice scoop stored in one of two nourishment rooms (West Wing); and 2. Failure to provide one (Resident #4) of four sampled residents with timely narcotic pain medication related to not submitting a prescribed narcotic prescription to the pharmacy timely. Findings included: 1. The facility developed a plan of correction that included the following: - On 12/21/21, the Dietary manager completed a kitchen sanitation and food storage audit in the kitchen. On 12/20/21, the Dietary manager completed a sanitation and food storage in the facilities nutrition rooms. Any concerns identified were addressed at that time and actions taken/systems put into place to reduce the risk of future occurrence. On 12/21/21 and 12/22/21, the Dietary manager and/or designee educated the Dietary staff on sanitation, hair and beard coverings, food storage and spillage. How the corrective action(s) will be monitored to ensure the practice will not recur: Dietary Manager and/or designee will conduct a daily quality review of sanitation weekly x 4 weeks and then 2 x a month x 2 months to ensure equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials, staff members are properly trained in the cleaning and maintenance of all equipment, food contact equipment is cleaned and sanitized after every use, non-food contact equipment is clean, and submit any repairs, The findings of these quality reviews will be reported to Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Services when completing their systems review. Inspection of the facility's kitchen on 2/23/22 at 9:23 a.m., revealed that the Registered Dietician (RD) entered the kitchen and proceeded to the office located in the kitchen. An interview with the RD at this time, revealed that she visited the facility one time a week and knew she should have her hair covered but just came in to talk to the Accounts Manager. Continued observations during the tour of the kitchen revealed that there were two air vents mounted to the ceiling, one located over the prep table and the other located over the steam table. Both units were noted to have condensation on them dripping on both the prep table and the tray-line table. The Accounts Manager confirmed that the two vents had condensation and was dripping on the prep table and the tray-line table. The Accounts Manager proceeded to use her body to move the prep table and the tray-line table from under the vents. She reported she was not aware of anything being done regarding the condensation dripping on the tables. Continued inspection at this time, revealed the West wing nutrition room was noted to have an ice scoop sitting on the top of a cloth located on the ice cart. The ice scoop was not in an appropriate container to prevent contamination. The Accounts Manager reported that the ice scoop was not appropriately stored and she would send it back to the kitchen to be cleaned. In an interview with the Maintenance Director on 2/23/22 at 11:20 a.m., he said they cleaned the vents, but did not realize that condensation was still dripping onto the prep table and the tray-line. He reported that the tables had been moved and would stay where they were until the vents could be fixed. Review of the facility policy titled Staff Attire with an original date of 5/2014 and a Revised date of 9/2017 revealed the following: -1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. 2. The facility developed a plan of correction that included: 1. On 12/29/21, the ADCS and/or designee re-educated the licensed nursing staff on pain management and providing ordered pain medication in a timely manner. 2. Any newly hired licensed nursing staff or any agency licensed nursing staff will be educated on pain management and providing ordered pain medication in a timely manner. 2. On 2/23/22 at 8:55 a.m., Resident #4 was overheard from the surveyor conference room to be in her room yelling out oh I need help, no one ever comes in this room, I'm in pain, I need help, I need to go to the hospital. The resident continued to moan and call out in pain and call out for help. One staff member came into the resident's room and the resident stated she did not want her breakfast she only wanted a cup of ice water. On 2/23/22 at 9:30 a.m., Resident #4 was overheard from the surveyor conference room continuing to call out for help, she stated, I need my pills, no one ever comes down here, I haven't even gotten my water yet. She moaned in pain and stated, I want to go back to the hospital. Review of Resident #4's admission record revealed she was admitted on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/22 at 11:23 a.m., the paramedics were observed to be outside of Resident #4's room. The resident indicated she felt like she could not breathe and her chest hurt. The paramedics were heard telling the resident you have oxygen on, we are going to take you to the hospital. The resident stated okay good. The resident started to complain her back was hurting and the paramedics wheeled her out of the facility on a gurney. Review of Resident #4's physicians order revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further physician order review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a physician's order to start on 2/23/22 with no end date for Acetaminophen 325 mg give 3 tablets by mouth every 8 hours as needed for mild pain 1-4 related to pain. Another physician's order was reviewed to start on 2/22/22 with no end date for Acetaminophen 325 mg give 3 tablets by mouth every 8 hours as needed for pain/fever. Review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #4 on 2/22/22 or 2/23/22. Review of Resident #4's nurses progress notes revealed a note dated 2/23/22 at 11:20 a.m., Resident called 911 stating she had chest pain. Transferred via medics to [NAME] Dunedin Hospital. An interview was conducted with Resident #4's nurse Staff A, Registered Nurse (RN) on 2/23/22 at 2:20 p.m. She said Resident #4 called the paramedics herself because she was in pain, and she could not wait. I guess the pharmacy did not receive any of the narcotics faxes that were sent over yesterday so someone had to go down there and give them the prescriptions. Staff A, RN stated she could not access the emergency drug kit (EDK) for pain medication for the resident because this was her first time working with the resident and the pharmacy did not have her narcotic prescriptions. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) Unit Manager on 2/23/22 at 3:ppm. She said, The nurse overnight said the fax was not working, I guess it kept kicking back her prescription and saying error. So, this morning I tried to refax the narcotic prescriptions on all the other fax machines and none of them were working. I also called the pharmacy, and they were going to call a carrier to pick up all the prescriptions but that was going to take an hour and I did not want to have to wait that long. There were nine prescriptions that did not go through to the pharmacy yesterday. The pain management physician came yesterday, and the prescriptions were for narcotic refills, so residents did not run out of their narcotics. [Resident #4] was our only new admission with a narcotic yesterday. I explained the situation to Resident #4 and told her it would be about an hour before I could get the authorization code from pharmacy to get her pain medication and she was fine with that. But, after I went across the street to fax the prescriptions, I was on the phone with the pharmacy getting the authorization code to get her narcotic, she called the paramedics, so I canceled her authorization code. Earlier in the morning [Resident #4] was telling me she was having neck pain, that is why I was trying to get her narcotics. When the paramedics came, she was saying she had chest pain. She did look worse than she did when I first saw her this morning. The hospital actually admitted her for congestive heart failure which was not a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Director of Nursing (DON) on 2/23/22 at 3:17 p.m. She said, [Resident #4] was having chest pain, initially said she was having shoulder and neck pain. She just got here last night, and the pharmacy had a problem with our fax machine. So, we went over next door to use their fax machine. We couldn't pull from the EDK (Emergency Drug Kit) without a faxed authorization. The pharmacy wouldn't give us a code without the script. While the unit manager was trying to get the scripts faxed, the resident called the paramedics herself. Some of our faxes give a confirmation and some don't. I would have to check the west wing fax because that is where her prescription was faxed from to see if it gives a confirmation or not. I don't know the full details of Resident #4 yet. She was the only one that it effected. I did not see if there were any other problems with the other fax machines or new admissions, but no one was complaining. An interview was conducted with the DON and Nursing Home Administrator (NHA) on 2/23/22 at 4:30 p.m., they indicated they thought their plan of correction went fine they went over all the citations and provided education and conducted audits. They indicated their QAPI (Quality Assurance and Performance Improvement) team met December 23, 2021, to discuss the citations they received and created a plan to correct each citation. The team met again on January 21, 2022 to review audits and the team continued to meet again on February 17, 2022 to further discuss their audits. The DON indicated she was having trouble with staff attendance at the meetings to educate them so she held a virtual meeting hoping she would have a better turn out because of the convenience factor. The virtual meeting had some technical difficulties and did not have a good turn out, so she had been coming into the facility to educate the nursing staff on medication administration individually. The DON also indicated Resident #4's nurse was a newly hired nurse and she had not attended the virtual meeting related to medication administration and the DON had not had time to do an individual education with her the morning of the survey. The NHA stated that new hires met with the Assistant Director of Nursing (ADON) to go over their new hire paperwork and at that time they were also introduced to the facility's education portal that had all their education that was needed.

2. The facility developed a plan of correction that included: 1. On 12/29/21, the ADCS and/or designee re-educated the licensed nursing staff on pain management and providing ordered pain medication in a timely manner. 2. Any newly hired licensed nursing staff or any agency licensed nursing staff will be educated on pain management and providing ordered pain medication in a timely manner. 2. On 2/23/22 at 8:55 a.m., Resident #4 was overheard from the surveyor conference room to be in her room yelling out oh I need help, no one ever comes in this room, I'm in pain, I need help, I need to go to the hospital. The resident continued to moan and call out in pain and call out for help. One staff member came into the resident's room and the resident stated she did not want her breakfast she only wanted a cup of ice water. On 2/23/22 at 9:30 a.m., Resident #4 was overheard from the surveyor conference room continuing to call out for help, she stated, I need my pills, no one ever comes down here, I haven't even gotten my water yet. She moaned in pain and stated, I want to go back to the hospital. Review of Resident #4's admission record revealed she was admitted on [DATE] from an acute care hospital with diagnoses that included but were not limited to chronic obstructive pulmonary disease, anxiety disorder, idiopathic peripheral autonomic neuropathy, major depressive disorder, chronic pain syndrome, and pain. On 2/23/22 at 11:23 a.m., the paramedics were observed to be outside of Resident #4's room. The resident indicated she felt like she could not breathe and her chest hurt. The paramedics were heard telling the resident you have oxygen on, we are going to take you to the hospital. The resident stated okay good. The resident started to complain her back was hurting and the paramedics wheeled her out of the facility on a gurney. Review of Resident #4's physicians order revealed an order for Oxycodone 5 mg give 1 tablet by mouth every 6 hours as needed for chronic pain to start on 2/22/22 with no end date. Further physician order review revealed an order for Oxycodone 5 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 5-10 related to pain to start on 2/23/22 with no end date. Further review revealed a physician's order to start on 2/23/22 with no end date for Acetaminophen 325 mg give 3 tablets by mouth every 8 hours as needed for mild pain 1-4 related to pain. Another physician's order was reviewed to start on 2/22/22 with no end date for Acetaminophen 325 mg give 3 tablets by mouth every 8 hours as needed for pain/fever. Review of Resident #4's medication administration record revealed neither Acetaminophen nor Oxycodone were administered to Resident #4 on 2/22/22 or 2/23/22. Review of Resident #4's nurses progress notes revealed a note dated 2/23/22 at 11:20 a.m., Resident called 911 stating she had chest pain. Transferred via medics to [NAME] Dunedin Hospital. An interview was conducted with Resident #4's nurse Staff A, Registered Nurse (RN) on 2/23/22 at 2:20 p.m. She said Resident #4 called the paramedics herself because she was in pain, and she could not wait. I guess the pharmacy did not receive any of the narcotics faxes that were sent over yesterday so someone had to go down there and give them the prescriptions. Staff A, RN stated she could not access the emergency drug kit (EDK) for pain medication for the resident because this was her first time working with the resident and the pharmacy did not have her narcotic prescriptions. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) Unit Manager on 2/23/22 at 3:ppm. She said, The nurse overnight said the fax was not working, I guess it kept kicking back her prescription and saying error. So, this morning I tried to refax the narcotic prescriptions on all the other fax machines and none of them were working. I also called the pharmacy, and they were going to call a carrier to pick up all the prescriptions but that was going to take an hour and I did not want to have to wait that long. There were nine prescriptions that did not go through to the pharmacy yesterday. The pain management physician came yesterday, and the prescriptions were for narcotic refills, so residents did not run out of their narcotics. [Resident #4] was our only new admission with a narcotic yesterday. I explained the situation to Resident #4 and told her it would be about an hour before I could get the authorization code from pharmacy to get her pain medication and she was fine with that. But, after I went across the street to fax the prescriptions, I was on the phone with the pharmacy getting the authorization code to get her narcotic, she called the paramedics, so I canceled her authorization code. Earlier in the morning [Resident #4] was telling me she was having neck pain, that is why I was trying to get her narcotics. When the paramedics came, she was saying she had chest pain. She did look worse than she did when I first saw her this morning. The hospital actually admitted her for congestive heart failure which was not a diagnosis she came in with. An interview was conducted with the Director of Nursing (DON) on 2/23/22 at 3:17 p.m. She said, [Resident #4] was having chest pain, initially said she was having shoulder and neck pain. She just got here last night, and the pharmacy had a problem with our fax machine. So, we went over next door to use their fax machine. We couldn't pull from the EDK (Emergency Drug Kit) without a faxed authorization. The pharmacy wouldn't give us a code without the script. While the unit manager was trying to get the scripts faxed, the resident called the paramedics herself. Some of our faxes give a confirmation and some don't. I would have to check the west wing fax because that is where her prescription was faxed from to see if it gives a confirmation or not. I don't know the full details of Resident #4 yet. She was the only one that it effected. I did not see if there were any other problems with the other fax machines or new admissions, but no one was complaining. An interview was conducted with the DON and Nursing Home Administrator (NHA) on 2/23/22 at 4:30 p.m., they indicated they thought their plan of correction went fine they went over all the citations and provided education and conducted audits. They indicated their QAPI (Quality Assurance and Performance Improvement) team met December 23, 2021, to discuss the citations they received and created a plan to correct each citation. The team met again on January 21, 2022 to review audits and the team continued to meet again on February 17, 2022 to further discuss their audits. The DON indicated she was having trouble with staff attendance at the meetings to educate them so she held a virtual meeting hoping she would have a better turn out because of the convenience factor. The virtual meeting had some technical difficulties and did not have a good turn out, so she had been coming into the facility to educate the nursing staff on medication administration individually. The DON also indicated Resident #4's nurse was a newly hired nurse and she had not attended the virtual meeting related to medication administration and the DON had not had time to do an individual education with her the morning of the survey. The NHA stated that new hires met with the Assistant Director of Nursing (ADON) to go over their new hire paperwork and at that time they were also introduced to the facility's education portal that had all their education that was needed. Based on observations, record reviews, and interviews, the facility failed to ensure that its Quality Assurance plan was effective related to 1. Failure to prepare, distribute, and serve food in accordance with professional standards for food service safety related to a staff member not wearing hair restraints, condensation leaking from vents above the serving line and food prep table in one of one kitchen, and an uncovered ice scoop stored in one of two nourishment rooms (West Wing); and 2. Failure to provide one (Resident #4) of four sampled residents with timely narcotic pain medication related to not submitting a prescribed narcotic prescription to the pharmacy timely. Findings included: 1. The facility developed a plan of correction that included the following: - On 12/21/21, the Dietary manager completed a kitchen sanitation and food storage audit in the kitchen. On 12/20/21, the Dietary manager completed a sanitation and food storage in the facilities nutrition rooms. Any concerns identified were addressed at that time and actions taken/systems put into place to reduce the risk of future occurrence. On 12/21/21 and 12/22/21, the Dietary manager and/or designee educated the Dietary staff on sanitation, hair and beard coverings, food storage and spillage. How the corrective action(s) will be monitored to ensure the practice will not recur: Dietary Manager and/or designee will conduct a daily quality review of sanitation weekly x 4 weeks and then 2 x a month x 2 months to ensure equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials, staff members are properly trained in the cleaning and maintenance of all equipment, food contact equipment is cleaned and sanitized after every use, non-food contact equipment is clean, and submit any repairs, The findings of these quality reviews will be reported to Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Regional Director of Clinical Services when completing their systems review. Inspection of the facility's kitchen on 2/23/22 at 9:23 a.m., revealed that the Registered Dietician (RD) entered the kitchen and proceeded to the office located in the kitchen. An interview with the RD at this time, revealed that she visited the facility one time a week and knew she should have her hair covered but just came in to talk to the Accounts Manager. Continued observations during the tour of the kitchen revealed that there were two air vents mounted to the ceiling, one located over the prep table and the other located over the steam table. Both units were noted to have condensation on them dripping on both the prep table and the tray-line table. The Accounts Manager confirmed that the two vents had condensation and was dripping on the prep table and the tray-line table. The Accounts Manager proceeded to use her body to move the prep table and the tray-line table from under the vents. She reported she was not aware of anything being done regarding the condensation dripping on the tables. Continued inspection at this time, revealed the [NAME] wing nutrition room was noted to have an ice scoop sitting on the top of a cloth located on the ice cart. The ice scoop was not in an appropriate container to prevent contamination. The Accounts Manager reported that the ice scoop was not appropriately stored and she would send it back to the kitchen to be cleaned. In an interview with the Maintenance Director on 2/23/22 at 11:20 a.m., he said they cleaned the vents, but did not realize that condensation was still dripping onto the prep table and the tray-line. He reported that the tables had been moved and would stay where they were until the vents could be fixed. Review of the facility policy titled Staff Attire with an original date of 5/2014 and a Revised date of 9/2017 revealed the following: -1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on interview with facility staff, a family member, and review of the resident ' s medical record and facility policy, it was determined that the facility failed to protect the rights of one (#2) of 40 residents with a Full Code status, according to the midnight census list of [DATE] and the resident code status audit tool updated [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation (CPR) when the resident was found without respirations and a pulse. The facility staff did not begin the administration of CPR and did not call 911 for medical aide in accordance with their policy and procedure (Advance Directives - Nursing effective [DATE], Cardiopulmonary Resuscitation effective [DATE], and Code Blue effective [DATE]). The facility did not honor the advanced directives expressed by the health care proxy/family member of an incapacitated resident. Failure of the facility staff to correctly implement advanced directives resulted in findings of immediate jeopardy which was removed on [DATE] at 4:40 p.m. and the severity and scope was reduced to a D. Findings include: 1. Clinical record review for resident #2 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and a date of admission to the facility of [DATE]. The face sheet also indicated the resident ' s primary payer source was Hospice. A review of the advanced directives contained in the record revealed a health care proxy/acceptance of designation form dated [DATE] which appointed resident#2 ' s daughter as the " individual who shall be responsible for making healthcare decisions on behalf of " the resident. The resident had a certificate of incapacity signed by her attending physician on [DATE] which documented that this resident " is unable to make health care decisions for him/herself or provide informed consent to medical treatment. " No additional advanced directives were present in the resident ' s clinical record. Review of the Hospice notes revealed the following relevant entries: [DATE] handwritten progress note by the regular hospice nurse: " Hospice nurse spoke with patient ' s daughter regarding patient ' s current status. Daughter states I want my mom to go to the hospital if she needs to. Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. " [DATE] computerized note by the regular hospice nurse: Patient in bed resting - appears weak, listless and moans when abdomen is palpated and also brings left arm up over right forehead area occasionally and moans. Patient unable to make needs known-does make eye contact when spoken to. Staff nurse reports patient having difficulty taking meds by mouth today. [MEDICATION NAME] liquefied and patient was able to take without difficulty ...I also called patient ' s daughter today. We discussed patient status and the fact that patient has no advanced directives/Do Not Resuscitate orders (DNR) in place. Daughter just states that she " wants her mother to go to the hospital if needed. " Daughter did not express any other decisions about DNR/advanced directives during this conversation ... I also spoke with the facility Social Worker (SW) regarding patient ' s daughter ' s wishes that patient be hospitalized if needed and that I was concerned that patients daughter is very young and seems to be having difficulty making decisions regarding DNR/Advanced Directives. Facility SW stated that patient ' s " daughter is just not ready to make those decisions. " [DATE] computerized note by the weekend/evening hospice nurse: Facility staff notified office of time of death of 7:00 p.m. for this patient. No family present. Facility staff states there were no signs she was eminent. Had seen patient 10 minutes prior to death and had went back to check on her and she had died . Death checklist completed ... Review of the facility ' s nurses ' notes for [DATE] revealed the following entries: 8:00 p.m. Resident up in wheel chair with helmet on to dining room for dinner ate 100%. Checked on her at 6:15 p.m. resident showing no signs or symptoms of distress or pain. Certified Nursing Assistant (C.N.A.) went in at 7:00 p.m. Resident had expired. No lung sounds present, no heartbeat heard, no pulse felt, patient ' s color had changed. Had C.N.A. clean patient up and put in bed. Contacted physician at 7:15 p.m.after contacting nursing supervisor, Director of Nursing (DON). Advanced Registered Nurse Practitioner (ARNP) gave a telephone order to pronounce resident expired at 7 p.m. and ok to release body. Called hospice. Hospice showed up by 8 p.m. called family members and funeral home picked up resident at 9:50 p.m. (signed by Licensed Practical Nurse C/LPN C) Review of the physician ' s telephone orders dated [DATE] revealed an " order to pronounce patient deceased at 7:00 p.m. O.K. to pronounce and release the body. " 2. Interview with resident #2 ' s regular hospice RN, who had been coming to this facility for 9 years, on [DATE] at 12:53 p.m. revealed she works on the burgundy team and was familiar with resident #2. The hospice RN recalled the resident having come to the facility from the hospital where she had undergone brain surgery and developed an infection in the flap. The hospice nurse described resident #2 as very young, in her 40 ' s. When the resident was first admitted to the nursing home back in late March of 2012, she was discussed as a possible hospice resident, but her daughter/health care proxy needed time to think about it. The hospice nurse said the resident ' s daughter was very young, only about [AGE] years old, and was down in Florida for about a week and then returned back up north to her home. The daughter later decided she wanted hospice for her mom, and hospice evaluated her and admitted her for services on [DATE]. The hospice nurse stated the resident also had a [AGE] year old son who lived in a neighboring county and required psycho-social help. Hospice worked with the neighboring county to obtain special services and counseling to help the resident ' s teenage son. When resident #2 was first admitted to hospice, her flap was healing. The hospice nurse recalled the resident speaking only one time, she said " yeah " . The hospice nurse also recalled holding resident #2 ' s hand on one occasion and the hospice nurse said to the resident " [AGE] year old sons ' can be a real pain in the butt sometimes. " The hospice nurse stated the resident squeezed her hand and smiled when she said this. The hospice nurse also recalled another time about a week before resident #2 passed when the resident had kissed her hand. The nurse stated the resident did this after she had told the resident she was really sorry for everything she had been through. The hospice nurse stated the resident would follow with her eyes, but she could not necessarily tell for sure if she understood what was happening or if the responses she received were true responses. The hospice nurse said the resident fed herself at the beginning of her stay when the utensil was placed in her hand but towards the end (the last week) she thought staff were helping her with meals because she was eating less and less. The hospice nurse clearly recalled discussing advanced directives with resident #2 ' s daughter and stated she documented this in the resident ' s chart. The hospice nurse thumbed through the resident ' s clinical record and pulled out a form labeled " Progress Notes. " The document was dated [DATE] and noted Hospice nurse spoke with patient ' s daughter regarding resident ' s current status. Daughter states " I want my mom to go to the hospital if she needs to. " Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. The hospice nurse then went on to state to the surveyor that it was her understanding that the resident had no advanced directives. The daughter was not ready to discuss that. The daughter was so young and " we weren ' t going to shove DNR or advanced directives down her throat. " The hospice nurse stated there really wasn ' t time to sit and work through this with the daughter as we didn ' t have resident #2 under our care for a very long time. 3. Interview with the hospice social worker on [DATE] at 1:42 p.m. revealed she had a difficult time assessing how much resident #2 was aware of because she had major brain surgery. The social worker stated resident #2 was either in bed or in a reclining geri-chair, and she always wore a helmet. The social worker never could get a real good read as to whether or not the resident could understand her or not. The social worker stated the resident ' s family dynamics were difficult to navigate. She had a daughter who lived out of the state who was a young mom about [AGE] years old with an infant. The social worker called her daughter to introduce herself and explain her role when the resident was first admitted to hospice. The social worker did not think the daughter ' s take on the situation was realistic. The daughter was asking questions like " is my mom going to get chemo? " The social worker asked the resident ' s daughter questions about what her mom was like before she got sick. The social worker talked to the daughter about a DNR, but she didn ' t want one, at least at that point in time. She was still asking questions about chemo. The social worker was slowly trying to educate the daughter to understand the finality of the situation, but the daughter was not there yet. The social worker sent the resident ' s daughter a booklet about end of life, what to expect, and advance directives. That was about as far as the social worker got with her as the social worker went on leave and resident #2 died during that timeframe. 4. Telephone interview on [DATE] at 5:03 p.m. with resident #2 ' s daughter and health care proxy revealed she was surprised when she received a call to tell her that her mom had died on [DATE]. The daughter said her mother had been doing really well. The daughter said she knew that she was being treated with antibiotics for pneumonia about a week before she died but everything was going okay. The daughter stated she didn ' t ask for any details on how her mom had died when she was called by the facility. The daughter stated she had just received the death certificate which stated cause of death as natural causes, [MEDICAL CONDITION] metastasize to the brain. The surveyor asked the daughter if she had wanted her mother to have any life saving measures and the daughter stated " She was not a DNR. They were supposed to do anything they needed to. " The daughter was not aware that the facility had not attempted to perform CPR and transferred the resident to the hospital in accordance with her expressed wishes. 5. Interview with the facility ' s administrator (NHA) and Director of Nursing (DON) on [DATE] at 9:39 a.m. revealed the facility recently had an incident in which two nurses did not honor the advanced directives of resident #2. The resident was found unresponsive on [DATE] by C.N.A. A. Immediately, C.N.A. A, alerted LPN B of resident #2 ' s condition. LPN B described the resident as blue in color and already deceased . LPN B then got the nurse assigned to resident #2 (LPN C). LPN C reviewed the resident ' s chart and did not see a do not resuscitate order (DNR) but stated she didn ' t see anything that indicated CPR was needed because the resident was on hospice. 6. Review of the facility ' s policies and procedures for " Advance Directives - Nursing " with an effective date of [DATE] (,[DATE]) revealed the following relevant information: Policy: The facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with the company ' s policies regarding the withholding or withdrawing of life support treatment. Procedure: 1. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident... 2. Nursing staff must use a means of identification for those residents who have " DNR " in their medical records through advance directives and written orders from the attending physician. 3. Nursing staff must be aware of other advance directives regarding residents ' wishes before certain treatments are initiated (i.e. intravenous feeding). 4. Follow these steps in an emergency situation: a. If a resident stops breathing or there is an absence of pulse or heartbeat, staff will check to determine whether a DNR order has been entered b. If there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately. Page " Code Blue " to summon anyone in the facility who has been certified to administer CPR. At the same time, call emergency paramedic support. The attending physician also must be notified. Review of the facility ' s " Cardiopulmonary Resuscitation (CPR) " policy and procedures effective ,[DATE] ([DATE]) revealed the following relevant information: Policy: 1. Cardiopulmonary resuscitation is initiated on all residents except those with a " no code " order and appropriate documentation. 2. Cardiopulmonary resuscitation is performed only by individuals certified in CPR. 3. All licensed nurses are to be certified in CPR and must be re-certified in accordance with certifying agency - American Heart Association-Red Cross. Procedure: 1. In the case of cardiac and/or [MEDICAL CONDITION] arrest, CPR is initiated immediately using the Red Cross Guidelines - American Heart Association. 2. Use the paging system and call " Code Blue " to Room Number ____, three times. 3. CPR is continued until life support systems are available, or it may be discontinued if: A. The resident responds. B. The physician orders [REDACTED]. C. EMS arrives and takes over. 4. Contact the physician and family 5. Document details of occurrence in the Nursing Notes 6. Update the care plan as needed Review of the facility ' s " Code Blue " policies and procedures with an effective date of ,[DATE] revealed the following relevant information: Policy: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by a physician on their medical records. Procedure: 1. When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. *Confirm DNR status with the physician ' s written order. 2. In the event that the resident is identified as a Full Code and the person finding the resident is trained in CPR they will: *Call for help and state " Code Blue " *Initiate CPR 3. The individual responding to the call for help will call " Code Blue " over the intercom, 3 times, identifying: *The floor/unit *Room number or area where the resident is located. 4. If the first individual finding the resident is not trained in CPR, they will immediately call over the intercom a " Code Blue " identifying the specific floor and area. 5. Clinical staff in this facility will respond to the " Code Blue " pages. 6. The Nurse Manager/Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: *Summon emergency equipment to the room *Activate the EMS system *Assign a person to document the on-going code *Notify the doctor *Complete a Transfer Form *Call emergency room and give report to Admitting Nurse *Assure the family has been notified *Obtain order to transfer resident to hospital *Document code in medical record *Restock code cart 7. Telephone interview with C.N.A. A on [DATE] at 2:19 p.m. revealed he works at the facility on an as needed basis (PRN) approximately ,[DATE] times a week on the 3:00 p.m. - 11:00 p.m. shift. The C.N.A. stated he had no set assignment but recalled caring for resident #2 in the past. The C.N.A. remembered resident #2 as a female resident who wore a helmet on her head and was a very quiet person. C.N.A. A thought this resident was under the care of hospice. The C.N.A. also stated the resident was total care and could not do anything for herself. She required the use of a hoyer lift for all transfers to the bed and chair and needed assistance with eating. On [DATE] the C.N.A. recalled he had come back from the dining room and resident #2 was in her room in the geri-chair around 6:00 p.m. - 6:15 p.m. The C.N.A. went to care for the resident directly across the hall from resident #2 and when that was complete he entered resident#2 ' s room around 7:00 p.m. to get her ready for bed. The C.N.A. noticed resident #2 was not moving and she was leaning back in the chair. He stated the resident was not breathing and he knew this because he looked up close and did not see her chest moving up or down. The C.N.A. stated the resident ' s fingers and face were discolored and pale. He stated the resident was not blue. C.N.A. A immediately called for LPN B who was at the nurse ' s station, just two steps from the resident ' s room. C.N.A. A told LPN B the resident was not breathing. LPN B then came in and " checked her pulse and everything. " LPN B then got another nurse to check the patient as well. This C.N.A. then went to went to get another aide to get the resident out of the chair and put her in bed while the nurses were making their calls. He stated this was the normal procedure for preparing the body once somebody dies. 8. Telephone interview with LPN B on [DATE] at 4:00 p.m. revealed she had been an LPN since January of 2006 and came to work at this facility in late February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. She stated she was somewhat familiar with resident #2 prior to the day she expired because she had been on her assignment for a little while and was later moved to a different room. She recalled resident #2 had a [MEDICAL CONDITION], was aphasic and didn ' t ' speak. On [DATE] she was at the nurse ' s station charting when C.N.A. A asked her to come into the resident ' s room. LPN B stated she was not the nurse for resident #2 that night. LPN C was the nurse for the resident that night, but she was on her lunch break. Review of LPN C ' s time sheet for [DATE] revealed she did not clock out for her lunch break therefore the exact time she went on break was unknown. Continued interview with LPN B revealed that when she entered the resident ' s room, she saw the resident seated in her geri-chair. At that point it was very clear she had expired. She checked her apical and radial pulses, and the resident was cold to the touch, stiff, and cyanotic. The resident ' s eyes were wide open and no pulses were palpable with her stethoscope and no respirations were present. LPN B then proceeded back to the nurse ' s station to page LPN C. LPN C responded right away. LPN B informed LPN C that resident #2 had expired. LPN B said that LPN C asked her " what am I supposed to do? " LPN B told the resident ' s nurse to call the supervisor as both LPN B and LPN C were new to the facility. In addition, LPN B stated she thought LPN C was a new nurse. LPN B heard LPN C speaking with the Director of Nurses (DON) by telephone so LPN B assumed that everything was under control, and she went back to work. LPN B recalled LPN C grabbing the chart and entering resident #2 ' s room. LPN B was on the treatment cart but stated she called out to LPN C that she was right there if she needed her. LPN B stated again, " I thought she had it under control. " LPN B stated she spoke with the hospice nurse that night on [DATE], exact time unknown, but did not discuss anything specific about resident #2. LPN B stated she did not look at resident #2 ' s chart on the night of [DATE]. LPN B stated she had received training on how to respond when a resident was found without vital signs in other facilities but not at this facility. LPN B stated orientation at this facility was one day on the floor and she had to learn the policies and procedures as she worked. LPN B stated she did not call the physician, hospice, or family that night. She stated her CPR certification was up to date. LPN B stated this incident happened on a Sunday evening and she was called in that Monday morning to give a statement. She stated they in-serviced her on the facility code guidelines and then suspended her that Monday morning. LPN B stated she was terminated the following Friday, [DATE]. 9. A telephone interview with LPN C on [DATE] at 10:51 a.m. revealed she had been an LPN since [DATE]. LPN C began working at the facility in February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. LPN C stated she was not too familiar with resident #2 because she had just moved onto her assignment about a week or so before she had expired. LPN C recalled resident #2 had surgery on her head because she wore a helmet when out of bed. LPN C stated all of resident #2 ' s medications were crushed or liquid because she had trouble eating/swallowing so she had to be watched very carefully. LPN C recalled this resident as needing total care with activities of daily living (ADL ' s). LPN C also recalled this resident received breathing treatments on her shift at 5:00 p.m. and 9:00 p.m. On [DATE], LPN C remembered being on her lunch break when resident #2 passed away. She stated she had given resident #2 her medications at 6:15 p.m. on [DATE] and she was fine. LPN C stated she went on her lunch break at 7:00 p.m. and told LPN B she was going on break. LPN C received an overhead page around 7:15 p.m. on [DATE] to come back to the floor. She went back to the floor and was informed by LPN B that the C.N.A. ' s found resident #2 not breathing and LPN B had already checked her out and " pronounced her dead. " LPN C stated she informed LPN B that nurses can ' t pronounce a patient. LPN C stated she went into the resident ' s room to look at her. LPN C stated the resident was already turning a dark color from lack of oxygen, she was not breathing, there was no heartbeat, and no pulse. LPN C stated she used her stethoscope to check and could not find a carotid pulse. LPN C stated she tried to call the person who was on call but they did not answer the call so she immediately proceeded to call the DON. She informed the DON of the situation. The DON asked LPN C if the resident was on hospice and she stated " yes. " The DON told her to call the resident ' s physician and get a telephone order for 2 LPN ' s to pronounce the resident as deceased and get a telephone order from the doctor to release the body to the funeral home. The DON also told LPN C to call hospice. LPN C stated LPN B called the doctor and got the telephone orders while LPN C called hospice. LPN C recalled the hospice nurse coming out to the facility about an hour later. LPN C stated the hospice nurse contacted the family and the funeral home for her. LPN C stated she had called the DON that night because she didn ' t know what the procedure was when somebody died . LPN C stated LPN B was new to the facility also and she didn ' t know what to do. LPN C stated she looked at the resident ' s chart and did not see a DNR order, but she thought the resident was a DNR because she was on hospice. LPN C stated that when hospice came in that night she didn ' t say anything about the resident ' s code status, and the hospice nurse had reviewed the resident ' s chart too. LPN C stated she had not received any training from the facility on how to respond when a resident was found without vital signs. She stated they only showed her where the oxygen was kept and other rooms like clean and dirty utility rooms. LPN C stated she knew the crash cart was kept in the dining room because she had asked them where it was. LPN C stated she only called the DON and hospice that night. LPN C stated she had current CPR certification. The LPN said she came into work the following Monday morning, [DATE] to cover for someone who had called off on 7:00 a.m. -3:00 p.m. LPN C was already on the schedule to work on [DATE] from 3:00 p.m. - 11:00 p.m. and had planned on working a double that day. LPN C was pulled off the medication cart on [DATE] at around 9:15 a.m. to give a statement relating to the incident. LPN C stated she was suspended that Monday morning and later terminated because she did not know what the facility ' s procedure was. 10. LPN B was contacted via telephone on [DATE] at 11:37 a.m. to verify she had spoken to resident #2 ' s doctor on the night of [DATE] as was reported in the telephone interview with LPN C. LPN B stated " I actually thought about it last night and that is absolutely right. " LPN B confirmed that she spoke to the Advanced Registered Nurse Practitioner (ARNP) for resident #2 ' s physician on [DATE]. LPN B said the ARNP gave orders to pronounce and release. 11. Interview on [DATE] at 3:10 p.m. with the hospice evening/weekend Registered Nurse (RN) for the burgundy team revealed she was the nurse that came out to the facility on the night of [DATE]. The facility had called the evening/weekend office when resident #2 died and the office in turn notified her to come out to the facility. The hospice nurse stated she probably came out to the facility around 7:30 p.m. on [DATE]. She offered to call the funeral home and the physician but both had already been done. The hospice nurse did notify the resident ' s family as the facility nurses had not been able to get a hold of anyone. The hospice nurse could not reach the resident ' s daughter on her home phone number so she called the daughter ' s fiance and asked to please speak to resident #2 ' s daughter. The hospice nurse told the daughter who she was and informed her that her mother had expired. The daughter started to cry and she thanked me for calling. The hospice nurse informed the daughter of counseling that they could provide her with and she provided the daughter with her personal number in case she had any questions because she seemed to be in shock. The daughter called the hospice nurse later, probably around 9 p.m., and told her about some family things that were going on. The daughter also asked if the hospice had called the resident ' s boyfriend who cared for resident #2 ' s [AGE] year old son. The hospice nurse informed the daughter that she had called the boyfriend but did not get an answer and had not heard back from him yet. The hospice nurse stated that the daughter then sent someone over to the boyfriend ' s house to notify him. The boyfriend then called the hospice nurse around 9:30 p.m. to find out if the resident ' s death was in fact true. The hospice nurse informed him it was. The hospice nurse stated the resident ' s daughter and boyfriend never asked what happened to the resident that night. The facility told the hospice nurse that the resident had no visitors and the boyfriend had never brought the [AGE] year old son to visit. The facility nurses never informed the hospice nurse that resident #2 did not have a DNR order. The hospice nurse stated she noticed that there was no DNR order in the record. The hospice nurse said she asked the nurses, " was she able to be revived? " The nurses said " no. " 12. Interview with the DON on [DATE] at 5:25 p.m. revealed the nurses normally call her when residents go to the hospital or expire. The DON remembered LPN C called her on the night of [DATE] and stated about 25 minutes ago resident #2 expired. LPN C informed the DON that the resident was on hospice and LPN C asked " what ' s the procedure for a death in the facility? " The DON proceeded to tell her to call the doctor, call hospice, and explained the orders LPN C needed to retrieve. LPN C never told the DON that resident #2 didn ' t have a DNR order. The DON stated " I don ' t know all of them right off the top of my head. " The DON did not remember if she asked LPN C if resident #2 had a DNR order, but " I will from now on. " 13. Telephone interview with the ARNP for resident #2 ' s attending physician revealed he recalled the facility contacting him in regards to resident #2 ' s death on [DATE]. The ARNP stated nothing stood out in his mind about the call as typically they are just asking for orders to pronounce and release which he provided. The ARNP did not recall the nurse ' s telling him of any problem related to her death such as it being unexpected or anything out of the ordinary. The ARNP remembered resident #2 as " a younger gal " with failure to thrive. She had [MEDICAL CONDITION] which metastasized to the brain. The ARNP remembered the resident looked terrible about a week before she died . " She was a gal that was not doing well at all and it was really a terrible, terrible case. " The ARNP did not recall being informed that resident #2 did not have a DNR order. He would expect facility staff to in institute CPR, call a code, and do all of the things necessary for a resident who was found without pulse and respirations and no DNR order. " Legally you would need to call a code. " 14. Interview with resident #2 ' s attending physician and the medical director for the facility on [DATE] at 2:44 p.m. revealed he was not on call the night resident #2 had passed. He confirmed that the ARNP was on call that evening, and the doctor had found out indirectly about resident #2 ' s death. The doctor could not recall exactly when he was informed or who had informed him. The physician recalled that resident #2 was not at the facility for very long. She had a " horrible past history. " Metastatic [MEDICAL CONDITION] to the brain with a couple of craniotomies and an infection of the flap. The resident was non-communicative and would sort of stare at you. The doctor said he never spoke to the resident ' s family. He communicated with the facility nurses and hospice in regards to resident #2. The physician/medical director stated he had been informed that the resident did not have DNR orders and stated " I guess they assumed that since she was hospice. " The physician could not recall when he was informed of the lack of DNR orders for this resident. The physician stated his expectation for a resident who had no DNR orders and was found without pulse of respirations would be to call 911 and start CPR procedures. 15. Interview with the unit manager for resident #2 on [DATE] at 2:33 p.m. revealed he ' s an LPN and had worked at the facility for about a year. The unit manager stated he did not remember resident #2 ever talking or responding at all. She had a flap, surgery to the brain, was hospice, full code, and had to have a helmet on when she was out of bed. The resident required total care and had weight issues too. Hospice was talking to the family about possibly getting a peg tube for her if they planned to keep her a full code. The unit manager stated he never spoke to the resident ' s family, but this information was relayed to him by Hospice personnel. On Monday morning, [DATE], the unit manager stated he reviewed the 24 hour reports, telephone orders and other documents to see what had happened over the weekend. During his review, he noticed that resident #2 had expired. Shortly thereafter, he ran into LPN C in the hall and said " I heard you had a rough weekend, " resident #2 expired. LPN C responded yes it was busy ...The unit manager stated to LPN C " I know I would not have wanted to be here pumping and jumping on her. " LPN C looked at the unit manager and said what do you mean? The unit manager said " you know, doing CPR. " LPN C responded by saying " we didn ' t do CPR. " The unit manager said " really, what did the paramedics say when they got here? " LPN C said " we didn ' t call 911, we called the doctor and pronounced. " The unit manager stated he told LPN " you know she was a full code? " LPN C looked at the unit manager funny and did not say anything. The unit manager proceeded to review resident #2 ' s chart to see if there was any change in her DNR status and then he read the nurses note from [DATE]. The unit manager stated he remembered his chin just dropped as he read the nurses note. At that moment the DON was coming down the hall and the DON said to LPN C " tell me you did CPR? " The unit

Based on interview with facility staff and a family member, and review of the resident ' s medical record and facility policy, and performance violation investigation reports, it was determined that the facility failed to ensure that needed services for resuscitation were initiated for one(#2) of 40 residents identified as full code, according to the midnight census list of [DATE] and the resident code status audit tool updated [DATE]. The facility did not initiate Cardio-Pulmonary Resuscitation (CPR) when the resident was found absent of respirations and pulse. The facility staff did not implement their policy and procedure, Cardiopulmonary Resuscitation (CPR) and Code Blue effective [DATE], as staff did not begin the administration of CPR and did not call 911 for medical aide. The facility did not honor the expressed wishes of the health care proxy/family member of an incapacitated resident. Failure of the facility staff to correctly implement the response policy/guidelines resulted in findings of immediate jeopardy which was removed on [DATE] at 4:40 p.m. and the severity and scope was reduced to a D. Findings include: 1. Interview with the facility ' s administrator (NHA) and Director of Nursing (DON) on [DATE] at 9:39 a.m. revealed the facility recently had an incident in which two nurses did not honor the advanced directives of resident #2. The resident was found unresponsive on [DATE] by employee A (Certified Nursing Assistant- C.N.A. A). C.N.A. A immediately alerted employee B (Licensed Practical Nurse - LPN B). LPN B described the resident as blue in color and already deceased . LPN B then got the nurse assigned to resident #2 (LPN C). LPN C reviewed the resident ' s chart and did not see a do not resuscitate order (DNR) but stated she didn ' t see anything that indicated CPR was needed because the resident was on hospice. 2. Telephone interview on [DATE] at 5:03 p.m. with resident #2 ' s daughter and health care proxy revealed she was surprised when she received a call to tell her that her mom had died . The daughter said her mother had been doing really well. The daughter said she knew that she was being treated with antibiotics for pneumonia about a week before she died but everything was going okay. The daughter stated she didn ' t ask for any details on how her mom had died when she was called by the facility. The daughter stated she had just received the death certificate which stated cause of death as natural causes, [MEDICAL CONDITION] metastasize to the brain. The surveyor asked the daughter if she had wanted her mother to have any life saving measures and the daughter stated " She was not a DNR. They were supposed to do anything they needed to. " The daughter was not aware that the facility had not attempted to perform CPR and transferred the resident to the hospital in accordance with her expressed wishes. 3. Telephone interview with C.N.A. A on [DATE] at 2:19 p.m. revealed he works at the facility on an as needed basis (PRN) approximately ,[DATE] times a week on the 3:00 p.m. - 11:00 p.m. shift. The C.N.A. stated he has no set assignment but recalled caring for resident #2 in the past. The C.N.A. remembered resident #2 as a female resident who wore a helmet on her head and was a very quiet person. C.N.A. A thought this resident was under the care of hospice. The C.N.A. also stated the resident was total care and could not do anything for herself. She required the use of a hoyer lift for all transfers to the bed and chair and needed assistance with eating. On [DATE] the C.N.A. recalled he had come back from the dining room and resident #2 was in her room in the geri-chair around 6:00 p.m. - 6:15 p.m. The C.N.A. went to care for the resident directly across the hall from resident #2 and when that was complete he entered resident#2 ' s room around 7:00 p.m. to get her ready for bed. The C.N.A. noticed resident #2 was not moving and she was leaning back in the chair. He stated the resident was not breathing and he knew this because he looked up close and did not see her chest moving up or down. The C.N.A. stated the resident ' s fingers and face were discolored and pale. He stated the resident was not blue. C.N.A. A immediately called for LPN B who was at the nurse ' s station, just two steps from the resident ' s room. C.N.A. A told LPN B the resident was not breathing. LPN B then came in and " checked her pulse and everything. " LPN B then got another nurse to check the patient as well. This C.N.A. then went to went to get another aide to get the resident out of the chair and put her in bed while the nurses were making their calls. He stated this was the normal procedure for preparing the body once somebody dies. 4. Telephone interview with LPN B on [DATE] at 4:00 p.m. revealed she had been an LPN since January of 2006 and came to work at this facility in late February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. She stated she was somewhat familiar with resident #2 prior to the day she expired because she had been on her assignment for a little while and was later moved to a different room. She recalled resident #2 had a [MEDICAL CONDITION], was aphasic and didn ' t ' speak. On [DATE] she was at the nurse ' s station charting when C.N.A. A asked her to come into the resident ' s room. LPN B stated she was not the nurse for resident #2 that night. LPN C was the nurse for the resident that night, but she was on her lunch break. Review of LPN C ' s time sheet for [DATE] revealed she did not clock out for her lunch break therefore the exact time she went on break was unknown. Continued interview with LPN B revealed that when she entered the resident ' s room, she saw the resident seated in her geri-chair. At that point it was very clear she had expired. She checked her apical and radial pulses, and the resident was cold to the touch, stiff, and cyanotic. The resident ' s eyes were wide open and no pulses were palpable with her stethoscope and no respirations were present. LPN B then proceeded back to the nurse ' s station to page LPN C. LPN C responded right away. LPN B informed LPN C that resident #2 had expired. LPN B said that LPN C asked her " what am I supposed to do? " LPN B told the resident ' s nurse to call the supervisor as both LPN B and LPN C were new to the facility. In addition, LPN B stated she thought LPN C was a new nurse. LPN B heard LPN C speaking with the Director of Nurses (DON) by telephone so LPN B assumed that everything was under control, and she went back to work. LPN B recalled LPN C grabbing the chart and entering resident #2 ' s room. LPN B was on the treatment cart but stated she called out to LPN C that she was right there if she needed her. LPN B stated again, " I thought she had it under control. " LPN B stated she spoke with the hospice nurse that night on [DATE], exact time unknown, but did not discuss anything specific about resident #2. LPN B stated she did not look at resident #2 ' s chart on the night of [DATE]. LPN B stated she had received training on how to respond when a resident was found without vital signs in other facilities but not at this facility. LPN B stated orientation at this facility was one day on the floor and she had to learn the policies and procedures as she worked. LPN B stated she did not call the physician, hospice, or family that night. She stated her CPR certification was up to date. LPN B stated this incident happened on a Sunday evening and she was called in that Monday morning to give a statement. She stated they in-serviced her on the facility code guidelines and then suspended her that Monday morning. LPN B stated she was terminated the following Friday, [DATE]. 5. A telephone interview with LPN C on [DATE] at 10:51 a.m. revealed she had been an LPN since [DATE]. LPN C began working at the facility in February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. LPN C stated she was not too familiar with resident #2 because she had just moved onto her assignment about a week or so before she had expired. LPN C recalled resident #2 had surgery on her head because she wore a helmet when out of bed. LPN C stated all of resident #2 ' s medications were crushed or liquid because she had trouble eating/swallowing so she had to be watched very carefully. LPN C recalled this resident as needing total care with activities of daily living (ADL ' s). LPN C also recalled this resident received breathing treatments on her shift at 5:00 p.m. and 9:00 p.m. On [DATE], LPN C remembered being on her lunch break when resident #2 passed away. She stated she had given resident #2 her medications at 6:15 p.m. on [DATE] and she was fine. LPN C stated she went on her lunch break at 7:00 p.m. and told LPN B she was going on break. LPN C received an overhead page around 7:15 p.m. on [DATE] to come back to the floor. She went back to the floor and was informed by LPN B that the C.N.A. ' s found resident #2 not breathing and LPN B had already checked her out and " pronounced her dead. " LPN C stated she informed LPN B that nurses can ' t pronounce a patient. LPN C stated she went into the resident ' s room to look at her. LPN C stated the resident was already turning a dark color from lack of oxygen, she was not breathing, there was no heartbeat, and no pulse. LPN C stated she used her stethoscope to check and could not find a carotid pulse. LPN C stated she tried to call the person who was on call but they did not answer the call so she immediately proceeded to call the DON. She informed the DON of the situation. The DON asked LPN C if the resident was on hospice and she stated " yes. " The DON told her to call the resident ' s physician and get a telephone order for 2 LPN ' s to pronounce the resident as deceased and get a telephone order from the doctor to release the body to the funeral home. The DON also told LPN C to call hospice. LPN C stated LPN B called the doctor and got the telephone orders while LPN C called hospice. LPN C recalled the hospice nurse coming out to the facility about an hour later. LPN C stated the hospice nurse contacted the family and the funeral home for her. LPN C stated she had called the DON that night because she didn ' t know what the procedure was when somebody died . LPN C stated LPN B was new to the facility also and she didn ' t know what to do. LPN C stated she looked at the resident ' s chart and did not see a DNR order, but she thought the resident was a DNR because she was on hospice. LPN C stated that when hospice came in that night she didn ' t say anything about the resident ' s code status, and the hospice nurse had reviewed the resident ' s chart too. LPN C stated she had not received any training from the facility on how to respond when a resident was found without vital signs. She stated they only showed her where the oxygen was kept and other rooms like clean and dirty utility rooms. LPN C stated she knew the crash cart was kept in the dining room because she had asked them where it was. LPN C stated she only called the DON and hospice that night. LPN C stated she had current CPR certification. The LPN said she came into work the following Monday morning, [DATE] to cover for someone who had called off on 7:00 a.m. -3:00 p.m. LPN C was already on the schedule to work on [DATE] from 3:00 p.m. - 11:00 p.m. and had planned on working a double that day. LPN C was pulled off the medication cart on [DATE] at around 9:15 a.m. to give a statement relating to the incident. LPN C stated she was suspended that Monday morning and later terminated because she did not know what the facility ' s procedure was. 6. LPN B was contacted via telephone on [DATE] at 11:37 a.m. to verify she had spoken to resident #2 ' s doctor on the night of [DATE] as was reported in the telephone interview with LPN C. LPN B stated " I actually thought about it last night and that is absolutely right. " LPN B confirmed that she spoke to the Advanced Registered Nurse Practitioner (ARNP) for resident #2 ' s physician on [DATE]. LPN B said the ARNP gave orders to pronounce and release. 7. Interview with resident #2 ' s regular hospice RN, who had been coming to this facility for 9 years, on [DATE] at 12:53 p.m. revealed she works on the burgundy team and was familiar with resident #2. The hospice RN recalled the resident having come to the facility from the hospital where she had undergone brain surgery and developed an infection in the flap. The hospice nurse described resident #2 as very young, in her 40 ' s. When the resident was first admitted to the nursing home back in late March of 2012, she was discussed as a possible hospice resident, but her daughter/health care proxy needed time to think about it. The hospice nurse said the resident ' s daughter was very young, only about [AGE] years old, and was down in Florida for about a week and then returned back up north to her home. The daughter later decided she wanted hospice for her mom, and hospice evaluated her and admitted her for services on [DATE]. The hospice nurse stated the resident also had a [AGE] year old son who lived in a neighboring county and required psycho-social help. Hospice worked with the neighboring county to obtain special services and counseling to help the resident ' s teenage son. When resident #2 was first admitted to hospice, her flap was healing. The hospice nurse recalled the resident speaking only one time, she said " yeah " . The hospice nurse also recalled holding resident #2 ' s hand on one occasion and the hospice nurse said to the resident " [AGE] year old sons ' can be a real pain in the butt sometimes. " The hospice nurse stated the resident squeezed her hand and smiled when she said this. The hospice nurse also recalled another time about a week before resident #2 passed when the resident had kissed her hand. The nurse stated the resident did this after she had told the resident she was really sorry for everything she had been through. The hospice nurse stated the resident would follow with her eyes, but she could not necessarily tell for sure if she understood what was happening or if the responses she received were true responses. The hospice nurse said the resident fed herself at the beginning of her stay when the utensil was placed in her hand but towards the end (the last week) she thought staff were helping her with meals because she was eating less and less. The hospice nurse clearly recalled discussing advanced directives with resident #2 ' s daughter and stated she documented this in the resident ' s chart. The hospice nurse thumbed through the resident ' s clinical record and pulled out a form labeled " Progress Notes. " The document was dated [DATE] and noted Hospice nurse spoke with patient ' s daughter regarding resident ' s current status. Daughter states " I want my mom to go to the hospital if she needs to. " Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. The hospice nurse then went on to state to the surveyor that it was her understanding that the resident had no advanced directives. The daughter was not ready to discuss that. The daughter was so young and " we weren ' t going to shove DNR or advanced directives down her throat. " The hospice nurse stated there really wasn ' t time to sit and work through this with the daughter as we didn ' t have resident #2 under our care for a very long time. 8. Interview with the hospice social worker on [DATE] at 1:42 p.m. revealed she had a difficult time assessing how much resident #2 was aware of because she had major brain surgery. The social worker stated resident #2 was either in bed or in a reclining geri-chair, and she always wore a helmet. The social worker never could get a real good read as to whether or not the resident could understand her or not. The social worker stated the resident ' s family dynamics were difficult to navigate. She had a daughter who lived out of the state who was a young mom about [AGE] years old with an infant. The social worker called her daughter to introduce herself and explain her role when the resident was first admitted to hospice. The social worker did not think the daughter ' s take on the situation was realistic. The daughter was asking questions like " is my mom going to get chemo? " The social worker asked the resident ' s daughter questions about what her mom was like before she got sick. The social worker talked to the daughter about a DNR, but she didn ' t want one, at least at that point in time. She was still asking questions about chemo. The social worker was slowly trying to educate the daughter to understand the finality of the situation, but the daughter was not there yet. The social worker sent the resident ' s daughter a booklet about end of life, what to expect, and advance directives. That was about as far as the social worker got with her as the social worker went on leave and resident #2 died during that timeframe. 9. Interview on [DATE] at 3:10 p.m. with the hospice evening/weekend Registered Nurse (RN) for the burgundy team revealed she was the nurse that came out to the facility on the night of [DATE]. The facility had called the evening/weekend office when resident #2 died and the office in turn notified her to come out to the facility. The hospice nurse stated she probably came out to the facility around 7:30 p.m. on [DATE]. She offered to call the funeral home and the physician but both had already been done. The hospice nurse did notify the resident ' s family as the facility nurses had not been able to get a hold of anyone. The hospice nurse could not reach the resident ' s daughter on her home phone number so she called the daughter ' s fiance and asked to please speak to resident #2 ' s daughter. The hospice nurse told the daughter who she was and informed her that her mother had expired. The daughter started to cry and she thanked me for calling. The hospice nurse informed the daughter of counseling that they could provide her with and she provided the daughter with her personal number in case she had any questions because she seemed to be in shock. The daughter called the hospice nurse later, probably around 9 p.m., and told her about some family things that were going on. The daughter also asked if the hospice had called the resident ' s boyfriend who cared for resident #2 ' s [AGE] year old son. The hospice nurse informed the daughter that she had called the boyfriend but did not get an answer and had not heard back from him yet. The hospice nurse stated that the daughter then sent someone over to the boyfriend ' s house to notify him. The boyfriend then called the hospice nurse around 9:30 p.m. to find out if the resident ' s death was in fact true. The hospice nurse informed him it was. The hospice nurse stated the resident ' s daughter and boyfriend never asked what happened to the resident that night. The facility told the hospice nurse that the resident had no visitors and the boyfriend had never brought the [AGE] year old son to visit. The facility nurses never informed the hospice nurse that resident #2 did not have a DNR order. The hospice nurse stated she noticed that there was no DNR order in the record. The hospice nurse said she asked the nurses, " was she able to be revived? " The nurses said " no. " 10. Interview with the DON on [DATE] at 5:25 p.m. revealed the nurses normally call her when residents go to the hospital or expire. The DON remembered LPN C called her on the night of [DATE] and stated about 25 minutes ago resident #2 expired. LPN C informed the DON that the resident was on hospice and LPN C asked " what ' s the procedure for a death in the facility? " The DON proceeded to tell her to call the doctor, call hospice, and explained the orders LPN C needed to retrieve. LPN C never told the DON that resident #2 didn ' t have a DNR order. The DON stated " I don ' t know all of them right off the top of my head. " The DON did not remember if she asked LPN C if resident #2 had a DNR order, but " I will from now on. " 11. Telephone interview with the ARNP for resident #2 ' s attending physician revealed he recalled the facility contacting him in regards to resident #2 ' s death on [DATE]. The ARNP stated nothing stood out in his mind about the call as typically they are just asking for orders to pronounce and release which he provided. The ARNP did not recall the nurse ' s telling him of any problem related to her death such as it being unexpected or anything out of the ordinary. The ARNP remembered resident #2 as " a younger gal " with failure to thrive. She had [MEDICAL CONDITION] which metastasized to the brain. The ARNP remembered the resident looked terrible about a week before she died . " She was a gal that was not doing well at all and it was really a terrible, terrible case. " The ARNP did not recall being informed that resident #2 did not have a DNR order. He would expect facility staff to in institute CPR, call a code, and do all of the things necessary for a resident who was found without pulse and respirations and no DNR order. " Legally you would need to call a code. " 12. Interview with resident #2 ' s attending physician and the medical director for the facility on [DATE] at 2:44 p.m. revealed he was not on call the night resident #2 had passed. He confirmed that the ARNP was on call that evening, and the doctor had found out indirectly about resident #2 ' s death. The doctor could not recall exactly when he was informed or who had informed him. The physician recalled that resident #2 was not at the facility for very long. She had a " horrible past history. " Metastatic [MEDICAL CONDITION] to the brain with a couple of craniotomies and an infection of the flap. The resident was non-communicative and would sort of stare at you. The doctor said he never spoke to the resident ' s family. He communicated with the facility nurses and hospice in regards to resident #2. The physician/medical director stated he had been informed that the resident did not have DNR orders and stated " I guess they assumed that since she was hospice. " The physician could not recall when he was informed of the lack of DNR orders for this resident. The physician stated his expectation for a resident who had no DNR orders and was found without pulse of respirations would be to call 911 and start CPR procedures. 13. Clinical record review for resident #2 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and a date of admission to the facility of [DATE]. The face sheet also indicated the resident ' s payer source was Hospice. A review of the advanced directives contained in the record revealed a health care proxy/acceptance of designation form dated [DATE] which appointed resident#2 ' s daughter as the " individual who shall be responsible for making healthcare decisions on behalf of " the resident. The resident had a certificate of incapacity signed by her attending physician on [DATE] which documented that this resident " is unable to make health care decisions for him/herself or provide informed consent to medical treatment. " Review of the hospital history and physical dated [DATE] revealed the following: History of present illness: Patient was aphasic at that time. She was unable to give information. All of this history and physical had been done through chart review. " The patient is a [AGE] year-old white female with a [DIAGNOSES REDACTED]. The patient has a history of [DIAGNOSES REDACTED] status [REDACTED]. Apparently, the patient has a history of [MEDICAL CONDITION] to the brain that initially was removed initially but the patient came back with a huge, recurring lesion that required removal of the entire bone flap and postoperatively the patient did well but a small area of CSF leak was done so the reason the replacement was performed. The patient was admitted as transfer from " another area hospital " because of apparently 5 days of altered mental status, [MEDICAL CONDITION], and generalized weakness. On arrival to the ER the patient had an MRI. The MRI of the head showed a large calvarial lesion with history of actual tumor extension intracranially causing severe mass effect with left to right middle line shift with sub-falcine herniation and uncal herniation. The initial neurosurgeon is aware of that and the patient was transferred to ICU. The patient right now is clinically stable. " The hospital history and physical continues on and notes the following " Assessment and Plan: 1. The patient has history of [MEDICAL CONDITION] status [REDACTED]. Neurosurgeon is consulted for evaluation of the patient. 2. The patient has history of [MEDICAL CONDITION] secondary to new [MEDICAL CONDITION] in the brain along with evidence of increased intracranial pressure. 3. The patient has history of [MEDICAL CONDITION]. 4. History of anxiety " Review of the resident ' s care plan ' s contained in the facility ' s clinical record and dated [DATE] revealed the following problems/concerns: *Nutritional risk related to (r/t) cognitive loss. [DIAGNOSES REDACTED]. *Risk for complications r/t [MEDICAL CONDITION] activity *Comfort care measures r/t end stage disease process and resident is under hospice comfort care. *Potential to develop dehydration *Risk for falls r/t cognitive status *Impaired cognition r/[MEDICAL CONDITION] of the brain status [REDACTED]. *Impaired communication r/t cognitive loss *Potential for signs and symptoms of pain: breakthrough, discomfort, intermittent, incision, cancer lung, cancer brain *At risk for skin breakdown r/t cognitive status, immobility, incontinent of bowel and bladder *Urinary incontinence: functional incontinence related to inability to transfer, unable to clean self, not aware of toileting needs, cognitive impairment Review of the facility ' s nurses ' notes for [DATE] revealed the following entries: 0120 - Vital signs: blood pressure ,[DATE], temperature 98.2, pulse 64, and respirations 18. Continues on antibiotics for upper respiratory infection (URI) without side effect noted. No complaints voiced or cough, congestion, respiratory difficulties noted. Resting quietly in bed without discomfort noted. Will continue to monitor. 1:02 p.m. Resident resting with eyes closed. No acute distress noted. Vital signs: blood pressure ,[DATE], pulse 62, respirations 20, and temperature 97.4. No signs and symptoms of pain or discomfort noted at present time. Resident has antibiotic Z pack in progress for URI. No adverse effect noted. No congestion or cough noted. Respirations even and unlabored. Will continue to monitor resident progress. 8:00 p.m. Resident up in wheel chair with helmet on to dining room for dinner ate 100%. Checked on her at 6:15 p.m. resident showing no signs or symptoms of distress or pain. C.N.A. went in at 7:00 p.m. Resident had expired. No lung sounds present, no heartbeat heard, no pulse felt, patient ' s color had changed. Had C.N.A. clean patient. up and put in bed. Contacted physician at 7:15 p.m. after contacting nursing supervisor, DON. ARNP gave a telephone order to pronounce resident expired at 7 p.m. and ok to release body. Called hospice. Hospice showed up by 8 p.m. called family members and funeral home picked up resident at 9:50 p.m. (signed by LPN C) There was a [DATE] telephone order: " order to pronounce patient deceased at 7:00 p.m. O.K. to pronounce and release the body " Review of the Hospice notes revealed the following relevant entries: [DATE] handwritten progress note by the regular hospice nurse: " Hospice nurse spoke with patient ' s daughter regarding patient ' s current status. Daughter states I want my mom to go to the hospital if she needs to. Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. " [DATE] computerized note by the regular hospice nurse: Patient in bed resting - appears weak, listless and moans when abdomen is palpated and also brings left arm up over right forehead area occasionally and moans. Patient unable to make needs known-does make eye contact when spoken to. Staff nurse reports patient having difficulty taking meds by mouth today. [MEDICATION NAME] liquefied and patient was able to take without difficulty ...I also called patient ' s daughter today. We discussed patient status and the fact that patient has no advanced directives/DNR in place. Daughter just states that she " wants her mother to go to the hospital if needed. " Daughter did not express any other decisions about DNR/advanced directives during this conversation ... I also spoke with the facility Social Worker (SW) regarding patient ' s daughter ' s wishes that patient be hospitalized if needed and that I was concerned that patients daughter is very young and seems to be having difficulty making decisions regarding DNR/Advanced Directives. Facility SW stated that patient ' s " daughter is just not ready to make those decisions. " [DATE] computerized note by the weekend/evening hospice nurse: Facility staff notified office of time of death of 7:00 p.m. for this patient. No family present. Facility staff states there were no signs she was eminent. Had seen patient 10 minutes prior to death and had went back to check on her and she had died . Death checklist completed ... 14. Interview with the unit manager for resident #2 on [DATE] at 2:33 p.m. revealed he ' s an LPN and has worked at the facility for about a year. The unit manager stated he did not remember resident #2 ever talking or responding at all. She had a flap, surgery to the brain, was hospice, full code, and had to have a helmet on when she was out of bed. The resident required total care and had weight issues too. Hospice was talking to the family about possibly getting a peg tube for her if they planned to keep her a full code. The unit manager stated he never spoke to the resident ' s family, but this information was relayed to him by Hospice personnel. On Monday morning, [DATE], the unit manager stated he reviewed the 24 hour reports, telephone orders and other documents to see what had happened over the weekend. During his review, he noticed that resident #2 had expired. Shortly thereafter, he ran into LPN C in the hall and said " I heard you had a rough weekend, " resident #2 expired. LPN C responded yes it was busy ...The unit manager stated to LPN C " I know I would not have wanted to be here pumping and jumping on her. " LPN C looked at the unit manager and said what do you mean? The unit manager said you know, doing CPR. LPN C responded by saying " we didn ' t do CPR. " The unit manager said " really, what did the paramedics say when they got here? " LPN C said " we didn ' t call 911, we called the doctor and pronounced. " The unit manager stated he told LPN " you know she was a full code? " LPN C looked at the unit manager funny and did not say anything. The unit manager proceeded to review resident #2 ' s chart to see if there was any change in her DNR status and then he read the nurses note from [DATE]. The unit manager stated he remembered his chin just dropped as he read the nurses note. At that moment the DON was coming down the hall and the DON said to LPN C " tell me you did CPR? " The unit manager stated obviously the DON had found out about the situation. LPN C was immediately taken off the floor. She gave a statement and was escorted off the property. The unit manager stated LPN C hadn ' t worked since that day. The unit manager stated within 10 minutes of realizing this event, they immediately started in -service with all the 7:00 a.m. - 3:00 p.m. staff. The 3:00 p.m. - 11:00 p.m. staff and the 11:00 p.m. - 7:00 a.m. staff were also in-serviced prior to starting their shift. The focus on the training was what

Based on review of the Florida Nurse Practice Act, clinical record review, staff interviews, facility policy review and job description reviews for the Director of Nursing (DON)and Licensed Practical Nurse (LPN)effective [DATE] it was determined that the facility did not ensure services for resuscitation were provided in accordance with professional standards of quality for one(#2) of 40 residents identified as full code, according to the midnight census list of [DATE] and the resident code status audit tool updated [DATE]. The Licensed Practical Nurses did not initiate Cardio-Pulmonary Resuscitation for a full code resident after identifying the resident to be without pulse or respirations. In addition, the Director of Nursing failed to provide appropriate supervision and direction in accordance with her job description and facility ' s policies and procedures when she was notified that resident #2 was absent of vital signs. Failure of the facility to ensure nurses meet professional standards and act in accordance with the Nurse Practice Act as defined in the Florida Statutes, Chapter 464, resulted in findings of immediate jeopardy which was removed on [DATE] at 4:40 p.m. and the severity and scope was reduced to a D. Findings include: 1. The Florida Nurse Practice Act includes: 3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 2. Review of the Charge Nurse (LPN) job description signed by LPN B on [DATE] and LPN C on [DATE] revealed the following relevant information: Position Summary: The primary purpose of the Charge Nurse is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines and regulations that govern or facility ... Customer Service: Demonstrates positive customer service when performing the role of the Charge Nurse, with residents, family members, facility staff and medical staff. Displays flexibility, team spirit, [MEDICATION NAME], respect honesty, politeness, and accountability when dealing with residents, family members and facility staff. Demonstrates an awareness and sensitivity for resident ' s rights in all interfaces with residents and family members. Charting and Documentation: Report all discrepancies noted concerning physician's order [REDACTED]., to the Nurse Supervisor. Nursing Care Functions: Review the resident ' s chart for specific treatments, medication orders, diets, etc., as necessary. Implement and maintain established nursing objectives and standards. Administer professional services such as: ...care for the dead/dying, etc., as required. Ensure that personnel providing direct care to residents are providing such care in accordance with the resident ' s care plan and wishes. Inform family members of the death of the resident. Care Plan and Assessment Functions: Review care plans daily to ensure that appropriate care is being rendered. Ensure that your nurses ' notes reflect that the care plan is being followed when administering nursing care or treatment. Resident Rights: Ensure that all nursing service personnel are knowledgeable of the residents ' responsibilities and rights ... Ensure that nursing staff personnel honor the resident ' s refusal of treatment request. Ensure that such requests are in accordance with the facility ' s policies governing advance directives Minimum Skills/Experience/Education: Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long term care. Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality of care. 3. Review of the Director of Nursing (DON) job description with an effective date of [DATE] revealed the following relevant information: Position Summary: The primary purpose of the DON is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility. And as may be directed by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority: The DON, is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. In the absence of the Medical Director, the DON is responsible for carrying out the resident care policies established by this facility. Customer Service: Demonstrates an awareness of and sensitivity for resident ' s rights in all interfaces with residents and family members. Communicates effectively via open, straightforward communication, including use of listening skills and by accessing the appropriate chain of command. Seeks validation of knowledge base, quality, decision-making and skill level by actively questioning when necessary. Essential Duties and Responsibilities: Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long term care facility. Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents ' total regimen of care. Personnel Functions: Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents. Recommend the number and level of nursing personnel to be employed. Assign a sufficient number of licensed practical and/or registered nurses for each tour of duty to ensure that quality care is maintained. Develop work assignments and schedule duty hours, and/or assist nursing supervisory staff in completing and performing such tasks. Make daily rounds of the nursing department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Nursing Care Functions: Review nurses ' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident ' s response to the care, and that such care is provided in accordance with the resident ' s wishes. Staff Development: Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on " how to do the job, " and ensure a well-educated nursing department. Develop, implement, and maintain an effective orientation program that orients the new Employee to the facility, its policies and procedures, and to his/her job position and duties. Provide leadership training that includes the administrative and supervisory principles essential for Nurse Supervisors/Charge Nurses. Assist the In-service Director/Educator in developing advance directive in-service training programs that relate to the nursing service department. Care Plan and Assessment Functions: Ensure that all personnel involved in providing care to the resident are aware of the resident ' s care plan. Ensure that nursing personnel refer to the resident ' s care plan prior to administering daily care to the resident. Review nurses ' notes to determine if the care plan is being followed. Ensure that medical and nursing care is administered in accordance with the resident ' s wishes, including the implementation of advance directives. Resident Rights: Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect. Ensure that all nursing service personnel are knowledgeable of the residents ' responsibilities and rights including the right to refuse treatment. Leadership: A. Supervises: Assistant Director of Nursing, Nursing Supervisors B. Supervisory Authority: Has the ability to hire , discipline, assign, appraise, terminate assigned Employees. Minimum Skills/Experience/Education: Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care. Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel. Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc. that are necessary for providing quality care. 4. Interview with the facility ' s administrator (NHA) and DON on [DATE] at 9:39 a.m. revealed the facility recently had an incident in which two nurses did not honor the advanced directives of resident #2. The resident was found unresponsive on [DATE] by employee A (Certified Nursing Assistant- C.N.A. A). C.N.A. A immediately alerted employee B (Licensed Practical Nurse - LPN B). LPN B described the resident as blue in color and already deceased . LPN B then got the nurse assigned to resident #2 (LPN C). LPN C reviewed the resident ' s chart and did not see a do not resuscitate order (DNR) but stated she didn ' t see anything that indicated CPR was needed because the resident was on hospice. 5. Telephone interview on [DATE] at 5:03 p.m. with resident #2 ' s daughter and health care proxy revealed she was surprised when she received a call to tell her that her mom had died . The daughter said her mother had been doing really well. The daughter said she knew that she was being treated with antibiotics for pneumonia about a week before she died but everything was going okay. The daughter stated she didn ' t ask for any details on how her mom had died when she was called by the facility. The daughter stated she had just received the death certificate which stated cause of death as natural causes, [MEDICAL CONDITION] metastasize to the brain. The surveyor asked the daughter if she had wanted her mother to have any life saving measures and the daughter stated " She was not a DNR. They were supposed to do anything they needed to. " The daughter was not aware that the facility had not attempted to perform CPR and had not transferred the resident to the hospital in accordance with her expressed wishes. 6. Clinical record review for resident #2 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and a date of admission to the facility of [DATE]. The face sheet also indicated the resident ' s payer source was Hospice. A review of the advanced directives contained in the record revealed a health care proxy/acceptance of designation form dated [DATE] which appointed resident#2 ' s daughter as the " individual who shall be responsible for making healthcare decisions on behalf of " the resident. The resident had a certificate of incapacity signed by her attending physician on [DATE] which documented that this resident " is unable to make health care decisions for him/herself or provide informed consent to medical treatment. " Review of the Hospice notes contained in resident #2 ' s clinical record revealed the following relevant entries: [DATE] handwritten progress note by the regular hospice nurse: " Hospice nurse spoke with patient ' s daughter regarding patient ' s current status. Daughter states I want my mom to go to the hospital if she needs to. Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. " [DATE] computerized note by the regular hospice nurse: Patient in bed resting - appears weak, listless and moans when abdomen is palpated and also brings left arm up over right forehead area occasionally and moans. Patient unable to make needs known-does make eye contact when spoken to. Staff nurse reports patient having difficulty taking meds by mouth today. [MEDICATION NAME] liquefied and patient was able to take without difficulty ...I also called patient ' s daughter today. We discussed patient status and the fact that patient has no advanced directives/DNR in place. Daughter just states that she " wants her mother to go to the hospital if needed. " Daughter did not express any other decisions about DNR/advanced directives during this conversation ... I also spoke with the facility Social Worker (SW) regarding patient ' s daughter ' s wishes that patient be hospitalized if needed and that I was concerned that patients daughter is very young and seems to be having difficulty making decisions regarding DNR/Advanced Directives. Facility SW stated that patient ' s " daughter is just not ready to make those decisions. " [DATE] computerized note by the weekend/evening hospice nurse: Facility staff notified office of time of death of 7:00 p.m. for this patient. No family present. Facility staff states there were no signs she was eminent. Had seen patient 10 minutes prior to death and had went back to check on her and she had died . Death checklist completed ... Review of the facility ' s nurses ' notes for [DATE] revealed the following entries: 0120 - Vital signs: blood pressure ,[DATE], temperature 98.2, pulse 64, and respirations 18. Continues on antibiotics for upper respiratory infection (URI) without side effect noted. No complaints voiced or cough, congestion, respiratory difficulties noted. Resting quietly in bed without discomfort noted. Will continue to monitor. 1:02 p.m. Resident resting with eyes closed. No acute distress noted. Vital signs: blood pressure ,[DATE], pulse 62, respirations 20, and temperature 97.4. No signs and symptoms of pain or discomfort noted at present time. Resident has antibiotic Z pack in progress for URI. No adverse effect noted. No congestion or cough noted. Respirations even and unlabored. Will continue to monitor resident progress. 8:00 p.m. Resident up in wheel chair with helmet on to dining room for dinner ate 100%. Check on her at 6:15 p.m. resident showing no signs or symptoms of distress or pain. C.N.A. went in at 7:00 p.m. Resident had expired. No lung sounds present, no heartbeat heard, no pulse felt, patient ' s color had changed. Had C.N.A. clean patient. up and put in bed. Contacted physician at 7:15 p.m. after contacting nursing supervisor, DON. ARNP gave a telephone order to pronounce resident expired at 7 p.m. and ok to release body. Called hospice. Hospice showed up by 8 p.m. called family members and funeral home picked up resident at 9:50 p.m. (signed by LPN C) Review of the physician telephone orders dated [DATE] revealed an " order to pronounce patient deceased at 7:00 p.m. O.K. to pronounce and release the body " 7. Telephone interview with C.N.A. A on [DATE] at 2:19 p.m. revealed he works at the facility on an as needed basis (PRN) approximately ,[DATE] times a week on the 3:00 p.m. - 11:00 p.m. shift. The C.N.A. stated he had no set assignment but recalled caring for resident #2 in the past. The C.N.A. remembered resident #2 as a female resident who wore a helmet on her head and was a very quiet person. C.N.A. A thought this resident was under the care of hospice. The C.N.A. also stated the resident was total care and could not do anything for herself. She required the use of a hoyer lift for all transfers to the bed and chair and needed assistance with eating. On [DATE] the C.N.A. recalled he had come back from the dining room and resident #2 was in her room in the geri-chair around 6:00 p.m. - 6:15 p.m. The C.N.A. went to care for the resident directly across the hall from resident #2 and when that was complete he entered resident#2 ' s room around 7:00 p.m. to get her ready for bed. The C.N.A. noticed resident #2 was not moving and she was leaning back in the chair. He stated the resident was not breathing and he knew this because he looked up close and did not see her chest moving up or down. The C.N.A. stated the resident ' s fingers and face were discolored and pale. He stated the resident was not blue. C.N.A. A immediately called for LPN B who was at the nurse ' s station, just two steps from the resident ' s room. C.N.A. A told LPN B the resident was not breathing. LPN B then came in and " checked her pulse and everything. " LPN B then got another nurse to check the patient as well. This C.N.A. then went to went to get another aide to get the resident out of the chair and put her in bed while the nurses were making their calls. He stated this was the normal procedure for preparing the body once somebody dies. 8. Telephone interview with LPN B on [DATE] at 4:00 p.m. revealed she had been an LPN since January of 2006 and came to work at this facility in late February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. She stated she was somewhat familiar with resident #2 prior to the day she expired because she had been on her assignment for a little while and was later moved to a different room. She recalled resident #2 had a [MEDICAL CONDITION], was aphasic and didn ' t ' speak. On [DATE] she was at the nurse ' s station charting when C.N.A. A asked her to come into the resident ' s room. LPN B stated she was not the nurse for resident #2 that night. LPN C was the nurse for the resident that night, but she was on her lunch break. Review of LPN C ' s time sheet for [DATE] revealed she did not clock out for her lunch break therefore the exact time she went on break was unknown. Continued interview with LPN B revealed that when she entered the resident ' s room, she saw the resident seated in her geri-chair. At that point it was very clear she had expired. She checked her apical and radial pulses, and the resident was cold to the touch, stiff, and cyanotic. The resident ' s eyes were wide open and no pulses were palpable with her stethoscope and no respirations were present. LPN B then proceeded back to the nurse ' s station to page LPN C. LPN C responded right away. LPN B informed LPN C that resident #2 had expired. LPN B said that LPN C asked her " what am I supposed to do? " LPN B told the resident ' s nurse to call the supervisor as both LPN B and LPN C were new to the facility. In addition, LPN B stated she thought LPN C was a new nurse. LPN B heard LPN C speaking with the Director of Nurses (DON) by telephone so LPN B assumed that everything was under control, and she went back to work. LPN B recalled LPN C grabbing the chart and entering resident #2 ' s room. LPN B was on the treatment cart but stated she called out to LPN C that she was right there if she needed her. LPN B stated again, " I thought she had it under control. " LPN B stated she spoke with the hospice nurse that night on [DATE], exact time unknown, but did not discuss anything specific about resident #2. LPN B stated she did not look at resident #2 ' s chart on the night of [DATE]. LPN B stated she had received training on how to respond when a resident was found without vital signs in other facilities but not at this facility. LPN B stated orientation at this facility was one day on the floor and she had to learn the policies and procedures as she worked. LPN B stated she did not call the physician, hospice, or family that night. She stated her CPR certification was up to date. LPN B stated this incident happened on a Sunday evening and she was called in that Monday morning to give a statement. She stated they in-serviced her on the facility code guidelines and then suspended her that Monday morning. LPN B stated she was terminated the following Friday, [DATE]. 9. A telephone interview with LPN C on [DATE] at 10:51 a.m. revealed she had been an LPN since [DATE]. LPN C began working at the facility in February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. LPN C stated she was not too familiar with resident #2 because she had just moved onto her assignment about a week or so before she had expired. LPN C recalled resident #2 had surgery on her head because she wore a helmet when out of bed. LPN C stated all of resident #2 ' s medications were crushed or liquid because she had trouble eating/swallowing so she had to be watched very carefully. LPN C recalled this resident as needing total care with activities of daily living (ADL ' s). LPN C also recalled this resident received breathing treatments on her shift at 5:00 p.m. and 9:00 p.m. On [DATE], LPN C remembered being on her lunch break when resident #2 passed away. She stated she had given resident #2 her medications at 6:15 p.m. on [DATE] and she was fine. LPN C stated she went on her lunch break at 7:00 p.m. and told LPN B she was going on break. LPN C received an overhead page around 7:15 p.m. on [DATE] to come back to the floor. She went back to the floor and was informed by LPN B that the C.N.A. ' s found resident #2 not breathing and LPN B had already checked her out and " pronounced her dead. " LPN C stated she informed LPN B that nurses can ' t pronounce a patient. LPN C stated she went into the resident ' s room to look at her. LPN C stated the resident was already turning a dark color from lack of oxygen, she was not breathing, there was no heartbeat, and no pulse. LPN C stated she used her stethoscope to check and could not find a carotid pulse. LPN C stated she tried to call the person who was on call but they did not answer the call so she immediately proceeded to call the DON. She informed the DON of the situation. The DON asked LPN C if the resident was on hospice and she stated " yes. " The DON told her to call the resident ' s physician and get a telephone order for 2 LPN ' s to pronounce the resident as deceased and get a telephone order from the doctor to release the body to the funeral home. The DON also told LPN C to call hospice. LPN C stated LPN B called the doctor and got the telephone orders while LPN C called hospice. LPN C recalled the hospice nurse coming out to the facility about an hour later. LPN C stated the hospice nurse contacted the family and the funeral home for her. LPN C stated she had called the DON that night because she didn ' t know what the procedure was when somebody died . LPN C stated LPN B was new to the facility also and she didn ' t know what to do. LPN C stated she looked at the resident ' s chart and did not see a DNR order, but she thought the resident was a DNR because she was on hospice. LPN C stated that when hospice came in that night she didn ' t say anything about the resident ' s code status, and the hospice nurse had reviewed the resident ' s chart too. LPN C stated she had not received any training from the facility on how to respond when a resident was found without vital signs. She stated they only showed her where the oxygen was kept and other rooms like clean and dirty utility rooms. LPN C stated she knew the crash cart was kept in the dining room because she had asked them where it was. LPN C stated she only called the DON and hospice that night. LPN C stated she had current CPR certification. The LPN said she came into work the following Monday morning, [DATE] to cover for someone who had called off on 7:00 a.m. -3:00 p.m. LPN C was already on the schedule to work on [DATE] from 3:00 p.m. - 11:00 p.m. and had planned on working a double that day. LPN C was pulled off the medication cart on [DATE] at around 9:15 a.m. to give a statement relating to the incident. LPN C stated she was suspended that Monday morning and later terminated because she did not know what the facility ' s procedure was. 10. LPN B was contacted via telephone on [DATE] at 11:37 a.m. to verify she had spoken to resident #2 ' s doctor on the night of [DATE] as was reported in the telephone interview with LPN C. LPN B stated " I actually thought about it last night and that is absolutely right. " LPN B confirmed that she spoke to the Advanced Registered Nurse Practitioner (ARNP) for resident #2 ' s physician on [DATE]. LPN B said the ARNP gave orders to pronounce and release. 11. Interview on [DATE] at 3:10 p.m. with the hospice evening/weekend Registered Nurse (RN) for the burgundy team revealed she was the nurse that came out to the facility on the night of [DATE]. The facility had called the evening/weekend office when resident #2 died and the office in turn notified her to come out to the facility. The hospice nurse stated she probably came out to the facility around 7:30 p.m. on [DATE]. She offered to call the funeral home and the physician but both had already been done. The hospice nurse did notify the resident ' s family as the facility nurses had not been able to get a hold of anyone. The hospice nurse could not reach the resident ' s daughter on her home phone number so she called the daughter ' s fiance and asked to please speak to resident #2 ' s daughter. The hospice nurse told the daughter who she was and informed her that her mother had expired. The daughter started to cry and she thanked me for calling. The hospice nurse informed the daughter of counseling that they could provide her with and she provided the daughter with her personal number in case she had any questions because she seemed to be in shock. The daughter called the hospice nurse later, probably around 9 p.m., and told her about some family things that were going on. The daughter also asked if the hospice had called the resident ' s boyfriend who cared for resident #2 ' s [AGE] year old son. The hospice nurse informed the daughter that she had called the boyfriend but did not get an answer and had not heard back from him yet. The hospice nurse stated that the daughter then sent someone over to the boyfriend ' s house to notify him. The boyfriend then called the hospice nurse around 9:30 p.m. to find out if the resident ' s death was in fact true. The hospice nurse informed him it was. The hospice nurse stated the resident ' s daughter and boyfriend never asked what happened to the resident that night. The facility told the hospice nurse that the resident had no visitors and the boyfriend had never brought the [AGE] year old son to visit. The facility nurses never informed the hospice nurse that resident #2 did not have a DNR order. The hospice nurse stated she noticed that there was no DNR order in the record. The hospice nurse said she asked the nurses, " was she able to be revived? " The nurses said " no. " 12. Interview with the DON on [DATE] at 5:25 p.m. revealed the nurses normally call her when residents go to the hospital or expire. The DON remembered LPN C called her on the night of [DATE] and stated about 25 minutes ago resident #2 expired. LPN C informed the DON that the resident was on hospice and LPN C asked " what ' s the procedure for a death in the facility? " The DON proceeded to tell her to call the doctor, call hospice, and explained the orders LPN C needed to retrieve. LPN C never told the DON that resident #2 didn ' t have a DNR order. The DON stated " I don ' t know all of them right off the top of my head. " The DON did not remember if she asked LPN C if resident #2 had a DNR order, but " I will from now on. " 13. Interview with resident #2 ' s regular hospice RN, who had been coming to this facility for 9 years, on [DATE] at 12:53 p.m. revealed she works on the burgundy team and was familiar with resident #2. The hospice RN recalled the resident having come to the facility from the hospital where she had undergone brain surgery and developed an infection in the flap. The hospice nurse described resident #2 as very young, in her 40 ' s. When the resident was first admitted to the nursing home back in late March of 2012, she was discussed as a possible hospice resident, but her daughter/health care proxy needed time to think about it. The hospice nurse said the resident ' s daughter was very young, only about [AGE] years old, and was down in Florida for about a week and then returned back up north to her home. The daughter later decided she wanted hospice for her mom, and hospice evaluated her and admitted her for services on [DATE]. The hospice nurse stated the resident also had a [AGE] year old son who lived in a neighboring county and required psycho-social help. Hospice worked with the neighboring county to obtain special services and counseling to help the resident ' s teenage son. When resident #2 was first admitted to hospice, her flap was healing. The hospice nurse recalled the resident speaking only one time, she said " yeah " . The hospice nurse also recalled holding resident #2 ' s hand on one occasion and the hospice nurse said to the resident " [AGE] year old sons ' can be a real pain in the butt sometimes. " The hospice nurse stated the resident squeezed her hand and smiled when she said this. The hospice nurse also recalled another time about a week before resident #2 passed when the resident had kissed her hand. The nurse stated the resident did this after she had told the resident she was really sorry for everything she had been through. The hospice nurse stated the resident would follow with her eyes, but she could not necessarily tell for sure if she understood what was happening or if the responses she received were true responses. The hospice nurse said the resident fed herself at the beginning of her stay when the utensil was placed in her hand but towards the end (the last week) she thought staff were helping her with meals because she was eating less and less. The hospice nurse clearly recalled discussing advanced directives with resident #2 ' s daughter and stated she documented this in the resident ' s chart. The hospice nurse thumbed through the resident ' s clinical record and pulled out a form labeled " Progress Notes. " The document was dated [DATE] and noted Hospice nurse spoke with patient ' s daughter regarding resident ' s current status. Daughter states " I want my mom to go to the hospital if she needs to. " Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. The hospice nurse then went on to state to the surveyor that it was her understanding that the resident had no advanced directives. The daughter was not ready to discuss that. The daughter was so young and " we weren ' t going to shove DNR or advanced directives down her throat. " The hospice nurse stated there really wasn ' t time to sit and work through this with the daughter as we didn ' t have resident #2 under our care for a very long time. 14. Interview with the hospice social worker on [DATE] at 1:42 p.m. revealed she had a difficult time assessing how much resident #2 was aware of because she had major brain surgery. The social worker stated resident #2 was either in bed or in a reclining geri-chair, and she always wore a helmet. The social worker never could get a real good read as to whether or not the resident could understand her or not. The social worker stated the resident ' s family dynamics were difficult to navigate. She had a daughter who lived out of the state who was a yo

Based on clinical record review, policy and procedure review for Code Blue, CPR, and Advanced Directives, job description reviews, and interviews with facility staff and a family member, it was determined that administration failed to provide resource management to meet the needs for one (#2) of 40 residents identified as full code, according to the midnight census list of [DATE] and the resident code status audit tool updated [DATE]. Administration did not ensure the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities. This related to not implementing policies and procedures for advanced directives and failure to administer CPR and ensuring that staff maintained current training in CPR to carry out this function to ensure the highest degree of attention and care was provided to residents. Failure to ensure that staff would properly implement training on emergency policies and procedures led to neglect of one resident when staff did not perform CPR and call for Emergency Medical Services (EMS/911). These actions resulted in findings of immediate jeopardy which was removed on [DATE] at 4:40 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of the job description for the Administrator with an effective date of ,[DATE] revealed the following relevant information: Position Summary: The primary purpose of the Administrator is to oversee, manage and direct the day-to-day functions and overall operations of the facility in accordance with the current federal, state, and local government regulations that govern long-term care facilities and the Operators requirements. The Administrator ' s focus is on maintaining the highest degree of quality care for the resident/patient while achieving the facility ' s business objectives. Essential Duties and Responsibilities: Administrative Functions: ? Leads facility management staff in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. Monitors each department ' s activities, communicates policies, evaluates performance, provides feedback, and assist ' s, observes, coaches and disciplines as needed. ? Adopt, implement, and maintain written policies and procedures that govern the operation of the facility. ? Adopt, implement, and maintain written job descriptions for each staff position in accordance with the Americans with Disabilities Act, OSHA, and other pertinent laws governing job descriptions. ? Interpret the facility ' s policies and procedures to Employees ...etc., as necessary ? Oversees regular rounds to monitor delivery of nursing care ...and ensures resident needs are being addressed. ? Ensure that all Employees ...follow established policies and procedures. Personnel Functions: ? Manage turnover and ensure current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development. ? Ensure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents. ? Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary. Resident Rights: Ensure that the resident ' s rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights ...are well established and maintained at all times. Leadership: A. Supervises: Oversees entire facility operation ... B. Supervisory Authority: Has the ability to hire, discipline, assign, appraise, terminate facility Employees. Miscellaneous: Ensure that all resident receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Ensure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. 2. Clinical record review for resident #2 revealed a face sheet with a date of birth of [DATE] ([AGE] years old) and a date of admission to the facility of [DATE]. The face sheet also indicated the resident ' s payer source was Hospice. A review of the advanced directives contained in the record revealed a health care proxy/acceptance of designation form dated [DATE] which appointed resident#2 ' s daughter as the " individual who shall be responsible for making healthcare decisions on behalf of " the resident. The resident had a certificate of incapacity signed by her attending physician on [DATE] which documented that this resident " is unable to make health care decisions for him/herself or provide informed consent to medical treatment. " No additional advanced directives were present in the clinical record. Review of the facility ' s nurses ' notes for [DATE] revealed the following relevant entry: 8:00 p.m. Resident up in wheel chair with helmet on to dining room for dinner ate 100%. Check on her at 6:15 p.m. resident showing no signs or symptoms of distress or pain. C.N.A. went in at 7:00 p.m. Resident had expired. No lung sounds present, no heartbeat heard, no pulse felt, patient ' s color had changed. Had C.N.A. clean patient up and put in bed. Contacted physician at 7:15 p.m. after contacting nursing supervisor, DON. ARNP gave a telephone order to pronounce resident expired at 7 p.m. and ok to release body. Called hospice. Hospice showed up by 8 p.m. called family members and funeral home picked up resident at 9:50 p.m. (signed by LPN C) Review of the physician ' s telephone orders dated [DATE] revealed an " order to pronounce patient deceased at 7:00 p.m. O.K. to pronounce and release the body. " Review of the Hospice notes revealed the following relevant entries: [DATE] handwritten progress note by the regular hospice nurse: " Hospice nurse spoke with patient ' s daughter regarding patient ' s current status. Daughter states I want my mom to go to the hospital if she needs to. Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. " [DATE] computerized note by the regular hospice nurse: Patient in bed resting - appears weak, listless and moans when abdomen is palpated and also brings left arm up over right forehead area occasionally and moans. Patient unable to make needs known-does make eye contact when spoken to. Staff nurse reports patient having difficulty taking meds by mouth today. [MEDICATION NAME] liquefied and patient was able to take without difficulty ...I also called patient ' s daughter today. We discussed patient status and the fact that patient has no advanced directives/DNR in place. Daughter just states that she " wants her mother to go to the hospital if needed. " Daughter did not express any other decisions about DNR/advanced directives during this conversation ... I also spoke with the facility Social Worker (SW) regarding patient ' s daughter ' s wishes that patient be hospitalized if needed and that I was concerned that patients daughter is very young and seems to be having difficulty making decisions regarding DNR/Advanced Directives. Facility SW stated that patient ' s " daughter is just not ready to make those decisions. " [DATE] computerized note by the weekend/evening hospice nurse: Facility staff notified office of time of death of 7:00 p.m. for this patient. No family present. Facility staff states there were no signs she was eminent. Had seen patient 10 minutes prior to death and had went back to check on her and she had died . Death checklist completed ... 3. Interview with the facility ' s administrator (NHA) and Director of Nursing (DON) on [DATE] at 9:39 a.m. revealed the facility recently had an incident in which two nurses did not honor the advanced directives of resident #2. The resident was found unresponsive on [DATE] by employee A (Certified Nursing Assistant- C.N.A. A). C.N.A. A immediately alerted employee B (Licensed Practical Nurse - LPN B). LPN B described the resident as blue in color and already deceased . LPN B then got the nurse assigned to resident #2 (LPN C). LPN C reviewed the resident ' s chart and did not see a do not resuscitate order (DNR) but stated she didn ' t see anything that indicated CPR was needed because the resident was on hospice. 4. Telephone interview on [DATE] at 5:03 p.m. with resident #2 ' s daughter and health care proxy revealed she was surprised when she received the call on [DATE] to tell her that her mom had died . The daughter said her mother had been doing really well. The daughter said she knew that she was being treated with antibiotics for pneumonia about a week before she died but everything was going okay. The daughter stated she didn ' t ask for any details on how her mom had died when she was called by the facility. The daughter stated she had just received the death certificate which stated cause of death as natural causes, [MEDICAL CONDITION] metastasize to the brain. The surveyor asked the daughter if she had wanted her mother to have any life saving measures and the daughter stated " She was not a DNR. They were supposed to do anything they needed to. " The daughter was not aware that the facility had not attempted to perform CPR and had not transferred the resident to the hospital in accordance with her expressed wishes. 5. Review of the facility ' s policies and procedures for " Advance Directives - Nursing " with an effective date of [DATE] (,[DATE]) revealed the following relevant information: Policy: The facility nursing staff will abide by resident advance directives, if known, and if those directives are not in conflict with the company ' s policies regarding the withholding or withdrawing of life support treatment. Procedure: 1. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident... 2. Nursing staff must use a means of identification for those residents who have " DNR " in their medical records through advance directives and written orders from the attending physician. 3. Nursing staff must be aware of other advance directives regarding residents ' wishes before certain treatments are initiated (i.e. intravenous feeding). 4. Follow these steps in an emergency situation: a. If a resident stops breathing or there is an absence of pulse or heartbeat, staff will check to determine whether a DNR order has been entered b. If there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately. Page " Code Blue " to summon anyone in the facility who has been certified to administer CPR. At the same time, call emergency paramedic support. The attending physician also must be notified. Review of the facility ' s " Cardiopulmonary Resuscitation (CPR) " policy and procedures effective ,[DATE] ([DATE]) revealed the following relevant information: Policy: 1. Cardiopulmonary resuscitation is initiated on all residents except those with a " no code " order and appropriate documentation. 2. Cardiopulmonary resuscitation is performed only by individuals certified in CPR. 3. All licensed nurses are to be certified in CPR and must be re-certified in accordance with certifying agency - American Heart Association-Red Cross. Procedure: 1. In the case of cardiac and/or [MEDICAL CONDITION] arrest, CPR is initiated immediately using the Red Cross Guidelines - American Heart Association. 2. Use the paging system and call " Code Blue " to Room Number ____, three times. 3. CPR is continued until life support systems are available, or it may be discontinued if: A. The resident responds. B. The physician orders [REDACTED]. C. EMS arrives and takes over. 4. Contact the physician and family 5. Document details of occurrence in the Nursing Notes 6. Update the care plan as needed Review of the facility ' s " Code Blue " policies and procedures with an effective date of ,[DATE] revealed the following relevant information: Policy: CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR order written by a physician on their medical records. Procedure: 1. When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident ' s code status. *Confirm DNR status with the physician ' s written order. 2. In the event that the resident is identified as a Full Code and the person finding the resident is trained in CPR they will: *Call for help and state " Code Blue " *Initiate CPR 3. The individual responding to the call for help will call " Code Blue " over the intercom, 3 times, identifying: *The floor/unit *Room number or area where the resident is located. 4. If the first individual finding the resident is not trained in CPR, they will immediately call over the intercom a " Code Blue " identifying the specific floor and area. 5. Clinical staff in this facility will respond to the " Code Blue " pages. 6. The Nurse Manager/Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: *Summon emergency equipment to the room *Activate the EMS system *Assign a person to document the on-going code *Notify the doctor *Complete a Transfer Form *Call emergency room and give report to Admitting Nurse *Assure the family has been notified *Obtain order to transfer resident to hospital *Document code in medical record *Restock code cart 6. Telephone interview with C.N.A. A on [DATE] at 2:19 p.m. revealed he works at the facility on an as needed basis (PRN) approximately ,[DATE] times a week on the 3:00 p.m. - 11:00 p.m. shift. The C.N.A. stated he has no set assignment but recalled caring for resident #2 in the past. The C.N.A. remembered resident #2 as a female resident who wore a helmet on her head and was a very quiet person. C.N.A. A thought this resident was under the care of hospice. The C.N.A. also stated the resident was total care and could not do anything for herself. She required the use of a hoyer lift for all transfers to the bed and chair and needed assistance with eating. On [DATE] the C.N.A. recalled he had come back from the dining room and resident #2 was in her room in the geri-chair around 6:00 p.m. - 6:15 p.m. The C.N.A. went to care for the resident directly across the hall from resident #2 and when that was complete he entered resident#2 ' s room around 7:00 p.m. to get her ready for bed. The C.N.A. noticed resident #2 was not moving and she was leaning back in the chair. He stated the resident was not breathing and he knew this because he looked up close and did not see her chest moving up or down. The C.N.A. stated the resident ' s fingers and face were discolored and pale. He stated the resident was not blue. C.N.A. A immediately called for LPN B who was at the nurse ' s station, just two steps from the resident ' s room. C.N.A. A told LPN B the resident was not breathing. LPN B then came in and " checked her pulse and everything. " LPN B then got another nurse to check the patient as well. This C.N.A. then went to went to get another aide to get the resident out of the chair and put her in bed while the nurses were making their calls. He stated this was the normal procedure for preparing the body once somebody dies. 7. Telephone interview with LPN B on [DATE] at 4:00 p.m. revealed she had been an LPN since January of 2006 and came to work at this facility in late February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. She stated she was somewhat familiar with resident #2 prior to the day she expired because she had been on her assignment for a little while and was later moved to a different room. She recalled resident #2 had a [MEDICAL CONDITION], was aphasic and didn ' t ' speak. On [DATE] she was at the nurse ' s station charting when C.N.A. A asked her to come into the resident ' s room. LPN B stated she was not the nurse for resident #2 that night. LPN C was the nurse for the resident that night, but she was on her lunch break. Review of LPN C ' s time sheet for [DATE] revealed she did not clock out for her lunch break therefore the exact time she went on break was unknown. Continued interview with LPN B revealed that when she entered the resident ' s room, she saw the resident seated in her geri-chair. At that point it was very clear she had expired. She checked her apical and radial pulses, and the resident was cold to the touch, stiff, and cyanotic. The resident ' s eyes were wide open and no pulses were palpable with her stethoscope and no respirations were present. LPN B then proceeded back to the nurse ' s station to page LPN C. LPN C responded right away. LPN B informed LPN C that resident #2 had expired. LPN B said that LPN C asked her " what am I supposed to do? " LPN B told the resident ' s nurse to call the supervisor as both LPN B and LPN C were new to the facility. In addition, LPN B stated she thought LPN C was a new nurse. LPN B heard LPN C speaking with the Director of Nurses (DON) by telephone so LPN B assumed that everything was under control, and she went back to work. LPN B recalled LPN C grabbing the chart and entering resident #2 ' s room. LPN B was on the treatment cart but stated she called out to LPN C that she was right there if she needed her. LPN B stated again, " I thought she had it under control. " LPN B stated she spoke with the hospice nurse that night on [DATE], exact time unknown, but did not discuss anything specific about resident #2. LPN B stated she did not look at resident #2 ' s chart on the night of [DATE]. LPN B stated she had received training on how to respond when a resident was found without vital signs in other facilities but not at this facility. LPN B stated orientation at this facility was one day on the floor and she had to learn the policies and procedures as she worked. LPN B stated she did not call the physician, hospice, or family that night. She stated her CPR certification was up to date. LPN B stated this incident happened on a Sunday evening and she was called in that Monday morning to give a statement. She stated they in-serviced her on the facility code guidelines and then suspended her that Monday morning. LPN B stated she was terminated the following Friday, [DATE]. 8. A telephone interview with LPN C on [DATE] at 10:51 a.m. revealed she had been an LPN since [DATE]. LPN C began working at the facility in February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift. LPN C stated she was not too familiar with resident #2 because she had just moved onto her assignment about a week or so before she had expired. LPN C recalled resident #2 had surgery on her head because she wore a helmet when out of bed. LPN C stated all of resident #2 ' s medications were crushed or liquid because she had trouble eating/swallowing so she had to be watched very carefully. LPN C recalled this resident as needing total care with activities of daily living (ADL ' s). LPN C also recalled this resident received breathing treatments on her shift at 5:00 p.m. and 9:00 p.m. On [DATE], LPN C remembered being on her lunch break when resident #2 passed away. She stated she had given resident #2 her medications at 6:15 p.m. on [DATE] and she was fine. LPN C stated she went on her lunch break at 7:00 p.m. and told LPN B she was going on break. LPN C received an overhead page around 7:15 p.m. on [DATE] to come back to the floor. She went back to the floor and was informed by LPN B that the C.N.A. ' s found resident #2 not breathing and LPN B had already checked her out and " pronounced her dead. " LPN C stated she informed LPN B that nurses can ' t pronounce a patient. LPN C stated she went into the resident ' s room to look at her. LPN C stated the resident was already turning a dark color from lack of oxygen, she was not breathing, there was no heartbeat, and no pulse. LPN C stated she used her stethoscope to check and could not find a carotid pulse. LPN C stated she tried to call the person who was on call but they did not answer the call so she immediately proceeded to call the DON. She informed the DON of the situation. The DON asked LPN C if the resident was on hospice and she stated " yes. " The DON told her to call the resident ' s physician and get a telephone order for 2 LPN ' s to pronounce the resident as deceased and get a telephone order from the doctor to release the body to the funeral home. The DON also told LPN C to call hospice. LPN C stated LPN B called the doctor and got the telephone orders while LPN C called hospice. LPN C recalled the hospice nurse coming out to the facility about an hour later. LPN C stated the hospice nurse contacted the family and the funeral home for her. LPN C stated she had called the DON that night because she didn ' t know what the procedure was when somebody died . LPN C stated LPN B was new to the facility also and she didn ' t know what to do. LPN C stated she looked at the resident ' s chart and did not see a DNR order, but she thought the resident was a DNR because she was on hospice. LPN C stated that when hospice came in that night she didn ' t say anything about the resident ' s code status, and the hospice nurse had reviewed the resident ' s chart too. LPN C stated she had not received any training from the facility on how to respond when a resident was found without vital signs. She stated they only showed her where the oxygen was kept and other rooms like clean and dirty utility rooms. LPN C stated she knew the crash cart was kept in the dining room because she had asked them where it was. LPN C stated she only called the DON and hospice that night. LPN C stated she had current CPR certification. The LPN said she came into work the following Monday morning, [DATE] to cover for someone who had called off on 7:00 a.m. -3:00 p.m. LPN C was already on the schedule to work on [DATE] from 3:00 p.m. - 11:00 p.m. and had planned on working a double that day. LPN C was pulled off the medication cart on [DATE] at around 9:15 a.m. to give a statement relating to the incident. LPN C stated she was suspended that Monday morning and later terminated because she did not know what the facility ' s procedure was. 9. LPN B was contacted via telephone on [DATE] at 11:37 a.m. to verify she had spoken to resident#2 ' s doctor on the night of [DATE] as was reported in the telephone interview with LPN C. LPN B stated " I actually thought about it last night and that is absolutely right. " LPN B confirmed that she spoke to the Advanced Registered Nurse Practitioner (ARNP) for resident #2 ' s physician on [DATE]. LPN B said the ARNP gave orders to pronounce and release. 10. Interview on [DATE] at 3:10 p.m. with the hospice evening/weekend Registered Nurse (RN) for the burgundy team revealed she was the nurse that came out to the facility on the night of [DATE]. The facility had called the evening/weekend office when resident #2 died and the office in turn notified her to come out to the facility. The hospice nurse stated she probably came out to the facility around 7:30 p.m. on [DATE]. She offered to call the funeral home and the physician but both had already been done. The hospice nurse did notify the resident ' s family as the facility nurses had not been able to get a hold of anyone. The hospice nurse could not reach the resident ' s daughter on her home phone number so she called the daughter ' s fiance and asked to please speak to resident #2 ' s daughter. The hospice nurse told the daughter who she was and informed her that her mother had expired. The daughter started to cry and she thanked me for calling. The hospice nurse informed the daughter of counseling that they could provide her with and she provided the daughter with her personal number in case she had any questions because she seemed to be in shock. The daughter called the hospice nurse later, probably around 9 p.m., and told her about some family things that were going on. The daughter also asked if the hospice had called the resident ' s boyfriend who cared for resident #2 ' s [AGE] year old son. The hospice nurse informed the daughter that she had called the boyfriend but did not get an answer and had not heard back from him yet. The hospice nurse stated that the daughter then sent someone over to the boyfriend ' s house to notify him. The boyfriend then called the hospice nurse around 9:30 p.m. to find out if the resident ' s death was in fact true. The hospice nurse informed him it was. The hospice nurse stated the resident ' s daughter and boyfriend never asked what happened to the resident that night. The facility told the hospice nurse that the resident had no visitors and the boyfriend had never brought the [AGE] year old son to visit. The facility nurses never informed the hospice nurse that resident #2 did not have a DNR order. The hospice nurse stated she noticed that there was no DNR order in the record. The hospice nurse said she asked the nurses, " was she able to be revived? " The nurses said " no. " 11. Interview with the DON on [DATE] at 5:25 p.m. revealed the nurses normally call her when residents go to the hospital or expire. The DON remembered LPN C called her on the night of [DATE] and stated about 25 minutes ago resident #2 expired. LPN C informed the DON that the resident was on hospice and LPN C asked " what ' s the procedure for a death in the facility? " The DON proceeded to tell her to call the doctor, call hospice, and explained the orders LPN C needed to retrieve. LPN C never told the DON that resident #2 didn ' t have a DNR order. The DON stated " I don ' t know all of them right off the top of my head. " The DON did not remember if she asked LPN C if resident #2 had a DNR order, but " I will from now on. " 12. Telephone interview with the ARNP for resident #2 ' s attending physician revealed he recalled the facility contacting him in regards to resident #2 ' s death on [DATE]. The ARNP stated nothing stood out in his mind about the call as typically they are just asking for orders to pronounce and release which he provided. The ARNP did not recall the nurse ' s telling him of any problem related to her death such as it being unexpected or anything out of the ordinary. The ARNP remembered resident #2 as " a younger gal " with failure to thrive. She had [MEDICAL CONDITION] which metastasized to the brain. The ARNP remembered the resident looked terrible about a week before she died . " She was a gal that was not doing well at all and it was really a terrible, terrible case. " The ARNP did not recall being informed that resident #2 did not have a DNR order. He would expect facility staff to in institute CPR, call a code, and do all of the things necessary for a resident who was found without pulse and respirations and no DNR order. " Legally you would need to call a code. " 13. Interview with resident #2 ' s attending physician and the medical director for the facility on [DATE] at 2:44 p.m. revealed he was not on call the night resident #2 had passed. He confirmed that the ARNP was on call that evening, and the doctor had found out indirectly about resident #2 ' s death. The doctor could not recall exactly when he was informed or who had informed him. The physician recalled that resident #2 was not at the facility for very long. She had a " horrible past history. " Metastatic [MEDICAL CONDITION] to the brain with a couple of craniotomies and an infection of the flap. The resident was non-communicative and would sort of stare at you. The doctor said he never spoke to the resident ' s family. He communicated with the facility nurses and hospice in regards to resident #2. The physician/medical director stated he has been informed that the resident did not have DNR orders and stated " I guess they assumed that since she was hospice. " The physician could not recall when he was informed of the lack of DNR orders for this resident. The physician stated his expectation for a resident who has no DNR orders and was found without pulse of respirations would be to call 911 and start CPR procedures. 14. Interview with resident #2 ' s regular hospice RN, who had been coming to this facility for 9 years, on [DATE] at 12:53 p.m. revealed she works on the burgundy team and was familiar with resident #2. The hospice RN recalled the resident having come to the facility from the hospital where she had undergone brain surgery and developed an infection in the flap. The hospice nurse described resident #2 as very young, in her 40 ' s. When the resident was first admitted to the nursing home back in late March of 2012, she was discussed as a possible hospice resident, but her daughter/health care proxy needed time to think about it. The hospice nurse said the resident ' s daughter was very young, only about [AGE] years old, and was down in Florida for about a week and then returned back up north to her home. The daughter later decided she wanted hospice for her mom, and hospice evaluated her and admitted her for services on [DATE]. The hospice nurse stated the resident also had a [AGE] year old son who lived in a neighboring county and required psycho-social help. Hospice worked with the neighboring county to obtain special services and counseling to help the resident ' s teenage son. When resident #2 was first admitted to hospice, her flap was healing. The hospice nurse recalled the resident speaking only one time, she said " yeah " . The hospice nurse also recalled holding resident #2 ' s hand on one occasion and the hospice nurse said to the resident " [AGE] year old sons ' can be a real pain in the butt sometimes. " The hospice nurse stated the resident squeezed her hand and smiled when she said this. The hospice nurse also recalled another time about a week before resident #2 passed when the resident had kissed her hand. The nurse stated the resident did this after she had told the resident she was really sorry for everything she had been through. The hospice nurse stated the resident would follow with her eyes, but she could not necessarily tell for sure if she understood what was happening or if the responses she received were true responses. The hospice nurse said the resident fed herself at the beginning of her stay when the utensil was placed in her hand but towards the end (the last week) she thought staff were helping her with meals because she was eating less and less. The hospice nurse clearly recalled discussing advanced directives with resident #2 ' s daughter and stated she documented this in the resident ' s chart. The hospice nurse thumbed through the resident ' s clinical record and pulled out a form labeled " Progress Notes. " The document was dated [DATE] and noted Hospice nurse spoke with patient ' s daughter regarding resident ' s current status. Daughter states " I want my mom to go to the hospital if she needs to. " Facility nurse and ADON made aware that patient ' s daughter wants hospitalization for patient if needed. The hospice nurse then went on to state to the surveyor that it was her understanding that the resident had no advanced directives. The daughter was not ready to discuss that. The daughter was so young and " we weren ' t going to shove DNR or advanced directives down her throat. " The hospice nurse stated there really wasn ' t time to sit and work through this with the daughter as we didn ' t have resident #2 under our care for a very long time. 15. Interview with the hospice social worker on [DATE] at 1:42 p.m. revealed she had a difficult time assessing how much resident #2 was aware of because she had major brain surgery. The social worker stated resident #2 was either in bed or in a reclining geri-chair, and she always wore a helmet. The social worker never could get a real good read as to whether or not the resident could understand her or not. The social worker stated the resident ' s family dynamics were difficult to navigate. She had a daughter who lived out of the state who was a young mom ab