Every finding on record at Aviata at Orange Park

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety sanitation standards and food handling practices to prevent injury to residents and the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to serve dinnerware and trays in clean and good condition, clean food debris stuck on and around the meat slicer blade, and clean one of two microwaves located in the 300-600 unit nourishment room. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure that compromises residents' well-being.The findings include:A tour of the kitchen was conducted on 11/19/2025 at 11:00 AM. During the tour, cracked plates, cracked bowls, and meal trays with rusted, cracked edges were observed on the tray line and dish rack located across from the reach-in refrigerator. It was also observed that the meat slicer, located on the bottom shelf of the prep table, was filled with food debris on and around the blade. One of two microwaves in the nourishment room located on the 300-600 unit, was filled with food debris stuck on and around the inside of the microwave. (Photographic evidence obtained)An interview was conducted on 11/20/2025 at 10:31 AM with [NAME] A, who reported that all kitchen staff were responsible for cleaning kitchen equipment after each use. Dietary Aides were assigned to washing dishes and watching for broken and rusted dinnerware and utensils. The Dietary Manager was responsible for cleaning the microwave ovens in the nourishment rooms.An interview was conducted on 11/20/2025 at 10:48 AM with Dietary Aide B, who reported that all staff/the [NAME] were responsible for cleaning the meat slicer daily. Dietary Aides washed dishes using the dish machine and were responsible for ensuring dinnerware and utensils were clean and in good condition. Nursing was responsible for cleaning the microwave ovens in the nourishment rooms.An interview was conducted on 11/20/2025 at 11:03 AM with Dietary Aide C who reported cooks were responsible for cleaning the meat slicer after each use. Dietary Aides washed dishes using the dish machine and were responsible for ensuring dinnerware and utensils were clean and in good condition. Dietary Aide C reported that she was unsure of who cleaned the microwave ovens in the nourishment rooms, and stated Dietary was not responsible for that task.An interview was conducted on 11/20/2025 at 11:41 AM with the Food Service Director who reported that Dietary Aides were responsible for running the dish machine and reporting any concerns with dinnerware and utensils to the Certified Dietary Manager/Food Service Director. The cooks were responsible for cleaning kitchen and food service equipment such as the meat slicer after each use. The Food Service Director was unsure of who was responsible for cleaning the microwave ovens in the nourishment rooms.A review of the facility's policy and procedure titled Environment (Effective 5/2014, Revised 6/2025), revealed:Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.Procedures:. 3. All food contact surfaces will be cleaned and sanitized after each use. (Copy obtained)According to the FDA Food Code (2022) at https://www.fda.gov/media/164194/download, (Accessed on 11/25/2025), revealed:Chapter 4. Equipment, Utensils, and Linens 4-6 Cleaning of Equipment and Utensils, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Cleanability; 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; and (3) Free of sharp internal angles, corners, and crevices.

Based on observations, interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure food was served as ordered by the physician, in sufficient quantities to meet residents' needs, by failing to ensure five (Residents #62, #136, #103, #73, and #67) of five resident meals served, from a total sample of 40 residents, matched the physicians' diet orders. Failure to ensure dietary staff meet the nutritional needs of residents in accordance with established national guidelines has the potential to affect residents' clinical outcomes. Serving the correct diet ensures safety, supports healing, and protects resident rights.The findings include: A tour of the kitchen was conducted on 11/19/2025 at 11:00 AM. During the tour, tray line observations revealed the following: One meal ticket read: Regular large protein, 3 ounces (oz.) One meal ticket read: Large protein, 4 oz Two meal tickets read: Regular, 3oz. An observation of Resident #62's meal ticket on the 200 hallway read: Regular, double protein TID (three times a day), 3 oz. There was no difference in the amount of protein provided for the regular, large protein, 3 oz., regular, double protein TID, 3 oz., or regular 3 oz plates. A review of Resident #62's nutritional assessment, dated 9/3/2025, revealed a regular diet, regular texture with thin liquids and double protein portions for all meals. The resident's meal ticket documented regular, double protein TID, 3oz. A review of Resident #136's nutritional assessment, dated 11/14/2025, revealed staff were to add large protein portions to all meals, TID, to promote wound healing. The resident's meal ticket documented regular, large protein 3 oz. A review of Resident #103's nutritional assessment, dated 10/27/2025, revealed consistent carbohydrate diet (CCD), regular texture, thin liquids with large protein portions at all meals. The resident's meal ticket documented regular, large protein 4 oz. A review of Resident #73's nutritional assessment, dated 11/17/2025, revealed regular No Added Salt (NAS) diet, regular texture, regular/thin liquids consistency. Recommend: Large protein portions TID. The resident's meal ticket documented regular, 3oz. A review of Resident #67's nutritional assessment, dated 10/21/2025, revealed regular, regular texture, thin liquids, bedtime (HS) snack. The resident's meal ticket documented regular, 3oz. During an interview conducted with the Registered Dietitian (RD) on 11/20/2025 at 11:31 AM, she confirmed that she worked 16 hours per week (Tuesdays and Fridays) to provide clinical services to the facility. At 3:29 PM on this date, the RD was asked to explain the difference between large protein, double protein, and regular protein. She stated she did not think the facility had double protein or it would be a larger portion of protein; 1/2 servings versus 2 servings. The regular would be 1 serving at 3oz., large would be 1-1/2 servings at 4 1/2 oz., and the double would be 2 servings at 6 oz. During an interview with the Food Service Director on 11/20/2025 at 11:41 AM, she was asked if a resident's diet order was for double portions, what are they served? She stated, It is specified if it is double protein or double portion. Double protein and large portion is more of each item. A review of the facility's policy titled Therapeutic Diets (Effective 5/2014, Revised 10/2022), revealed: Policy Statement: All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Procedures: . 3. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. (Copy Obtained)

Based on record review and interviews, the facility failed to protect the resident's rights to be free from physical abuse for one (Resident #1) of three residents reviewed for abuse. The findings include:A review of the medical record for Resident #1 revealed an admission date of 8/16/2021. His medical diagnoses included quadriplegia; major depressive disorder; chronic pain; anemia; neuromuscular dysfunction bladder; polyneuropathy; and diabetes mellitus. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #1 required assistance of one staff member for most activities of daily living.A review of the nursing progress notes for Resident #1 revealed an entry dated 7/23/2025 08:32 - Between 0500-0545 this writer was working down 300 hall passing medication when police entered building asking who's the nurse and CNA for the resident, I had no idea what was going on at the time. CNA previously came down hall and told me she was gone for the shift and that she leaves early because of school. I didn't think anything of it because staff stated she always leaves early and had prior arrangements. Resident called 911 and reported abuse. Full body assessment was completed once notified by police and resident. Upon assessment there is bright red abrasions on right upper quadrant, right forearm, and right hand. Patient stated he's not in pain. VS are WNL- Temp: 98.2 BP 130/80 RR 18 HR 96 SPOs 98%. DON, administrator, and doctor notified of incident. Family made aware. A review of the Physician Progress Note for Resident #1 dated 7/23/2025 15:31- APRN (Advanced Practice Registered Nurse) was notified by DON that resident made allegations of physical abuse in regard to a nurse. Resident was examined sleeping in bed in no acute distress. APRN woke resident. Resident denies pain. Resident showed APRN his right hand. Erythema, dry flaking skin, and five small open abrasions were noted between resident's lateral wrist and lateral little finger MCP joint. No bleeding was noted. No scabbing noted. Additionally, on residence lateral right lower quadrant of his abdomen were six to seven straight lined excoriations. No open areas, and no bleeding. Resident has bilateral upper extremity contractures, including within his fingers. He is able to move his bilateral upper extremities with some movement in his fingers. Complete movement of fingers was not appreciated by APRN.During an interview conducted on 7/24/2025 at 9:20 AM with the Administrator, she said, I received a phone call from the DON that police was in the facility, that a resident had stated that he was physically assaulted because he asked for ice. The CNA has been suspended pending investigation.During an interview conducted on 7/24/2025 with Director of Nursing (DON), she said, When the nurse called the CNA, she said that she took the phone and put it on the dresser. That he used another phone to call 911. There were abrasions to the abdomen and scratches to the right hand. I had the nurse do a head-to-toe assessment.During an interview conducted on 7/24/2025 at 9:35 AM with Resident #1, he stated, It started during the night. That CNA always had a snotty attitude. I asked for a cup of ice. She told me the ice machine was broken, I told her the other CNAs go to the other side to get it, she said she wasn't. I told her I would write a grievance on her, and she sat the urinal unemptied back on my table, and started screaming at me, calling me a cripple. I told her I was recording her when I really wasn't. That's when she began trying to snatch my phone from me. There was a struggle. She hit me on the arm. She scratched me on my stomach and my hand. When she took my phone, she looked through it looking for the recording I said I took of her. She then put my phone on the dresser under the TV and said now I want to see your crippled ass go get it. I called 911 from the phone I play games on. (Photographic evidence obtained)During an interview conducted on 7/24/2025 at 9:45 AM with Resident #1's roommate, he was asked if he witnessed the incident. He said that he only heard what was going on because the curtain was between them but stated that it happened just as Resident #1 said.During an interview conducted on 7/24/2025 at 9:50 AM with Resident #2, she stated, Everybody here is very good. No problems with anyone. Nobody has complained about any of the staff. I heard him screaming at the CNA, he was saying that she hit him. He called her all kinds of names.During an interview conducted on 7/24/2025 at 9:55 AM with Assistant Director of Nursing (ADON), she said, The DON called at 7:30. The CNA had left and didn't tell anyone that anything had happened.Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation, issue date of 11/30/2014, last approval date of 11/16/2022, reads, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees at the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to maintain cleanliness and good repair of the walls in the chemical storage closet, kitchen floors, and baseboards. Live roaches were observed crawling on plastic drink lids and packages of bread. The facility failed to seal and date mark two open bundles of bread on the bread rack and failed to clean one of two microwaves located in the north unit nourishment room. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 11/06/23 at 7:25 a.m. During the tour, the kitchen floor tile was covered with food substance and grime. Floor tiles were cracked around the cook and prep area, in and around the utility room, and between the drink and ice machine area. Baseboards were cracked, filled with debris, and pulled away from the wall in the cook and prep area, the dish machine room, the utility room, and behind the drink machine next to the door entrance from the dining room. A utility cart holding plastic cups and lids had dark residue around the bottom shelf and a live roach crawling on the plastic container of lids. The wall panel was pulled away from the wall in the dish machine room and utility room. (Photographic evidence obtained) No date markings were observed on two open bundles of bread located on the bread rack in the dry storage room. A live insect was observed crawling in one open bundle of bread, which was provided to the Certified Dietary Manager (CDM) to discard. Another observation was made again on 11/07/2023 at 9:04 a.m. During this time, new observations of two open bundles of bread were on the bread rack in the dry storage room with no date marking. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 11/8/23 at 11:30 a.m. New observations of black substances of unknown origin were spread over the walls and door in the chemical storage closet located in the dish room next to the utility room. The chemical storage closet floor tile was filled with loose dirt and debris. Used standing mop water was found sitting in a mop bucket in the utility room. Baseboards were cracked, filled with debris, and were pulled away from wall behind the drink machine next to the door entrance from the dining room and cracked and stained floor tiles were observed in the nourishment room on the north unit. (Photographic evidence obtained) On 11/08/23 at 11:45 a.m., the microwave in one of two nourishment rooms located on the north unit was observed to have food debris and black substances of unknown origin resembling biological growth on the inside top panel. (Photographic evidence obtained) An interview was conducted on 11/09/23 at 1:03 p.m. with Dietary Aide A, who confirmed that the Dietary Aides cleaned the floor areas in the tray line area, dish room, dry storage room, freezer, and refrigerator daily. The Cooks were responsible for cleaning the floor daily in the stove and prep area. She thought deep cleaning of the kitchen floor occurred monthly. She confirmed that the facility's policy for date marking leftover bread was to close the bread and label it with the date opened and use by date. When asked who was responsible for cleaning the nourishment room microwave, she replied Housekeeping. An interview was conducted on 11/09/23 at 1:20 p.m. with Dietary Aide B, who confirmed that all Dietary Aides were responsible for cleaning the floor in the kitchen. The floors were cleaned nightly. Deep cleaning of the kitchen floor was completed monthly but she was unaware of who completed the task. She confirmed that opened and used bread placed back on the bread rack was to be dated. When asked who was responsible for cleaning the nourishment room microwave, she replied, the dietary aides. An interview was conducted on 11/09/23 at 1:28 p.m. with Cook C, who stated the Dietary Aides were responsible for sweeping and mopping the entire kitchen floor. Maintenance /Housekeeping deep cleaned the floor monthly, overnight. Kitchen floors were cleaned twice daily. Cook C confirmed that opened and used bread placed back on the bread rack was to be dated and used wihint three days. When asked who was responsible for cleaning the nourishment room microwave, she stated the CDM (Certified Dietary Manager) cleaned the microwaves in the nourishment rooms. An interview was conducted on 11/09/23 at 1:46 p.m. with Maintenance Director D, who stated he received maintenance requests verbally or from the maintenance logbook located at each nursing station. Any staff could report or add to the logbook. He confirmed receiving maintenance requests from Dietary related to the missing floor tiles and grout. He also noticed the grout in the kitchen and stated he could repair it as soon as possible but needed to locate the tile pieces and schedule two evenings to complete the repairs. He stated kitchen staff were responsible for cleaning the kitchen floor at the end of each day and Housekeeping was responsible for deep cleaning the kitchen floor. An interview was conducted on 11/09/23 at 1:58 p.m. with Environmental Service Director E, who confirmed that Dietary cleaned the kitchen floors, and Environmental Services/Housekeeping provided a monthly deep cleaning of the kitchen floors. An interview was conducted on 11/09/23 at 2:00 p.m. with Dietary Aide E, who confirmed that the kitchen staff were responsible for cleaning the nourishment room refrigerators and microwave ovens. A review of the facility's policy and procedure titled Safety (dated 7/2014), revealed: The kitchen and associated equipment will be properly maintained and all Dining Services staff will follow safe operating practices. All kitchen and kitchen equipment issues will be promptly reported to facility staff and recorded according to facility protocol. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 11/14/2023) Page 156. Chapter 6. Physical Facilities. 6-5 Maintenance and Operation. 6-501 Premises, Structures, Attachments, and Fixtures - Methods. 6-501.11 Repairing. Physical Facilities shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) Physical Facilities shall be cleaned as often as necessary to keep them clean. A review of the facility's policy and procedure entitled Preventing Foodborne Illness - Food Handling (dated 7/2014), revealed: Food will be stored, prepared, handled, and s.erved so that the risk of foodborne illness is minimized. Policy and procedure entitled Safety (dated 7/2014), revealed: The kitchen and associated equipment will be properly maintained and that all Dining Services staff follow safe operating practices. All kitchen and kitchen equipment issues will be promptly reported to facility staff and recorded according to facility protocol. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023) Annex 4. Equipment, Utensils, and Linens. 4-602.12. Cooking and Baking Equipment. Page 129. (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 4-602.13 Nonfood-Contact Surfaces. Nonfood-Contact Surfaces of Equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on facility document review and staff interview, the facility failed to ensure a registered nurse (RN) worked at least eight consecutive hours a day, seven days a week on two (9/10/23 and 9/16/23) of seven days reviewed. Nurse staffing in nursing homes has a substantial impact on the quality of care and outcomes that residents experience. Failure to staff a registered nurse for at least 8 hours a day could result in a negative impact on resident care. Review of the facility calculating state minimum nursing staff for long term-care facilities worksheet dated 9/10/23 through 9/16/23 revealed on 9/10/23 and 9/16/23 there were 0.00 hours documented in the R.N. hours column of the form. (Copy obtained) On 9/28/23 at 2:20 PM, an interview was conducted with the Administrator regarding the calculated staffing report. After reviewing the report, the Administrator acknowledged the lack of RN coverage on 9/10/23 and 9/16/23. He added that he would be working with their staffing coordinator, who is new to the role, to be sure there is an RN every day.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that drugs and biologicals used in the facility were safely stored for 1 (Resident #4) of 4 sampled residents, demonstrated by medication left at the resident's bedside. The findings include: On 3/9/2023 at 12:50 PM, an observation of Resident #4's room was made. Upon entering the resident's room three stacks of several small pill cups were observed labeled with the resident's room # written in black marker at the resident's bedside. Two (2) of the cups contained several small round tablets. The tablets were dark brown, beige, and peach in color. Two (2) large round yellow wafers were observed in one of the pill cups. In addition, two (2) inhalers and a clear plastic cup filled with cough drops were also observed. (Photographic evidence obtained) Resident #4 was not in the room at this time. A review of Resident #4's clinical records revealed an admitted [DATE]. The resident's diagnoses included cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), pain in right knee, atrial fibrillation (A-fib), anxiety disorder, malaise, constipation, and cognitive communication deficit. A review of the physician's orders for Resident #4 included: 8/25/21 Colace 100mg: give one capsule by mouth two times a day (may hold for loose stool) 8/26/21: Senna 8.6mg: give two tablets by mouth at bedtime for constipation 9/27/21: Eliquis 5mg: one tablet by mouth twice a day for A Fib 1/2/22: Trelegy Ellipta Aerosol powder 100-62.5-25 MCG/INH: 1 puff inhale orally one time a day for COPD 10/22/22: Tizanidine 2mg: one tablet by mouth four times a day for muscle spasm 3/4/23: Singulair oral chewable tablet 5mg: give one tablet by mouth twice a day for allergic rhinitis 11/29/21: Proventil HFA 108: one inhalation every 4 hours as needed for SOB On 3/9/3023 at 2:28 PM, a follow up visit was made to Resident #4's room. The resident was still not in his room. However, the medications previously observed at the resident's bedside remained. Also, at this time a small round white tablet had been placed in one of the pill cups. An interview was conducted with Resident #4 on 3/9/2023 at 3:27 PM. During this time all the pill cups containing medication remained at the resident's bedside. When the resident was asked about the pills, he confirmed the pills were his prescription medications. He stated that when the nurse brought them, he put them back in the cup. When asked what the pills were, he stated the pills were a mixture of laxatives and Singulair. He explained the laxatives upset his stomach and the Singulair raises his blood pressure. He had stomach pains the night before and didn't want to further upset his stomach, so he did not take the laxatives. He stated he's afraid to take the Singulair and that his doctor is adjusting the dosage, so it doesn't raise his blood pressure. He stated the round white tablet that had been added was his muscle relaxer, which he planned to take at a later time. (Photographic evidence obtained) A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indication Resident #4 was cognitively intact. Further medical record review for Resident #4 revealed he did not have a doctor's order for self-administering of any medications. Review of Resident #4's care plan revealed no care plan related to independent medication administrator. On 3/9/2023 at 3:53 PM, the Administrator and Employee C, a Licensed Practical Nurse (LPN) Unit Manager entered Resident #4's room. They observed all the round tablets, except for two large yellow wafers, which were no longer present. Many of the pill cups were no longer present. Upon seeing the two yellow wafers, the LPN stated, Those look like TUMS, which shouldn't be here either. Prior to leaving the room several small tablets (dark brown, beige, and peach in color) were observed in a clear plastic bag in a small garbage receptacle located next to the resident's bed. The LPN and Administrator were directed to the clear bag in the garbage receptacle. The LPN confirmed the pills were medications. Looking closer into the bag she stated, This looks like Singular. When was asked about residents having medications at bedside, she stated, They would have to be assessed and if it was deemed safe, they would be given a lock box to keep the medications stored in in their rooms. She confirmed Resident #4 had not been assessed for self-administration of medication and therefore the medications should not have been at his bedside. When asked about the medications being in a clear bag in the garbage receptacle, she stated this should not have been done. When asked about proper medication disposal, she stated, The facility practice is to crush and dispose of unused medications. A review of the facility's policy and procedure titled Self-Administration of Medication at Bedside (Document name: N-872, with effective date on 11/30/2014 and revised on 8/22/2023) revealed: The resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. Procedure: The MAR (medicine administration record) must identify meds that are self-administered and the medication nurse will need to follow up with resident as to documentation and storage of the medication during each med pass. If kept at bedside, medication must be kept in a locked drawer. (Photographic evidence obtained)

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to provide adequate supervision to ensure the safety and prevent the elopement of one (Resident #3) of three residents sampled. The facility failed to adequately supervise residents in the smoking area. This practice has the potential of negatively impacting the safety and well-being of residents who smoke in the designated smoking area. The findings include: Record review for Resident #3, revealed an admitted [DATE] and readmitted [DATE] from the hospital. Her diagnoses included [CONDITION(S)], polyneuropathy, anxiety disorder, and [CONDITION(S)]. Review of the 7/23/2022 quarterly minimum data set (MDS) assessment revealed she had a brief interview for mental status (BIMS) score of 15 out of 15, indicating cognitively intact. Wandering was noted as none. A review of her functional status revealed she needed extensive assistance/one person assist physical assist for locomotion on/off unit. Wanderguard was noted as being used daily. A review of Resident #3's discharge (return to facility anticipated) MDS assessment conducted on 8/15/2022 revealed Resident #3 showed potential indicators of [CONDITION(S)], hallucinations, delusions, behaviors (not directed toward others): 4-6 days, and rejection of care: 1-3 days. Further record review for Resident #3 revealed an assessment for elopement risk was conducted on 4/24/2022 which showed high risk for elopement. The record reveled a wanderguard device was placed on that day. Review of the resident's eTAR (electronic treatment record) revealed the wanderguard device was signed of as in place and functional as ordered each day from date of placement. A nursing progress note for Resident #3 dated 8/15/2022 at 12:58 pm stated, Resident sent to OPMC ER for eval of altered mental status per psych. Resident was crying, delusional and exit seeking. (Photographic evidence obtained) A review of facility records revealed Resident #3 eloped from the facility on 9/2/2022. A review of Resident #3's physician's order dated 9/2/2022, revealed 1:1 monitoring for exit seeking behaviors. Record review of the care plan for Resident #3 found she was care planned for the following: - Focus: Resident has behaviors related to refusal of medications, urinates on floor, and exit seeks and wanders (date initiated 4/26/2022, revision 9/6/2022) Goal: Resident will have fewer episodes by the review date (Target date 10/21/2022) Interventions: Administer medications as ordered. Monitor for side effects and effectiveness. Explain all procedures to the resident before starting and allow resident 5 minutes to adjust to changes -Focus: Resident is an elopement risk/wanderer related to impaired safety awareness (date initiated 8/24/2022, revision 9/6/2022) Goal: The resident's safety will be maintained through the review date (initialed 9/3/2022) The resident will not leave the facility unattended through the review date (initiated 9/3/2022) Interventions: 1:1 monitoring (initiated 9/2/2022) Assess for elopement risk (initiated 9/3/2022) Electronic monitoring device (initiated 9/3/2022) -Focus: Resident is an occasional smoker (date initiated 8/9/2022, revision 9/6/2022) Goal: The resident will not smoke with supervision through the review date. Interventions: Observe clothing and skin for signs of cigarette [CONDITION(S)]. (Photographic evidence obtained) During a tour of the resident smoking area at the end of the 600 hall on 9/8/2022 at 10:25 am, residents were observed being let inside the building by a staff member. A sign posted on the door read, Smoking Times Effective August 16, 2022: 8:00, 10:00, 2:00, 4:00, 7:00, 9:00. The smoking area consist of a cement patio with two benches. To the left of the smoking area, grass leads to the parking lot with no established pathway. Behind the smoking patio, grass leads to trees and a wooded area. To the right of the smoking patio is a cement walkway. The cement walkway goes around the facility with the oxygen storage shed on the left and into the parking lot on the right. There was no fencing, or any type of barrier observed around the smoking area. (Photographic evidence obtained) During an interview with Resident #4 on 9/8/2022 at 10:35 am, she was asked if she goes outside to smoke on scheduled smoking breaks. She stated, Yes. When asked if staff are outside with residents during smoking breaks. She stated, Usually, but not always. She was asked if she has been outside smoking when staff were not present. She stated, Well, I've only been here for about a week, but yes, I've been outside smoking and there was no staff out there a couple times. A review of Resident #4's medical record revealed that no BIMS score had been recorded yet. During an interview with Resident #5 on 9/8/2022 at 10:40 am, she was asked if she smokes. She stated, Yes. When asked if she goes outside to the smoking patio during the scheduled smoking breaks. She stated, Yes. When asked if staff are outside with the residents during the scheduled smoking breaks. She stated, Not always, they weren't outside with us last night during the last smoking break. She was asked if staff often leave the scheduled smoking break unattended. She stated, It's fine during the day, it's at night that it happens. Last night for the 9:00 pm break, they just held the door open and let us outside, but there was no staff out there with us. During the same interview, Resident #6 stated, We just want to do what we're supposed to do, follow the rules. I smoke too, and I just want to do what we're supposed to do. She was asked if she had attended any scheduled smoking breaks where staff was not outside with the residents. She stated Yeah, last night. It's just like she said, they held the door open for us and let us go outside, but no one stayed out there with us. A review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating cognitively intact. An interview was conducted with Resident #7 on 9/8/2022 at 12:45 pm. He was asked if he recalled a recent incident with another resident leaving the facility grounds during a scheduled resident smoking break. He stated, Sure, I know it was Resident #3. I was there and I can tell you what happened. I watched her. Resident #3 was outside with us, smoking. She got up and pushed her wheelchair over the grassy area, you know, she stood up and used her wheelchair like a walker. Then when she got to the walkway, she sat down in her wheelchair, and she kept going. Now, she did the same thing the night before, but she ended up going back into the building on the 300-unit door. But Employee C told me if I see her leave the area again to just let the staff know. So, I figured, I better let the staff know, because it looked like she was gonna just keep going this time. So, I knocked on the door until a CNA (Certified Nurse's Aide) came to the door. I told her that Resident #3 just got up and left, and she just looked at me and didn't say anything. She went back inside, and she must have told the others because next thing I know, there was 4 or 6 CNAs out here looking for Resident #3. They said they ended up finding her on the other side of [NAME] Ave, and I don't know how she made it across the street but I'm just glad she didn't fall or get hit by a car. When he was asked when this all occurred. He stated, It was dark out. It was this past Friday. When he was asked if any staff were outside in the smoking area when Resident #3 left the smoking area. He stated, No, there was no staff out with us. That's how it's been. Sometimes staff is outside with us, but usually not. I don't know if a CNA is supposed to be outside with us. Usually, the only time I see them is if another resident is on a one to one, then the CNA will be out there with us. When that resident wants to go back in, that CNA has to go in with them. A review of Resident #7's quarterly minimum data set (MDS) assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating cognitively intact. An interview was conducted with Resident #3 on 9/8/2022 at 12:55 pm. She was asked if we could talk about something that happened the other night. She shrugged. She was asked if she remembered leaving the building on her own. She said, No. She was asked if she smokes. She stated, Yes, sometimes, but not as much anymore. She was asked if she recalled leaving the smoking area outside to go away from the facility recently. She stated, No, I don't think so. During an interview with the Administrator on 9/8/2022 at 1:30 pm, he was asked to review the elopement incident that occurred on 9/2/2022. He stated, Resident #3 was outside smoking and one of our residents let staff know she left the area, that she walked her wheelchair over the grassy area and left the area. Once staff were aware, they started looking for her. One of our CNAs found her outside a business across the street. He was asked to confirm if he meant she was found by staff across [NAME] Ave, meaning she had crossed four lanes of traffic. He stated, Yes. He was asked why there was no staff outside with the residents during the smoking break. He stated, There is no good reason why. It was staff miscommunication. We have re-educated staff. He was asked if staff are supposed to be outside with residents during smoking breaks. He stated, Yes. During a phone interview with Employee B conducted on 9/8/2022 at 9:25 pm, she was asked if she was assigned to monitor the resident smoking break at 7:00 pm on Friday [DATE]. She stated, I work 7 pm until 7 am, I'm always here before 7 pm, I'll supervise the 7 pm smoking breaks, I wasn't scheduled on that Friday for the smoking break, but I did go out there to supervise. I opened the door to let the residents out as a group. I was standing at the door, and I can see the smoking area and the residents. I can see everybody from the door. I was letting residents in and out. She was asked if any other staff were outside with the residents while she was letting them in and out at the door. She stated, No. She was asked how she learned Resident #3 had left the smoking area. She stated, Another resident told us, and we didn't see her, so everyone started looking for her. She was asked if the resident was located. She stated, Yes, they found her. I'm not sure exactly where, but outside, out front of the facility. She was asked if she was re-educated on the policy for resident's smoking breaks after the elopement incident on [DATE]. She stated, Yes. I had an in-service. We know better now; we cannot stand at the door. We must sit outside with the residents when they are outside. A review of Education In-Service Record dated 9/6/2022, topic: 1:1 Education Smoke Patio Protocol: Summary of training session: revealed: Staff MUST attend the scheduled smoke breaks. Staff are to be on the actual patio with the residents. Staff are to remain on the smoke patio for the ENTIRE length of the smoke breaks. Residents are NEVER to be left alone. Employee B's signature was documented on the form. (Photographic evidence obtained) During a follow-up interview with Resident #3 on 9/9/2022 at 8:45 am, she was asked how she was feeling today. She displayed a flat affect and stated, I'm ok. She was asked if she recalled leaving the facility grounds a few nights ago from the smoking area. She stated, Yes, I remember. I don't want to talk about it. She was asked if staff were outside with her the night, she left the facility grounds. She stated, No, they weren't out there that night, but I don't want to talk about. Interview was ended at that point so as not to upset the resident. During an interview with Employee C on 9/9/2022 at 9:35 am, she was asked if Resident #3 resides on her unit. She stated, Yes, on the South Wing. When asked what Resident #3's cognitive status was. She stated, She's alert and oriented. She was asked if Resident #3 had been assessed for her risk level of possible elopement. She stated, Yes, when she was admitted in April, and when she was readmitted in August. Employee C stated that the assessment revealed the resident was an elopement risk, so a wanderguard was placed on her. She was asked if the resident was agreeable to wearing the wanderguard device. She stated, Yes. She was asked how long the resident has worn the wanderguard device. She stated, She was admitted on [DATE], and the wanderguard was placed on 4/24/2022. When asked how residents who smoke with a wanderguard device get out to the smoking patio. She stated, Out the 600-hall door, the staff opens the door for them. The staff will put in the code to bypass the alarm, the door will still alarm if it's open for I think longer than 10 seconds, so they put the code in again and shut the door. She was asked if staff are supposed to stay outside with the residents while they are smoking. She stated, Yes. She was asked if she knew how she was able to wander away from the smoking area. She stated, I wasn't here when it happened but according to one of the residents, she just backed up her wheelchair to the grass, stood up and started walking. She was asked if she knew if there was a staff member outside with Resident #3 when she eloped from the facility grounds. She stated I don't know. There was a 1:1 CNA out there with another resident but I don't know if she was out there when Resident #3 actually left. I wasn't here, I was called to come in once they discovered she was missing, so I don't have an answer for that. She was asked if she was aware of any other incident where Resident #3 had wandered away from the smoking patio area. She stated, No. An interview was conducted with the Assistant Director of Nursing (ADON) on 9/9/2022 at 3:15 pm. She was asked how supervision is provided to residents who require a wanderguard device. She stated, Based on their care plans needs and severity, they may need a one-on-one staff, or they may be able to walk in the building if they are not exit seeking. She was asked if a resident is exit seeking, what interventions are implemented. She stated, They will usually be placed on a one on one with staff. We'll get a psych eval, review their chart, review their doctors' notes, check labs and urine to see if there is a systemic process that is causing the behavior. She was asked how the facility is keeping these residents safe. She stated, We do education with staff, spot checks or frequent checks every 15 minutes. The restorative CNA performs frequent checks of all residents who wear a wanderguard. We address it based on other factors, such as if this was also a behavior at home or if this a new behavior. We'll use one on one staff if a resident is exit seeking until they consistently no longer demonstrate exit seeking behaviors. A review of the staff scheduled on 9/2/2022 revealed that Employees A and B were both scheduled to work 7 pm to 7 am on that date. The schedule revealed Employee A was assigned to 7 pm smoking break. (Photographic evidence obtained) A review of Education In-Service Record dated 9/6/2022, topic: 1:1 Education Smoke Patio Protocol: Summary of training session: revealed: Staff MUST be on time for scheduled smoke break duty. Staff MUST remain on the patio for the entire break. Staff MUST immediately report any conflicts with timing/tasks that conflict with assigned smoke break times. (Reviewed with Employee A via phone 9/6/2022 at 14:30) (Photographic evidence obtained) A review of the facility's policy Smoking- Supervised with effective date 11/30/2014 and revised on 2/7/2020 read: Policy: The center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. (Photographic evidence obtained)

Based on observations and interview, the facility failed to store, prepare, and distribute food in a safe and sanitary manner to prevent foodborne illness by failing to practice appropriate hand hygiene and glove use when necessary, during food preparation activities to prevent cross-contamination. The findings include: During lunch service in the kitchen on 6/10/2022, at 11:15 AM, the following were noted: 1. At 12:03 PM, Employee A, Dietary Staff member was observed wearing gloves, opened the warmer by the handles, pulled out a pan of cornbread and placed it on the stove top. Employee A grabbed the spatula and began to cut the cornbread and guide it on to the spatula with the gloved hand. There was no hand hygiene and glove change performed in-between each task. 2. At 12:05 PM, Employee B, Dietary Staff member was observed grabbing plates of food prepared for the residents and placing them on the trays to be delivered to the units and dropped the top to a plate warmer on the floor. Employee B picked up the top and placed it on top of the milk cooler and then continued to place resident plates on the warmers by grabbing the rim of the plates. Hand hygiene was not completed in between tasks. During an interview with the Certified Dietary Manager (CDM) on 06/10/2022 at 12:09 PM, the CDM verified that hand hygiene should be completed, and gloves should be changed in between the tasks. She then asked the staff members to wash their hands and don a new pair of gloves. On 6/10/2022 at 12:45 PM, the CDM was observed grabbing clean silverware, designated for the residents, with bare hands and rolling them in napkins for dining. No hand hygiene was observed prior to completing the task. On 6/10/2022 at 12:46 PM, Employee B was observed grabbing the handle of the walk-in freezer to open it. The staff member then reached in to grab Magic Cup and continued to fix resident meals without performing hand hygiene.

Based on resident interviews, staff interviews, and record review, the facility failed to consider resident group views, and act promptly upon the grievances and recommendations of the group's concerns regarding resident care and life in the facility. Specifically, the facility failed to act promptly to concerns regarding food preferences, timeliness of food service, and palatability of food. The facility failed to demonstrate its response and rationale for such response. The findings include: A review of the Food Committee minutes for 10/2021, revealed that residents had voiced concerns regarding not getting food that they like, Residents want more meat for breakfast., and Residents want more food, larger portions. These concerns were documented as having been forwarded to the registered dietitian. A review of the Food Committee minutes for 11/2021, revealed that residents stated the menu changed often, so they didn't know what was being served. The reason was identified that the food distributor had not sent or cancelled certain food items such as those for use in carrot cake or dutch apple pie recipes. Residents also stated the facility did not have enough food left over for second helpings or double portions, and meat was only offered at breakfast two or three times per week. Residents voiced concerns with repeated menu items, indicating they were tired of the same items. They stated overall, they felt dietary services had declined. No prior concerns with resolutions were documented. Continued review of the Food Committee minutes revealed that no minutes were completed for 12/2021 or 1/2022. A review of the Resident Council minutes from 10/2021 through 1/2022, revealed no documentation of the facility's resolution of any previous food complaints. Resident #42 was interviewed on 1/18/22 at 12:24 p.m. He stated the food was often served cold, and had no taste to it. Resident #61 was interviewed on 1/18/22 at 12:41 p.m. She stated the facility food was horrible. Resident #18 was interviewed on 1/18/22 at 2:10 p.m. He stated he had not received a beverage, utensils, condiments, or dessert. He further stated the food was often overcooked, like the potato wedges, which he said were hard and inedible. Resident #80 was interviewed on 1/18/22 at 2:10 p.m. He stated the facility food was always served cold because the staff delivered it too late. He further stated the certified nursing assistants (CNAs) helped to serve meals on other units first, he would be served his tray later. Resident #64 was interviewed on 1/19/22 at 10:00 a.m. She stated she was unaware that she could put her preferences on her meal ticket. She had eaten grits, toast, coffee, and juice for breakfast, but would have preferred a biscuit instead of toast. She said she often ordered out for pizza or Chinese food. The Registered Dietitian (RD) was interviewed on 1/21/22 at 4:40 p.m. She stated she had recently returned to work at the facility full-time. She restarting the Food Committee meetings, as she was unable to find minutes for the past few months. She stated she was beginning to communicate with the residents more directly. Over the past year, she had only assisted the Certified Dietary Manager (CDM) on a quarterly basis. She said she had been involved with resident food preferences in the past year, but was now going to take on more responsibility. She had redone some food preferences. She said she had not been privy to the past six months of Food Committee notes, or Resident Council meeting notes. She said if something was brought up to her, she would find out what the residents' preferences were and then meet with the residents. She said she spoke with the dietary staff, but they do come and go. She had also spoken with the kitchen staff to see whether there were any current concerns. She helped to resolve them if she was made aware. She believed that the resolution process for resident concerns was currently a broken system. She said the last CDM was no longer at the facility, and a lot of things fell off. She said she would now be here five days a week, perhaps not all day, but would try to get to the facility every day. She had given her phone number to the residents, so she could be informed if there were problems that required correction. She said some RDs did not want to work on food. The Activities Director (AD) was interviewed on 1/21/22 at 5:05 p.m. She stated she scribed the minutes during the Resident Council meetings. If there was a resident complaint, she wrote up a grievance and gave it to the appropriate department for follow up. In the next monthly meeting, she would ask if old business had been resolved. She said she was not involved in what the resolutions were. If there was a group grievance, she would not write it up, but would bring it to the following morning's stand-up meeting. The staff from the assigned department would then take ownership of the concern. Social Services would investigate for resolutions, but there had not been a Social Services Director at the facility for a few weeks. She said she did not oversee whether resolutions to concerns were completed/not completed, nor did she oversee/follow up if the residents continued to state the same concerns. The Administrator (NHA) was interviewed on 1/21/22 at 5:35 p.m. He stated grievances were discussed in the morning meetings. The departments would then discuss resolutions. If there were concerns or difficulties in the resolution process, he would develop a performance improvement plan. The facility's policy on Complaint/Grievance, initiated on 11/30/14 and last revised on 8/9/18, revealed: The intent of this guideline is to support each resident's right to voice grievances and to assure that after receiving a complaint/grievance, the center actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution.

Based on observations, interviews, and record review, the facility facility failed to develop and implement a discharge care plan for one resident (#84) in a total sample of 44 residents. The findings include: On 01/18/22 at 2:45 PM, Resident #84 was observed accompanied by a staff member for one on one (1:1) supervision. In an interview on 01/18/22 at 2:55 PM, Resident #84 stated she did not want to be at the facility and had notified the staff about her willingness to leave but no one responded. While holding back tears, she continued to state that she came to the facility to stay with her husband who passed away in December. She added that since her husband's death her depression had increased. She also mentioned that her roommate passed away as well and she was now afraid to sleep. She requested a psychologist. A review of the clinical record revealed that Resident #84 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the January 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS) assessment, dated 10/18/21, revealed the resident had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. She was documented as independent for all actvities of daily living (ADLs). A review of the resident's care plan revealed that she demonstrated behaviors related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident is physically aggressive toward staff, as evidenced by pushing staff. Interventions included but were not limited to Resident on 1:1 supervision. There was no care plan available that was related to the resident's plan for discharge. (Copy obtained) On 01/20/22 at 12:11 PM, Licensed Practical Nurse (LPN)/Unit Manager K, stated the resident had been having increased behaviors of wandering from room to room, hence the 1:1 supervision. She added that the behaviors had increased after the resident's spouse's death, and that the facility's plan had been to have the resident placed in another facility, but she was not sure if the intervention was ever pursued. When asked about the resident's psychiatric evaluation, LPN K stated the resident was seen weekly by psychiatry and had been prescribed [MEDICATION(S)] (antipsychotic medication), but she refused to take the medication and therefore it was discontinued. When asked if other interventions had been attempted, LPN K stated the resident was alert and oriented, and it had been difficult to get her to do anything she was unwilling to do. LPN K mentioned that psychiatry had been seeing her quite often and had not deemed a psychologist's visit necessary at this time. LPN K stated he was not sure what the resident's discharge plan was, as it was not outlined in her care plan. During another interview with Resident #84 on 01/20/22 at 12:44 PM, she stated she did not want to be in the facility. She reiterated that she was in the facility because of her husband and he had passed way. The facility was not making any progress on her plan for discharge. A review of the Social Services progress note dated 12/30/21 read, The administrator, the unit manager for [Resident 84's] unit, and I had a meeting with her today to discuss a few things that have been brought to our attention. A few residents on Resident 84's hall, 300 hall, as well as a few residents from the 200 hall, have been complaining about [Resident #84] wandering into their rooms, taking things from their rooms, and placing them in other rooms, moving things around in their rooms, and interrupting their conversations with each other. [Resident #84] denied all of these things. She accused the unit manager of lying about the accusations that other residents have made. The unit manager tried to explain that the residents on her unit came to her upset and trying to find a resolution to their problems. [Resident #84] became very upset and called the unit manager a liar. We also spoke with the resident about her hygiene. [Resident #84] is refusing showers and not allowing staff to assist her with her bathroom needs. Again [Resident #84] denies refusing help. We asked her what we can do to be more accommodating toward her, since she feels the unit manager doesn't like her and the residents on her unit are telling lies about her. [Resident #84] said she would like to move to an Assisted Living Facility (ALF) or Independent Living (IL). I told [Resident #84] I would look into those options for her, and I would keep her posted on the facilities I find for her, so we can work on a transition plan that will best suit her needs. In an interview on 01/20/22 at 1:58 PM, Social Services Assistant (SSA) L stated the resident had mentioned she would like to be discharged to another facility. SSA L confirmed that the request for placement was not followed up on. When asked about the discharge care plan, she stated the Social Services Director (SSD) was responsible for developing the care plan upon admission. She confirmed that Resident #84's care plan was never developed. On 01/20/22 at 4:02 PM, MDS Coordinator M stated discharge plans were initiated upon admission and evaluated as needed. When asked about the discharge care plan, she stated Social Services was responsible for that particular care plan. When asked about the discharge care plan for Resident #84, she confirmed it was missing. When asked if she conducted care plan audits, she stated she was new at the facility and planned to review all care plans quarterly for completeness. On 01/20/22 at 4:10 PM during an interview with the Director of Nursing (DON), he stated Resident #84 was placed on 1:1 supervision due to safety concerns. The resident had a behavior of going into other residents' rooms and did not remember having done it. He added that psychiatry and corporate would determine when it was safe to discontinue Resident #84's 1:1 supervision. When asked about the resident's discharge plan, the DON stated he was not sure about that and would check with corporate. He stated the resident wanted to return to her apartment, but the resident's son and sister-in-law stated she was not safe. The DON confirmed there was no documentation to verify that communication took place. A review of the facility's policy and procedure titled: Discharge Planning (effective 11/30/2014), revealed it was the facility's policy to evaluate the resident's health status and formulate the best plan of discharge for each resident. Discharge Planning begins the day of admission. The process involves the resident and family, Care Management/Social Services and other members of clinical team. Procedure: 1. An initial evaluation of a resident is completed upon admission. A discharge goal and length of stay will be established upon admission and reviewed/revised at plan of care conferences. The goal is based upon clinical findings, availability of community and family resources and resident/family goals. 2. Discharge planning record will be completed within seven (7) days after admission. Discharge planning is adjusted as appropriate. 3. All discharge plans will be reviewed after sixty (60) to ninety (90) according to level of care. ( Copy obtained).

Based on record review and staff and resident interviews, the facility failed to identify and provide needed care and services that are resident centered for one (Resident #61) of five residents reviewed for planning and set-up of follow-up appointments, from a total of 44 sampled residents. Specifically, the facility failed to ensure professional standards of practice with regard to a cardiology follow-up appointment as set out by admission documentation to the facility, and documented physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: A review of Resident #61's medical record revealed that she was admitted on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was designated as a Full Code (in the event of cardiac/pulmonary arrest, cardiopulmonary resuscitation was to be initiated), and scored 15 out of a possible 15 points on her BIMS (brief interview for mental status), indicating no cognitive impairment. She underwent a R (right) heart catheterization on 11/23/21 prior to admission to the facility. An interview with Resident #61 was conducted on 01/18/22 at 12:41 PM. She verbalized concerns regarding follow-up appointments with her cardiologist and pulmonologist. She stated she still needed to be seen by each of those specialists. She stated she was admitted on [DATE] after having a defib put in. A cardiology consultation, dated 11/16/21 for elevated cardiac enzymes, documented that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's 12/3/21 hospital discharge form (3008) stated the resident had an internal cardiac defibrillator. A review of the 12/3/21 hospital discharge medical record documented a physician follow-up appointment was to be scheduled in 1-2 weeks, along with a cardiac-physio appointment in 1-2 weeks. A Social Services progress note dated 12/20/21, documented in part that they had followed up with [Resident #61] this morning about her DC (discharge) information. She informed me she is not going back to the previous place. The progress note also documented that the resident had spoken with facility staff about starting an application for her to become LTC (long term care). I let the resident know that I would follow up. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing (DON) on 1/21/22 at 3:06 PM regarding the follow-up appointment process, he stated once a resident was admitted to the facility, the Unit Coordinator/Transport Aide established a list of follow-up appointments for the resident and coordinated these with corporate transportation. This individual was currently unavailable at the facility, however. The DON verbalized that the team of clinicians, i.e.: Unit Manager and DON took on that responsibility in this instance. An interview with Unit Manager G was conducted on 1/21/22 at 3:24 PM. She stated Resident #61 had been seen by in-house cardiology every Tuesday and Thursday. She further stated with regard to the 12/3/21 discharge order and 12/4/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A request was made to review documentation of the in-house cardiology follow-up/consults, and Unit Manager G stated she would provide the documentation for review. At the completion of the recertification survey on 1/21/22 at 6:43 PM, no documented evidence of in-house cardiology follow-ups/consults were provided for Resident #61.

Based on observations, interviews and record review, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice, for two (Residents #73 and #355) of 44 sampled residents. The findings include: 1. On 1/18/2022 at 11:22 a.m., Resident #73 was observed sitting up in bed in his room, which was located on the COVID unit. The resident stated he was supposed to be receiving Oxygen (O2) but he had not received it. He stated when he was taken to the COVID unit, he was given an oxygen concentrator but it didn't work. He stated staff confirmed the concentrator was not working and removed it from his room. He stated it had not been replaced. On 1/19/2022 at 10:25 a.m., Resident #73 was observed to have been moved to another room. O2 still was not present in the resident's new room. Resident #73 stated he was told that someone would be bringing the O2 sometime today. On 1/19/2022 at 1:55 p.m., Resident #73 was observed resting in bed. O2 was still not present in the resident's room. He confirmed that the O2 had not been delivered. On 1/20/2022 at 3:21 p.m., Resident #73 was observed sitting up in bed. O2 was still not present. Again, the resident stated that no one had provided O2 as ordered. On 1/21/2022 at 12:10 p.m., Resident #73 was observed eating in bed. O2 was not observed in his room. He stated staff had not mentioned anything further about the O2 and confirmed that as of this interview, it had not been delivered. A review of Resident #73's medical record revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the January 1, 2022 through January 20, 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's care plan, last reviewed on 12/8/2021, included interventions to: administer medications as ordered and assess oxygen saturations every shift. During an interview on 1/21/2022 at 12:22 p.m. with Licensed Practical Nurse (LPN)/Unit Manager G, she confirmed that O2 was not present and she could not explain why. She asked the resident about the O2 and he stated he had not had O2 since it was ordered. He explained to her that the initial O2 concentrator did not work, was removed from his room and was never replaced. He also advised the LPN that his O2 saturation levels were not being taken as ordered. She chuckled. LPN G did not respond to the resident's claims, but stated she would have to contact the physician regarding the order for O2. 2. On 1/18/2022 at 11:50 a.m., Resident #355 was observed lying in bed receiving O2 via nasal cannula (NC). The oxygen flow rate was observed to be set at 5 liters per minute (LPM). Resident #355 stated, The O2 is supposed to be at 5 LPM; it is at 5, right? Oh ok, yes that's where it's supposed to be, at 5. On 1/19/2022 at 12:00 p.m., Resident #355 was observed sitting in a chair receiving O2 via NC with a flow rate of 5 LPM. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxygen therapy orders were not found anywhere in the resident's medical record (hard chart or electronic medical record). On 1/20/2022 at 2:04 p.m., LPN H was asked to find O2 therapy orders for Resident #355. She proceeded to search for the orders and then stated, I don't see the orders for oxygen therapy. I would know if a resident had orders for oxygen either by orders for it from the doctor, in the MAR, or from the morning report. I see the orders for the oxygen saturation monitoring, but I'll be honest, I didn't see orders for the oxygen orders themselves. Well, in case of no orders and a resident is on O2 but there are no orders, I will let my unit manager (LPN G) know and notify the doctor. On 1/20/2022 at 2:19 p.m., the physician gave verbal orders for respiratory therapy for Resident #355 as follows: Oxygen at 2 liters via nasal cannula - continuous. On 1/20/2022 at 3:17 p.m., Resident #355's O2 flow rate was set at 5 LPM. (Photographic evidence obtained) On 1/20/2022 at 3:19 p.m., LPN H asked, Did you see the new oxygen therapy orders for [Resident #355]? She was informed that the new order was reviewed for 2 LPM, however the resident's O2 remained set at 5 LPM. LPN H immediately went to Resident #355's room and adjusted the flow rate to 2 LPM. Resident #355 was informed of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/21/2022 at 9:49 a.m., the facility's Oxygen Therapy policy and procedure (effective 11/30/2014 and revised 08/28/2017) was reviewed. On page one under Procedures was documented, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews and record reviews, the facility failed to ensure accurate acquiring, receiving, dispensing, and administration of medications for four (Residents #20, #201, #204, and #206) of a total sample of 44 residents. The findings include: 1. A review of facility records revealed an a allegation of misappropriation dated 11/30/21. The documentation stated that on 11/30/21, as Licensed Practical Nurse (LPN) P, assigned to Resident #20, prepared to change the resident's [MEDICATION(S)] (narcotic pain medication) patch, she identified that there were no patches remaining and contacted the pharmacy. The Pharmacist reported patches were delivered to the facility on [DATE] at 8:41 PM and were signed as having been received by Registered Nurse (RN) Q. The Director of Nursing (DON) was notified. A review of Resident #20's medical record revealed an admitted [DATE] and a re-entry date of 7/10/21 with a primary diagnosis of polyneuropathy. Secondary diagnoses included [CONDITION(S)] and chronic pain syndrome, contractures of the left leg, and pain at the knees. A review of the Quarterly Minimum Date Set (MDS) assessment, dated 10/11/21, revealed a Brief Interview for Mental Status (BIMS) score of 15 our of a possible 15 points, indicating intact cognition. The resident required extensive assistance for bed mobility and toileting. A review of the physician's orders revealed orders for: [MEDICATION(S)] patch 25 micrograms per hour (mcg/hr), change patch every 72 hours, [MEDICATION(S)] 10 mg (milligrams) every 4 hours as needed for pain, [MEDICATION(S)] 600 mg three times a day, acetaminophen (Tylenol) 650 mg by mouth every 6 hours as needed for mild pain for a pain scale of 1-3/0-10. A review of the care plan revealed that Resident #20 had chronic pain related to spondylosis with [CONDITION(S)], [CONDITION(S)], recent complaints of knee pain, and a decline in function. In an interview on 01/20/22 at 11:39 AM, Resident #20 denied having pain. He stated he received a pain patch and revealed one patch on his left upper shoulder. He added that there were a few days that the patch was missing and had been informed that the pharmacy had not delivered it. A review of the January 2022 electronic medication administration record (EMAR), revealed the [MEDICATION(S)] patch was not administered on 1/11/22 or 1/17/22 with a description that read, Awaiting order from pharmacy. (Copy obtained) On 01/20/22 at 11:56 AM, LPN N explained that medications were re-ordered when there was a 5-day stock to ensure that residents did not miss any medication. She stated the process of re-ordering medication was electronic and pharmacy would call the facility if and when there were issues with the re-ordering process. When asked what would happen if medication was not delivered on time, she replied, The first thing is to check if the medication is in the emergency kit and obtain pharmacy authorization for controlled drugs. If medications are not available, the physician would be notified of missed doses. When asked to explain the process for controlled medication reconciliation, she stated medications were signed off after administration, the oncoming and offgoing nurse counted the medication at the beginning of each shift, and when narcotics were received from the pharmacy, two nurses signed the narcotic sheet and also the manifest. In an interview on 01/20/22 at 12:07 PM , LPN K/Unit Manager stated the facility received the emergency drug kit (EDK) replacement daily. When asked about Resident #20's having missed the [MEDICATION(S)] medication on 1/11/22 and 1/17/21, she said, There is no reason for the resident to miss the medication, since medications are available in the EDK box. She added that if there were issues with the pharmacy delivery, the nurses should notify the manager to request an as soon as possible (STAT) delivery. LPN K stated she was on leave when the other medication went missing. When asked about the facility's process for receiving medications from the pharmacy, she stated two nurses should co-sign the controlled drugs and sign the manifest. A copy of the manifest was left at the facility and another copy was sent back to the pharmacy. She confirmed that at the time Resident #20's medication went missing, he staff on duty had not followed this policy. In an interview on 01/20/22 at 4:20 PM, the DON stated on 11/30/21, he was informed that Resident #20's [MEDICATION(S)] patches were missing. After contacting the pharmacy, he was informed that the medications were delivered on 11/28/21. He stated after an extensive search, the medication could not be located. When asked about the process for receiving medication from the pharmacy, he confirmed that on 11/28/21, the nurses on duty did not follow the policy. He added that education was provided to nursing about medication administration and controlled substance reconciliation, and that he conducted audits for controlled substances and missing medication. The DON could not provide a copy of the medication audit he stated he completed. He was asked about Resident #20's missed doses of [MEDICATION(S)] patches on 1/11/22 and 1/17/22. He confirmed that the medication was not administered and stated he would follow up with the nurses involved, as the medication had been available in the EDK. He also confirmed that the physician was not informed of the missed doses. A review of the facility's policy and procedure titled Inventory Control of Controlled substances, effective 12/01/07 and last revised on 01/01/13, revealed the following: The facility should maintain a separate, individual controlled substance record on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substance Declining Inventory Record. This record should include: Resident name: Prescription number, Medication name, strength, dosage form dosage: and Total quantity received by the facility. (Copy obtained) 2. A review of Resident #206's medical record revealed an admitted [DATE]. Her primary medical diagnosis was novel coronavirus (COVID-19) with a secondary diagnosis of [CONDITION(S)]. A review of the Admission Nursing Assessment, dated 1/17/2022, revealed Resident #206 was alert and oriented to person, place, and time. She required assistance from staff for activities of daily living (ADLs). On 1/18/2022 at 2:25 p.m., an interview was conducted with Resident #206. She explained that she had not received her intravenous (IV) antibiotics since being admitted to the facility. A review of Resident #206's physician's orders revealed an order dated 1/17/2022 for [MEDICATION(S)] 4.5 grams (gm) to be given intravenously every 8 hours for a diagnosis of [CONDITION(S)]. The first dose was scheduled to be given on 1/17/2022 at 9:00 p.m. (Photographic Evidence Obtained) A review of Resident #206's medication administration records (MARs) for January 2022, revealed the [MEDICATION(S)] (antibiotic) was not administered on 1/17/2022 9:00 p.m., on 1/18/2022 6:00 a.m., on 1/18/2022 2:00 p.m., on 1/18/2022 10:00 p.m., or on 1/19/2022 6:00 a.m. (Photographic Evidence Obtained) A review of the nursing progress notes revealed entries dated 1/17/2022 9:44 p.m. and 1/18/2022 at 5:59 a.m. which indicated the facility was awaiting delivery of the [MEDICATION(S)] from the pharmacy. The notes did not indicate that the resident's physician had been notified off the errors. (Photographic Evidence Obtained) On 1/20/2022 at 1:25 p.m., an interview was conducted with the Unit Manager. She confirmed that Resident #206 was ordered to receive [MEDICATION(S)] three times daily for a diagnosis of [CONDITION(S)]. The Unit Manager confirmed that the resident had not received any doses of [MEDICATION(S)] since admission on 1/17/2022. The Unit Manager explained that she called the pharmacy on 1/19/2022 and asked them to send the medication after she had been made aware the medication was not available. She further explained that she had to contact the pharmacy again on 1/20/2022 and ask again for the medication to be sent and that when she called the pharmacy on 1/20/2022, the pharmacy informed her that they did not have an order for the medication. When asked about the facility's processes for medications that were not available, the Unit Manager explained that the physician should be notified that the medication was not available for administration. She was not sure whether any of the assigned nurses on 1/17/2022, 1/18/2022, or 1/19/2022 had contacted the physician. She stated she notified the Infectious Diseases practitioner and new orders were obtained to extend the resident's dosages and obtain labs to ensure no harm had come to the resident. According to the Centers for Disease Control at https://www.cdc.gov/[CONDITION(S)]/what-is-[CONDITION(S)].html (accessed on 1/21/2022 at 3:05 p.m.), [CONDITION(S)] is the body's extreme response to an infection. It is a life-threatening emergency and without timely treatment, [CONDITION(S)] can rapidly lead to tissue damage, organ failure, and death. According to WebMD at https://www.webmd.com/drugs/2/drug- /[MEDICATION(S)]-intravenous/details (accessed on 1/21/2022 at 3:15 p.m), [MEDICATION(S)] is a penicillin antibiotic that works by stopping the growth of bacteria. 3. A review of Resident #204's medical record revealed a readmitted [DATE]. His primary diagnosis was urinary tract infection. Resident #204 required extensive to total assistance by staff for activities of daily living. A review of the resident's physician's orders revealed an order for [MEDICATION(S)] 750 milligrams (mg) to be given intravenously twice daily for the treatment of a urinary tract infection. (Photographic Evidence Obtained) A review of the medication administration records (MARs) for January 2022, revealed the [MEDICATION(S)] had not been administered on 1/13/2022 at 9:00 a.m., on 1/16/2022 at 9:00 a.m., on 1/17/2022 at 9:00 a.m., or on 1/19/2022 at 9:00 a.m. (Photographic Evidence Obtained) A review of Resident #204's nursing progress notes revealed no entries indicating the physician had been notified of the missed doses of [MEDICATION(S)]. On 1/21/2022 at 1:25 p.m., during an interview with the Unit Manager, she reviewed Resident #204's medication administration records and confirmed that the resident's [MEDICATION(S)] had not been administered on 1/13/2022 at 9:00 a.m., on 1/16/2022 at 9:00 a.m., on 1/17/2022 at 9:00 a.m., or on 1/19/2022 at 9:00 a.m. 4. A review of Resident #201's medical record, revealed an admitted [DATE]. The resident's primary medical diagnosis was COVID-19. The Admission Nursing Assessment, dated 1/17/2022, indicated the resident was alert and oriented to person, place, and time. Resident #201 required assistance by staff for activities of daily living. A review of Resident #201's physician's orders revealed an order for [MEDICATION(S)] 750 mg to be given once daily for a respiratory infection. The first dose was due to be given on 1/18/2022 at 9:00 a.m. (Photographic Evidence Obtained) A review of the medication administration record revealed that the 1/18/2022 9:00 a.m. dose had not been administered. The reason was marked as See Nurse's Notes. (Photographic Evidence Obtained) A review of Resident #201's nurses notes revealed an entry dated 1/18/2022 at 10:03 a.m. which indicated the [MEDICATION(S)] was not administered, but it did not specify a reason the medication was not administered. On 1/21/2022 at 1:25 p.m., during an interview with the Unit Manager, she reviewed Resident #201's medication administration records and confirmed that the resident's [MEDICATION(S)] had not been administered on 1/18/2022 at 9:00 a.m. According to WebMD at https://www.webmd.com/drugs/2/drug- -8235/[MEDICATION(S)]-oral/[MEDICATION(S)]-oral/details (accessed 1/21/2022 at 3:20 p.m.), [MEDICATION(S)] is an antibiotic medication used to treat bacterial infections. .

Based on observation, staff interviews, resident interview, clinical record review and policy and procedure review, the facility failed to ensure the environment remained as free of accident hazards as possible for one (Resident #1) of three residents sampled for unsafe environment. The facility failed to identify and implement additional care plan measures regarding the lengthy oxygen tubing used by the resident to maintain her mobility. The findings include: During an observation of Resident #1 on 05/05/2021 at 10:48 AM, she was lying on her bed with a nasal cannula (NC). Her oxygen (O2) concentrator had several feet of oxygen tubing lying on the floor next to the bed (Photographic evidence obtained). During an observation and interview with Employee J, Licensed Practical Nurse (LPN) on 05/05/2021 at 10:52 AM, she acknowledged Resident #1's O2 tubing and proceeded to wrap up the O2 tubing and lay it on top of the concentrator. She explained that Resident #1 needed to keep her NC on when she goes to the bathroom and the tubing needed to be long enough to reach into the bathroom. During an observation and interview with Resident #1 in her room on 05/05/2021 at 2:32 PM, the O2 concentrator was running and oxygen tubing was observed in a pile on the floor next to the bed. Resident #1 wanted to have the O2 tubing an extended length because she wants to be able to go into the bathroom and to the doorway when desired. She stated that prior to having the long tubing she had to move the O2 concentrator around in her room so she could use the bathroom. Now it is long enough to reach. A review of Resident #1's care plan, last reviewed on 03/25/2021 revealed the following focus areas: Initiated on 03/03/2021: At risk for falls related to deconditioning, gait/balance problems. Initiated on 03/03/2021: Activities of daily living self-care performance deficit related to impaired balance; limited mobility. There were no updates related to recent falls due to the tubing or for when the resident chooses not to use her call bell for assistance to the bathroom. The resident's documented Brief Interview for Mental Status (BIMS) score was 14, indicating intact cognition. A review of the nursing notes for Resident #1 revealed the following: On 03/05/2021, resident returned from the hospital at approximately 4:30 PM with a diagnosis of T12 compression fracture. The MD (physician) was notified and there were no new orders. On 03/07/2021, the resident was alert and oriented and able to make needs known. Resident was trying to go to the restroom. Feet tangled in oxygen tubing. On 03/26/2021, Resident #1 with multiple falls on 3/23 and 3/25 with no injuries. Resident fell on ,d+[DATE] attempting to get nasal cannula tubing off floor. On 3/25 attempting to go to the bathroom and fell . During an interview with the Minimum Data Set (MDS) Coordinator on 05/05/21 at 4:15 PM, she confirmed that the O2 tubing for Resident #1 would be considered a fall risk hazard. She stated they would have to figure out a way to secure it when she is in the bed. She was not aware that Resident #1 was moving the oxygen concentrator around in her room. She stated, She's always had long tubing so she could go into the bathroom and to the door of her room if needed. During an interview with the Director of Nursing on 05/05/2021 at 4:40 PM, she thought the O2 tubing on the floor could be a fall risk for any resident. She stated she would look at it as a cause of the falls going forward. She did not believe that taking the tubing away would be a viable option for Resident #1 as she needed it to go the restroom, and stated she would have to think about a way to keep it up off the floor. A review of the facility's policy and procedure entitled Fall Management with last revision date of 07/29/2019, revealed: Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. Purpose: to identify residents at risk for falls and establish/modify interventions to decrease the risk of future fall (s) and minimize the potential for a resulting injury. Fall Mitigation: Residents to be evaluated for fall risk on admission/re-admission, quarterly, annually or upon identification of a significant change in status. C. Environmental factors. Post Fall Strategies: 4. Re-evaluate fall risk utilizing the Post Fall Evaluation. 7. Interdisciplinary Team to review fall documentation and complete root cause analysis. D. QAPI Review fall trends monthly during QAPI.

Based on record reviews and staff interviews, the facility failed to: 1) Honor a resident's Do Not Resuscitate Order (DNRO) when he was discovered to be unresponsive and without vital signs, and 2) Ensure that a resident's Do Not Resuscitate preference was reflected in the resident's electronic medical record. This involved one (Resident #1) of three residents reviewed for quality of care. Resident #1 had a DNRO and staff initiated cardiopulmonary resuscitation (CPR) with chest compressions and artificial respirations in opposition to Resident #1's Advanced Directives. The facility's failure to honor the resident's wishes to not be resuscitated, deprived him of a natural death, as well as the likelihood that he would experience major physical trauma including broken ribs, lung bruising, internal bleeding and damage to his airway and internal organs. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:30 a.m. on [DATE]. On [DATE] at 3:00 a.m., the Immediate Jeopardy (IJ) began. On [DATE] at 6:00 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed, effective [DATE], at the time of survey exit on [DATE] at 4:00 PM. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: A review of Resident #1's clinical record revealed an initial admission date of [DATE]. His most recent readmission was on [DATE], following isolation precautions and treatment for [REDACTED]. He was a [AGE] year-old male with [DIAGNOSES REDACTED]. The paper medical record indicated that he had a DNRO and a Florida DNRO form on goldenrod (yellow) paper was in place, dated and signed by the physician on [DATE]. Resident #1's son, who was designated as his durable power of attorney (DPOA), chose the DNR status for Resident#1 on [DATE]. A review of the facility's Abuse and Neglect Immediate Report, dated [DATE], revealed the facility's Executive Director (ED) reported an incident involving Resident #1 that occurred on [DATE] at approximately 3:00 a.m., and was identified as neglect. The ED documented that she notified the resident's representative and law enforcement on [DATE]. She also notified the Florida State Abuse Registry on [DATE]. The report revealed that Resident #1 was found unresponsive on [DATE] at approximately 3:00 a.m. by Employee C, Certified Nursing Assistant (CNA), who immediately reported it to the nurse on duty (Employee A, Licensed Practical Nurse (LPN). Employee C stated to Employee A, I don't think he's okay. Prior to that, the resident was noted as last seen at approximately midnight when the CNA observed him sleeping with no issues noted at that time. Employee A immediately went into the resident's room and found the resident unresponsive, without a pulse or respirations and warm to the touch. Employee A was unable to locate the paper medical record at that time to verify the resident's code status. She then reviewed the electronic medical record (EMR) and confirmed a full code order there. She initiated Cardiopulmonary Resuscitation (CPR) immediately and a Code Blue was called at that time. Employee B, LPN, responded to the Code Blue notification and assisted with CPR. The paramedics arrived onsite and took over care, but the resident expired. Resident #1's paper medical chart was reviewed following the pronouncement of his death. A signed Do Not Resuscitate form was present in the record. A review of the facility's CPR Policy, dated [DATE], revealed, Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a fully executed Florida Do Not Resuscitate order (DNR). The code procedures included to first call for assistance in the event of [MEDICAL CONDITION]. The second step was for two licensed nurses to verify the resident's code status and check for a fully executed Florida DNR order. The third step was to use the paging system to call a Code Blue. The staff member should begin CPR after determining the resident did not have a fully executed Florida DNR order. CPR was not to be stopped unless Emergency Medical Technicians assumed responsibility for CPR or if the resident responded. The Medical Director and family were to be notified. A review of Resident #1's nursing progress note, written by Employee A, LPN, and dated [DATE](late entry), revealed Resident #1 was found unresponsive on [DATE]. Around three a.m. that morning the CNA called this nurse into the resident room and resident was unresponsive, started CPR and when EMS (Emergency Medical Services) arrived they took over and pronounced resident expired at around 3:20 am. On [DATE] at 11:25 a.m. during an interview with Employee A, LPN, who was assigned to Resident #1, she stated, At the time I could not find the chart to check his code status. I checked the electronic record and he was a full code (perform CPR). We found out later it (the resident's code status) was never updated. The resident was not a full code. He had a DNR order in the chart. There was a discrepancy. I felt bad. I found out after paramedics took over and pronounced him dead. This poor guy was a DNR. The son wanted DNR. Employee B helped me with the CPR. I told Employee B he was a full code in the electronic system, and I started CPR. We were in-serviced to make sure two nurses must verify the chart together before any action is taken. We go by the yellow DNR paper order because it overpowers the electronic system. We verify the DNR paper to check the resident identification and two signatures. The Unit Manager was supposed to check to make sure it was accurate or the Director of Nursing. We found his chart after we coded him, and he was a DNR. The chart was shoved in an unnumbered slot. I don't know if someone looked at it and shoved it in there. A review of Resident #1's nursing transfer form, dated [DATE], revealed Resident #1 was noted as a DNR on the form. Employee D, LPN/Unit Manager, documented the reason for transfer was COVID-19. A review of the Nursing Readmission Assessment, dated [DATE], revealed the Advanced Directive Discussion form was not completed. The same nurse (Employee D) transferred the resident out and readmitted him to the facility following care for a [DIAGNOSES REDACTED]. On [DATE] at 12:10 p.m. during an interview with the Regional Director of Clinical Services (RDCS), she stated Resident #1 tested positive for COVID-19 on [DATE] and was transferred to a sister facility. She stated Resident #1 came back to the facility on [DATE] and he was still a DNR. Employee D, LPN, was the admission nurse and she did not complete the Advanced Directive Discussion form upon readmission on [DATE]. The RDCS stated, I educated her one-to-one. The admission process was not correct. Once the resident came back in the building, she put a new chart together. She put full code status. He had a DNR order and the nurses are supposed to verify it on the admission sheet. She did not complete the Advanced Directive section on the admission sheet. The responsible party was not notified. On [DATE] at 1:00 p.m. during an interview with Employee D, LPN/Unit Manager, she stated Resident #1 was readmitted on [DATE]. She confirmed that she admitted him and received the paperwork. She stated she did not do the Advanced Directive Discussion form because the Social Worker was responsible for that. She stated she thought the Social Worker did them. Now, we go over that information if the resident wants a full code or DNR upon admission. Nursing will now explain it to the resident or the family and go over if they want a DNR or full code. We can also call the family or responsible party. For (Resident#1), a copy of the DNR paper would have been sent to the facility when we transferred him. Looking back, I would have called (Resident #1's) son and he probably would have mentioned the DNR. All new charts are reviewed in our daily clinical morning meeting. I don't know how we missed it. She confirmed that Resident #1's DNR order was not followed. A review of Resident #1's Physician's Progress note, dated [DATE], revealed an order for [REDACTED]. A review of Resident #1's Psychiatric Evaluation note, dated [DATE], revealed Code Status: No CPR. A review of Resident #1's Physician's Progress note, dated [DATE], revealed Code Status: No CPR. During an interview on [DATE] at 1:20 p.m., Resident #1's son, the resident's DPOA, stated the DNR was the best option for his father. He stated, At this point, my last hope was for him to be a DNR. It was painful to see he did not know almost anything. I chose for him to be a DNR. I'm at work. I have to go. The interview abruptly ended at that point. During an interview on [DATE] at 4:40 p.m., the RDCS stated, (Resident #1's) admission process was not done the proper way. The Advanced Directive Discussion form was not done. (Employee D, LPN) was waiting for the Social Worker to do it. The Social Worker and the clinical team were also supposed to review it. It was not done. I came in that day to do education and found out they coded (Resident #1). (Resident #1) was a DNR. They used the code cart on him. We reported ourselves immediately. The Director of Nursing (DON) was suspended. The DON is the leader of the building and was to bring all new admission/readmission charts to the morning meeting for review, and it was not done. During an interview on [DATE] at 12:00 p.m., the Social Services Director (SSD) revealed that she had just begun employment with the facility three months ago and could not provide a response regarding the incident with Resident #1 on [DATE]. When asked about the process for following Advanced Directives, she stated, I'm still new. I'm supposed to check the chart for new admissions. I look for any type of Social Services such as DNR and living will, checking for a family member or responsible party, doing Social Service assessment, going over if a full code or DNR, and fulfilling the wishes of a resident. During an interview on [DATE] at 1:00 p.m., Employee E, LPN, stated, (Resident #1) had a signed DNR and I was not aware of it. The chart was there in the nursing station. The DNR form is in the front of the chart very accessible. Everything that could go wrong did go wrong. The DNR order is an order and it did not make it into the electronic medical record. We did audits and it was missed. (Resident #1) had a valid DNR. I don't know why it did not make it into the electronic record. A review of the facility's written statement given by Employee B, LPN, revealed that on [DATE] (no time noted), Employee B relied upon Employee A's verbal direction instead of verifying the true code status in the resident's paper chart. When Employee B arrived at the room, chest compressions were being performed by Employee A. Per the witness statement she stated, I heard Code Blue stated by Employee C, CNA, to room [ROOM NUMBER]. Upon arriving at the scene, I asked Employee A, the nurse, if 911 had been called and she said yes. I was informed that (Resident #1) was a full code per information on the computer. CPR was actively given, and I volunteered to switch with Employee A. I continued alternating with Employee A. The crash cart was at the scene. The Ambu (artificial manual breathing unit) bag was used. CPR was performed until the paramedics arrived and took over. Employee B did not verify the resident's code status as the second nurse per the facility's policy requirements. During an interview with the RDCS on [DATE] at 1:45 p.m., she confirmed that Resident #1 had a DNR code status, and the facility's policy required two nurses to verify the resident identification and the DNR order. This did not occur on [DATE]. She stated CPR was provided to Resident#1 for approximately twenty minutes. During an interview on [DATE] at 4:00 p.m., Employee F, LPN, stated, (Resident #1) was very confused. He didn't even recognize anyone, even his own son. I took care of him for months. He is pleasant during the day and sundowning during the evening. He would try to climb out of his bed. I am aware that there was a discrepancy with his code status. The electronic record did not match the signed DNR form. We all have been re-educated to find out on admission the code status and complete the Advanced Directive Discussion form. The Social Worker must also make sure the form is completed. We also have been re-educated on our CPR policy. First, call for assistance in the event of [MEDICAL CONDITION], second is for two nurses to verify the code status. Call Code Blue if the resident is a full code. If I call Code Blue, it means CPR might be started. We verify first with another nurse then call Code Blue if the resident is a full code. If they're a DNR, we do nothing. If they're a full code, we start CPR. CPR is not stopped unless paramedics say to stop CPR. The Medical Director and family are notified. During an interview on [DATE] at 12:45 p.m., the Medical Director revealed she was made aware of the incident involving Resident #1 immediately. She stated, This should never have happened. (Resident #1) was a DNR and CPR should not have been provided. It was unfortunately a mistake when they coded him. He passed away and they coded him. This gentleman expired and they resuscitated him. I was furious about it because they have a system in place. They have an audit process. We are responsible for this. This should not happen at any time. I don't like to use excuses because the DNR order was not honored. It's our fault. Opportunities have been missed to check the medical record. A program is now in place for safe transition and two nurses must verify together. Luckily, the patient did not need to be intubated. We learned from our mistake. They moved the resident to a different room, and they did not move the chart to the correct slot. They did not look at the previous slot to find the chart. If I put myself in their shoes, they should have looked at the other slot to find the chart. Either way, it's not acceptable. I will discuss with the Administrator to flag charts with a big red mark to make sure we honor the DNR wishes of the residents. We need to learn and come up with plans to make it better. Make sure this won't happen. It is very important to do the best, no excuses. We have to deliver. Not one day goes by that the Administrator does not call me to go over plans. They work very hard. My heart breaks. We have to deliver the best care we can. Throughout the survey, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team as follows: On [DATE], the Regional Director of Clinical Services (RDCS) reviewed Resident #1's chart and concluded that the resident's code status was DNR. She initiated education to include the CPR Policy/Procedure, Advanced Directives Policy/Procedure, Resident Rights Policy/Procedure, Following the Care Plan Policy/Procedure and the Abuse/Neglect Policy/Procedure. She also initiated a full investigation to include medical record reviews, staff interviews and event reenactment. On [DATE], an Immediate Federal Report for neglect of Resident #1 was submitted to the State Agency by the Administrator. On [DATE], an Advanced Directive quality review of current residents was completed by the RDCS, SSD and Employee A, LPN/Unit Manager. The RDCS initiated audits on 100% of the in-house medical records regarding resuscitation status on [DATE]. As part of the quality review, the Advanced Directives Discussion form was completed for current residents. The presence of code status orders and goldenrod Do Not Resuscitate orders was verified. This audit was completed at the nurses' station and no concerns were identified. The electronic medical record audit also found no concerns. On [DATE], Employee D, LPN, received one to one education from the RDCS related to the facility's admission process, Code Blue/CPR and Advanced Directives consents. On [DATE], Employee B, LPN, received one to one education from the RDCS related to the DNR process and the requirement for two nurses to validate a resident's code status. On [DATE], the Director of Nursing was suspended pending investigation. She was terminated on [DATE]. On [DATE], a Performance Improvement Plan (PIP) was developed and initiated based upon Root Cause Analysis. On [DATE], current nursing staff received education on the facility's procedure for obtaining and implementation of the Advanced Directives Discussion form and consents, quality review of current residents to ensure their code status was honored, ensuring orders were correct in the electronic health record and the care plan was current. Staff education on the procedure for Code Blue and FL goldenrod DNR order forms requiring two nurses to validate the resident's code status was also initiated on [DATE]. Eighteen of twenty licensed nurses participated and were in-serviced on [DATE]. The two remaining nurses were out sick but will complete their education prior to returning to work and accepting an assignment. The training included information on the location of the residents' goldenrod DNR forms in the medical records, obtaining Advanced Directives consents, the fact that the two nurses must validate the resident's code status in the medical record before initiating CPR for residents who are a full code, and the code procedure. Licensed nurses were given a post-test related to DNR orders after education was provided. Those scoring less than 80% received re-education until they demonstrated understanding at 80% or above. Mock Code Blue drills were conducted on various shifts for licensed staff on [DATE]. Sixteen of twenty licensed nursing staff completed the mock drills. Participants were competent with CPR and the Code Blue protocol. The four remaining nurses will complete the mock Code Blue drills prior to returning to accept an assignment by [DATE]. The mock Code Blue drills will continue twice weekly every shift to include weekends. Any staff member that did not complete the mock drill and education related to the above-mentioned training was removed from the schedule. The facility's Quality Assessment Performance Improvement (QAPI) meeting minutes, dated [DATE], were reviewed and the Root Cause Analysis and DNR order quality reviews were discussed in the QAPI meeting. On [DATE], the ad hoc QAPI meeting was held to review the results of the completed facility-wide quality reviews. On [DATE], Employee D, LPN/Unit Manager and the SSD contacted current residents or their responsible parties to review their current code status and determine whether this was still what they wished going forward. This was completed on [DATE]. Newly hired staff will receive education in orientation.

Based on record reviews and staff interviews, the facility failed to follow the facility's Cardiopulmonary Resuscitation (CPR) policy and ensure staff were familiar with facility policies. The facility policies related to CPR required two nurses to verify resident information and Do Not Resuscitate Orders (DNROs) before CPR was initiated. This involved one (Resident #1) of three residents reviewed for quality of care. Resident #1 was discovered unresponsive and without respirations by a certified nursing assistant (CNA). The resident's assigned nurse was immediately notified and went to the resident's bedside. She found him without a pulse or respirations and provided CPR. Facility policy required two nurses to verify a resident's code status prior to the provision of CPR. This did not occur. Resident #1 had a DNRO but the staff nurse initiated CPR with chest compressions and artificial respirations in opposition to the resident's Advanced Directives. The facility's actions deprived Resident #1 of a natural death, as well as the likelihood that he would experience major physical trauma including broken ribs, lung bruising, internal bleeding, and damage to his airway and internal organs. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:30 a.m. on [DATE]. On [DATE] at 3:00 a.m., the Immediate Jeopardy (IJ) began. On [DATE] at 6:00 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed, effective [DATE], at the time of survey exit on [DATE] at 4:00 PM. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: A review of Resident #1's clinical record revealed an initial admission date of [DATE]. His most recent readmission was on [DATE], following isolation precautions and treatment for [REDACTED]. He was a [AGE] year-old male with [DIAGNOSES REDACTED]. The paper medical record indicated that he had a DNRO, and a Florida DNRO form on goldenrod (yellow) paper was in place, dated and signed by the physician on [DATE]. Resident #1's son, who was designated as his durable power of attorney (DPOA), chose the DNR status for Resident#1 on [DATE]. A review of the facility's Abuse and Neglect Immediate Report, dated [DATE], revealed the facility's Executive Director (ED) reported an incident involving Resident #1 that occurred on [DATE] at approximately 3:00 a.m., and was identified as neglect. The ED documented that she notified the resident's representative and law enforcement on [DATE]. She also notified the Florida State Abuse Registry on [DATE]. The report revealed that Resident #1 was found unresponsive on [DATE] at approximately 3:00 a.m. by Employee C, Certified Nursing Assistant (CNA), who immediately reported it to the nurse on duty (Employee A, Licensed Practical Nurse (LPN). Employee C stated to Employee A, I don't think he's okay. Prior to that, the resident was noted as last seen at approximately midnight when the CNA observed him sleeping with no issues noted at that time. Employee A immediately went into the resident's room and found the resident unresponsive, without a pulse or respirations and warm to the touch. Employee A was unable to locate the paper medical record at that time to verify the resident's code status. She then reviewed the electronic medical record (EMR) and confirmed a full code order there. She initiated Cardiopulmonary Resuscitation (CPR) immediately and a Code Blue was called at that time. Employee B, LPN, responded to the Code Blue notification and assisted with CPR. The paramedics arrived onsite and took over care, but the resident expired. Resident #1's paper medical chart was reviewed following the pronouncement of his death. A signed Do Not Resuscitate form was present in the record. A review of the facility's CPR Policy, dated [DATE], revealed, Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a fully executed Florida Do Not Resuscitate order (DNR). The code procedures included to first call for assistance in the event of [MEDICAL CONDITION]. The second step was for two licensed nurses to verify the resident's code status and check for a fully executed Florida DNR order. The third step was to use the paging system to call a Code Blue. The staff member should begin CPR after determining the resident did not have a fully executed Florida DNR order. CPR was not to be stopped unless Emergency Medical Technicians assumed responsibility for CPR or if the resident responded. The Medical Director and family were to be notified. A review of Resident #1's nursing progress note, written by Employee A, LPN, and dated [DATE](late entry), revealed Resident #1 was found unresponsive on [DATE]. Around three a.m. that morning the CNA called this nurse into the resident room and resident was unresponsive, started CPR and when EMS (Emergency Medical Services) arrived they took over and pronounced resident expired at around 3:20 am. On [DATE] at 11:25 a.m. during an interview with Employee A, LPN, who was assigned to Resident #1, she stated, At the time I could not find the chart to check his code status. I checked the electronic record and he was a full code (perform CPR). We found out later it (the resident's code status) was never updated. The resident was not a full code. He had a DNR order in the chart. There was a discrepancy. I felt bad. I found out after paramedics took over and pronounced him dead. This poor guy was a DNR. The son wanted DNR. Employee B helped me with the CPR. I told Employee B he was a full code in the electronic system, and I started CPR. We were in-serviced to make sure two nurses must verify the chart together before any action is taken. We go by the yellow DNR paper order because it overpowers the electronic system. We verify the DNR paper to check the resident identification and two signatures. The Unit Manager was supposed to check to make sure it was accurate or the Director of Nursing. We found his chart after we coded him, and he was a DNR. The chart was shoved in an unnumbered slot. I don't know if someone looked at it and shoved it in there. A review of Resident #1's nursing transfer form, dated [DATE], revealed Resident #1 was noted as a DNR on the form. Employee D, LPN/Unit Manager, documented the reason for transfer was COVID-19. A review of the Nursing Readmission Assessment, dated [DATE], revealed the Advanced Directive Discussion form was not completed. The same nurse (Employee D) transferred the resident out and readmitted him to the facility following care for a [DIAGNOSES REDACTED]. On [DATE] at 12:10 p.m. during an interview with the Regional Director of Clinical Services (RDCS), she stated Resident #1 tested positive for COVID-19 on [DATE] and was transferred to a sister facility. She stated Resident #1 came back to the facility on [DATE] and he was still a DNR. Employee D, LPN, was the admission nurse and she did not complete the Advanced Directive Discussion form upon readmission on [DATE]. The RDCS stated, I educated her one-to-one. The admission process was not correct. Once the resident came back in the building, she put a new chart together. She put full code status. He had a DNR order and the nurses are supposed to verify it on the admission sheet. She did not complete the Advanced Directive section on the admission sheet. The responsible party was not notified. On [DATE] at 1:00 p.m. during an interview with Employee D, LPN/Unit Manager, she stated Resident #1 was readmitted on [DATE]. She confirmed that she admitted him and received the paperwork. She stated she did not do the Advanced Directive Discussion form because the Social Worker was responsible for that. She stated she thought the Social Worker did them. Now, we go over that information if the resident wants a full code or DNR upon admission. Nursing will now explain it to the resident or the family and go over if they want a DNR or full code. We can also call the family or responsible party. For (Resident#1), a copy of the DNR paper would have been sent to the facility when we transferred him. Looking back, I would have called (Resident #1's) son and he probably would have mentioned the DNR. All new charts are reviewed in our daily clinical morning meeting. I don't know how we missed it. She confirmed that Resident #1's DNR order was not followed. A review of Resident #1's Physician's Progress note, dated [DATE], revealed an order for [REDACTED]. A review of Resident #1's Psychiatric Evaluation note, dated [DATE], revealed Code Status: No CPR. A review of Resident #1's Physician's Progress note, dated [DATE], revealed Code Status: No CPR. During an interview on [DATE] at 4:40 p.m., the RDCS stated, (Resident #1's) admission process was not done the proper way. The Advanced Directive Discussion form was not done. (Employee D, LPN) was waiting for the Social Worker to do it. The Social Worker and the clinical team were also supposed to review it. It was not done. I came in that day to do education and found out they coded (Resident #1). (Resident #1) was a DNR. They used the code cart on him. We reported ourselves immediately. The Director of Nursing (DON) was suspended. The DON is the leader of the building and was to bring all new admission/readmission charts to the morning meeting for review, and it was not done. During an interview on [DATE] at 1:00 p.m., Employee E, LPN, stated, (Resident #1) had a signed DNR and I was not aware of it. The chart was there in the nursing station. The DNR form is in the front of the chart very accessible. Everything that could go wrong did go wrong. The DNR order is an order and it did not make it into the electronic medical record. We did audits and it was missed. (Resident #1) had a valid DNR. I don't know why it did not make it into the electronic record. A review of the facility's written statement given by Employee B, LPN, revealed that on [DATE] (no time noted), Employee B relied upon Employee A's verbal direction instead of verifying the true code status in the resident's paper chart. When Employee B arrived at the room, chest compressions were being performed by Employee A. Per the witness statement she stated, I heard Code Blue stated by Employee C, CNA, to room [ROOM NUMBER]. Upon arriving at the scene, I asked Employee A, the nurse, if 911 had been called and she said yes. I was informed that (Resident #1) was a full code per information on the computer. CPR was actively given, and I volunteered to switch with Employee A. I continued alternating with Employee A. The crash cart was at the scene. The Ambu (artificial manual breathing unit) bag was used. CPR was performed until the paramedics arrived and took over. Employee B did not verify the resident's code status as the second nurse per the facility's policy requirements. During an interview with the RDCS on [DATE] at 1:45 p.m., she confirmed that Resident #1 had a DNR code status, and the facility's policy required two nurses to verify the resident identification and the DNR order. This did not occur on [DATE]. She stated CPR was provided to Resident#1 for approximately twenty minutes. During an interview on [DATE] at 4:00 p.m., Employee F, LPN, stated, (Resident #1) was very confused. He didn't even recognize anyone, even his own son. I took care of him for months. He is pleasant during the day and sundowning during the evening. He would try to climb out of his bed. I am aware that there was a discrepancy with his code status. The electronic record did not match the signed DNR form. We all have been re-educated to find out on admission the code status and complete the Advanced Directive Discussion form. The Social Worker must also make sure the form is completed. We also have been re-educated on our CPR policy. First, call for assistance in the event of [MEDICAL CONDITION], second is for two nurses to verify the code status. Call Code Blue if the resident is a full code. If I call Code Blue, it means CPR might be started. We verify first with another nurse then call Code Blue if the resident is a full code. If they're a DNR, we do nothing. If they're a full code, we start CPR. CPR is not stopped unless paramedics say to stop CPR. The Medical Director and family are notified. During an interview on [DATE] at 12:45 p.m., the Medical Director revealed she was made aware of the incident involving Resident #1 immediately. She stated, This should never have happened. (Resident #1) was a DNR and CPR should not have been provided. It was unfortunately a mistake when they coded him. He passed away and they coded him. This gentleman expired and they resuscitated him. I was furious about it because they have a system in place. They have an audit process. We are responsible for this. This should not happen at any time. I don't like to use excuses because the DNR order was not honored. It's our fault. Opportunities have been missed to check the medical record. A program is now in place for safe transition and two nurses must verify together. Luckily, the patient did not need to be intubated. We learned from our mistake. They moved the resident to a different room, and they did not move the chart to the correct slot. They did not look at the previous slot to find the chart. If I put myself in their shoes, they should have looked at the other slot to find the chart. Either way, it's not acceptable. I will discuss with the Administrator to flag charts with a big red mark to make sure we honor the DNR wishes of the residents. We need to learn and come up with plans to make it better. Make sure this won't happen. It is very important to do the best, no excuses. We have to deliver. Not one day goes by that the Administrator does not call me to go over plans. They work very hard. My heart breaks. We have to deliver the best care we can. Throughout the survey, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team as follows: On [DATE], the Regional Director of Clinical Services (RDCS) reviewed Resident #1's chart and concluded that the resident's code status was DNR. She initiated education to include the CPR Policy/Procedure, Advanced Directives Policy/Procedure, Resident Rights Policy/Procedure, Following the Care Plan Policy/Procedure and the Abuse/Neglect Policy/Procedure. She also initiated a full investigation to include medical record reviews, staff interviews and event reenactment. On [DATE], an Immediate Federal Report for neglect of Resident #1 was submitted to the State Agency by the Administrator. On [DATE], an Advanced Directives quality review of current residents was completed by the RDCS, SSD and Employee A, LPN/Unit Manager. The RDCS initiated audits on 100% of the in-house medical records regarding resuscitation status on [DATE]. As part of the quality review, the Advanced Directives Discussion form was completed for current residents. The presence of code status orders and goldenrod Do Not Resuscitate orders was verified. This audit was completed at the nurses' station and no concerns were identified. The electronic medical record audit also found no concerns. On [DATE], Employee D, LPN, received one to one education from the RDCS related to the facility's admission process, Code Blue/CPR and Advanced Directives consents. On [DATE], Employee B, LPN, received one to one education from the RDCS related to the DNR process and the requirement for two nurses to validate a resident's code status. On [DATE], the Director of Nursing was suspended pending investigation. She was terminated on [DATE]. On [DATE], a Performance Improvement Plan (PIP) was developed and initiated based upon Root Cause Analysis. On [DATE], current nursing staff received education on the facility's procedure for obtaining and implementation of the Advanced Directives Discussion form and consents, quality review of current residents to ensure their code status was honored, ensuring orders were correct in the electronic health record and the care plan was current. Staff education on the procedure for Code Blue and FL goldenrod DNR order forms requiring two nurses to validate the resident's code status was also initiated on [DATE]. Eighteen of twenty licensed nurses participated and were in-serviced on [DATE]. The two remaining nurses were out sick but will complete their education prior to returning to work and accepting an assignment. The training included information on the location of the residents' goldenrod DNR forms in the medical records, obtaining Advanced Directives consents, the fact that the two nurses must validate the resident's code status in the medical record before initiating CPR for residents who are a full code, and the code procedure. Licensed nurses were given a post-test related to DNR orders after education was provided. Those scoring less than 80% received re-education until they demonstrated understanding at 80% or above. Mock Code Blue drills were conducted on various shifts for licensed staff on [DATE]. Sixteen of twenty licensed nursing staff completed the mock drills. Participants were competent with CPR and the Code Blue protocol. The four remaining nurses will complete the mock Code Blue drills prior to returning to accept an assignment by [DATE]. The mock Code Blue drills will continue twice weekly every shift to include weekends. Any staff member that did not complete the mock drill and education related to the above-mentioned training was removed from the schedule. The facility's Quality Assessment Performance Improvement (QAPI) meeting minutes, dated [DATE], were reviewed and the Root Cause Analysis and DNR order quality reviews were discussed in the QAPI meeting. On [DATE], the ad hoc QAPI meeting was held to review the results of the completed facility-wide quality reviews. On [DATE], an audit of nurses' CPR cards was completed by the Human Resource Coordinator and all nurses' cards were active. Newly hired staff will receive education in orientation.

Based on record reviews and staff interviews, the facility failed to maintain an accurate and complete record that was readily accessible to ensure a resident's DNR (Do Not Resuscitate) preference was reflected in both the resident's paper medical record as well as the resident's electronic medical record. This involved one (Resident #1) of three residents reviewed for quality of care. The findings include: A review of Resident #1's clinical record revealed an initial admission date of [DATE]. His most recent readmission was on [DATE], following isolation precautions and treatment for [REDACTED]. The paper medical record indicated that he had a Do Not Resuscitate Order (DNRO), and a Florida DNRO form on goldenrod (yellow) paper was in place, dated and signed by the physician on [DATE]. Resident #1's son, who was designated as his durable power of attorney (DPOA), chose the DNR status for Resident#1 on [DATE]. During an interview on [DATE] at 11:25 a.m. with Employee A, Licensed Practical Nurse (LPN), she confirmed she was assigned to Resident #1 on [DATE]. She stated she looked in the electronic medical record for Resident #1's code status, because she could not find the paper chart. Once the paper chart was located, she stated the code status in the paper chart conflicted with the code status in the electronic medical record, which documented the resident as a full code. She further stated, We go by the yellow DNR paper order because it overpowers the electronic system. The Unit Manager was supposed to check to make sure it was accurate or the Director of Nursing. We found his chart after we coded him, and he was a DNR. The chart was shoved in a slot unnumbered. I don't know if someone looked at it and shoved it in there. During an interview on [DATE] at 1:00 p.m., Employee E, LPN, stated, (Resident #1) had a signed DNR and I was not aware of it. The chart was there in the nursing station. The DNR form is in the front of the chart very accessible. Everything that could go wrong did go wrong. The DNR order is an order and it did not make it into the electronic medical record. We did audits and it was missed. (Resident #1) had a valid DNR. I don't know why it did not make it into the electronic record. During an interview on [DATE] at 11:35 a.m., the Director of Medical Records stated, (Resident #1's) original signed DNR paper is in front of the paper chart. I have also been scanning everything and putting it into the miscellaneous section of the electronic medical record. Everything including the doctor's progress notes are under the miscellaneous tab. During an interview on [DATE] at 12:45 p.m., the Medical Director revealed she was made aware of the incident involving Resident #1 immediately. She stated, This should never have happened. (Resident #1) was a DNR and CPR should not have been provided. It was unfortunately a mistake when they coded him. He passed away and they coded him. This gentleman expired and they resuscitated him. I was furious about it because they have a system in place. They have an audit process. We are responsible for this. This should not happen at any time. I don't like to use excuses because the DNR order was not honored. It's our fault. Opportunities have been missed to check the medical record. A program is now in place for safe transition and two nurses must verify together. Luckily, the patient did not need to be intubated. We learned from our mistake. They moved the resident to a different room, and they did not move the chart to the correct slot. They did not look at the previous slot to find the chart. If I put myself in their shoes, they should have looked at the other slot to find the chart. Either way, it's not acceptable. I will discuss with the Administrator to flag charts with a big red mark to make sure we honor the DNR wishes of the residents. We need to learn and come up with plans to make it better. Make sure this won't happen. It is very important to do the best, no excuses. We have to deliver. Not one day goes by that the Administrator does not call me to go over plans. They work very hard. My heart breaks. We have to deliver the best care we can.

Based on record reviews and staff interviews, the facility failed to provide care and services which met professional standards of quality by failing to ensure all newly admitted residents were appropriately assessed and observed for changes in condition. It failed to ensure the review of all pertinent information provided by the hospital at the time of admission, including medications for one (Resident #1) of three sampled residents, and it failed to ensure the appropriate administration of medication (anticoagulant) as ordered for one (Resident #2) of three sampled residents. The facility's failure to complete physical assessments, including those for changes in condition, and its failure to ensure a review of hospital records provided upon admission, which included a need for continued use of anticoagulant medication, contributed to the formation of a blood clot in Resident #1's leg, necessitating further hospitalization to remove it. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as, The performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical and social sciences, which shall include but is not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. The practice of practical nursing is the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: 1. A review of the clinical record revealed that Resident #1 was hospitalized from [DATE] through 7/27/20. She underwent left hip surgery on 7/17/20 and on 7/23/20, she underwent surgery to the right malleolus (ankle) and left ulna (forearm). Due to extensive leg injuries she was non-weight bearing on both legs. During her hospital stay she was ordered [MEDICATION NAME] (blood thinner) 30 mg (milligrams) twice daily to prevent blood clots. Upon discharge she was ordered dressing changes to the left hip, left arm and right lower leg. She was to wear a hinged knee brace to the left leg at all times. She was to receive physical and occupational therapy (PT, OT) and remain non-weight bearing for four weeks. She was also ordered [MEDICATION NAME] (opioid pain medication) every 12 hours. A review of Resident #1's hospital record, provided to the facility by the hospital upon the resident's nursing home admission, revealed the following: On 7/27/20, Resident #1 was seen by the trauma Advanced Practice Registered Nurse (APRN) for discharge orders. The orders included: Follow up with the orthopedic surgeon in one week for suture removal, PT and OT daily, non-weight bearing x 4 weeks, pain control, regular diet, maintain dressings clean and dry to all sites, and [MEDICATION NAME] 40 mg twice daily to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot). Also, on 7/27/20 the hospitalist working with the APRN documented that he reviewed the resident's history, personally evaluated the resident and agreed with the APRN's assessment and plan. The addendum included [MEDICATION NAME]. A review of the surgeon's note dated 7/27/20, included the following instructions: Pain control, regular diet, non-weight bearing right and left leg, five pound weight bearing for left upper arm, elevate left upper arm and right lower leg, PT and OT, [MEDICAL CONDITION] (prevention) and [MEDICATION NAME] 40 mg twice daily. A review of the Admission Data Collection form dated 7/28/20, revealed there was no time of data collection recorded, it did not include vital signs, surgical dressings in place, multiple fractures, knee immobilizer in place or a pain assessment. There were no initial nursing notes or a physical assessment. Further review of the record revealed that upon admission on 7/28/20, Registered Nurse (RN) A completed a medication reconciliation form. The form was to be completed by utilizing the following data sources (check all that apply): History and Physical, Discharge Summary, previous medication administration records (MAR) and interview with resident/resident representative. Part 1 of the form: The nurse checked off that she reviewed the hospital History and Physical and Discharge Summary. Part 2 of the form: List medications needing clarification. RN A checked No medication issues identified. Part 3 of the form: Physician contact. RN A documented the physician's name but not that the physician was notified. Had the hospital records been reviewed per the form's instructions, RN A would have been aware of the need for [MEDICATION NAME] (blood thinner) and the need to report the findings to the physician. A review of the nursing notes for 7/29/20 and 7/30/20 lacked any physical assessments including surgical sites, circulation or physical changes of the extremities due to multiple fractures. Further review of the record found no nursing notes or assessments for 7/31/20 or 8/1/20. The nursing documentation for 8/2/20 found no physical assessments recorded. The nursing note dated 8/3/20 on the 11PM to 7AM shift, revealed no documentation of a change in condition related to the resident's left leg. There were no nursing notes completed or assessments performed for the 7AM to 3PM or 3PM to 11PM shifts on 8/3/20 related to the change of condition warranting a Doppler study of the left leg. A physician's orders [REDACTED]. Results of the Doppler study revealed an occlusive venous [MEDICAL CONDITION] (blood clot) of the left leg. An order was found on 8/3/20 for Eliquis (anticoagulant - blood thinner) 5 mg twice daily during a review of the physician's orders [REDACTED]. The first dose was not administered until 9AM on 8/4/20. Resident #1 was at very high risk for development of blood clots related to recent traumatic injuries from a motor vehicle accident (MVA) that resulted in multiple fractures requiring surgery to repair her left hip, right malleolus and left ulna. Due to the extensive injuries and significant pain associated with those injuries, she was unable to move or reposition herself. She was also bed-bound due to her non-weight bearing status on both legs. This inability to move put her at greater risk of developing a blood clot. There was no nursing note or physical assessment for 8/4/20. A review of the transfer sheet for transport to the hospital, dated 8/4/20 at 4:56PM gave no reason for the transfer or notification of Resident #1's family. Resident #1 was admitted to the hospital on [DATE] and underwent surgery to remove the blood clot in her left leg. During an interview with the interim Director of Nursing (DON) on 8/17/20 at 1:30PM, she was asked if there were nursing notes for Resident #1 on 7/31/20, 8/1/20, 8/3/20 or 8/4/20. She stated she would check with the Medical Records Department. When she returned, she said she was told everything the resident had on file was in the record. She was asked whether the nurses documented every shift on residents who were receiving skilled services. She said, Usually once a day and more if there were changes or new orders. She was asked if there were daily skilled nursing (SN) notes for Resident #1. After a review of the notes, she stated the record was incomplete and no skilled nursing notes had been recorded for several days. She was asked if any of the notes in the chart reflected a change in condition or a need to transfer Resident #1 to the hospital and she replied no. The DON was also asked if the medication reconciliation form (MRF) was to be signed by the physician, and she replied no, it was a tool for the nurses. She was asked to review the MRF for Resident #1, dated 7/28/20. When asked if the nurse checked off that she had reviewed the hospital records, the DON said yes. She was asked whether the nurse documented any reference from the hospital physicians for the continued need for [MEDICATION NAME]. She said not that she could find. An interview was conducted with the Regional Director of Clinical Services at 4:20PM. She was asked if there was a policy regarding the medication reconciliation form. She said she would look. At 4:38PM, she reported there was no policy regarding medication reconciliation; it was included in the Admission Assessment policy. A review of the Admission Assessment policy revealed the following: At the time of admission or readmission the nurse shall initiate the data collection forms. Pertinent information shall be collected by physical review, interview with resident and family and review of the resident's available medical records. The data collection form will be completed within 24 hours. According to RxList at https://www.rxlist.com/[MEDICATION NAME]-side-effects-drug-center.html: [MEDICATION NAME] ([MEDICATION NAME] sodium) Injection is an anticoagulant (blood thinner) used to prevent blood clots that are sometimes called [MEDICAL CONDITIONS], which can lead to blood clots in the lungs. A [MEDICAL CONDITION] can occur after certain types of surgery, or in people who are bed-ridden due to a prolonged illness. Obese patients are at higher risk for [MEDICAL CONDITION]. According to Healthline at https://www.healthline.com/health/[MEDICATION NAME]-injectable-solution: [MEDICATION NAME] is used to thin your blood. It keeps your blood from forming clots. Blood clots are dangerous because they can lead to serious blockages in your blood vessels. This can cause a stroke or a [MEDICAL CONDITION]. This drug is used to prevent blood clots in people who are hospitalized . It may be used if you 're too sick to move around. It ' s also used to prevent blood clots at home after you ' ve had stomach surgery or a hip or knee replacement. This drug is also used to treat existing blood clots in the hospital or at home. If you stop taking the drug suddenly or don ' t take it at all: You ' ll have a higher risk for a blood clot. This could lead to serious problems, such as a stroke or death. Take this drug on the schedule set by your doctor. Don ' t stop taking it without speaking with your doctor first. 2. A record review for Resident #2 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was documented as alert with confusion. A review of the admitting medication orders revealed they included [MEDICATION NAME] (anticoagulant) 30 mg daily for 3 days. A review of the July 2020 MARs revealed that [MEDICATION NAME] 30 mg was ordered to be administered at 9AM on 7/29/20, 7/30/20 and 7/31/20. On 7/29/20, the medication was circled, indicating it was not administered. On 7/31/20, the medication was not signed off as having been administered; it was left blank. Resident #2 missed two of three doses ordered. An interview was conducted with the Director of Nursing (DON) at 5:50PM. She was asked to review the MAR for the administration of [MEDICATION NAME]. She confirmed that on 7/29/20, the circled initial indicated an omission or indication the medication was not available. She would expect a note on the back of the MAR indicated [REDACTED]. When asked if the physician had been notified of the missed doses, she said there was no verification of that, as it had not been noted on the MAR. She further added the physician should have been notified and an order requested to continue the medication to ensure the resident received three doses. A review of the admission records revealed the Admission Data Collection form for 7/28/20 was blank. There was no admission assessment or initial nursing note. (Photographic evidence obtained) A review of the daily skilled nursing notes found entries for 7/29/20, 7/30/20 and 8/3/20. There was no documentation of physical assessments or vital signs having been completed on 8/1/20 or 8/2/20. On 8/30/20, Resident #1 was found unresponsive at 9:15AM. Her pulse was thready (barely audible), her oxygen saturation level was not reading on the pulse oximeter, her oxygen was administered at 5 liters per minute and then increased to 90% saturation. Emergency Medical Services (EMS) was called, and she was more responsive when paramedics arrived. She was transferred to the hospital. During an interview with the Regional Nurse Consultant at 3:50 PM on 8/17/20, she was asked about the time frame for completing the Admission Assessment. She stated the expectation was that the admitting nurse would complete the assessment within two to four hours of admission. She was asked to review the assessment and she confirmed that the form was blank. The admitting nurse did not even sign it. She confirmed that the admission assessment had not been completed for this resident. According to the Mayo Clinic at https://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]-fibrillation/symptoms-causes/syc- 624 on 8/17/20: A major concern with [MEDICAL CONDITION] is the potential to develop blood clots within the upper chambers of the heart. These blood clots forming in the heart may circulate to other organs and lead to blocked blood flow (ischemia). According to Drugs.com at https://www.drugs.com/[MEDICATION NAME].html: [MEDICATION NAME] ([MEDICATION NAME]) is an anticoagulant that helps prevent the formation of blood clots.

Based on record reviews and staff interviews, the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to ensure all newly admitted residents were appropriately assessed, including reconciliation of medications with hospital discharge records for one (Resident #1) of three sampled residents. The facility also failed to ensure anticoagulant medication (blood thinning medication) was administered as ordered for one (Resident #2) of three sampled residents. The facility's failure to complete physical assessments, including those for changes in condition, and its failure to ensure a review of hospital records provided upon admission, which included a need for continued use of anticoagulant medication, contributed to the formation of a blood clot in Resident #1's leg, necessitating further hospitalization to remove it. The findings include: 1.A review of Resident #1's clinical record revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was hospitalized from [DATE] through 7/27/20. She underwent left hip surgery on 7/17/20 and on 7/23/20, she underwent surgery to the right malleolus (ankle) and left ulna (forearm). Due to extensive leg injuries she was non-weight bearing on both legs. During her hospital stay she was ordered [MEDICATION NAME] (blood thinner) 30 mg (milligrams) twice daily to prevent blood clots. Upon discharge she was ordered dressing changes to the left hip, left arm and right lower leg. She was to wear a hinged knee brace to the left leg at all times. She was to receive physical and occupational therapy (PT, OT) and remain non-weight bearing for four weeks. She was also ordered [MEDICATION NAME] (opioid pain medication) every 12 hours. A review of Resident #1's hospital record, provided to the facility by the hospital upon the resident's nursing home admission, revealed the following: On 7/27/20, Resident #1 was seen by the trauma Advanced Practice Registered Nurse (APRN) for discharge orders. The orders included: Follow up with the orthopedic surgeon in one week for suture removal, PT and OT daily, non-weight bearing x 4 weeks, pain control, regular diet, maintain dressings clean and dry to all sites, and [MEDICATION NAME] 40 mg twice daily to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot). Also, on 7/27/20 the hospitalist working with the APRN documented that he reviewed the resident's history, personally evaluated the resident and agreed with the APRN's assessment and plan. The addendum included [MEDICATION NAME]. A review of the surgeon's note dated 7/27/20, included the following instructions: Pain control, regular diet, non-weight bearing right and left leg, five pound weight bearing for left upper arm, elevate left upper arm and right lower leg, PT and OT, [MEDICAL CONDITION] (prevention) and [MEDICATION NAME] 40 mg twice daily. A review of the Admission Data Collection form dated 7/28/20, revealed there was no time of data collection recorded, it did not include vital signs, surgical dressings in place, multiple fractures, knee immobilizer in place or a pain assessment. There were no initial nursing notes or a physical assessment. Further review of the record revealed that upon admission on 7/28/20, Registered Nurse (RN) A completed a medication reconciliation form. The form was to be completed by utilizing the following data sources (check all that apply): History and Physical, Discharge Summary, previous medication administration records (MAR) and interview with resident/resident representative. Part 1 of the form: The nurse checked off that she reviewed the hospital History and Physical and Discharge Summary. Part 2 of the form: List medications needing clarification. RN A checked No medication issues identified. Part 3 of the form: Physician contact. RN A documented the physician's name but not that the physician was notified. Had the hospital records been reviewed per the form's instructions, RN A would have been aware of the need for [MEDICATION NAME] (blood thinner) and the need to report the findings to the physician. A review of the nursing notes for 7/29/20 and 7/30/20 lacked any physical assessments including surgical sites, circulation or physical changes of the extremities due to multiple fractures. Further review of the record found no nursing notes or assessments for 7/31/20 or 8/1/20. The nursing documentation for 8/2/20 found no physical assessments recorded. The nursing note dated 8/3/20 on the 11PM to 7AM shift, revealed no documentation of a change in condition related to the resident's left leg. There were no nursing notes completed or assessments performed for the 7AM to 3PM or 3PM to 11PM shifts on 8/3/20 related to the change of condition warranting a Doppler study of the left leg. A physician's orders [REDACTED]. Results of the Doppler study revealed an occlusive venous [MEDICAL CONDITION] (blood clot) of the left leg. An order was found on 8/3/20 for Eliquis (anticoagulant - blood thinner) 5 mg twice daily during a review of the physician's orders [REDACTED]. The first dose was not administered until 9AM on 8/4/20. Resident #1 was at very high risk for development of blood clots related to recent traumatic injuries from a motor vehicle accident (MVA) that resulted in multiple fractures requiring surgery to repair her left hip, right malleolus and left ulna. Due to the extensive injuries and significant pain associated with those injuries, she was unable to move or reposition herself. She was also bed-bound due to her non-weight bearing status on both legs. This inability to move put her at greater risk of developing a blood clot. There was no nursing note or physical assessment for 8/4/20. A review of the transfer sheet for transport to the hospital, dated 8/4/20 at 4:56PM gave no reason for the transfer or notification of Resident #1's family. Resident #1 was admitted to the hospital on [DATE] and underwent surgery to remove the blood clot in her left leg. During an interview with the interim Director of Nursing (DON) on 8/17/20 at 1:30PM, she was asked if there were nursing notes for Resident #1 on 7/31/20, 8/1/20, 8/3/20 or 8/4/20. She stated she would check with the Medical Records Department. When she returned, she said she was told everything the resident had on file was in the record. She was asked whether the nurses documented every shift on residents who were receiving skilled services. She said, Usually once a day and more if there were changes or new orders. She was asked if there were daily skilled nursing (SN) notes for Resident #1. After a review of the notes, she stated the record was incomplete and no skilled nursing notes had been recorded for several days. She was asked if any of the notes in the chart reflected a change in condition or a need to transfer Resident #1 to the hospital and she replied no. The DON was also asked if the medication reconciliation form (MRF) was to be signed by the physician, and she replied no, it was a tool for the nurses. She was asked to review the MRF for Resident #1, dated 7/28/20. When asked if the nurse checked off that she had reviewed the hospital records, the DON said yes. She was asked whether the nurse documented any reference from the hospital physicians for the continued need for [MEDICATION NAME]. She said not that she could find. An interview was conducted with the Regional Director of Clinical Services at 4:20PM. She was asked if there was a policy regarding the medication reconciliation form. She said she would look. At 4:38PM, she reported there was no policy regarding medication reconciliation; it was included in the Admission Assessment policy. A review of the Admission Assessment policy revealed the following: At the time of admission or readmission the nurse shall initiate the data collection forms. Pertinent information shall be collected by physical review, interview with resident and family and review of the resident's available medical records. The data collection form will be completed within 24 hours. 2. A record review for Resident #2 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was documented as alert with confusion. A review of the admitting medication orders revealed they included [MEDICATION NAME] (anticoagulant) 30 mg daily for 3 days. A review of the July 2020 MARs revealed that [MEDICATION NAME] 30 mg was ordered to be administered at 9AM on 7/29/20, 7/30/20 and 7/31/20. On 7/29/20, the medication was circled, indicating it was not administered. On 7/31/20, the medication was not signed off as having been administered; it was left blank. Resident #2 missed two of three doses ordered. An interview was conducted with the Director of Nursing (DON) at 5:50PM. She was asked to review the MAR for the administration of [MEDICATION NAME]. She confirmed that on 7/29/20, the circled initial indicated an omission or indication the medication was not available. She would expect a note on the back of the MAR indicated [REDACTED]. When asked if the physician had been notified of the missed doses, she said there was no verification of that, as it had not been noted on the MAR. She further added the physician should have been notified and an order requested to continue the medication to ensure the resident received three doses. A review of the admission records revealed the Admission Data Collection form for 7/28/20 was blank. There was no admission assessment or initial nursing note. (Photographic evidence obtained) A review of the daily skilled nursing notes found entries for 7/29/20, 7/30/20 and 8/3/20. There was no documentation of physical assessments or vital signs having been completed on 8/1/20 or 8/2/20. On 8/30/20, Resident #1 was found unresponsive at 9:15AM. Her pulse was thready (barely audible), her oxygen saturation level was not reading on the pulse oximeter, her oxygen was administered at 5 liters per minute and then increased to 90% saturation. Emergency Medical Services (EMS) was called, and she was more responsive when paramedics arrived. She was transferred to the hospital. During an interview with the Regional Nurse Consultant at 3:50 PM on 8/17/20, she was asked about the time frame for completing the Admission Assessment. She stated the expectation was that the admitting nurse would complete the assessment within two to four hours of admission. She was asked to review the assessment and she confirmed that the form was blank. The admitting nurse did not even sign it. She confirmed that the admission assessment had not been completed for this resident.

Based on record review and staff and physician interview, the facility failed to ensure the physician reviewed the resident's total program of care, including medications and treatments, by failing to ensure that after a recent hospitalization , the attending physician reviewed the hospital discharge summary and hospital progress notes received upon the admission of one (Resident #1) of three sampled residents. Failure to review this documentation, which explained the need for continued anticoagulant medication, contributed to the development of a blood clot in Resident #1's leg, necessitating her return to the hospital for surgical removal of the clot. The findings include: A review of Resident #1's clinical record revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was hospitalized from [DATE] through 7/27/20. She underwent left hip surgery on 7/17/20 and on 7/23/20, she underwent surgery to the right malleolus (ankle) and left ulna (forearm). Due to extensive leg injuries she was non-weight bearing on both legs. During her hospital stay she was ordered [MEDICATION NAME] (blood thinner) 30 mg (milligrams) twice daily to prevent blood clots. Upon discharge she was ordered dressing changes to the left hip, left arm and right lower leg. She was to wear a hinged knee brace to the left leg at all times. She was to receive physical and occupational therapy (PT, OT) and remain non-weight bearing for four weeks. She was also ordered [MEDICATION NAME] (opioid pain medication) every 12 hours. A review of Resident #1's hospital record, provided to the facility by the hospital upon the resident's nursing home admission, revealed the following: On 7/27/20 while hospitalized , Resident #1 was seen by the trauma Advanced Practice Registered Nurse (APRN) for discharge orders. The orders included: Follow up with the orthopedic surgeon in one week for suture removal, physical and occupational therapy daily, non-weight bearing for four weeks, pain control, regular diet, maintain dressings clean and dry to all sites, and [MEDICATION NAME] 40 mg (milligrams)twice daily to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot). Also, on 7/27/20 the hospitalist working with the APRN documented that he reviewed the resident's history, personally evaluated the resident and agreed with the APRN's assessment and plan. The addendum included [MEDICATION NAME]. A review of the surgeon's note, dated 7/27/20 (the day before the resident was discharged from the hospital and admitted to the facility), included the following instructions: Pain control, regular diet, non-weight bearing right and left leg, five pound weight bearing for left upper arm, elevate left upper arm and right lower leg, PT and OT, [MEDICAL CONDITION] (prevention) and [MEDICATION NAME] 40 mg twice daily. A review of the medication list sent from the hospital, revealed it did not include an order for [REDACTED]. Also included was Do not stop taking except on the advise of your physician. An interview was conducted with the attending physician for Resident #1 on 8/17/20 at 1:40 pm. He was asked if he had treated Resident #1 when she was at the facility. He said yes, she had been in a motor vehicle accident (MVA) with multiple fractures. When asked why she had been transferred to the hospital on [DATE] he stated she had developed a blood clot in her leg. He was asked if he had ordered anticoagulant (blood thinner) medication upon admission, and he stated he ordered Eliquis after a Doppler study revealed a blood clot in her leg. When asked whether she had received the Eliquis, he stated he did not know but said she did go to the hospital the day after the Doppler. He was asked whether he was aware that Resident #1 was taking [MEDICATION NAME] during her hospital stay and that two physicians and an APRN documented on 7/27/20 (the day before admission to the facility) that she needed to continue the [MEDICATION NAME]. He said he did not recall if he saw her or his partner saw her, but it would be in the progress notes. He was asked if he had reviewed the hospital discharge records, and he stated he would need to refer to the progress notes. When asked where he documented his progress notes, he stated they were dictated and brought to the facility to be filed in the record. He was informed that there were no physician's progress notes in the the resident's clinical record (20 days after the resident's admission). He stated he would contact his office and have the notes sent to the facility via e-mail so they would be available. He further stated that in his notes, or if it was his partner that saw her, in their notes, there would be a reference to the hospital records and any need for an anticoagulant. During an interview with the Administrator on 8/17/20 at 2:15 pm, she was asked if she had received the physician's progress notes for Resident #1. She said she had not yet received them, but would provide them as soon as the email arrived. She was asked again at 3:30 pm and 4:30 pm, and said she would call the physician's office to find out where they were. At the time of the exit conference (6:15 pm), the progress notes had not been provided. The Administrator emailed the physician's progress notes to the field office on 8/21/20 at 4:30 pm (four days after the survey exit). A review of the progress notes revealed that physician visits were made on 7/29/20, 7/31/20 and a telehealth visit was conducted on 8/3/20. A review of the visit note for 7/29/20, revealed the physician documented there were no current medications or allergies on file and an examination had been performed. The resident was noted as an obese female lying in bed at the time of the assessment. She was noted with left upper and lower immobilizers in place. The visit assessment/[DIAGNOSES REDACTED]. Deconditioning, physical and occupational therapy ordered and she had been in a motor vehicle accident with multiple fractures. The visit summary/care plan addressed constipation with laxative medication, it addressed pain with pain medication and it noted: MVA resulting in multiple fractures, patient with a follow up appointment with the hospital physician on 8/10/20. Physical deconditioning with therapy ordered. Monitor the resident's temperature daily, continue with therapy, follow up with hospital orthopedic team, and facility nursing staff was to notify the provider of abnormal lab work or any changes in condition. There was no documentation indicating that the hospital history and physical (H&P) and discharge summary, indicating an ongoing need for [MEDICATION NAME], were reviewed by the attending physician. There was no mention of anticoagulant use. A review of the visit note for 7/31/20, revealed that an examination was performed, and allergies/medications were reviewed from the resident's facility clinical record. The resident was documented as having been lying in bed with immobilizers on the left upper and lower extremities at the time of the evaluation. Unmanaged pain and weakness were noted. [DIAGNOSES REDACTED]. The visit summary/care plan addressed pain with medication, constipation with medication and it noted multiple fractures with follow up by the hospital physician scheduled for 8/10/20. Therapy was to be continued and the nursing staff were monitor the resident's temperature daily, and notify the physician about any abnormal lab work or sudden changes in condition. There was no documentation indicating that the hospital history and physical (H&P) and discharge summary, indicating an ongoing need for [MEDICATION NAME], were reviewed by the attending physician. There was no mention of anticoagulant use. A review of the visit note for 8/3/20, revealed the visit was conducted via telehealth. The resident was noted in bed during the evaluation with immobilizers in place on the left upper and lower extremities. The progress note indicated findings of a physical exam performed including: eyes, pupils equal, round reactive to light, respirations abnormal decreased sounds at bases, soft, nontender abdomen without masses and active bowel signs. The resident complained of left lower leg pain, and a Doppler study was ordered to rule out [MEDICAL CONDITIONS]. [DIAGNOSES REDACTED]. The visit summary/care plan addressed pain with medication, constipation with medication and it noted multiple fractures with follow up by the hospital physician scheduled for 8/10/20. Therapy was to be continued and the nursing staff were monitor the resident's temperature daily, and notify the physician about any abnormal lab work or sudden changes in condition. There was no documentation indicating that the hospital history and physical (H&P) and discharge summary, indicating an ongoing need for [MEDICATION NAME], were reviewed by the attending physician. There was no mention of anticoagulant use. According to RxList at https://www.rxlist.com/[MEDICATION NAME]-side-effects-drug-center.html: [MEDICATION NAME] ([MEDICATION NAME] sodium) Injection is an anticoagulant (blood thinner) used to prevent blood clots that are sometimes called [MEDICAL CONDITIONS], which can lead to blood clots in the lungs. A [MEDICAL CONDITION] can occur after certain types of surgery, or in people who are bed-ridden due to a prolonged illness. Obese patients are at higher risk for [MEDICAL CONDITION]. According to Healthline at https://www.healthline.com/health/[MEDICATION NAME]-injectable-solution: [MEDICATION NAME] is used to thin your blood. It keeps your blood from forming clots. Blood clots are dangerous because they can lead to serious blockages in your blood vessels. This can cause a stroke or a [MEDICAL CONDITION]. This drug is used to prevent blood clots in people who are hospitalized . It may be used if you 're too sick to move around. It ' s also used to prevent blood clots at home after you ' ve had stomach surgery or a hip or knee replacement. This drug is also used to treat existing blood clots in the hospital or at home. If you stop taking the drug suddenly or don ' t take it at all: You ' ll have a higher risk for a blood clot. This could lead to serious problems, such as a stroke or death. Take this drug on the schedule set by your doctor. Don ' t stop taking it without speaking with your doctor first.

Based on observations, record reviews, and staff interviews, the facility failed to adhere to infection control procedures by failing to use insulin pens per the manufacturer's specifications, affecting two (Residents #207 and #208) of three sampled residents, out of 12 residents currently receiving insulin via Flex Pens. The same [MEDICATION NAME] Insulin Flex Pen was used for two separate residents (#207 & 208). This can lead to the spread of blood-borne pathogens such as [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV), human immunodeficiency virus ,[MEDICAL CONDITION]. and [MEDICAL CONDITION]-Resistant staphylococcus Aureus (MRSA). On 10/10/18 at 5:00 p.m., Immediate Jeopardy (IJ) started. On 10/12/18 at 4:19 p.m., the Administrator was notified of the Immediate Jeopardy determination. On 10/12/2018 at 5:38 p.m., the facility provided an acceptable Credible Allegation of Compliance (A[NAME]). On 10/12/18 at 8:30 p.m., the Immediate Jeopardy was removed after validation of the implementation of the A[NAME]. The findings include: On 10/10/2018 at 4:35 p.m., Employee B, Licensed Practical Nurse (LPN) was observed performing blood glucose testing on the 400 hall. She tested Resident #207 and his blood glucose reading was 222. Employee B stated the resident required insulin per sliding scale, but he was a new admission today and he had none of his medication yet. The nurse was not observed administering insulin to Resident #207. On 10/10/2018 at 4:50 p.m., Employee B was observed performing blood glucose testing for Resident #208. His blood glucose reading was 301. The nurse went to retrieve the appropriate insulin, and she stated there was no [MEDICATION NAME] Insulin (Flex Pen) in the medication cart for this resident. The nurse went to the Emergency Drug Kit (EDK) to remove the [MEDICATION NAME] Flex Pen. The nurse then went back to Resident #208, dialed 17 on the dial and administered the insulin in the resident's right arm. A record review for Resident #207 revealed a physician's orders [REDACTED]. On 10/11/2018 at 8:00 a.m., the (MONTH) (YEAR) Medication Administration Record [REDACTED]. It revealed a sliding scale indicating that for a blood sugar between 200-250, four units of [MEDICATION NAME] were to be given. The nurse had signed to verify that four units were given on 10/10/2018 at 4:30 p.m. The MAR indicated [REDACTED]. Facility record review revealed the resident's [MEDICATION NAME]was not delivered until 10/10/2018 at 11:29 p.m. The Director of Nursing (DON) on 10/11/2018 at 8:45 a.m. stated she looked into both EDK boxes, and insulin was not removed for Resident #207, nor was it delivered until later that evening, so the nurse could not have given it to him at 4:30 p.m. LPN B was interviewed on 10/11/2018 at 1:15 p.m. She stated she did not have the [MEDICATION NAME] Flex Pen for Resident #207 at dinner yesterday, so she borrowed it from Resident #208. She used the same [MEDICATION NAME] Flex Pen for Resident #207 that she used for Resident #208. She gave the insulin around 5:00 p.m. She did not want Resident #207's blood sugar to rise too high. LPN B stated she did not think it was an infection control problem, because she changed the needle before using the Flex Pen to administer insulin to Resident #207. The DON was present, and she stated this was not an infection control problem; however, the nurse should not have done it. On 10/12/2018 at 8:30 a.m., Resident #207 was interviewed. He had a [MEDICAL CONDITION] in place and was unable to speak. He shook his head, mouthed his words, or wrote on his communication board to answer questions. He did not remember staff telling him yesterday about receiving the insulin injection using another resident's Flex Pen. He nodded his head in affirmation that they drew blood from him last night. The unit manager was asked to come to the resident's room and explain the incident to him. The resident shook his head from side to side and mouthed the phrase, That could be a costly mistake. A record review for Resident #208 revealed a 9/1/2018 History and Physical. It revealed he was in the hospital in (MONTH) of (YEAR) and developed complications of [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). He had a past medical history possible [MEDICAL CONDITION] with [MEDICAL CONDITION]. There was a physician's orders [REDACTED].#208 which read, discharge home with medications. On 10/12/2018 at 8:50 a.m., the DON stated she did not know if anyone had notified Resident #208 at home about the medication error with the [MEDICATION NAME] Insulin [MEDICATION NAME] he was sent home with. A call was placed (on speaker phone) to Resident #208's home by the assistant director of nursing at 9:10 a.m. on 10/12/2018. The resident's mother answered the phone and stated he was asleep. His mother stated he was discharged with two insulin Flex Pens, one containing [MEDICATION NAME]and the other containing [MEDICATION NAME] insulin. The [MEDICATION NAME] Flex Pen was empty. The resident's mother stated the resident did use the [MEDICATION NAME] Flex Pen once after returning home. Resident #208's physician was called on 10/12/2018 at 9:15 a.m. He stated he was not told that the resident's Flex Pen was used for a second resident. Resident #207's physician was called on 10/12/2018 at 11:00 a.m. She stated she was at the facility when she was informed of the nurse using Resident #208's insulin Flex Pen for Resident #207. She stated she did not tell the resident of this occurrence, but asked the unit manager to explain it to him. She did her due diligence and ordered labs for HIV/[MEDICAL CONDITION]. On 10/12/2018 at 12: 10 p.m., the regional nurse was told Resident #208 was discharged home with his medications (including the Flex Pen), and no one from the facility had notified him. She stated she was not aware of this. The medical director was called on 10/12/2018 at 1:30 p.m. He stated he followed no residents at this facility. He was a hospitalist. He came for the monthly quality assurance meetings and was available as needed for questions/concerns that may arise at the facility. He was not made aware the insulin Flex Pen was used for more than one resident. He stated You should not do it., but added he did not feel it was an infection control issue. The facility's policy and procedure for Insulin Administration-Injection Pens: Effective 12/22/2014 (revised 10/10/2017) read, Follow the manufacturer's instructions for administration. The manufacturer's instructions provided by the regional nurse revealed, Never share a [MEDICATION NAME] Flex Pen between patients. Advise patients that they must never share [MEDICATION NAME] Flex Pens even if the needle is changed, because doing so carries a risk for transmission of blood-borne pathogens. The Centers for Disease Control (CDC) website (https://www.cdc.gov/injectionsafety/clinical-reminders/insulin-pens.html) was accessed on 10/11/2018 at 7:10 p.m. for article: CDC Clinical Reminder: Insulin Pens Must Never Be Used for More than One Person. It revealed: Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. These devices are designed to permit self-injection and are intended for single-person use. In healthcare settings, these devices are often used by healthcare personnel to administer insulin to patients. Insulin pens are designed to be used multiple times, for a single person, using a new needle for each injection. Insulin pens must never be used for more than one person. Regurgitation of blood into the insulin cartridge can occur after injection, creating a risk of blood-borne pathogen transmission if the pen is used for more than one person, even when the needle is changed. On 10/12/18 at 4:19 p.m., the Administrator was notified of the Immediate Jeopardy determination. Information was shared regarding Licensed Practical Nurse B using one [MEDICATION NAME]Flex Pen to administer insulin to two separate residents on 10/10/18 between 4:00 p.m. and 5:00 p.m. The facility presented an acceptable Credible Allegation of Compliance (A[NAME]) on 10/12/18 at 5:38 p.m. that included the following immediate actions taken by the facility: 1. LPN B was provided with one to one counseling/education on 10/11/18 related to emergency drug kits, contacting the pharmacy to request ordered medications and not using an insulin Flex Pen for more than one resident. 2. A quality review was conducted by the DON on 10/11/18 to ensure individual insulin pans and vials were available for the twelve current residents who required insulin. All 12 residents had their own insulin pen or vial. 3. A quality review was conducted by the DON on 10/12/18 to ensure all multiple dose medications were available in facility. 4. From 10/11/18 to 10/12 18, the DON re-educated 38 of 41 nurses employed by the facility regarding ensuring insulin pens are for individual use only, each resident requiring insulin has their own pen/vial of insulin available, utilizing emergency drug kits (EDKs), calling the pharmacy for delivery of ordered medication, and when accessing the EDK for insulin, nursing was only able to use it for one dose before it had to be disposed of. No nurse would be assigned to a resident receiving insulin via Flex Pen until they had received this training. 5. A quality review will be conducted by the DON to ensure residents requiring insulin receive their own individual insulin pen or vial weekly x4 weeks, and then every two weeks and as needed. 6. Residents #207 and #208 as well as their physicians were notified by 10/12/18 that the residents were affected by the procedure used to administer insulin with the same insulin Flex Pen. Both residents had the potential to be affected. Resident #207's physician ordered lab work ([MEDICAL CONDITIONS] and human immunodeficiency virus ,[MEDICAL CONDITION]. and a specimen was drawn on 10/11/18 at 6:51 p.m. Resident #208 was discharged home on[DATE]. The facility was in contact with him on 10/12/18 and offered the same laboratory testing as was offered to Resident #207. The team lifted the Immediate Jeopardy at 8:30 p.m. on 10/12/18, after validation of the implementation of the A[NAME]. Validation was made through facility record reviews, observations, and staff interviews by the survey team, including: 1. A review of the education provided to LPN B related to not using insulin Flex Pens for more than one resident, use of the emergency drug kits (EDKs), and contacting the pharmacy to obtain resident medications as ordered, verified that the nurse had been educated. 2. A review of the education provided to facility nurses related to not using insulin Flex Pens for more than one resident and ensuring that each resident receiving insulin had their own Flex Pen or vial of insulin available verified that 38 of 41 nurses had been educated by 10/12/18. Education also included: Insulin obtained from the EDK can only be used for a one-time dose and then must be destroyed, and nurses not educated prior to the survey team's exit would not be assigned to a resident using an insulin Flex Pen until training had been completed. 3. A review of Resident #207's lab work revealed that a blood sample was collected on 10/11/18 at 6:51 p.m. in order to test for [MEDICAL CONDITION] and B as well as for Human Immunodeficiency Virus ,[MEDICAL CONDITION]. with results pending. 4. A review of the facility's policy and procedure, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, effective 12/1/2007 and revised on 5/1/2010 and 1/1/2013, revealed that the facility should ensure that the storage location of the interim/stat/emergency boxes is known to all personnel handling medications, that the manufacturer's/supplier's guidelines are being followed, and that any medications with makeshift, incomplete, damaged or missing labels are destroyed and reordered. 5. A review of the facility's policy and procedure, 6.0 General Dose Preparation and Medication Administration, effective 12/1/2007 and revised on 5.1.2010 and 1/1/2013, revealed that the facility staff should comply with facility policy, applicable law and the state operations manual when administering medication. Facility staff should not administer a medication if the medication or prescription label is missing. Facility staff should dispose of unused medication portions in accordance with facility policy. 6. Observations were made on 10/12/18 of all insulin supplies for the 12 residents' currently using insulin to ensure that each resident had their own Flex Pen or insulin vial. 7. Interviews were conducted with five nurses on 10/11/18 between 4:15 p.m. and 4:30 p.m. related to the proper use of a Flex Pen, whether a Flex Pen could be used for more than one resident, what should be done if a resident's insulin could not be found, how many doses of insulin could be administered from a vial or Flex Pen obtained from the emergency drug kit, and who could label residents' medications. All five nurses were able to properly describe how to use a Flex Pen, not to use an insulin pen for more than one resident, the procedure to be used to obtain insulin if none could be located, how to access and use insulin from the EDK, and who was able to label a resident's medication. 8. Four nurses were observed for competency related to use of the Flex Pens on 10/11/18 with no concerns. Seven nurses were observed for competency related to use of the Flex Pens on 10/12/18 with no concerns.

Based on record review and staff interviews, the facility failed to ensure a resident who did not enter the facility with a pressure sore did not develop a pressure sore for 1 of 3 sampled residents with pressure ulcers, from a total sample of 39 residents (Resident #177). The findings include: Record review for Resident #177 revealed a [AGE] year old male, admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of the initial nursing assessment, dated 4/29/16, revealed he was alert and oriented, and required assistance with transfers, bed mobility, bathing, and dressing. He was continent of bowel and bladder, and could eat independently. The initial skin assessment indicated his skin was warm and dry. He had three surgical sites to the right hip with staples intact. Pressure ulcer risk assessment, dated 4/29/16, revealed a score of 11, indicating at risk for development of pressure ulcers. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #177 was not admitted with pressure ulcers. Review of nursing notes, dated 6/16/16, revealed the resident was found with a small open area to the right outer ankle, with beginning of skin breakdown. The nurse documented to keep pressure off right ankle. Review of the physician progress notes [REDACTED]. He has had a right [MEDICAL CONDITION] with repair, and leg had been everted, which was chronic and not new for resident. Because of the pressure that his right outer ankle had with that eversion on his bed, there was an open area on the right outer ankle, which was reddened, not infected, and with some breakdown noted. He discussed with nursing about taking care of it and off-loading the ankle. An order was given to cleanse the wound with normal saline, apply [MEDICATION NAME] ointment, and dry dressing daily. Review of the nursing notes, dated 7/4/16, stated treatment was performed to right ankle, area with light tan drainage and no odor. On 7/7/16, a new order was received for wound care to right ankle. Cleanse with normal saline, apply Santyl ointment to yellow slough in wound bed, and cover with dry dressing. Review of the pressure ulcer record revealed no documentation, including measurements, staging, condition of wound, drainage, or odor until 7/7/16, when the right ankle wound was documented as Stage III, with yellow slough, no drainage or odor. The measurements were recorded as 0.8cm x 0.8cm x 0.1 cm. On 7/13/16, the nurse documented Resident #177 was medicated for pain to right ankle prior to dressing change. An interview was conducted with the Unit Manager (Employee T) on 08/04/2016 12:07:02 PM. When asked about the status of the right ankle wound, she stated it was healing. She stated he had a [MEDICAL CONDITION], and right leg rotated outward and caused pressure on the right ankle, and he developed skin breakdown. When asked what stage was the wound, she stated it was Stage 3, it had yellow slough. She stated the wound developed in house. When asked for the pressure ulcer reports for June 2016, she stated she could not locate any. When asked what interventions were put into place when the wound was discovered, she stated they elevated the lower leg on a pillow. She was asked if a care plan was initiated when the wound was found, and she stated there was a care plan regarding the potential for impaired skin integrity. She stated the facility did not initiate a new care plan regarding the development of a right ankle wound, including stage of the wound, specific treatments, or pressure relieving measures to right ankle. An interview was conducted with Resident #177 on 8/4/16 at 10:30 am. When asked about the dressing observed to the right ankle, he stated there was a pressure sore on the right outer ankle. When asked if the wound was present on admission, he stated, No. He said it happened about a month after he arrived. He fell prior to admission and suffered a [MEDICAL CONDITION]. Prior to the fracture, his leg rotated outward somewhat. Because of the [MEDICAL CONDITION], he could not re-position himself, and that he also had pain upon movement. He was not aware there was so much pressure on the ankle until the nurse informed him of the open area. When asked what did the staff do to relieve the pressure off the right ankle, he stated that sometimes, he had a pillow under the leg in bed. He was up in a wheelchair during the day to go to therapy. He was asked if he had any pain to the right ankle, and he stated his hip was doing better with less pain; however, now he was taking medications for pain to the right ankle.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory services to meet the continuous oxygen needs of 3 sampled residents (Residents #190, #187, and #79), of 39 sampled residents, resulting in below normal oxygenation values due to an inadequate supply of portable supplemental oxygen. Residents who require continuous supplementation of oxygen are not able to meet the body's oxygen demands to maintain vital organ and physiological body functions independently; making it critical that a continuous supply of supplemental oxygen be provided to maintain healthy body functioning. The facility failed to identify and replace depleted portable oxygen supply tanks in a timely manner. The findings include: 1. On 8-1-16 at 10:30 AM, during the initial facility tour, an unsampled resident was observed on the 300 hall in a wheelchair, the resident had nasal cannula (NC) in place, and it was connected to a portable oxygen tank. The oxygen tank pressure valve indicator was observed registering in the red area, and the resident was on 2 LPM flow. The physical therapy assistant accompanying the resident was asked about the level of oxygen in the portable tank. The physical therapy assistant (PTA) looked at the tank pressure meter and stated, The tank is empty; I will get her a new tank. The PTA returned minutes later with a full portable oxygen tank and connected the resident's tubing to the new tank. 2. On 8-1-16 at 11:00 AM, Resident #190 was observed sitting in a wheelchair in the day room on the South Wing. The resident was observed with a nasal cannula (NC) in use; the tubing was connected to a portable oxygen tank. The portable tank pressure valve indicator was observed registered at 500 psi with 2 LPM flow. On 8-1-16 at 12:25 PM, a return observation was conducted on the South Wing's day room area for Resident #190. Resident #190 was observed sitting in a wheelchair, facing towards the TV, looking forward with blank stare, and she appeared pale. The resident continued with NC in place, and the portable oxygen tank pressure valve indicator was observed registered in the red. The resident's respiratory rate was 22, her color was pale, her nail beds were pale, and her lips were pale with little color. Employee L was requested to check on Resident #190. Employee L asked the resident, Are you okay? Resident #190 looked at the nurse and smiled; she did not respond verbally. Employee L was asked about the resident's oxygen tank level, and she stated, Her tank is out; we need to get her a new tank. Employee L checked Resident #190's oxygenation with a pulse oximetry device. Her oxygen saturation level registered below normal at 87%, and her heart rate was 67. Employee L asked Resident #190, How are you doing? Resident #190 did not respond verbally to the question, she smiled and grinned in childlike manner. On 8-1-16 at 12:29 PM an observation was conducted in Resident #190 ' s room. The resident ' s portable oxygen tank was changed. The new tank registered full 2000 psi, the flow was set at 2lpm. Resident #190 ' s oxygen saturation was checked following the tank change; her saturation had improved, the reading was 98% and her heart rate was 60. Resident #190 ' s color had greatly improved; her lips and nail beds now were pink in color. Her respiratory rate was 18. On 8-1-16 at 12:45 PM, an interview was conducted with Employee L. The employee stated Resident #190 was oxygen dependent and she received supplemental oxygen by portable tanks or by oxygen concentrator. The resident had a portable oxygen concentrator in the room. Employee L stated the concentrator was used when the resident was in her room or in bed. Employee L was asked how did staff know when to change portable oxygen tanks, and she stated that when the portable oxygen tank got close to or started to register in the red zone, the tank should be changed. Employee L stated that Resident #190's saturation level was low, and stated her tank should have been changed. Employee L was not able to say what Resident #190's baseline oxygen saturation was. 3. On 8-2-16 at 12:05 PM, an observation in the day room area of the South Wing was conducted. Resident #187 was observed in a wheelchair hunched over with her head down nearly in her lap; the hood of her sweat shirt covered her head, and her face was not visible. The resident had a portable oxygen tank with NC tubing attached to the tank. The portable oxygen tank pressure valve was observed registering in the red. The resident was observed with movement in her hands and her legs. On 8-2-16 at 12:06 PM, an interview was conducted with Resident #187. The resident was asked, How are you doing today? Resident #187 raised her head slowly and stated, I am so tired today; I don't feel good. Resident #187's lips were pale, her skin color was pale, and her nail beds were pale blue. The resident put her head back down. The Unit Manager of South Wing (UM-S) was asked to come check Resident #187. The UM-S asked the resident, How do you feel? Resident #187 raised her head and said, I just don't feel good; I feel so tired. The UM-S was asked about the resident's portable oxygen tank. The UM-S stated, Oh, her tank needs to be changed. The UM-S asked a Certified Nursing Assistant (CNA) to get a new tank. The UM-S immediately checked Resident #187's oxygen level with a pulse-oximeter device; the oximeter reading was below normal at 84%; her heart rate was 80 beats per minute (bpm), and her respiration rate was 24. Resident #187's portable oxygen tank was changed out. Resident #187's oxygen saturation was re-checked by the UM-S, and it had improved to 94% and the HR was 80 beats per minute (BPM), and the tank flow rate was set a 2 lpm. Resident #187's baseline oxygen saturation level reviewed in the medical record was 94% to 98%. On 8-2-16 at 12:10 PM, an observation of Resident #187 revealed the resident's color had improved. She was in bed with NC attached to the oxygen concentrator, with a flow rate of 2 lpm. The resident was able to stay awake, and she had pink coloring in her lips and in the nail beds of her fingers. Her respiratory rate was down from 24 breaths per minute to 18 per minute. 4. On 8-2-16 at 12:15 PM, an observation in the main dining room revealed Resident #79's portable oxygen tank was in the red zone, and Resident #79 appeared fatigued, with a pale tone coloring to her face and hands. At this time, Resident #79 was questioned if she was receiving oxygen through her tubing, and she replied, No. At this time, Employee A walked over and confirmed Resident #79's portable tank was empty because it was in the red. She also indicted no oxygen flow from the tubing after she removed and attempted to check oxygen flow. She proceeded to check Resident #79's oxygenation with a pulse oximetry device. The pulse oximetry read an oxygen saturation level at 88%, and her heart rate was 62. Employee A stated, I will change her portable oxygen tank right away. 5. An interview was conducted with the UM-S on 8-2-16 at 12:20 PM. The UM-S stated that Resident #187 had just been started on oxygen. The UM-S stated that residents with portable oxygen tanks require oxygen around the clock; that portable tanks were monitored by staff, such as CNAs, nursing, and therapy department staff. On 8-2-16 at 12:40 PM, an interview was conducted with the Administrator and DON. The DON was asked how the facility ensured that residents receiving portable oxygen were monitored. The DON stated that residents were given fresh oxygen tanks when they were up out of bed, and that the tanks were checked every 2 hours by staff thereafter. The DON stated there were no logs or documentation for tank change outs for residents receiving continuous portable oxygen. He stated that portable oxygen was at 1/4 tank when registering in the red zone, and would last for 1 hour and 10 minutes (70 minutes) with a flow rate of 2 lpm. The DON was asked how do staff know when to change portable oxygen tanks? The DON stated that staff were instructed to change tanks out when the pressure valve indicator was near or in the red zone. The DON stated he would provide information on tank capacity from the manufacturer for review. The Administrator was asked to provide a list of residents in the facility receiving continuous oxygen by portable tanks. At 1:25 PM on 8-2-16, during an interview with Employee R, she stated, Everyone, all staff know to check portable oxygen tanks. She stated usually someone would identify and change the tank. She was asked at what point on the pressure valve indicator was a portable tank determined to be empty, and she stated that the tank should be changed just before or at the time it registered in the red. She stated the red zone on the tank's pressure valve was there as an alert. Employee R stated that oxygen was delivered 2 times a week. A list was provided for all residents who were receiving continuous oxygen by portable tanks; there were five (5) residents on the list. At 1:40 PM on 8-2-16, the Administrator provided a second list of residents receiving continuous oxygen by portable tanks; there were 7 residents on the second list. At 1:45 PM on 8-2-16, a facility audit of residents on portable continuous oxygen was conducted by the survey team, and it revealed that there were three (3) additional residents receiving portable oxygen not identified on the lists provided by the facility. The total number of residents receiving portable continuous oxygen was 10. The facility did not maintain an accurate record of residents who required continuous oxygen supplemented by portable oxygen tanks. On 8-2-16 at 1:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) Employee M. Employee M stated that he had checked Resident #187's tank when he got her up to the wheelchair on 8-2-16 at 9:00 AM. He stated the tank should have lasted much longer. Employee M was asked how he kept track of portable oxygen tanks, and he stated he just made sure he was checking regularly and kept an eye on the tanks. Employee M stated there was no place to document or check to see when a tank was last changed. The employee was visibly concerned; he stated that he checked residents' tanks every 2 hours. He stated that when a tank gets close to or was in the red, he went ahead and changed the tank. If the tank was still good when a resident was getting back into bed, he made sure the portable tank was tuned off and connected the resident to the oxygen concentrator in the resident's room. Employee M could not say why Resident #187's tank was not changed out, and he stated he had checked the tank and it should have lasted longer. He stated he gets new tanks from the oxygen storage room and places the empty tanks in the empty rack. On 8-3-16 at 12:55 PM, a record review was conducted for Resident #190, and it revealed physician orders, dated 7-21-16, for oxygen at 3 liters per minute (LPM) via NC continuous written on admission. There was a new order, dated 8-1-16, to check oxygen saturation every shift. The resident had a history of [REDACTED]. Resident #190 received two respiratory inhalers: [MEDICATION NAME], one time daily; and ProAir, given every 4 hours daily. The resident had an acute hospitalization on [DATE], and was admitted to the facility on [DATE]. Resident #190's baseline oxygen saturation was 94%, with a heart rate of 69; documented on the physician assistant's dictation note, dated 7-17-16, while in the hospital. There were no oxygen saturation levels documented by the facility on record. Resident #190's respiratory care plan had a goal to maintain clear and equal breath sounds through the next review, with interventions as follow: Oxygen as ordered 2 lpm continuous, pulse oximetry as ordered, medications as per physician orders, monitor lab reports as ordered, and thickened liquids as ordered. The respiratory plan of care did not have the correct liter flow rate (3 LPM continuous) ordered by the physician documented on the respiratory care plan interventions listed. On 8-3-16 at 1:15 PM, a record review was conducted for Resident #187. Resident #187 was admitted on [DATE], following an acute hospitalization on [DATE], with [DIAGNOSES REDACTED]. Resident #187's baseline vital signs on the 8-16-16 hospital encounter were: blood pressure 133/65, respiratory rate 15, heart rate 98, temperature 97.9, and oxygen saturation of 98%. On the Form 3008, dated and signed by a physician on 7-21-16, under treatments listed: oxygen 2 liters per minute (LPM) continuous via nasal cannula (NC). Review of the South Wing's Vital Signs log revealed no baseline oxygen saturation values. Review of the facility's admission data collection form, dated 7-21-16, revealed vital signs as follows: Blood pressure 140/83, heart rate 78, temperature 98.1, and oxygen via nasal cannula at 2 LPM with oxygen saturation of 94% recorded on the admission nursing note, page 10 of 10. On 8-4-16 at 7:40 AM, a record review was conducted for Resident #79 and review of the facesheet revealed the resident was admitted to the facility for long term care originally on 4/7/2016, with re-admission on 6/21/2016, and [DIAGNOSES REDACTED]. Review of the resident's discharge note post hospitalization , dated 6/20/2016, documentation plan oxygen 2-3L continuous. Review of physician progress notes [REDACTED]. Review of the physician orders, dated 6/23/2016, documented oxygen saturation checks every shift. Review of medication administration records, dated 6/21 to 6/30, 2016 revealed oxygen at 2L continuous via nasal cannula with oxygen saturations, dated 6/22/16 thru 6/28/16, with a range of 94-97%. 0n 8/04/2016 at 2:05 PM, a return observation was conducted in the day room area of the South Wing. Resident #187 was observed sitting in a wheelchair, her eyes were closed, she was sitting upright, she was covered with a blanket, NC in use, and the tubing was connected to the portable oxygen tank. The tank pressure valve was registered in the red zone; the flow rate was 2 LPM. The resident's respiratory rate was 22, and her color was pale. Resident #187 was approached and she stated, I am so cold. She stated, I am ok; I am just so cold; she asked if the surveyor could get another blanket for her. The DON was close by in the hallway, and was asked if he could check on the resident. The DON observed Resident #187's portable oxygen tank pressure valve, and it was in the red. The DON stated the tank would need to be changed. On 8-4-16 at 4:10 PM, an interview was conducted with the DON. The DON was asked if he could say when the portable oxygen tank for Resident #187 was last checked, and he stated, Tanks are checked every 2 hours, and stated that if we had waited 20 minutes more, he felt sure that staff would have checked Resident #187's tank, and it would have been changed. The DON was asked what process the facility had in place to ensure that oxygen dependent residents using portable oxygen tanks were not going without oxygen between tank changes. The DON stated there was no log to document resident name, date, and time when the tanks were changed out. He stated no documentation was required. The DON stated there was no one person appointed to check residents' portable tanks. He stated he had no written documentation to confirm 2-hour checks were completed. The DON stated he personally performed daily random resident portable tank audits to ensure residents' tanks were being changed. The DON was unable to provide a log of his independent audits. Review of the facility's policy and procedure for Oxygen Therapy, dated 11-9-15, stated, Oxygen Therapy is the administration of a FiO2 greater than 21% by means of various administration devices to: raise the resident's Pao2 to an acceptable baseline using the lowest FiO2, to treat arterial hypoxemia, to decrease work of breathing, to reverse and prevent tissue [MEDICAL CONDITION], to decrease [MEDICAL CONDITION] work. A review of a National Heart, Lung, and Blood Institute document titled, What Is Oxygen Therapy? revealed: Oxygen therapy is a treatment that provides extra oxygen, a gas that the body needs to work well. Normally, lungs absorb oxygen from the air. Some diseases and conditions can prevent getting enough oxygen. Oxygen therapy may help you function better and be more active. Oxygen is supplied in a metal cylinder or other container. Your Doctor will decide whether you need oxygen therapy based on the results of tests, such as an arterial blood gas and a pulse oximetry test. These measure how much oxygen is in your blood. A low oxygen level is a sign that you need oxygen therapy. Oxygen is considered a medicine, so your doctor must prescribe it. A review was conducted of a Mayo Clinic document, titled Hypoxemia (low blood oxygen), dated 12-25-2015, and it stated normal pulse oximeter readings usually ranged from 95% to100%. Values under 90% percent were considered low. When your blood oxygen level falls below a certain level, you might experience shortness of breath, headache and confusion. A review of an American Lung Association document titled, Supplemental Oxygen, dated 2016, stated: For people who do not get enough oxygen naturally, supplemented oxygen can have several benefits. Oxygen therapy can: Improve sleep and mood, Increase mental alertness, Allow a person's body to carry out normal functions, Prevent heart failure in people with severe lung disease. (Photo copy evidence provided).

Based on record reviews and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 7 residents sampled (Resident #1). This resulted in harm when Resident #1 did not receive his prescribed medications or wound care as ordered by the physician, which resulted in the resident having abnormal lab values and worsening of a pressure ulcer. Resident #1 experienced a change in his behavior, and an increase in his potassium levels, which required hospitalization for stabilization and treatment. The findings include: A record review for Resident #1 revealed an admission date of [DATE] and a discharge to the hospital on [DATE]. [DIAGNOSES REDACTED]. A review of the resident's Medication Administration Record [REDACTED]. The medications included Eliquis, 5 mg (blood thinner); Atrovent, 0.5 mg nebulizer (for breathing); [MEDICATION NAME], 50 mg (used for high blood pressure); [MEDICATION NAME], 200 mg (for high blood pressure); Levimir and [MEDICATION NAME] Insulin (for diabetes); [MEDICATION NAME], 5 mg (aids in digestion); and [MEDICATION NAME], 20 mg (for stomach acid). (Photographic evidence obtained.) A review of Resident #1's record revealed neither the physician nor the resident's family (who was the resident's Health Care Power of Attorney) was contacted to make them aware the resident did not receive his prescribed medications on 4/28/2016. A phone interview with the pharmacist on 6/14/2016 at 5:00 PM confirmed Resident #1's medication orders were received by the pharmacy at 7:00 PM on 4/28/2016 via facsimile. The pharmacist confirmed Resident #1's medications were sent to the facility in the early morning hours on 4/29/2016. A review of the facility's Policy and Procedures for Admissions Assessment, dated 11/30/2014, read, Notify Pharmacy of admission, new orders, and allergies [REDACTED]. An interview was conducted with the Director of Clinical Services, Registered Nurse (RN), on 6/14/2016 at 12:30 PM. He confirmed the nursing staff should contact the physician with a missed dose or a refusal of medication within a few hours. The Director was asked should he be notified as well and he replied, Yes. The Director then reviewed the MAR for Resident #1 and confirmed the resident's medications were not administered as ordered on the evening of the 4/27 and on 4/28/2016. The Director also confirmed he was not made aware of Resident #1 not receiving his scheduled medications, and did not see documentation in Resident #1's record where his physician had been notified of the missed dosages of medication. An interview with Employee L (Licensed Practical Nurse, LPN) on 6/14/2016 at 3:24 PM confirmed the staff were to call the physician or Advanced Registered Nurse Practitioner (ARNP) right away if a resident refuses or misses a dosage of medications. An interview with the Executive Director on 6/14/2016 at 3:55 PM confirmed she was not aware of any issues or concerns with Resident #1. She stated, I was never told anything in meetings and I don't have a grievance. 2. A review of the 3008 form received from the hospital upon admission and dated 4/27/2016, revealed Resident #1 had an unstageable pressure wound to his coccyx. An admission Minimum Data Set (MDS), dated [DATE], revealed the resident had an unstageable pressure ulcer. A review of Resident #1's Admission Data Collection Sheet, dated 4/27/2016 at 8:30 PM, revealed the section Skin conditions was left blank, and there was no documentation of the resident having a pressure ulcer on his coccyx. (Photographic evidence obtained.) An interview with Employee M, LPN, on 6/15/2016 at 10:55 AM confirmed the facility had no internal documentation of the pressure ulcer for Resident #1, and she gathered her information for the Minimum Data Set (MDS) from a physician's orders [REDACTED]. The facility's weekly skin integrity report for Resident #1 was found blank, with no documentation noted for wound care, measurements, staging, drainage, or treatments given to the unstageable pressure ulcer on his coccyx. (Photographic evidence obtained.) An interview was conducted with Employee L, LPN, on 6/14/2016 at 3:24 PM. She confirmed she performed wound care on Resident #1's pressure ulcer on 5/1/2016, and stated, It was bad; it needed debridement. She confirmed she was concerned about how the wound looked, and placed a call into the physician for a wound care consult, which had been ordered previously, but was not done. An interview was conducted with the Director of Clinical Services on 6/15/2016 at 3:55 PM, who confirmed the nursing staff were to assess a resident from head to toe upon admission, and were to document their findings of pressure ulcers or any skin issues. A review of the facility's Policy and Procedures (P&P) for Admission Assessment, dated 11/30/2014, read, Document skin condition and complete treatment record. (Photographic evidence obtained.) On 6/14/2016 at 4:48 PM, the Director of Clinical Services confirmed the facility had no documentation for Resident #1's unstageable pressure ulcer upon admission or during his stay. The Director also confirmed he was not made aware of Resident #1's wound, and never assessed it for measurements or staging before the resident was discharged on [DATE]. An interview was conducted on 6/15/2016 at 3:00 PM with Employee K, Certified Nursing Assistant (CNA), who confirmed she worked with Resident #1 on the evening of 5/1/2016. She stated, The daughter came in and was complaining of the smell in the resident's room and thought it was his [MEDICAL CONDITION], but I knew that smelled like an infected wound. I assisted the resident for Activities of Daily Living (ADL) care and when I turned him over, I observed he had a soiled dressing to his coccyx. I quickly went and got the nurse, and she said she had no idea this resident had a wound, and the admitting nurse never documented it. Employee K confirmed the dressing was old and hadn't been changed. She stated, You could tell it hadn't been changed, it smelled bad! 3. A physician's orders [REDACTED]. (Photographic evidence obtained.) A record review for Resident #1 revealed the lab work was not performed when ordered. A physician's orders [REDACTED]. (Photographic evidence obtained.) A review of the lab results, dated 4/30/2016, revealed a critical lab value for Potassium of 6.0 (range 3.5-5.1). On the bottom of the lab slip was a physician's orders [REDACTED]. (Photographic evidence obtained.) A review of Resident #1's May Medication Administration Record [REDACTED]. A lab result for Resident #1, dated 5/1/2016 at 8:13 AM, revealed the resident's potassium level was critical at 6.5. A physician's orders [REDACTED]. An interview on 6/15/2016 at 11:20 AM with the Advanced Registered Nurse Practitioner (ARNP) confirmed Resident #1's required stat lab work on 4/30/2016 was due to labs not being drawn as ordered on [DATE]. The ARNP also confirmed the facility never notified her the resident was not given his pills on the evening of 4/27/2016, or the day of 4/28/2016. 4. A physician's orders [REDACTED]. A record review for Resident #1 was conducted and no documentation could be found the staff monitored Resident #1's output as ordered. An interview on 6/15/2016 at 2:10 PM with Employee M, LPN, confirmed there was no documentation of output done for Resident #1 as ordered. 5. An interview was conducted with Resident #1's daughter on 6/14/16 at 8:30 AM. She expressed her concerns about her father not receiving his medications as ordered upon admission; not having ordered lab work drawn timely, and not receiving wound care as needed. She indicated that Resident #1's behavior and condition declined which included his refusal to take medications ordered for the elevated potassium level after the stat lab results were received. She was also aware of the poor condition of his pressure sore. Due to the facility's failure to provide needed care and services for Resident #1, he was discharged to the hospital on [DATE]. He remained in the hospital for 10 days for treatment and stabilization before he was discharged to a different nursing home.

Based on observation, resident and staff interview, and clinical record review, the facility failed to ensure that 2 (Resident #109, and #110) of 40 sampled residents were free from mistreatment by other another resident. Failure to prevent mistreatment resulted in actual mental harm to Resident #109 and Resident #110. The findings include: 1. On 10/24/11 at 1:20 PM during an interview with Resident #109, her roommate, Resident #67, walked over to Resident #109's side of the room and stated that Resident #109 talked too much and began pointing and yelling at Resident #109. Resident #109 revealed that Resident #67 always exhibited this behavior when she (Resident #109) had visitors or staff with her. Resident #67 yelled at Resident #109 to shut up. Then Resident #109 yelled back at Resident #67 for her to shut-up. An interview on 10/24/11 at 1:30 PM with Registered Nurse (RN) #1 revealed that Resident #67 had been relocated within the facility because of issues with the former roommate. RN #1 revealed that Resident #67 had told her that Resident #109 talked too much. RN #1 indicated that Resident #67 liked her room quiet and Resident #109 liked to talk. On 10/24/11 at 1:36 PM an interview was conducted with the Social Worker (SW). The SW revealed that Resident #67 was moved from her previous room, because she was agitated when the staff went into the room to provide care to the roommate. Per the SW Resident #67 would yell at staff and "run the staff out". On 10/24/11 at 1:50 PM an interview with Resident #109 revealed that Resident #67 had told her to shut up on more than one occasion. She stated that every time she had a visitor Resident #67 would get upset, because they were not there to see her. She stated that her visitors had to go to the nurses station and be escorted to her room because of Resident #67's behavior. Resident #109 revealed that the staff get on to her (Resident #109) for yelling back at Resident #67. On 10/24/11 at 2:13 PM an interview with certified nursing assistant (CNA) #1 revealed she was aware Resident #67 did not like anyone in her room for any reason. CNA #1 revealed that if the CNAs are talking or if they close the door Resident #67 gets upset and had used profanity. CNA #1 stated that the roommates were face to face yelling at each other one day and the staff had to calm them down. CNA #1 indicated that this concern had been reported to the nurses. An interview with CNA #2 on 10/24/11 at 2:15 PM revealed that Resident #67 spoke Italian and spoke very little English. She stated that she had never observed the two roommates yelling at each other. But states that the pair had gotten "a little antsy" with each other but it was "nothing of concern." CNA #2 stated that Resident #67 gets upset when Resident #109 talks loud. She stated that Resident #109 was hard of hearing and talked loud. The CNA stated that she whispers in Resident #109's ear and talked to her quietly so they would not disturb Resident #67. An interview with CNA #3 on 10/24/11 at 3:00 PM revealed that Resident #67 had been confrontative with staff in the past. She stated that Resident #67 had also gotten on to her one day for closing the door to her room when she was providing the roommate with personal care. CNA #3 stated that the nursing staff was aware of Resident #67's behavior. An interview with CNA #4 on 10/26/11 at 7:25 AM revealed that she had been employed with the facility for almost two years, and she worked on the night shift. She revealed that Resident #67 could be erratic and almost everything disturbed her. For example, passing ice and getting her roommate dressed. She stated that Resident #67's behaviors included throwing things and yelling. She stated that the behavior occurred, "mostly in the early morning." CNA #4 revealed that nursing staff had been notified, and that "sometimes they could hear." On 10/26/11 at 3:45 PM an interview with CNA #5 revealed that Resident #67 and Resident #109 "had been having issues for months." A staff interview with the Unit Manager (UM) on the GNR Unit on 10/27/11 at 3:10 PM revealed that Resident #67 had been on the GNR Unit for a couple of months. The UM stated that Resident #67 was moved to a different room because she was having behavior issues. She stated that Resident #67 would yell at her previous roommate in Italian, and then get up and turn off the roommate's television. She stated that the roommates family would observe Resident #67 get up and turn off the television. The UM stated that Resident #67 yelled at her roommate because of the TV, and about her space issue. The UM also stated that Resident #67 would block the entrance of her room, because she did not like staff going through her space to attend to her roommate. The UM also revealed that Resident #67 did not like staff closing the door when they cared for her roommate as well. On 10/27/11 at 3:36 PM an interview with the director of nursing revealed that she was aware Resident #67 had a history of [REDACTED]. Review of Resident #67's clinical record revealed the resident was admitted to the facility on [DATE]. The nursing notes revealed on 7/17/11 at 4:00 AM the resident called for the nurse every time the roommate turned on the television. On 7/24/11 at 11:00 PM the nurse indicated that Resident #67 became agitated when staff cared for her roommate. The nurse indicated that Resident #67 threw belongings and yelled at her roommate. The note indicated that Resident #67 was placed on 1:1 care. On 7/25/11 at 2:00 AM the nurse indicated that the resident was throwing her belongings when staff cared for her roommate and 1:1 care was provided. Clinical record review revealed Resident #67 had a Behavioral Management Care Plan completed on 07/26/11. The problem listed for the care plan was socially inappropriate behaviors. The inappropriate behavior listed was throwing things and verbally abusive as indicated by screaming. The care plan goal was that resident would not throw items at staff and would not verbally threaten others on a daily basis. This care plan was updated on 10/24/11 to include the problem that the resident was yelling at roommate and agitation. The clinical record revealed an additional Behavioral Management Care Plan completed on 10/14/11 for the problem of the resident resisting care related to activities of daily living (ADL)/showers, verbally abusive as identified as screaming at roommates, and physically inappropriate as identified as throwing objects at staff. The goals identified for each problem listed was that the resident would not demonstrate the behaviors on a daily basis. There was no evidence this care plan had been revised or updated since it was implemented on 10/14/11. Review of Resident #67's quarterly Minimum Data Set assessment, with an assessment reference date of 10/16/11 revealed in Section E, Behavior was coded as "2" meaning that the behaviors (physical behavioral symptoms directed towards others (i.e. hitting, kicking, pushing, scratching, grabbing); verbal behavioral symptoms directed towards others (i.e. threatening others, screaming at others, cursing at others) occurred 4 to 6 days but less than daily. Review of the social services notes in Resident #67's clinical record dated 07/22/11 Resident #67 spoke to the SW regarding a room change. The resident was advised that no beds were available at that time, but she would offer one when it became available. On 07/24/11 the SW spoke with the resident's daughter regarding a room change. She was told that no room was available, but would offer the change when one became available. On 07/25/11 the SW notes revealed that Resident #67 spoke with the SW to request a room change. Resident #67 complained to SW that she was "not able to sleep because people are coming in her room to care for her roommate all day and all night. She complained TV being up loud." The next entry in the SW notes was dated 10/25/11. The note was regarding the 10/24/11 incident when Resident #67 yelled at her roommate, as witnessed by the Agency for Health Care Administration (AHCA) surveyor. A review of the facility's Resident to Resident Abuse Policy and Procedure with an effective date of 01/07 revealed that "residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals....Abuse means the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or pain, or mental anguish, or deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being." The protocol included in the Resident Abuse Policy and Procedure with an effective date of 01/07 revealed in the protocol included "remove the residents from danger immediately; if applicable, move the resident causing the danger to another room or unit, pending investigation of the incident; closely monitor and document the behavior and condition of the residents involved to evaluate for any injury and to prevent recurrence of the incident; the facility must develop measures to prevent reoccurrence and document these measure in the resident's medical record to include revision of the plan of care." 2. On 10/25/11 at 8:35 AM with Resident #110 revealed she had an issue with her roommate Resident #97. The interview revealed that Resident #97 was no longer residing in the facility. Resident #110 stated that she had attended a cookie decorating activity the day before, but when she returned to her room there were about 10 -12 cookies there. Resident #110 stated that she thought someone was just kidding with her, so she took the cookies to the staff to distribute. Resident #110 stated that when Resident #97 returned to the room and realized the cookies were gone she became very upset. Resident #110 stated that Resident #97 carried on for a while and the facility eventually transferred Resident #97 out of the facility via stretcher. Resident #110 revealed that she had been having issues with Resident #97 since the resident was admitted to the room about a week ago. Per Resident #110 revealed that Resident #97 was "very bossy, it disturbed her to be disturbed, it was terrible. I thought I can't handle this. She was in here only about a week. I didn't let the staff know. But when I had to use the bathroom, the staff were taking me down to where you get the showers, not to disturb the roommate." Resident #110 revealed that the staff was taking her to the shower room to also get her dressed. "I didn't like that. She had gotten dangerous. I was afraid. They took her out of here last night. I had my first good night sleep last night since she came." A review of Resident #97's clinical record revealed that the resident was sent to the hospital for an involuntary examination (Baker Act) on 10/24/11. The Baker Act documentation revealed that Resident #97's mental illness [DIAGNOSES REDACTED]. The supporting documentation revealed Resident #97 had made statements of wanting to die, uncooperative with staff attempts to work with her; made threats to all roommates in the past week with daily behavior escalating and was refusing medications. Other information relied upon to determine the need for Baker Act included, but was not limited to Resident #97 being agitated, refusing care, and threatening other residents; a long term [MEDICAL CONDITION] disorder with worsening symptoms and risk to self and others escalating; and other residents are stating they are afraid of Resident #97. Review of the doctors progress note dated 10/18/11 revealed that Resident #97 had progressive depression and was becoming increasingly agitated, and that there were many issues with all her perspective roommates. A nurse's note dated 10/21/11 at 12:30 PM revealed that Resident #97 was very agitated and was verbally abusive to staff and roommate and had also threatened her roommate. A weekly progress note dated 10/22/11 revealed that Resident #97 was agitated and verbally abusive to staff and to Resident #110 on 10/21/11. A nurses note dated 10/21/11 at 5:30 PM revealed that Resident # 110 was afraid of Resident #97, and that she had cursed at her and had become very agitated. .

Based on observation, resident and staff interview, and medical record review, the facility failed to implement policies and procedure to ensure that 2 (Resident #109 and #110) of 40 sampled residents were free from mistreatment from another resident. Failure to implement the facility's policies and procedures resulted in actual mental harm and anguish for Resident #109 and #110. The findings include: Based on observation, resident and staff interview, and clinical record review, the facility failed to ensure that 2 (Resident #109, and #110) of 40 sampled residents were free from mistreatment by other another resident. Failure to prevent mistreatment resulted in actual mental harm to Resident #109 and Resident #110. The findings include: 1. On 10/24/11 at 1:20 PM during an interview with Resident #109, her roommate, Resident #67, walked over to Resident #109's side of the room and stated that Resident #109 talked too much and began pointing and yelling at Resident #109. Resident #109 revealed that Resident #67 always exhibited this behavior when she (Resident #109) had visitors or staff with her. Resident #67 yelled at Resident #109 to shut up. Then Resident #109 yelled back at Resident #67 for her to shut-up. An interview on 10/24/11 at 1:30 PM with Registered Nurse (RN) #1 revealed that Resident #67 had been relocated within the facility because of issues with the former roommate. RN #1 revealed that Resident #67 had told her that Resident #109 talked too much. RN #1 indicated that Resident #67 liked her room quiet and Resident #109 liked to talk. On 10/24/11 at 1:36 PM an interview was conducted with the Social Worker (SW). The SW revealed that Resident #67 was moved from her previous room, because she was agitated when the staff went into the room to provide care to the roommate. Per the SW Resident #67 would yell at staff and "run the staff out". On 10/24/11 at 1:50 PM an interview with Resident #109 revealed that Resident #67 had told her to shut up on more than one occasion. She stated that every time she had a visitor Resident #67 would get upset, because they were not there to see her. She stated that her visitors had to go to the nurses station and be escorted to her room because of Resident #67's behavior. Resident #109 revealed that the staff get on to her (Resident #109) for yelling back at Resident #67. On 10/24/11 at 2:13 PM an interview with certified nursing assistant (CNA) #1 revealed she was aware Resident #67 did not like anyone in her room for any reason. CNA #1 revealed that if the CNAs are talking or if they close the door Resident #67 gets upset and had used profanity. CNA #1 stated that the roommates were face to face yelling at each other one day and the staff had to calm them down. CNA #1 indicated that this concern had been reported to the nurses. An interview with CNA #2 on 10/24/11 at 2:15 PM revealed that Resident #67 spoke Italian and spoke very little English. She stated that she had never observed the two roommates yelling at each other. But states that the pair had gotten "a little antsy" with each other but it was "nothing of concern." CNA #2 stated that Resident #67 gets upset when Resident #109 talks loud. She stated that Resident #109 was hard of hearing and talked loud. The CNA stated that she whispers in Resident #109's ear and talked to her quietly so they would not disturb Resident #67. An interview with CNA #3 on 10/24/11 at 3:00 PM revealed that Resident #67 had been confrontative with staff in the past. She stated that Resident #67 had also gotten on to her one day for closing the door to her room when she was providing the roommate with personal care. CNA #3 stated that the nursing staff was aware of Resident #67's behavior. An interview with CNA #4 on 10/26/11 at 7:25 AM revealed that she had been employed with the facility for almost two years, and she worked on the night shift. She revealed that Resident #67 could be erratic and almost everything disturbed her. For example, passing ice and getting her roommate dressed. She stated that Resident #67's behaviors included throwing things and yelling. She stated that the behavior occurred, "mostly in the early morning." CNA #4 revealed that nursing staff had been notified, and that "sometimes they could hear." On 10/26/11 at 3:45 PM an interview with CNA #5 revealed that Resident #67 and Resident #109 "had been having issues for months." A staff interview with the Unit Manager (UM) on the GNR Unit on 10/27/11 at 3:10 PM revealed that Resident #67 had been on the GNR Unit for a couple of months. The UM stated that Resident #67 was moved to a different room because she was having behavior issues. She stated that Resident #67 would yell at her previous roommate in Italian, and then get up and turn off the roommate's television. She stated that the roommates family would observe Resident #67 get up and turn off the television. The UM stated that Resident #67 yelled at her roommate because of the TV, and about her space issue. The UM also stated that Resident #67 would block the entrance of her room, because she did not like staff going through her space to attend to her roommate. The UM also revealed that Resident #67 did not like staff closing the door when they cared for her roommate as well. On 10/27/11 at 3:36 PM an interview with the director of nursing revealed that she was aware Resident #67 had a history of [REDACTED]. Review of Resident #67's clinical record revealed the resident was admitted to the facility on [DATE]. The nursing notes revealed on 7/17/11 at 4:00 AM the resident called for the nurse every time the roommate turned on the television. On 7/24/11 at 11:00 PM the nurse indicated that Resident #67 became agitated when staff cared for her roommate. The nurse indicated that Resident #67 threw belongings and yelled at her roommate. The note indicated that Resident #67 was placed on 1:1 care. On 7/25/11 at 2:00 AM the nurse indicated that the resident was throwing her belongings when staff cared for her roommate and 1:1 care was provided. Clinical record review revealed Resident #67 had a Behavioral Management Care Plan completed on 07/26/11. The problem listed for the care plan was socially inappropriate behaviors. The inappropriate behavior listed was throwing things and verbally abusive as indicated by screaming. The care plan goal was that resident would not throw items at staff and would not verbally threaten others on a daily basis. This care plan was updated on 10/24/11 to include the problem that the resident was yelling at roommate and agitation. The clinical record revealed an additional Behavioral Management Care Plan completed on 10/14/11 for the problem of the resident resisting care related to activities of daily living (ADL)/showers, verbally abusive as identified as screaming at roommates, and physically inappropriate as identified as throwing objects at staff. The goals identified for each problem listed was that the resident would not demonstrate the behaviors on a daily basis. There was no evidence this care plan had been revised or updated since it was implemented on 10/14/11. Review of Resident #67's quarterly Minimum Data Set assessment, with an assessment reference date of 10/16/11 revealed in Section E, Behavior was coded as "2" meaning that the behaviors (physical behavioral symptoms directed towards others (i.e. hitting, kicking, pushing, scratching, grabbing); verbal behavioral symptoms directed towards others (i.e. threatening others, screaming at others, cursing at others) occurred 4 to 6 days but less than daily. Review of the social services notes in Resident #67's clinical record dated 07/22/11 Resident #67 spoke to the SW regarding a room change. The resident was advised that no beds were available at that time, but she would offer one when it became available. On 07/24/11 the SW spoke with the resident's daughter regarding a room change. She was told that no room was available, but would offer the change when one became available. On 07/25/11 the SW notes revealed that Resident #67 spoke with the SW to request a room change. Resident #67 complained to SW that she was "not able to sleep because people are coming in her room to care for her roommate all day and all night. She complained TV being up loud." The next entry in the SW notes was dated 10/25/11. The note was regarding the 10/24/11 incident when Resident #67 yelled at her roommate, as witnessed by the Agency for Health Care Administration (AHCA) surveyor. A review of the facility's Resident to Resident Abuse Policy and Procedure with an effective date of 01/07 revealed that "residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals....Abuse means the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or pain, or mental anguish, or deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being." The protocol included in the Resident Abuse Policy and Procedure with an effective date of 01/07 revealed in the protocol included "remove the residents from danger immediately; if applicable, move the resident causing the danger to another room or unit, pending investigation of the incident; closely monitor and document the behavior and condition of the residents involved to evaluate for any injury and to prevent recurrence of the incident; the facility must develop measures to prevent reoccurrence and document these measure in the resident's medical record to include revision of the plan of care." 2. On 10/25/11 at 8:35 AM with Resident #110 revealed she had an issue with her roommate Resident #97. The interview revealed that Resident #97 was no longer residing in the facility. Resident #110 stated that she had attended a cookie decorating activity the day before, but when she returned to her room there were about 10 -12 cookies there. Resident #110 stated that she thought someone was just kidding with her, so she took the cookies to the staff to distribute. Resident #110 stated that when Resident #97 returned to the room and realized the cookies were gone she became very upset. Resident #110 stated that Resident #97 carried on for a while and the facility eventually transferred Resident #97 out of the facility via stretcher. Resident #110 revealed that she had been having issues with Resident #97 since the resident was admitted to the room about a week ago. Per Resident #110 revealed that Resident #97 was "very bossy, it disturbed her to be disturbed, it was terrible. I thought I can't handle this. She was in here only about a week. I didn't let the staff know. But when I had to use the bathroom, the staff were taking me down to where you get the showers, not to disturb the roommate." Resident #110 revealed that the staff was taking her to the shower room to also get her dressed. "I didn't like that. She had gotten dangerous. I was afraid. They took her out of here last night. I had my first good night sleep last night since she came." A review of Resident #97s clinical record revealed that the resident was sent to the hospital for an involuntary examination (Baker Act) on 10/24/11. The Baker Act documentation revealed that Resident #97s mental illness [DIAGNOSES REDACTED]. The supporting doumentation revealed Resident #97 had made statements of wanting to die, uncooperative with staff attempts to work with her; made threats to all roommates in the past week with daily behavior escalating and was refusing medications. Other information relied upon to determine the need for Baker Act included, but was not limited to Resident #97 being agitated, refusing care, and threatening other residents; a long term [MEDICAL CONDITION] disorder with worsening symptoms and risk to self and others escalating; and other residents are stating they are afraid of Resident #97. Review of the doctors progress note dated 10/18/11 revealed that Resident #97 had progressive depression and was becoming increasingly agitated, and that there were many issues with all her perspective roommates. A nurse's note dated 10/21/11 at 12:30 PM revealed that Resident #97 was very agitated and was verbally abusive to staff and roommate and had also threatened her roommate. A weekly progress note dated 10/22/11 revealed that Resident #97 was agitated and verbally abusive to staff and to Resident #110 on 10/21/11. A nurses note dated 10/21/11 at 5:30 PM revealed that Resident # 110 was afraid of Resident #97, and that she had cursed at her and had become very agitated. A review of the facility's Resident to Resident Abuse Policy and Procedure revealed that "residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals."