Every finding on record at Aviata at San Jose

Based on observations, interviews, record reviews, and review of the facility's Oral Administration of Medication policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of four residents reviewed for medication management, by failing to follow physician's orders related to heart failure medication.The findings include:Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included unspecified systolic (congestive) heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, cardiac arrhythmia, unspecified, other cardiomyopathies; and presence of automatic (implantable) cardiac defibrillator. Review of Resident #1's Medicare/5-day MDS (minimum data set) dated 1/26/26 revealed a BIMS (brief interview for mental status) score of 14 out of 15, indicating she was cognitively intact. She required substantial assistance with toileting/transfers and required dialysis and IV access. Review of the care plan for Resident #1 noted the following: FOCUS: I have altered cardiovascular status r/t Hypertension, CAD, HF, h/o PE Date Initiated: 1/21/26, Revision on: 1/21/26. Goals: I will be free from complications of cardiac problems through the review date. Date Initiated: 1/21/26. Intervention: Monitor VITAL SIGNS as ordered. Notify MD of significant abnormalities. Date Initiated: 1/21/26, Revision on: 1/21/26. Review of the physician's orders for Resident #1 revealed the following: Carvedilol Oral Tablet 6.25mg by mouth two times daily for Heart Failure/HTN (hypertension). Hold for SBP (systolic blood pressure) Less than 115 and/or heart rate less than 60 (start date 1/21/26 at 2100). Review of the January medication administration record (MAR) for Resident #1 revealed the resident had been administered medications outside of physician ordered parameters four (4) times as shown below: (Copy obtained)On 1/26/26 at 2100, Employee A administered Carvedilol when the resident's BP reading was 114/58.On 1/27/26 at 0900, Employee B administered Carvedilol when the resident's BP reading was 102/72.On 1/27/26 at 1400, the next scheduled B/P reading was recorded and was documented as 92/54. The medication was held.On 1/27/26 at 2100, Employee C administered Carvedilol when the resident's BP reading was 110/60.On 1/31/26 at 2100, Employee C administered Carvedilol when the resident's BP reading was 112/70.Review of a second physician's order for Resident #1 revealed the following: Isosorbide Dinitrate Oral Tablet 20 mg by mouth three times daily for Heart Failure with reduced ejection fraction. Hold for SBP (systolic blood pressure) less than 115 (start date 1/21/26 at 1400, discontinued 1/30/26). Review of the January medication administration record (MAR) for Resident #1 revealed the resident had been administered medications outside of physician ordered parameters five (5) times as shown below: (Copy obtained)On 1/23/26 at 1400, Employee D administered Isosorbide Dinitrate when the resident's B/P reading was 110/71.On 1/26/26 at 2100, Employee A administered Isosorbide Dinitrate when the resident's B/P reading was 114/58. On 1/27/26 at 0800, Employee B administered Isosorbide Dinitrate when the resident's B/P reading was 102/72. On 1/27/26 at 2100, Employee C administered Isosorbide Dinitrate when the resident's B/P reading was 110/60.On 1/28/26 at 2100, Employee C administered Isosorbide Dinitrate when the resident's B/P reading was 114/72.Review of a third physician's order for Resident #1 revealed the following: Isosorbide Dinitrate Oral Tablet 20 mg by mouth three times daily every Tuesday, Thursday, Saturday and Sunday for Heart Failure with reduced ejection fraction related to Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris Hold for SBP (systolic blood pressure) less than 115 (start date 1/31/26 at 1400). Review of the January medication administration record (MAR) for Resident #1 revealed the resident had been administered medications outside of physician ordered one (1) time as shown below: (Copy obtained)On 1/31/26 at 2100, Employee C administered Isosorbide Dinitrate when the resident's B/P reading was 112/70. During an interview with the Director of Nursing (DON) on 2/5/26 at 5:15 PM, she confirmed the medications noted above had been administered to Resident #1 outside the parameters of the physician orders and on at least one occasion, on 1/27/26 at 1400 the resident's B/P was taken and found to be below the normal range for this resident. It was documented as 92/54. The DON was asked what her expectation was for the licensed nursing staff as it related to administering medications according to physician ordered parameters. She stated, I expect them to adhere to the 6 rights of medication administration, identifying the right resident, route and so on, and following physician orders. If they have any concerns or discrepancies about the physician orders, they should contact the provider for clarification. She was asked what kinds of in-service education was provided to the licensed nurses related to medication administration. She stated, We provide annual training, and if any concerns or issues arise, we do more in-services. Upon hire they also have that training.Review of the facility's Policy and Procedure titled, Medication-Oral Administration of, Document Name N-853, with an effective date: 11/30/14, and last revised: 8/15/19 revealed the following:Procedure:Review physician's orderReview the MAR (medication administration record) or EMAR (electronic medication administration record) should there be any uncertainties verify the MAR or EMAR with the Physician's Order Sheet (POS) and seek clarification as indicated. (Copy obtained)

Based on record review, staff interview, and facility policy and procedure review, the facility failed to ensure that residents with mental disorders were appropriately assessed on admission, or as needed, to determine the need for specialized services for five (Residents #32, #26, #50, #65 and #22) of five residents reviewed for Preadmission Screening and Resident Review (PASRR). Resident #32 was declared exempt from the PASRR upon admission for a period not to exceed 30 days and was not screened when the provisional admission ended. Resident #26's PASRR section I was incomplete and Section II was answered in the affirmative. Resident's #50's PASRR section I was incomplete and Resident #65's PASRR indicated that she had a Hospital Discharge exemption. Resident #22's Level I PASRR was not signed. The findings include: 1. A review of Resident #32's medical record revealed an admitted [DATE]. His diagnoses included hydrocephalus, polyneuropathies, seizures, major depression, bipolar disorder, insomnia, presence of cerebrospinal fluid drainage device, atherosclerotic heart disease, hypothyroidism, unspecified psychosis, anxiety disorder, and respiratory failure - unspecified with hypoxia or hypercapnia. A review of the State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) Level I Screening form 004 Part A, dated 07/22/2022, revealed that the box indicating the admission was a Provisional Admission was checked. No other PASRR screening was found in the medical record. During an interview with the Regional Nurse Consultant (RNC) on 04/24/2025 at 5:33 PM, he confirmed that Resident #32 had not been screened after the 30-day provisional admission ended. He stated the resident should have been screened again. 42442 2. A review of the medical record revealed that Resident #26 was admitted to the facility on [DATE] with a re-entry on 3/31/24. The resident's diagnoses included major depressive disorder, generalized anxiety disorder, alcohol abuse with alcohol induced psychotic disorder, and manic episode without psychotic symptoms. A review of the Level I PASRR, dated 8/3/15, revealed no diagnoses marked under Section I. In Section II: Other Indications for PASRR Screen Decision-Making, the following areas were marked as Yes: 1. Is there an indication within the past 3 to 6 months that the individual has a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage? 2. Does the individual typically have at least one of the following characteristics on a continuing or intermittent basis? A. Interpersonal functioning: The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or has been fired. B. Concentration, persistence, and pace: The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks. C. Adaptation to change: The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system. 3. The individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following. A. Psychiatric treatment more intensive than outpatient care. (Copy obtained) 3. A review of the medical record revealed that Resident #65 was admitted to the facility on [DATE] with a re-entry on 3/2/25 and diagnoses including schizoaffective disorder, bipolar disorder, major depressive disorder, generalized anxiety disorder, and manic episode severe with psychotic symptoms. The care plan initiated on 2/7/25 revealed that the resident had diagnoses including schizoaffective disorder, bipolar disorder, depression, generalized anxiety disorder with a history of in-patient psychiatric treatment for aggressive and violent behaviors; a history of making false accusations against others with delusional symptoms; occasions of auditory hallucinations, and a history of post-traumatic stress disorder (PTSD) with a history of traumatic experiences as a child. A review of the resident's PASRR Level I, dated 1/27/25, revealed that the resident had a diagnosis of schizophrenia. In Section II, Other Indications for PASRR Screen Decision-Making, the following areas were marked as Yes: 3. Individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following: A. Psychiatric treatment more intensive than outpatient care. B. Due to the mental illness the individual has experienced an episode of significant disruption to the normal living situation for which supportive services were required to maintain functioning at home or in a residential treatment environment or which resulted in intervention by housing or law enforcement officials. 4. Individual exhibited actions of behaviors that may make them a danger to themselves or others. Under Section III, PASRR screen provisional or Hospital discharge exemption, noted that the resident was being admitted under a 30-day Hospital Discharge exemption. If the individual's stay is anticipated to exceed 30 days, the nursing home must notify the Level I screener at the 25th day of stay, and the level II evaluation must be completed no later than the 40th day after admission. The form also indicated that the individual may not be admitted to the nursing facility. (Use this form as required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of serious mental illness.) (Copy obtained) 4. Resident #50 was admitted to the facility on [DATE] with a re-entry on 10/21/23 and diagnoses including paranoid schizophrenia, pseudobulbar affect (a neurological condition characterized by sudden, uncontrollable episodes of laughing or crying that are often inappropriate or out of proportion to the situation or the person's actual feelings), major depressive disorder, generalized anxiety disorder, restlessness and agitation. A review of the active physician's orders revealed: Nuedexta (central nervous systme agent) capsule 20 -10 mg (milligrams) every 12 hours related to pseudobulbar affect - order date 5/1/24. Haloperidol (antipsychotic) 100 mg/ml (milligrams per milliliter), inject 100 mg intramuscularly (IM) every 14 days for schizophrenia - order date 8/24/24. Depakote (anticonvulsant that can be used to treat bipolar disorder) 500 mg three times a day for mood disorder. Primidone (anticonvulsant) 50 mg at bedtime for essential tremors - order date 1/2/25. Trazadone (antidepressant and sedative) 50 mg two times a day (BID) for major depressive disorder - order date 3/6/25. A review of the Care Plan revealed a target completion date of 5/7/25 and indicated that Resident #50 was known to be physically aggressive as evidenced by kicking other residents related to paranoid schizophrenia and being developmentally delayed. She had impaired cognitive function and impaired thought processes related to developmental delay and paranoid schizophrenia. The care plan further noted that the resident was receiving antipsychotic therapy related to a diagnosis of mood disorder, paranoid schizophrenia, and mania. She was receiving an anticonvulsant medication for diagnoses of paranoid schizophrenia and mood disorder. A review of the Quarterly minimum data set (MDS) assessment with an Assessment Reference Date (ARD) of 1/15/25 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 possible points, indicating severe cognitive impairment. Active psychiatric diagnoses included schizophrenia, depression, and anxiety. A review of the Level I PASRR dated 6/2/21 revealed no diagnoses of schizophrenia, major depressive disorder, depression, or anxiety disorder documented. In an interview on 4/24/25 at 4:16 PM, the Social Services Director (SSD) stated she was responsible for ensuring that all PASRRs were completed on admission and as needed. She identified that some PASRRs were incomplete and/or inappropriately completed by the previous SSD. She stated she developed a plan to review five PASRRs weekly and was still in the process of reviewing them. She confirmed that she had reviewed the PASRR for all of the residents requested by the survey team, and they were incomplete and/or required a Level II screening. 45153 5. A review of Resident #22's Level 1 PASRR revealed no physician's signature and no date. A record review was conducted for Resident #22 noting an admitted [DATE] with an initial admission on 12/14/17. His diagnoses included schizophrenia, anxiety disorder, major depressive disorder, and insomnia due to other mental disorder. A review of Resident #22's active physician's orders revealed the following: Ativan (benzodiazepine/sedative) Oral Tablet 1 mg, give 1 tablet by mouth every 24 hours as needed for behaviors sleep aid per outside psychology (4/22/2025) Ativan Oral Tablet 1 mg, give 1 tablet by mouth every 8 hours as needed for increased behaviors for 14 days (4/22/2025) Buspirone HCL (hydrochloride) (anxiolytic) Tablet, 30 mg, give 30 mg by mouth two times a day related to anxiety disorder due to known physiological conditions (5/25/2024) Haloperidol Tablet (antipsychotic), 10 mg, give 2 tablets by mouth at bedtime related to schizophrenia, unspecified (5/25/2024) Melatonin Tablet (sleep supplement), 3 mg, give 2 tablets by mouth at bedtime related to insomnia due to other mental disorder (5/25/2024) Quetiapine Fumarate (antipsychotic) Tablet, 300 mg, give 2 tablets by mouth at bedtime related to schizophrenia, unspecified (5/25/2024) Trazodone HCL (antidepressant and sedative) Tablet, 150 mg, give 2 tablets by mouth at bedtime for depression, recurrent (5/25/2025). A review of the April 2025 Medication Administration Record (MAR) revealed that the abovementioned medications were provided as ordered. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident re-entered from a short-term hospital stay with a Brief Interview for Mental status (BIMS) score of 8 out of 15 possible points, indicating moderate cognitive impairment. On 4/24/25 at 2:02 PM, the Regional Nurse Consultant was asked to provide a copy of Resident #22's signed PASRR. On 4/24/25 at 2:10 PM, a Level 1 PASRR for Resident #22 was received with no physician's signature and no date. A review of the facility's Policy and Procedure titled Preadmission Screening and Resident Review (PASRR) - Document Name: SS-402, Revision Date: 11/08/21 revealed: Policy: The center will assure that all Serious Mentally IlI (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 2. If an individual is declared exempt from a PASRR screening, the center should make sure that appropriate documentation is in the chart upon admission. Individuals who are exempt from this assessment include: a. Those who are admitted after a release from an acute care hospital for a period not to exceed 30 days as part of a medically prescribed period of recovery. b. Those who are certified by a physician as to be terminally ill with a 6-month prognosis, and are not a danger to self or others. c. Those who are comatose, ventilator dependent, functions at significantly disabling Parkinson's Disease, Huntington's Disease, Amyotrophic Lateral Sclerosis, CHF or COPD. d. Those with a diagnosis of dementia or its related disorders with detailed documentation supporting this diagnosis. 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical record and any recommendations for services will be followed. 6. Recommendations will be incorporated in the individual resident's plan of care and approaches/interventions developed to meet the identified needs of the individual. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records. Reference: [NAME] Health Care Consulting Services, Inc.

Based on interviews, record review, and a review of facility policies and procedures, the facility failed to 1) Ensure that the consultant pharmacist's Medication Regimen Reviews/Recommendations were maintained/followed to minimize or prevent adverse consequences to the extent possible for one resident (#30), and 2) Ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for one resident (#23) of five residents reviewed for unnecessary medications, from a total survey sample of 38 residents. The findings include: 1. A review of Resident #30's Consultant Pharmacist Medication Regimen Review for 3/31/25 revealed recommendations made and agreed upon by the physician to either discontinue Apixaban or reduce Eliquis to 2.5 milligrams by mouth two times per day for a history of Deep Vein Thrombosis (DVT) were not carried out by the facility. A review of Resident #30's medical record revealed an admitted [DATE]. His diagnoses included encephalopathy, bipolar disorder, major depressive disorder, long-term (current) use of anticoagulants, long-term (current) use of insulin, chronic pain, and heart failure. A review of Resident #30's active physician's orders included the following: - Depakote Oral Tablet Delayed Release, 250 milligrams (mg), give 1 tablet by mouth two times a day for bipolar disorder (4/17/2025-4/22/2025) - Depakote Oral Tablet Delayed Release, 250 mg, give 1 tablet by mouth two times a day for bipolar disorder (04/22/2025) - Depakote Oral Tablet Delayed Release, 500 mg, give 1 tablet by mouth two times a day for bipolar disorder (4/17/2025-4/22/2025) - Depakote Oral Tablet Delayed Release, 500 mg, give 1 tablet by mouth two times a day for bipolar disorder, (4/22/2025) - Eliquis Oral Tablet 5 mg, give 1 tablet by mouth every 12 hours for DVT (8/10/2024) - Gabapentin Oral Capsule 400 mg, give 1 capsule by mouth every 12 hours for neuropathy (08/10/2024) - Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/milliliter (units per milliliter), inject 10 units subcutaneously two times a day for diabetes mellitus (2/19/2025) - Novolog FlexPen Subcutaneous Solution Pen-injector 100 units/milliliter, inject 8 units subcutaneously before meals and at bedtime for diabetes mellitus (2/19/2025) The electronic medical record (EMR) Miscellaneous Tab revealed a recommendation made by the consultant pharmacist on 3/31/2025; no response from the physician was noted. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/12/25, revealed the resident had a Brief Interview for Mental status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. High-risk drug class medications documented included an anticoagulant. Other high-risk drug class medications included antipsychotic, antidepressant, hypoglycemic, and anticonvulsant medications. Antipsychotics were received on a routine basis only; a GDR (gradual dose reduction) was completed on 2/6/2025 and was noted not clinically contraindicated. A review of the April 2025 Medication Administration Record (MAR) revealed that medications were administered as ordered by the physician. On 4/24/25 at 2:02 PM, the Regional Nurse Consultant reported that per the pharmacy, no recommendations had been made for Resident #30 since 11/2024. A copy of the pharmacist's medication review was requested. On 4/24/25 at 4:17 PM, the completed pharmacist's medication review form, dated 3/31/2025, was received and identified that a recommendation was made but there was no physician's response. No other consultant pharmacist reviews were provided. On 4/24/25 at 8:09 PM, the Regional Nurse Consultant confirmed that all pharmacist medication reviews identified were reviewed and signed by the physician. The Regional Nurse Consultant reviewed the facility's pharmacist medication book and stated he would continue to search for signed copies that were not in the binder. On 4/24/25 at 8:20 PM, the Regional Nurse Consultant provided a pharmacist medication review dated 3/31/2025 that revealed the physician's response: Agree, please write order. 48947 2. A review of Resident #23's monthly Pharmacy Recommendations/Reviews from 8/2024 through 4/2025, revealed that the only recommendations/reviews available were for the months of 8/30/24, 9/30/24, and 1/2025. The facility was unable to provide evidence that the consultant pharmacist was completing monthly medication reviews for this resident. A review of Resident #23's medical record revealed an admitted [DATE] and diagnoses including atherosclerotic heart disease, other specified polyneuropathies, diabetes mellitus - type 2, low back pain, anxiety disorder, other chronic pain, insomnia, alcohol abuse, pin in left hip, pain in right leg, Peripheral Vascular Disease (PVD), polysubstance abuse, ADHD (attention deficit hyperactive disorder), and depression/mood disorder. A review of the annual MDS (minimum data set) assessment, dated 2/21/25, revealed the resident had a BIMS (brief interview for mental status) score of 13 out of 15 possible points, indicating intact cognition. He was documented with no behaviors; he required set-up or clean-up assistance with eating, and was independent with toileting, bed mobility and transfer tasks. The assessment also indicated pain that occasionally interfered with day-to-day activities, at a 7 on a numerical scale of 0-10 with 10 being the worst possible pain. During the assessment look-back period, the resident received antianxiety, antidepressant, diuretic, opioid, and anticonvulsant medications. A review of the resident's active Care Plan revealed the following focus areas: - Alteration in usual functional performance in self-care related to weakness, debility, neuropathy (created 2/24/25, revised 3/12/25) - I have an ADL (activities of daily living) self-care performance deficit related to unsteady gait, balance, neuropathic pain, chronic pain, (CAD) Coronary Artery Disease, muscle spasms. I will refuse showers/bathing (created 3/29/23, revised 3/13/25). - I am receiving an over-the-counter sleep aid related to Insomnia (created 3/29/23, revised 3/13/25). - I am receiving an antidepressant for a diagnosis of depression (created 3/29/23, revised 3/13/25). - I am receiving an antianxiety medication for a diagnosis of anxiety disorder (created 3/29/23, revised 3/13/25). - I am receiving diuretic therapy related to hypertension (created 2/24/25, revised 3/13/25). - I have acute, chronic pain related to a diagnosis of low back pain, chronic pain, muscle spasms, neuropathic pain, and degenerative joint disease (created 3/29/23, revised 3/13/25). A review of the active physician's orders revealed orders for the following: - Alprazolam 0.5 mg (milligrams) by mouth twice daily for anxiety (5/26/24) - Torsemide 20 mg by mouth daily for edema (6/28/24) - Methadone 10 mg, give 4 tablets by mouth daily (9/25/24) - Trazodone 100 mg by mouth at bedtime for major depressive disorder, insomnia (2/13/25) - Percocet 5-325 mg by mouth every 4 hours as needed for joint pain (3/14/25) - Non-pharmacological interventions use every shift (9/30/24) - Assess for pain every shift (5/26/24) - Behavior Monitoring every shift (5/26/24) - Side effects monitoring every shift (5/26/24) A review of the resident's psychiatric progress notes revealed that he was followed by psychiatric care and services monthly and as needed for depression, anxiety, insomnia and alcohol abuse. A review of the April 2025 Medication Administration Record (MAR) revealed that all medications were administered as ordered. A review of the facility's policy titled Monthly Drug Regimen Review (N-866, effective: 04/21/2017, revised 3/28/2024), revealed: Procedure: To ensure the requirement is met for monthly drug regimen review, the ED/DON should implement the following process: Downloading of Pharmacist Consultant Report: Available from contracted pharmacy via secure email or database -Day 15-21 the DON/designee will contact the physicians with any outstanding recommendations, if no response from physician, the facility may notify the Medical Director for further assistance. Consultant Report-Continuous Print This report to be used by the DON/designee to record responses returned from the physician and for follow-up on any outstanding recommendations. If follow-up for consultant pharmacist recommendations are not completed within the specified time frame, this should be reported to the Medical Director for follow up with attending physician as indicated.

Based on observations, interviews, and record review, the facility failed to assist one resident (#81) in a total survey sample of 38 residents, to voice grievances. The facility failed to make prompt efforts to resolve a grievance and to keep the residents appropriately appraised of progress toward resolution. Failure to file and investigate grievances promptly placed the Resident at risk of further potential violations of resident rights. There were 38 residents in the total sample. The findings include: During an interview on 4/21/25 at 12:10 PM, Resident #81 voiced concerns regarding her care. She stated she pressed her call light on the evening of 4/15/25, because she needed assistance and was having a bowel movement. The resident stated it took over two hours for staff to respond to her request for assistance. When assigned staff arrived, she stated they did not want to clean her up because she was still having a bowel movement. The resident reported that she had spoken to the Social Services Assistant (SSA) during morning guardian angel rounds, regarding the Certified Nursing Assistant (CNA) not cleaning her and leaving her in that condition. She further reported to the SSA that she wanted to file a grievance regarding the issue. The SSA stated she would relay the information during the morning meeting. The resident stated she had not received any updates on the issue to date. On 4/23/25 at 11:20 AM, a follow-up interview was conducted with Resident #81. She said, I have not heard back from the facility staff regarding the grievance I asked the SSA to file regarding delays in care, and I would like to know what was done. A review of the resident's medical record revealed an admitted [DATE]. Her diagnoses included, but were not limited to, chronic atrial fibrillation, unspecified diastolic (congestive) heart failure, morbid obesity, moderate protein-calorie malnutrition, venous insufficiency, anemia, major depressive disorder, lymphedema, essential (primary) hypertension, and chronic pain syndrome. A review of the resident's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. Further, it revealed that the resident required maximum assistance with all Activities of Daily Living (ADLs) and was incontinent of bowel and bladder. A review of the resident's Care Plan, dated 4/19/25, revealed an ADL self-care performance deficit related to being bed bound, decreased mobility, multiple cardiac problems, morbid obesity, neuropathy, and chronic pain in conjunction with bowel and bladder incontinence. A review of the facility's Grievance Log from 4/1/25 through 4/21/25, revealed no record of a grievance filed by, or on behalf of, Resident #81. In an interview with the Social Services Director (SSD) on 4/24/25 at 11:45 AM, the SSD explained that if a resident or family had a concern/grievance, the person receiving the grievance should complete a grievance form. She explained that the grievance forms were available at the nurses' station and outside her office. She added that at times, the staff handed her the grievance form or slid it under her door during off hours. She added that at times when she was still in the building, the staff notified her right way when there was a concern, and she assisted in completing the grievance. After receiving the grievance, the concerns were reviewed during stand-up or stand-down meetings and assigned to the respective department to investigate. She further stated the grievances should be investigated within five days and the resident notified of the findings. She mentioned that some grievances may be extended more than five days; however, the resident should be kept abreast of the progress. After grievances were closed, she also followed up with the resident to ensure they were satisfied. Grievance reports were sent to the Administrator monthly. When asked if she had recent grievances from, or on behalf of Resident #81, she stated the last grievance was about a month a go and it was resolved. She reviewed the grievance log and confirmed there were no grievances from Resident #81 in April 2025. She was notified that the resident had care concerns and was asked to visit the resident and provide feedback to the surveyor. In a follow-up interview with the SSD on 4/24/25 at 1:36 PM, she stated she followed up with Resident #81 and the resident said that on the night of 4/15/25, she turned her call light on at approximately 1:00 AM, because she had a bowel movement (BM). A certified nursing assistant (CNA) came in at approximately 4:00 AM and stated she wasn't going to finish cleaning her because she still had BM in her rectum. Resident #81 stated she screamed until a nurse came and cleaned her. The resident stated she did not want that CNA caring for her anymore. She couldn't remember the CNA's name, but she notified the SSA the following morning during the guardian angel visit. The SSD confirmed that the grievance should have been filed for the resident. She added that she had notified the facility's Administrator and an investigation was initiated. During interview with the facility's Administrator on 4/24/25 at 1:51 PM, she stated the person receiving a grievance should complete a grievance form or assist the resident in completing it. She stated the goal was to have all grievances resolved within five days. Grievances were discussed daily in the morning and evening meetings. During off hours, staff should slide the grievance report under the SSD's door. When asked about the grievance related to Resident #18, she said, I was just informed of the issue with the resident by [the SSD]. I called [the SSA] regarding the incident and asked what happened. She said the CNA took too long to clean the resident (could not recall the timeframe), and did not clean the resident well enough until the nurse cleaned her. She confirmed that the staff did not follow the facility's grievance policy. A review of the facility's policy and procedure titled Complaint/Grievance, Document Name: N-1042 (revised on 10/24/2022), revealed: Policy: The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with whom grievances may be filed (State agency, Ombudsman, Quality Improvement Organizations). Procedure : 1. An employee receiving a complaint/grievance from a resident, family member, and/or visitor will initiate a Complaint/Grievance form. Complaint/Grievance forms will be available 24 hours per day, seven days a week in an unsecured common area. Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. 2. Original grievance forms are then submitted to the Grievance Officer/designee for further action. 3. The Grievance Officer shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame not exceeding 14 days. 5. The findings of the grievance shall be recorded on the Complaint/Grievance form. 6. The result will be forwarded to the Executive Director for review and filing. 7. The grievance official will log complaints/grievances in the monthly grievance log. 8. The individual voicing the grievance will receive follow up communication with the resolution, and a copy of the grievance resolution will be provided to the resident upon request.

Based on observations, interviews, record review, and facility policy and procedures review, the facility failed to provide enteral nutrition per the physician's order for one (Resident #100) of two residents reviewed for enteral nutrition, from a total of seven residents receiving enteral nutrition. The findings include: On 4/21/25 at 11:35 AM, enteral nutrition administration was observed in progress for Resident #100 via pump at 40 ml/hour (milliliters per hour). (Photographic evidence obtained) There was no resident identifier on the nutrition bottle. The nutrition bottle was labeled incorrectly (40 ml/hour). A record review revealed the resident had a physician's order for Jevity 1.5 at 45 ml/hour for 20 hours, on at 2:00 PM, off at 10:00 AM the next day - ordered 4/15/25, and two times a day water flush: 200 ml 2x/day for 400 ml for hydration, ordered 4/14/2025. On 4/22/25 at 11:58 AM, enteral nutrition administration was observed in progress for Resident #100 via pump at 40 ml/hour. (Photographic evidence obtained) A review of the medical record revealed that Resident #100 was admitted to the facility on [DATE] with diagnoses including unspecified severe protein-calorie malnutrition, adult failure to thrive, and feeding difficulties, unspecified. A review of the Admission MDS (minimum data set) assessment, dated 3/20/25, revealed that the resident had a BIMS (brief interview for mental status) score of 14 out of 15 possible points, indicating intact cognition. She was noted as dependent for eating, toileting and transfer tasks, and required substantial/maximal assistance with bed mobility. Her weight was recorded as 83 pounds and her height was 64 inches. A review of the active physician's orders revealed the following: Enteral: Check residual every shift and notify medical doctor for greater than 120 ml (milliliters) (3/19/25) Change feeding set per manufacturer's guidelines (3/19/25) Change tubing and syringe daily every night shift (3/19/25) Stoma care every night shift (3/19/25) Change the enteral feeding bottle per manufacturer's guidelines (3/19/25) Enhanced barrier precautions related to gastrostomy tube and Foley (urinary catheter) (3/20/25) Tube feeding - Check for placement every shift (3/19/25) Enteral feeding two times a day for tube feeding order Jevity 1.5 @ 45 ml (milliliters) for 20 hours on at 2:00 PM, off at 10:00 AM or until TV (total volume) is infused (TV - 900 ml) (4/22/25) Regular diet, dysphagia pureed texture, regular/thin liquids consistency (3/15/25) A review of the resident's Care Plan revealed the following focus area: I am receiving enteral feedings via enteral feeding tube due to dysphagia. I am also receiving by mouth diet. I am at risk for complications. Goal: I will maintain adequate nutritional and hydration status as evidenced by weight stable, no signs or symptoms of malnutrition or dehydration through next review date. Intervention: The resident is dependent with tube feeding and water flushes. See medical doctor orders for current feeding orders. [LPN] (licensed practical nurse), [RN] (Registered Nurse) (created 4/8/25, revised 4/8/25) On 4/23/25 at 11:37 AM, an interview was conducted with Certified Nursing Assistant (CNS) E, who was asked what her role was in taking care of a resident with a gastrostomy tube for enteral nutrition. She replied, When I give them a bath, I get the nurse to come and disconnect the feeding, let their head down, give the care, let their head back up and get the nurse to come and turn it back on. She stated there was never a time when she, the CNA, adjusted the feeding pump. On 4/23/25 at 2:40 PM, an interview was conducted with the Director of Nursing (DON), who was asked to explain the facility's process/protocol for the administration of enteral nutrition. She stated, I will need to review the policy. She was asked what the facility's policy was for what was required to be written on the enteral nutrition - what identifiers. She stated, The resident's name, the room number, the time you hang the bottle, the flow rate, and the flush rate. On 4/24/25 at 11:19 AM, an interview was conducted with Licensed Practical Nurse (LPN) L, who stated today she was responsible for the residents on the 200 and 300 hallways. She reviewed the electronic medical record daily to review changes with residents along with receiving report from the off-going nurse. She reported changes in conditions to the Medical Director and DON as needed to get additional treatment information. Whe she was asked about residents receiving enteral nutrition, she reported that she confirmed the physician's order in the resident's chart; she explained how to check for appropriate placement (she aspirates, and if she feels the tubing is dislodged, she will stop, inform the provider and ask for an x-ray to confirm or deny her suspicion). A review of the facility's policy and procedure titled Enteral Feeding - Enteral Nutrition Pump (N-405, effective 11/30/2014, revised 11/12/2018), revealed: Policy: Nurses administer enteral feedings when volume control is indicated and as ordered by the physician. Procedure: Obtain a physician's order. Follow pump manufacturer's guidelines. Set pump to physician's orders.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to provide oxygen therapy per the physicians' orders for two (Residents #24 and #59) of three residents reviewed for respiratory care, from a total survey sample of 38 residents. The findings include: 1. On 4/21/25 at 11:52 AM, while visiting the resident in his room, oxygen was observed infusing at 3.5 L/min (liters per minute) via NC (nasal cannula). (Photographic evidence obtained). The resident was asked if he knew what his oxygen flow rate should be. He replied, It should be all the way up. I need all I can get. On 4/22/25 at 12:49 PM, while visiting the resident in his room, oxygen was observed infusing at 3.5 L/min via NC. (Photographic evidence obtained) The resident stated, It's a little cooler in here today, but I'm still hot and I really don't feel like talking. A review of Resident #24's medical record revealed an admitted [DATE] and diagnoses including polyneuropathies, PVD (Peripheral Vascular Disease), morbid obesity, dysthymic disorder, tobacco use, bipolar disorder, major depressive disorder, generalized anxiety disorder, insomnia, iron deficiency anemia (chronic), COPD (Chronic Obstructive Pulmonary Disease), and diabetes mellitus (DM). A review of the Annual MDS (minimum data set) assessment, dated 3/14/25, revealed that the resident had a BIMS (brief interview for mental status) score of 15 out of 15 possible points, indicating intact cognition. He required partial/moderate assistance with bed mobility; supervision or touching assistance with toileting, and he refused transfer tasks and was independent with eating. A review of the active physician's orders revealed the following orders: - Respiratory: Oxygen - Continuous at 5 liters via nasal cannula for shortness of breath (SOB) every shift (5/25/24) - Change tubing, mask and/or nasal cannula weekly on Sunday night; may change sooner as needed (5/25/24) - Pulse Oximeter every shift for monitoring, Albuterol Sulfate Inhalation Nebulization Solution. 3 ml (milliliters), inhale orally via nebulizer every 6 hours as needed for shortness of breath. Check lung sounds, heart rate and respirations pre- and post-nebulizer treatment. Record minutes of nebulizer treatments (1/6/25) - Breztri Aerosphere Inhalation Aerosol 160-9-4.8 mcg/act (micrograms per actuation), 2 puffs inhale orally every 12 hours as needed for shortness of breath (2/24/25). A review of the Care Plan revealed the following focus area: - I have a diagnosis of COPD. I will become short of breath while lying flat and on exertion. Oxygen in use for shortness of breath. Goal: I will display optimal breathing patterns daily through review date. Interventions: Avoid extremes of hot and cold, monitor oxygen saturation as ordered, administer oxygen as ordered. (created 5/24/21, revised 1/13/25). On 4/22/25 at 4:35 PM, an interview was conducted with Licensed Practical Nurse (LPN) B, who was asked if she had been provided training/education about how to administer oxygen. She replied, Yes. She explained the steps for oxygen administration as: Get the oxygen concentrator, get the cannula, set the concentrator flow rate, and apply the cannula. She was asked how often the nurse was required to check the resident's oxygen flow rate. She replied, Every time she comes in the room. On 4/23/25 at 11:37 AM, an interview was conducted with Certified Nursing Assistant (CNA) E, who was asked to define her role in taking care of a resident who was receiving oxygen therapy. She stated, As far as oxygen, it's considered a medication, so the only thing I do is check to see if it's running, or if it's full and make sure it's in their nose. The nurse takes care of the oxygen itself. On 4/23/25 at 2:40 PM, an interview was conducted with the Director of Nursing (DON), who was asked what the facility's policy was for humidification of oxygen. She replied, I will need to review the policy and get back to you on that. She was asked what the facility's process was for ensuring that residents' supplemental oxygen was infusing at the ordered flow rate. She replied, I will need to review the policy and get back to you. When asked how often nursing staff were required to check residents' oxygen flow rates, she replied, I will need to review the policy and follow up with you on that. As of 4/24/25 at 5:50 PM (conclusion of the survey), the DON had not provided any responses to the abovementioned interview questions. 2. On 4/21/25 at 11:29 AM, while visiting the resident in his room, oxygen was observed infusing at 3 L/min (liters per minute) via nasal cannula (NC). No oxygen signage was observed on the resident's door. (Photographic evidence obtained) On 4/22/25 at 12:43 PM, while visiting the resident in his room, oxygen was observed infusing at 3 L/min (liters per minute) via nasal cannula (NC). (Photographic evidence obtained) A review of Resident #59's medical record revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, COPD, dependence on supplemental oxygen, unspecified diastolic congestive heart failure, bipolar disorder, major depressive disorder, and generalized anxiety. A review of the active physician's orders revealed the following orders: - Pulmicort Inhalation Suspension 0.5mg/2ml (milligrams per milliliters), Inhale orally twice daily related to COPD (1/9/25) - Brovana Inhalation Nebulization Solution 15 mcg/ml (micrograms per milliliter), 2 ml inhale orally for COPD (1/9/25) - Respiratory Oxygen-Continuous at 4 liters via nasal cannula every shift for SOB (shortness of breath)(1/9/25) - Pulse oximetry every day shift for monitoring (1/10/25) - Head of bed elevated to alleviate SOB every shift related to COPD (2/13/25). A review of the Annual MDS (minimum data set) assessment, dated 2/6/25, revealed that the resident had a BIMS (brief interview for mental status) score of 6 out of 15 possible points, indicating severe cognitive impairment. He required partial/moderate assistance with eating, toileting, bed mobility and was dependent for transfers. A review of the active Care Plan revealed the following focus areas: - I have an ADL (activities of daily living) self-care performance deficit related to unsteady balance/gait, impaired vision, COPD/asthma, and oxygen dependence (created 3/21/22, revised 12/12/24). - I have impaired cognitive function (created 3/16/23, revised 1/10/25). - I am receiving oxygen therapy. I will remove my oxygen. I will become SOB when lying flat. Wheezing noted. (created 10/12/2022, revised 1/10/25). - I have diagnosis of asthma/COPD. Risk for impaired gas exchange. I will become SOB (short of breath) while lying flat. Oxygen for SOB> Nodule to right lung base. (created 3/21/2022, revised 1/10/25). A review of the facility's policy and procedure for Oxygen Therapy (RT-430, effective 110/30/2014, revised 8/28/2017), revealed: Policy: Oxygen therapy is the administration of a FiO2 (fraction of inspired oxygen) greater than 21% by means of various administration devices to: Raise the resident's PaO2 (the pressure of oxygen dissolved in the arterial blood) to an acceptable baseline using the lowest FiO2; to treat arterial hypoxemia; to decrease the work of breathing; to reverse and prevent tissue hypoxia, and/or; to decrease myocardial work. Equipment: NO SMOKING sign Procedure: Physician's order for oxygen therapy shall include: FiO2 or liter flow rate. Review physician's order.

Based on observations, interviews, and record review, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to attain/maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected two (Residents #63 and #81) of a total survey sample of 38 residents with the potential to affect more of the facility's population. The findings include: 1. During the initial tour on 4/21/25 at 12:00 PM, Resident #63 was observed in bed wearing a hospital gown. His left arm was contracted. In an interview at 12:05 PM, Resident #63 stated someone came to his room at round 9:00 AM and placed the gloves in the gloves holder. He notified the staff person at that time (could not remember the name) that he wanted to get up. He said he had not seen anyone since then. He explained that he liked to get up after breakfast and get back in bed before dinner. He added that he did not get up the previous day despite asking staff several times. He said he preferred to get up daily. On 4/21/25 12:30 PM, Resident #63 was asked to activate the call light and notify staff that he would like to get up. The surveyor walked out of the resident's room and monitored the call light at the nurses' station. On 4/21/25 at 12:45 PM, the MDS (Minimum Data Set) Nurse responded to the call light. She notified the assigned nurse that Resident #63 was waiting for the Certified Nursing Assistant (CNA) to get him up. She stated she left the call light on per resident request. On 4/21/25 at 1:09 PM (with the call light still on and the resident wearing a hospital gown), a follow-up interview was conducted with Resident #63. He confirmed that he had asked three staff members to get up since 9:00 AM and none had attended to his needs. That was why he asked to have the call light left on until his needs were met. On 4/21/25 at 1:30 PM, the Assistant Director of Nursing (ADON) from the sister facility turned off Resident #63's call light. On 4/21/25 at 1:35 PM, a follow-up interview was conducted with Resident #63. He was having lunch at the time and was still wearing the hospital gown. He stated the call light was switched off because he was notified that his assigned CNA was in the dining room. He said, I am afraid that the light was turned off because when the staff comes back, she/he will not know that I need assistance. He activated the call light again. On 4/21/25 at 1:45 PM, the Administrator went to the resident's room and turned off the call light. During another follow-up interview on 4/21/25 at 1:50 PM, Resident #63 stated the Administrator had turned off the call light stating she was going to get someone to assist him. On 4/21/25 at 2:00 PM, Licensed Practical Nurse (LPN) F/Unit Manager was asked about Resident #63. She stated she worked on a different nursing unit and was moved to the current unit today, therefore she was not familiar with most of the residents. She was asked to accompany the surveyor to Resident #63's room. Resident #63 was observed in bed still in a hospital gown. He was asked to state his concerns to LPN F. He stated he had been asking to get up since 9:00 AM after breakfast and no one had assisted him yet. She asked the resident for his preferred time to get up. He responded, At 10:00 AM and back in bed around 4:00 PM. She stated she would update his care plan and would get the staff to assist him. As she was walking out of the resident's room, a staff member arrived to assist the resident. A review of the medical record revealed that Resident #63 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, type 2 diabetes, Atral fibrillation (AFIB) hypertension (HTN), and depression. A review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/20/25, revealed that the resident had a brief interview for mental status (BIMS) score of 10 out of 15 possible points, indicating moderate cognitive impairment. The assessment documented that the resident had upper extremity functional impairment on one side and was totally dependent on staff for bed mobility, toileting, dressing and transfers. 2. An observation made on 4/21/25 at 12:15 PM, revealed that Resident #81's call light was on. The resident stated she needed her pain medication and her brief changed. On 4/21/25 at 12:30 PM, the MDS nurse answered the call light and notified the nurse. She stated she left the call light on per resident request. On 4/21/25 at 1:00 PM, Resident #81's call light was still on. A follow-up interview was conducted with Resident #81 at this time and she was asked if she had been assisted yet. She stated she received the pain medication but her brief had not been changed. She said, You see what I am talking about; my light has been on for an hour. She added that she had not seen her assigned CNA since this morning. On 4/21/25 at 1:45 PM, Resident #81 stated she had been changed because she refused to receive her lunch tray before being cleaned up. In an interview with CNA E on 4/23/25 at 11:37 AM, she stated the call light should be answered by all staff. If the resident's need is not met, the call light should be left on. A review of the facility's payroll based journal report for October 1 - December 31, 2024 revealed that the facility had excessively low weekend staffing and a one-star rating. During an interview with the Staffing Coordinator on 4/24/25 at 11:25 AM, she explained that the facility census determined the daily staffing needs. When asked how frequently the facility experienced staffing issues, she said approximately three days of every week (random days and shifts). She confirmed that the facility had staffing issues. In an interview on 4/24/25 at 1:51 PM, the Administrator stated no one should walk past a call light. She stated the best practice was to leave the call light on until the resident's needs had been met. If the call light was turned off and the need was not met, the person turning off the call light should notify the resident about the situation. She said, For example, of a resident requests medication, the person can turn off the light and notify the nurse, then go back to the resident and explain the expected timeframe to receive the medication (For example, the nurse was passing medication to another resident, and she/he would be with you shortly.) When asked how soon resident needs should be addressed, she said whenever practicable. She was then asked about the PBJ (Payroll Based Journal) reporting. She stated the facility had contracted with an outside agency that was completing the reporting. She provided the contact information for the agency. During a telephone interview on 4/24/25 at 3:01 PM with a representative of the PBJ reporting agency, he explained that the information for PBJ was obtained from the facility's payroll. He stated before the report was submitted, he verified the data to ensure accuracy. He confirmed that the facility triggered for low weekend staffing and the concerns were relayed to the [NAME] President of Operations (VPO). In an interview on 4/24/25 at 3:14 PM, the VPO stated she was not aware of the low weekend staffing. She acknowledged that the facility had staffing issues and mentioned that she would put in place a staffing initiative plan. She added that the facility had posted advertisements for positions and was in the process of hiring a weekend manager. A review of the facility's Assessment Tool (updated on 3/21/240, revealed that the facility was licensed for 120 residents and the daily average was 100 residents. On Page 2: Acuity: Indicated that the facility utilized the CMS 802 as a resource to determine acuity. The facility also utilized a patient-driven payment model (PDPM) distribution report from Team TSI. This report generated a non-therapy ancillary (NTA) score based on submitted MDSs to determine nursing acuity. For long-term care residents, the facility utilized the ADL (activities of daily living) score generated from the MDS to determine nursing acuity. The assessment indicated that the average number of residents with behavioral health needs was 60. On Page 7: Individual staff assignment was determined based off the acuity. If the clinical staff observes high acuity, then additional staff will be needed. (Copy obtained).

Based on observations, interviews, record reviews, and facility policy and procedure review, the facility failed to ensure the residents' environment was as free as possible from hazards for two (Residents #23 and #59) of 38 residents in the total survey sample. The findings include: 1. On 4/21/25 at 11:10 AM, an observation was made of medications (pills) in a medication cup on the bedside table and a jar of medication on the nightstand at Resident #23's bedside. (Photographic evidence obtained). On 4/22/25 at 11:24 AM, an observation was made of medications in a medicine cup and also on the bedside table and night stand at Resident #23's bedside. (Photographic evidence obtained) On 4/22/25 at 11:25 AM an interview was conducted with Resident #23. When asked whether the nurse brought him his medication, he stated, No, I go to the cart and get it because I was getting my medications late, so I go get them. He was asked if he took his medications in front of the nurse or brought them back to his room to take them. He stated, I take my narcotics right there in front of the nurse. When he was asked how long the observed medication had been sitting on his table/nightstand, he replied, The nurse gave it to me this morning. (referring to the pills in the medicine cup). This is my potassium and I take this after I eat lunch so it won't upset my stomach. When asked about the remaining medications spilled on the table/nightstand, he stated, Those were given to me on another day and I didn't need them. Those are to make my bowels move or make them slow down. A record review revealed that Resident #23 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, other specified polyneuropathies, diabetes mellitus, type 2, low back pain, anxiety disorder, other chronic pain, insomnia, alcohol abuse, pin in left hip, pain in right leg, peripheral vascular disease, polysubstance abuse, ADHD (attention deficit hyperactive disorder), and depression/mood disorder. A review of the Annual MDS (minimum data set) assessment, dated 2/21/25, revealed a BIMS (brief interview for mental status) score of 13 out of 15 possible points, indicating intact cognition. The assessment revealed the resident had no behaviors, required setup or clean-up assistance with eating, and was independent with toileting, bed mobility and transfer tasks. It also indicated the presence of pain that occasionally interfered with day-to-day activities, on numerical pain scale at 07/10. A review of the Care Plan revealed the following focus areas: - Alteration in usual functional performance in self-care related to weakness, debility, neuropathy (created 2/24/25, revised 3/12/25) - ADL (activities of daily living) self-care performance deficit related to unsteady gait, balance, neuropathic pain, chronic pain, (CAD) Coronary Artery Disease, muscle spasms. I will refuse showers/bathing (created 3/29/23, revised 3/13/25). - I am receiving an over-the-counter sleep aid related to insomnia (created 3/29/23, revised 3/13/25). - I am receiving an antidepressant for a diagnosis of depression (created 3/29/23, revised 3/13/25). - I am receiving an anti-anxiety for a diagnosis of anxiety disorder (created 3/29/23, revised 3/13/25). - I am receiving diuretic therapy related to hypertension (created 2/24/25, revised 3/13/25). - I have acute, chronic pain related to a diagnosis of low back pain, chronic pain, muscle spasms, neuropathic pain, degenerative joint disease (created 3/29/23, revised 3/13/25). Further review of the record revealed no care plan to direct care for the resident to self-administer medications. A review of the active physician's orders revealed the following: Alprazolam (sedative) 0.5 mg (milligrams) by mouth twice daily for anxiety (5/26/24) Torsemide (diuretic) 20 mg by mouth daily for edema (6/28/24) Methadone (narcotic)10 mg, give 4 tablets by mouth daily (9/25/24) Trazadone (antidepressant and sedative) 100 mg by mouth at bedtime for major depressive disorder, insomnia (2/13/25) Percocet (narcotic) 5-325 mg by mouth every 4 hours as needed for joint pain (3/14/25) Non-pharmacological interventions use every shift (9/30/24) Assess for pain every shift (5/26/24) Behavior monitoring every shift (5/26/24) Side effects monitoring every shift (5/26/24) No physician's order was found permitting the resident to self-administer medications. A review of the psychiatric progress notes revealed that the resident was followed monthly and as needed for depression, anxiety, insomnia and alcohol abuse. Further review of the record revealed no assessment for self-administration of medications. On 4/22/25 at 11:39 AM an interview was conducted with Licensed Practical Nurse (LPN) A. When she was asked to describe the responsibilities of the nurse who was administering medications to a resident, she stated, The nurse is responsible to make sure that the resident has an adequate amount of water, that they swallow all the medication, that all medications are given with the correct dose, the correct medication, the correct frequency, and that all medications have a doctor's order. With inhalers, we make sure they get the correct dose, monitor them to make sure they don't have an adverse reaction, and they have the right to refuse medications. When she was asked if it was appropriate for medications to be stored at the resident's bedside, she replied, Well, it depends on what the medication is and if the resident has a doctor's order and the consents for self-administration of medications. If they can self-administer, we still have to monitor how they store it or whether it needs to be stored on the medication carts and also monitor for the expiration dates, and add it to the care plan. The nurse was accompanied to the resident's bedside and she confirmed that there was a medication cup with two pills in it and five additional, various pills on the bedside table. The nurse confirmed that one of the pills was the resident's potassium that had been administered on 4/22/25 (9:00 AM dose). She asked the resident's permission to remove all of the medications and he gave her permission. On 4/22/25 at 4:35 PM, a brief interview was conducted with LPN B. When she was asked what the facility's process was for residents self-administering medications, she stated, We get an order from the physician. She was asked if there were any residents currently in the facility who self-administered medications. She replied that she didn't think there were any residents who did. When she was asked what the nurse's responsibility was when administering medications to residents, she replied, The nurse's responsibility is to make sure the resident takes the meds and swallows them. On 4/23/25 at 11:37 AM, an interview was conducted with Certified Nursing Assistant (CNA) E, who was asked what she did if she found medications in a resident's room. She stated, I would ask the resident how long the medications had been there and let the nurse know that the resident still has it and hasn't taken it. When asked how often she saw medications in residents' rooms, she replied, Not often. She was asked if she knew whether or not there were residents in the facility who were able to self-administer their own medications, she replied, No, it's supervised. A review of the facility's policy and procedure titled Monthly Drug Regimen Review (N-866, effective: 04/21/2017, revised 3/28/2024), revealed: Procedure: To ensure the requirement is met for monthly drug regimen review the ED/DON (Executive Director/Director of Nursing) should implement the following process: Downloading of Pharmacist Consultant Report: Available from contracted pharmacy via secure email or database - Day 15-21 the DON/designee will contact the physicians with any outstanding recommendations. If no response from the physician, the facility may notify the Medical Director for further assistance. Consultant Report - Continuous Print This report is to be used by the DON/designee to record responses returned from the physician and for follow-up on any outstanding recommendations. If follow-up for the consultant pharmacist recommendations is not completed within the specified time frame, this should be reported to the Medical Director for follow up with attending physician as indicated. A review of the facility's policy and procedure titled Medication - Oral Administration (N-853, effective 11/30/2014, revision 8/15/2019), revealed: Procedure: Review physician's order. Document the administration and acceptance or decline of all medications administered. a. Should the resident decline or be unable to accept the medication, this will need to be documented following standard protocol. 2. On 4/21/25 at 11:29 AM, an observation was made of several razors in a plastic bag on the resident's dresser. (Photographic evidence obtained) A record review for Resident #59 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), dependence on supplemental oxygen, unspecified diastolic congestive heart failure, bipolar disorder, major depressive disorder, and generalized anxiety. A review of the Annual MDS (minimum data set) assessment, dated 2/6/25, revealed a BIMS (brief interview for mental status) score of 6 out of 15 possible points, indicating severe cognitive impairment. The resident required partial/moderate assistance with eating, bed mobility and toileting, and was dependent for transfers. The assessment also indicated that the resident received anticoagulants. A review of the resident's Care Plan revealed the following focus areas: I have an ADL (activities of daily living) self-care performance deficit related to unsteady balance/gait, impaired vision, COPD/asthma, oxygen dependent (created 3/21/22, revised 12/12/24). I have impaired cognitive function (created 3/16/23, revised 1/10/25). I am receiving anticoagulant therapy prophylaxis (created 1/10/25, revised 1/10/25). I am receiving oxygen therapy. I will remove my oxygen. I will become SOB (short of breath) when lying flat. Wheezing noted. (created 10/12/2022, revised 1/10/25). I have a diagnosis of asthma/COPD. Risk for impaired gas exchange. I will become SOB while lying flat. Oxygen for SOB, nodule at right lung base. (created 3/21/2022, revised 1/10/25). A review of the active physician's orders revealed the following: Pulmicort Inhalation Suspension 0.5 mg/2ml (milligrams per milliliter), Inhale orally twice daily related to COPD (1/9/25) Apixaban 5 mg by mouth, give 2 tablets twice daily for DVT (deep vein thrombosis) 7 days and give 1 tablet by mouth twice daily for DVT PPX (prophylaxis)(1/9/25) Brovana Inhalation Nebulization Solution 15 mcg/ml (micrograms per milliliter), 2 ml inhale orally for COPD (1/9/25) Respiratory oxygen-continuous 4 liters via nasal cannula every shift for SOB (1/9/25) Pulse oximetry every day shift for monitoring (1/10/25) Head of bed elevated to alleviate SOB every shift related to COPD (2/13/25) On 4/23/25 at 11:37 AM, an interview was conducted with CNA E, who was asked if the facility staff provided razors or shaving materials to the residents. She stated, Yes, if the resident is safe with sharp objects, but personally, I still supervise my residents when they shave. She was asked how the facility stored razors. She replied, Razors are stored in the supply closets on the units. When asked if razors were supposed to be stored in resident rooms, she replied, No, they can ask the staff for them and we supply the razors. When asked if resident rooms were keot neat and tidy, she repleid yes. When she was asked how often she cleaned the residents' areas, she replied, I make the bed, declutter the bedside table so it has room on it for the meal tray, and declutter the pathways to keep them safe. On 4/24/25 at 12:36 PM, an interview was conducted with LPN K, who was asked to describe some things she did to make the resident's environment safe. She stated, Make sure the call light is in reach, answer call lights quickly, rounding, signs up for oxygen, signage for any isolation precautions so everyone's aware, no fans because they can start a fire, and no rugs because they are a fall hazard. When asked if the facility staff provided razors or shaving materials to the residents, she replied, yes. When asked how the facility stored razors, she said, Locked in the clean linen closet. When asked if razors could be stored in resident rooms, she replied, I'll have to get back to you on that because I haven't really seen razors in resident rooms. When she was asked what she should do if she observed razors in a resident's room, she stated, I would probably confirm whether they are supposed to have it or not before I just remove it. A review of the facility's policy and procedure titled Safety Precautions-General (S-360, effective date: 11/30/2014, 2 pages), revealed: Policy: General safety rules will be followed by all personnel to prevent injury of employees, residents, and visitors. Sharps Disposal Policy Statement: The facility shall discard contaminated sharps into designated containers. Policy Interpretation and Implementation 1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. On 4/24/25 at 5:49 PM, Registered Nurse (RN) D was asked to provide a policy that pertained to safe handling/storage of razors. No policy was provided during the survey.

Based on observations and interviews, the facility failed to honor resident rights for respect and dignity for two (Residents #3 and #2) of four sampled residents reviewed for resident rights. Facility staff failed to knock before entering the resident's room. The findings include: During an interview with Resident #3 on 3/7/2023 at 10:57 AM, she stated concerns regarding facility staff entering her room without knocking on the door. Twice during the interview with Resident #3, unidentified staff members opened the door, without knocking, partially entering the resident's room. Upon seeing the resident was with someone, the staff immediately exited and closed the door. Resident #3 stated she has had to get onto them two times about knocking in the past. She stated it had occurred once while she was getting a bath in the room. During an interview with Resident #2 on 3/7/2023 at 11:00 AM, an unidentified staff member opened the resident's door without knocking. The staff member looked in the room, made eye contact, and looked over at the resident's roommate before turning around and exiting the room. On 3/7/2023 at 11:49 AM and again at 11:52 AM, staff members were observed entering two rooms on the 300 hall. Each time the staff member failed to knock and/or introduce themselves before entering. During an interview with the Director of Nursing (DON) on 3/7/2023 at 4:44 PM, she was asked about staff training on dignity. She stated training on dignity is done upon hire in Relias, then face to face. She added, it's updated annually and then as needed. She stated the facility doesn't have a policy specific for dignity. When advised of the observations during the survey, she confirmed that staff should be knocking when entering a resident's room.

Based on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (Residents #1, #2 and #3) of seven residents sampled. The findings include: Resident #1 was initially admitted to the facility on [DATE]. Her latest readmission was on 5/11/2016. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual Minimum Data Set (MDS) assessment, dated 3/2/2022, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. She was totally dependent for transfers; required extensive assistance with personal hygiene, toilet use, dressing and bed mobility; limited assistance with locomotion on and off the unit, and supervision with eating. Resident #2 was initially admitted to the facility on [DATE]. Her most recent readmission was on 3/8/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS assessment, dated 3/12/2022, revealed Resident #2 had a BIMS score of 15, indicating intact congition. She required extensive assistance with bed mobility, transfers, locomotion on unit, dressing, toilet use and personal hygiene. She received limited assistance with eating and locomotion off the unit. Resident #3 was admitted to the facility on [DATE]. Her most recent readmission was on 10/5/2021. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS assessment, dated 2/9/2022, revealed Resident #3 had a BIMS score of 14, indicating intact cognition. The resident required limited assistance with transfers, eating, toilet use and personal hygiene, and extensive assistance with dressing and bed mobility. A review of the shower book on the East Wing, revealed there were no showers documented for Resident #1 or #2 from 4/1/2022 through 4/25/2022. According to the schedule in the binder, Resident #1 was scheduled to receive showers on Mondays, Wednesdays and Fridays on the 7:00 a.m. to 3:00 p.m. shift. Resident #2 was scheduled to receive showers on Tuesdays, Thursdays and Saturdays on the 3:00 p.m. to 11:00 p.m. shift. Based on documentation, Resident #3 received a shower on 4/22/2022 on the 7:00 a.m. to 3:00 p.m. shift. The Bed Bath/Shower/Skin Assessment sheet was not signed by the nurse. There were no other assessment sheets located for Resident #3. A review of the shower sheets for 4/1/22 through 4/26/22, revealed Residents #1, #2 and #3 did not receive bathing services per their schedules during this period. During an interview on 4/26/2022 at 4:13 p.m. with Resident #2, she stressed that she wanted to receive full showers not bed baths and had advised the facility staff of this. She stated she has had three showers since her admission on 6/6/2021. She stated she was not given full bed baths either. She stated she was given a washcloth and basin with water to wash her face and underarms. She again stressed displeasure with this, stating she wanted to take showers. During an interview on 4/25/2022 at 10:38 a.m. with Resident #3, she expressed concern with receiving her showers as scheduled. She stated the facility had certain staff members designated to provide showers. Based on the electronic charting, Resident #3 received a shower on 4/12/22 (2:46 p.m.) and 2 bed baths on 4/13/22 (1:30 a.m. and 11:51 a.m.). Based on Certified Nursing Assistant (CNA) plan of care (POC) charting, Resident #2 did not receive bathing services from 4/16/22 through 4/25/22. On 4/26/2022, the resident was documented as having received a bed bath. There was no documentation verifying that Resident #3 received any bathing services between 4/16/22 and 4/22/22. During an interview on 4/26/2022 at 1:07 p.m. with CNA B, she stated she completed shower sheets, if she could, after the the resident had received their shower. She stated if she was not able to do it, then she tried to do it at the end of the shift and give it to the nurse to sign. She stated refusals were documented on the shower sheet and the nurse had to sign it. She stated showers were also documented in the resident's plan of care in the facility's Electronic Medical Record (EMR) system. She was given the shower book for Residents #1, #2 and #3. After reviewing the documents she stated Resident #3 received a shower on 4/22/2022. She confirmed there were no shower sheets for Residents #1 or #2. She stated she could not confirm if Residents #1 or #2 had received showers as scheduled and also stated, If they did, a shower sheet wasn't done for them. During an interview with Licensed Practical Nurse (LPN) A/Unit Manager at this time, he confirmed that there was no documentation verifying that the residents received bathing services as scheduled. He could not explain why the residents would have missed bathing services. He could not explain the lack of documentation for bathing services provided to the residents. He stated it was the responsibility of the nurse to ensure residents were receiving care services. .

Based on record review and interview, the facility failed to ensure that one (Resident #1) of seven sampled residents had the right to be free from misappropriation of resident property. The findings include: During an interview on 4/25/2022 at 2:43 p.m., Resident #1 stated during a recent room change in the facility, a staff member broke a mirror that was sitting on a table in her room and it was never replaced. She also stated several other items went missing and were never returned. She stated the items were valued at more than $200.00. She stated she had filed grievances and spoken to the Administrator regarding the missing items to no avail. She stated initially the Administrator told her that she would replace/reimburse the missing items, but recently rescinded that statement, stating she would not replace the missing items, as the resident signed an agreement in her admission packet stating the facility was not responsible for missing items. A review of the facility's admission packet revealed it did not include language to address items that were lost or stolen. Additionally, there was no language to address whether or not a resident could/would be reimbursed for lost/stolen/damaged items. A review of the facility's policy on Personal Property/Loss or Theft (Document name N-1037, revised 7/24/2017) revealed it covered minimizing the risk of loss or theft of residents' personal property, but did not state how it would be done or what would happen in the event that it occurred. Additionally, it did not address actions that would be taken by the facility in the event that a resident reported loss, stolen or damaged property. During an interview on 4/26/2022 at 12:59 p.m. with the Administrator, she confirmed there was no policy to address items that were lost, stolen, or broken in the facility. She stated she had also looked through the admission packet for information and was not able to locate anything. She was asked about the policy previously provided (Personal Property/Loss or Theft (revised 7/24/17), which covered minimizing the risk of loss or theft of resident's personal property, but did not state how this would be done or what would happen in the event it occurred. She apologized and again stated there was nothing in place to cover that. When she was asked what would be done if a resident reported a loss, stolen or broken item, the Administrator responded by shrugging her shoulders and shaking her head. .

Based on record reviews and interviews, the facility failed to ensure that three (Residents #5, #1 and #4) of seven residents sampled, received treatment and services that met professional standards of quality. Resident #5's nursing assessment did not capture all of the resident's wounds, delaying treatment orders. Resident #5's antibiotic medication was also delayed without documentation explaining why the facility could not accommodate the resident's antibiotic needs. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. A review of Resident #5's medical record revealed a [AGE] year-old male, admitted on [DATE] to room [ROOM NUMBER]A. He was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #5's hospital discharge paperwork revealed he had a RBKA in 2021. On his LLE, all toes were amputated on 3/16/22 while hospitalized . A physician's progress note written prior to his nursing home admission and dated 3/31/22 read, LLE and left foot ulcers with eschar, left toes amputation site with seropurulent drainage, no putrid odor. (Copy obtained) According to Wound Source at www.woundsource.com (accessed on 5/11/22 at 12:07 p.m.), Wound drainage that turns cloudy, yellow, or tan is called seropurulent and is usually a sign that the wound is becoming colonized and treatment changes are needed. Seropurulent wound drainage can have a variety of colors, including pink, gray, yellow, tan, brown, green, or white. Color alone is not necessarily an indicator of wound infection, but any change from clear drainage should be noted and examined. A review of the unsigned, undated transfer form (3008) from the hospital to the nursing home, revealed in Section T: RBKA, wound to LLE, pressure ulcer to sacrum. No wound treatments were documented. (Copy obtained) A review of the facility's Nursing Admission note, dated 4/1/22 at 12:14 PM and authored by the Assistant Director of Nursing (ADON)/Registered Nurse (RN) revealed, IV present, yes, midline, left arm, no redness/swelling/drainage. Skin, stage III sacrum, generalized psoriasis and scratch marks. Resident states he scratches his skin a lot; Left lower leg front amputation below knee; left toes, all toes amputated. No reference was made to the left toes amputation site with seropurulent drainage documented by the hospital physician on 3/31/22. There was no indication that the facility physician was made aware of this wound site. On 4/1/22 at 1:50 PM, the ADON documented: [AGE] year-old white male transported to facility via ambulance. Resident alert and oriented x 4. No complaint of pain noted. Resident has stage III wound to sacrum. Resident has midline in Left Upper Extremity (LUE). No signs or symptoms of infection noted. Resident has psoriasis on multiple areas of body. Vitals within normal limits (WNL). Resident educated on call light; bed remote. Family member at bed side during assessments. No reference was made to the left toes amputation site with seropurulent drainage documented by the hospital physician on 3/31/22. There was no indication that the facility physician was made aware of this wound site. Admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/1/2022 - 1:00 PM Flush with 10 milliliters (ml) normal saline every shift and as needed. (Peripherally inserted central catheter (PICC) 1:29 PM Weekly skin sweeps. 1:29 PM Change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. (PICC) 6:00 PM [MEDICATION(S)] 500 mg (milligrams), give 2 tabs twice daily until 4/7/22. On 4/2/2022- 9:00 AM [MEDICATION(S)] Hydrogen Chloride Solution (HCl) 1000 milligram/10 milliliter, 1gram Intravenously (IV) one time daily until 4/12/22. ([CONDITION(S)]) 3:00 PM Cleanse sacrum with NS (normal saline), pat dry. Pack wound with calcium and cover with border dressing daily (3:00 PM). No orders were noted related to the left toes amputation site with seropurulent drainage documented by the hospital physician on 3/31/22. There was no indication that the facility physician was made aware of this wound site. On 4/6/22 - 7:08 AM Wound care consult, LLE [CONDITION(S)], sacral ulcer. No reference was made to the left toes amputation site with seropurulent drainage documented by the hospital physician on 3/31/22. There was no indication that the facility physician was made aware of this wound site. A review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) A review of the nursing notes revealed no note indicating why the [MEDICATION(S)] HCl solution was not administered. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #5's care plan revealed: On 4/6/22, the care plan was updated to include: Impaired Skin Integrity-Sacrum, [CONDITION(S)] to bilateral (both) lower extremities (BLE): administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing; monitor dressing to ensure it is intact and adhering, report loose dressing to treatment nurse. On 4/13/22, the care plan was updated to include Impaired Skin Integrity-Sacrum, [CONDITION(S)] BLE, anterior knee, left shin, left heel, left hip, surgical wound left foot. On 4/26/22 at 2:45 PM, an interview was conducted with Registered Nurse (RN) E. The nurse stated assessments were done on new admissions from head to toe. If a resident came with a dressing or wound but no wound care orders, nurses was expected to phone the physician. If a resident was scheduled to receive IV [MEDICATION(S)] at a certain time but the medication had not been received, the medication could come from the emergency drug kit (EDK). The nurse stated he could not recall whether Resident #5 received his first dose of [MEDICATION(S)] on 4/2/22. He stated there should have been a nursing note explaining why the resident did not receive his antibiotic on 4/2/22. On 4/26/22 at 3:25 PM, an interview was conducted with the Assistant Director of Nursing. The ADON stated newly admitted residents should have a set of vital signs and a head-to-toe assessment completed along with a skin assessment and advanced directives. Skin assessments were in the electronic medical record (EMR). If a resident arrived without orders for a wound/dressing, the nurse should assess the type of wound and phone the physician for treatment orders and a referral to the wound care service as necessary. The ADON reviewed Resident #5's medical record and could not find any documentation verifying an assessment of the wound or dressing to the LLE or communication with the physician. The ADON reviewed the MAR for Resident #5 and acknowledged the 9 documented on 4/2/22 at 9:00 AM for the IV [MEDICATION(S)] dose. The ADON stated it usually meant the medication was not given and should have had a note to explain why in the EMR. 2. During an interview on 4/26/2022 at 2:43 p.m. with Resident #1, she stated she had a yeast infection since January 2022. She stated she had not received the medication prescribed for the yeast infection as ordered. A review of Resident #1's medical record revealed an admission on 3/24/2016 with her most recent readmission on 5/11/2016. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual minimum data set MDS assessment, dated 3/2/2022, revealed Resident #1 scored 15 out of a possible 15 points on the Brief Interview for Mental Status (BIMS) indicating her cognition was intact. During an interview with RN D on 4/27/2022 at 1:48 p.m. and the Director of Nursing (DON) regarding the medication order for Resident #1, RN D stated she had been a nurse since 1984. She stated she was responsible for putting orders in the EMR. Both employees were shown the written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They each confirmed that Resident #1 should have received the medication every day for a period of five days. At this time, the DON explained to RN D how the original order read. The DON acknowledged that the resident should have received five doses of the medication and again confirmed that she had received only two doses. The DON stated she reviewed new orders during the clinical meeting, which was held each morning. She stated she and the Unit Managers were responsible for reviewing the nurses' charting. She also stated she reviewed the EMR and the narcotic books for accuracy. A record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic medical administration record (EMAR) revealed RN D entered the order into the EMAR as [MEDICATION(S)] 200 mg by mouth once every five days. Further review of the EMAR revealed the resident was given the medication on 4/5/2022 and again on 4/10/2022, not as ordered by the physician. 3. A review of Resident #4's medical record revealed an admission on 1/28/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment, dated 2/3/2022, revealed Resident #4 had a BIMS score of 15, indicating she was cognitively intact. A review of the resident's Care Plan, with a review date of 3/8/2022, revealed interventions for ADL (activities of daily living) self-performance deficit and acute/chronic pain related to complaints of shoulder pain. On 4/26/2022 during a tour of the East Wing of the facility at approxmately 3:46 p.m., there was no nurse on the unit. A locked medication cart was parked next to the nurses' station. Several residents were observed in their wheelchairs waiting next to the nurses' station. Resident #4 was one of those residents. The white board with the daily schedule was blank for nurses scheduled for the 3:00 p.m. to 11:00 p.m. shift. A pharmacy delivery representative appeared on the unit at that time. He requested a nurse to sign off on the medication delivery. A Certified Nursing Assistant (CNA) on the unit advised him that the nurse was not there and that she would have to get someone to help him. After waiting several minutes, he advised another CNA that he was leaving and They won't be getting any meds today. At 3:58 p.m. as he prepared to leave, Licensed Practical Nurse (LPN) J, assigned to the West Wing of the facility, came to assist him. When asked who was the nurse scheduled on the East Wing for the 3:00 p.m. to 11:00 p.m. shift, LPN J stated she did not know and would have to check the schedule book. LPN J was accompanied to the West Wing to look at the schedule book. She advised that a RN was scheduled to be the nurse on the East Wing for the 3:00 p.m. to 11:00 p.m. shift. A CNA interrupted LPN J and told her that the RN assigned to the East Wing was off and not in the building. LPN J then stated, Well, I'm not sure who's the nurse. Upon arrival back at the East Wing nurses station at approximately 4:05 p.m., there was still no nurse on the unit. Resident #4, still seated next to the nurses' station asked if the surveyor was a nurse. She stated she was in pain, needed her medication and had been waiting for the nurse for some time. She advised that she had not had her afternoon pain medication. She reported a level 8 to 9 pain in her right arm demonstrating that she couldn't raise the arm without experiencing pain. At 4:05 p.m., the Administrator appeared on the East Wing. She was asked who was the scheduled nurse for the 3:00 p.m. to 11:00 p.m. shift on the East Wing. Initially she stated it was RN D, but then retracted that, stating RN D was scheduled for the 7:00 a.m. to 3:00 p.m. shift. She acknowledged that there was no nurse on the East Wing and stated RN D should not have left until her relief arrived. Again, she was asked who that relief should be. She stated she did not know but the Assistant Director of Nursing (ADON) would fill in until a nurse arrived. During an interview on 4/26/2022 at 4:11 p.m. with the ADON, he was asked about the nurse coverage for the 3:00 p.m. to 11:00 p.m. shift on the East Wing. He initially stated it was RN E, but he was advised that staff confirmed RN E was off this day. He then stated it was LPN A/Unit Manager. He was advised that LPN A was not in the building either. He then advised that he would need to check on that and would report back. On 4/26/2022 at 4:19 p.m., the ADON reported that LPN A was now in the building and would work as the nurse for the 3:00 p.m. to 11:00 p.m. shift on the East Wing. On 4/26/2022 at 4:29 p.m., Resident #4 was observed sitting in the doorway of her room. She stated she still had not received her pain medication nor had she seen the nurse. The resident again stated she was experiencing significant pain.

Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice, by failing to 1) Clarify residents' diet orders on admission, 2) Provide residents with cognitive and functional limitations assistance with meals, and 3) Appropriately assess a resident's respiratory status, perform finger sweeps and the [MEDICATION(S)] maneuver, following a choking incident for one (Resident #2) of two residents reviewed for dysphagia, from a total of four residents in the sample. These failures contributed to Resident #2's admission to an acute-care hospital's intensive care unit due to respiratory arrest following aspiration. On [DATE] at 6:00 p.m., Licensed Practical Nurse (LPN) A heard Resident #2, diagnosed with dysphagia, coughing. When she entered his room, he could not speak and struggled to breathe. He had been given a regular-textured dinner meal and was attempting to eat it alone in his private room. He was ordered a pureed/nectar-thick diet and was to have been assisted with his meal. When LPN A saw the resident coughing, holding his throat, and realized that he could not communicate with her, she left his room, called 911 from the nursing station, and waited for Emergency Medical Services (EMS). She did not assess his respirations or lung sounds. She did not do a finger sweep or attempt the [MEDICATION(S)] maneuver. EMS arrived at approximately 6:10 p.m. per interview (no time of arrival was documented) and transported a minimally responsive Resident #2 to the hospital. Upon arrival, he went into respiratory arrest. The facility's failure to provide Resident #2 with assistance with his meal, as well as its failure to appropriately assess his respiratory status, perform finger sweeps and the [MEDICATION(S)] maneuver following a choking incident, contributed to Resident #2 ' s admission to an acute care hospital ' s intensive care unit due to respiratory arrest following aspiration. On [DATE], the facility census was 82. There were nineteen residents who required assistance with meals. Sixteen of those nineteen residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Vice President of Operations was notified of the Immediate Jeopardy at 6:00 p.m. on [DATE]. The Immediate Jeopardy was ongoing as of the exit on [DATE]. The findings include: Cross reference F726, F805 and F867 A review of Resident #2's medical record revealed he was admitted to the facility on ,d+[DATE]//2022 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He required assistance with activities of daily living. A review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Admit to Skilled Nursing Facility, dated [DATE] (Tuesday) Full code, dated [DATE] Dietary liberty for special occasions, dated [DATE] Regular diet, regular texture, regular/thin liquids consistency, ordered [DATE] Percutaneous endoscopic gastrostomy (PEG) tube (feeding tube), change tubing and syringe daily, every night shift, ordered [DATE] Regular diet, dysphagia pureed texture, nectar-thickened fluids consistency, ordered [DATE] (Resident #2 had already been discharged on [DATE].) A review of a Diet Requisition Form for Resident #2 and dated [DATE] at 1:05 p.m. with Diet Change handwritten on the bottom, revealed that a regular diet, with dysphagia/puree, nectar consistency was checked off. A review of the facility's Admission Completion Check-Off List, outlining the forms required to be completed upon admission of a new resident, revealed the following: - Dietary Communication Form completed and sent to kitchen - Diet orders present/accurate - Telephone orders written for any clarifications not noted on discharge orders and/or 3008 (Florida) A review of the resident's Discharge Minimum Data Set (MDS) assessment, dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) score was not obtained. He was documented as requiring extensive assistance for bed mobility, transfers, eating and toilet use. He had a feeding tube and the section for mechanically altered diet was marked not applicable. A review of the baseline care plan, dated [DATE], revealed that the resident was documented with a regular diet and a feeding tube. His goal was documented as Will maintain stable weight. The intervention checked off was Diet and/or supplements as ordered. Under Self-Care Deficit, Resident #2 was documented as dependent for eating and requiring the assistance of one person. A review of Resident #2's comprehensive care plan, initiated on [DATE], revealed the following: Under the focus area Self-Care Deficit, the intervention related to eating was left blank. EATING: The resident is able to: (SPECIFY), Date Initiated: [DATE] Under the focus area Oral/Dental Health Problems (SPECIFY) related to (blank), the interventions included: Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted, Date initiated: [DATE] Under the focus area Requires Tube Feeding related to Dysphagia (difficulty swallowing), the Goals included: The resident will be free of aspiration through the review date. Target date: [DATE], Date initiated: [DATE]. Interventions included: Head of bed elevated 45 degrees during and thirty minutes after tube feed. Total assistance with tube feeding and water flushes. See MD (doctor's) orders for current feeding orders. Monitor/document/report as needed, any signs or symptoms of aspiration. Resident #2 was care planned on [DATE] with a focus area of Antipsychotic Therapy related to [CONDITION(S)] Resident #2 was care planned on [DATE] with a focus area of Advance Directives, Full Code. A review of the admission nursing assessment dated [DATE], and indicating an admitted [DATE] at 5:51 p.m., revealed that Resident #2 was alert and orientated to himself only. His speech was documented as aphasic (difficulty communicating). He was documented with mild shortness of breath. No cough observed. He was reportedly receiving oxygen at a flow rate of two liters per minute via nasal cannula (tubing delivering oxygen through the nostrils). He was noted with general weakness and under the heading Nutritional Approach, feeding tube was noted. He was documented as cognitively impaired with poor decision-making skills, not independently mobile, and was noted as receiving antipsychotic, antidepressant, antianxiety and hypnotic medications. On the last page of the assessment was documented, Unable to orient resident. A Nursing Progress Note, dated [DATE] at 10:38 p.m. read, Resident was eating dinner, suddenly started to cough, appeared to be choking. 911 called and transferred the resident to emergency room (ER) for evaluation, family member notified. A review if the Acute-Care Hospital History and Physical, revealed a Dietary assessment dated [DATE]. It indicated the resident was to receive nothing by mouth (NPO). Recommendations included adjusting the tube feeding to Glucerna 1.5 (a high-calorie liquid nutrition tube feeding formula designed to minimize blood sugar spikes) at 55 milliliters per hour (mL/Hour), which gave (1980 Kilo calories (Kcal), 108 grams (g) protein, 176 g carbohydrates (CHO), and 1002 mL of free water. This met 100% of the estimated Kcal and protein fluid, and 59% estimated fluid needs or at least 30 mL every 4 hours to prevent occlusion (blockage of the tube). The resident was anticipated to discharge the hospital with the tube feeding (TF) in place. If bolus feed (the delivery of smaller volume feeds at regular intervals) desired, recommend 8 ounces (oz.) of Glucerna 6 times per day to meet protein-Kcal needs. A review of the Acute-Care Hospital's Swallow Evaluation from the Speech Therapist (ST), entitled Modified [MEDICATION(S)] Swallow/Plan of Care (POC), dated [DATE], revealed recommendations for: Pureed and nectar/mildly thick liquid. Swallowing Precautions: Continue PEG as primary source of nutrition for now. Further assess for soft solids. A review of the Acute-Care Hospital intake notes, dated [DATE], the day the resident was discharged emergently from the skilled nursing facility to the hospital emergency room revealed, The patient presented with respiratory distress. The patient presents with difficulty breathing, respiratory problem and respiratory arrest. The onset was just prior to arrival. The course/duration of symptoms is constant. Degree at onset severe. Degree at present severe. Risk factors consist of dysphagia. [AGE] year old male presents to emergency department via EMS (Emergency Medical Services) with dyspnea, respiratory arrest, suspected choking episode. Patient is a resident of a nursing home and has chronic dysphagia of unknown origin. Patient has a tube secondary to his dysphagia. Patient diet recently escalated beyond his G-tube to pureed diet. EMS states that patient was given solid foods just prior to the initiation of his episode. On EMS arrival, patient was minimally responsive and choking. EMS removed multiple pieces of food from patient airway. Patient became unresponsive and EMS team attempted intubation. Unable to intubate secondary to suspected food bolus (semi-solid mass of food) in airway. EMS team able to remove multiple pieces of the food bolus and placed King tube (airway management device) successfully. On arrival in ED (Emergency Department), patient unresponsive with King tube in place. In an interview with the facility's Speech Therapist/Rehab Director on [DATE] at 9:45 a.m., she stated residents were assessed the first business day following their admission to the facility. When recommendations were made for diet changes, she completed a diet slip (consistency section) and verbally communicated to the nurse, who completed the diet slips and notified the Dietary Department. When asked how long it took for a resident to advance in their diet texture, she stated it was normally a case-by-case basis, dependent upon the individual resident's level of impairment and functional status. She stated diet texture advancement took longer than 24 hours unless there was an error in the diet prescription, and the resident could tolerate the other diet. When asked if she saw Resident #2 after admission, she stated she was out of the facility at the time. She reviewed the chart and stated the resident was seen by a different Speech Therapist (ST) on [DATE]. Per the Admission Diet Sheet, Resident #2 had a PEG tube and was NPO. She added that the note indicated the ST spoke with the resident's wife, who reported that Resident #2 was upgraded to a pureed diet with nectar-thickened liquids at the hospital. The resident's wife also reported that the resident aspirated on thin liquid and regular consistency foods. Recommendation included: puree and nectar-thick liquids. When asked if other food textures were tried, she replied, [Resident #2's] level of impairment with pureed food would not warrant an attempt at a different food texture. She added, According to the notes, the resident had difficulty with pureed. She concluded that the resident was left on a pureed diet. A review of the Speech Therapy Initial Evaluation, dated [DATE], revealed that the clinical impression and recommendation showed the resident demonstrated moderate oropharyngeal dysphagia (Per https://medical-dictionary.thefreedictionary.com/oropharyngeal+dysphagia on [DATE] at 2:18 p.m., Difficulty in propelling food or liquid from the oral cavity into the esophagus). The resident's current diet level was recently upgraded to a pureed texture and nectar-thickened liquids. The resident exhibits decreased lingual (random disorganization of tongue movements), labial (impaired oral sensation or decreased lip strength), and laryngeal (reduced elevation or closure) function with a moderate impairment with ROM (range of motion), strength, coordination, and rate. Upon observation, resident exhibited mild-moderate impairment with bolus (semi-solid mass of food) formation and extended bolus hold and moderate impairment with lingual residue and laryngeal elevation with nectar-thick liquid. (Copy obtained) In an interview on [DATE] at 11:15 a.m., Licensed Practical Nurse (LPN) A stated she had worked at the facility on an as needed (PRN) basis since [DATE]. When asked if she was familiar with Resident #2, she replied yes. She stated on [DATE] at 6:00 p.m. during dinner, she heard Resident #2 coughing, and upon entrance to the resident's room, she noted that the resident could not speak, was holding his throat, and was struggling to breathe. She walked out of the resident's room and called 911. When asked if Resident #2 received any assistance with meals she said no. She stated Resident #2 was capable of feeding himself. She further stated the resident had a PEG tube but was not receiving any nutrition through the tube. When asked what meal texture was provided to the resident, she stated the resident had dysphagia but was on a regular-textured diet. She stated she remembered seeing noodles and salad on he resident's plate. LPN A confirmed that she did not attempt the [MEDICATION(S)] maneuver. When she was asked to explain the process for the [MEDICATION(S)] maneuver, she could not describe the proper steps to take. She stated she received the training outside the facility at the same time she obtained her cardiopulmonary resuscitation (CPR) card. She added that she was the only nurse on the floor at the time, and the fastest thing she thought to do was to contact 911. LPN A could not recall whether she contacted the resident's physician. She stated she contacted the Director of Nursing (DON) and the resident's family. A review of the dinner menu for [DATE], revealed the following items: Option one - rancher's chicken thigh, black-eyed peas, corn bread, and country vegetable blend. Option two - smothered steak, buttered noodles, and parsley cauliflower. (consistent with the food suctioned/removed from the resident's mouth/throat) During an interview with the Director of Nursing (DON) on [DATE] at 11:25 a.m., she stated she vaguely remembered the resident. She confirmed that she had added the orders for a regular diet to Resident #2's medical record upon his admission. She added that the resident was admitted with a regular diet order and the order was changed on [DATE] to a pureed diet. She stated the resident also had a PEG tube, but she did not recall whether he was receiving any nourishment or hydration via the PEG tube. When asked whether she was notified of the incident on [DATE], she stated she was told the resident was choking and the staff had to call 911. When asked if staff attempted any type of first aid, she stated she was not sure. She was then asked where the initial admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She obtained form ,d+[DATE] and confirmed that it indicated the resident was to receive PEG tube feedings. When asked if the resident received anything via PEG tube, she stated there were no orders for PEG tube feedings. She further stated the facility followed the discharge orders from the hospital. After she reviewed the hospital discharge orders, she stated they indicated ml per day. When she was asked what that meant, she stated it was not clarified. She was then asked about the Speech Therapy recommendation dated [DATE], and she stated the new recommendation should be followed. When asked why the resident was offered regular-consistency meals, she stated she was not aware that the resident had a regular meal at the time of the incident. In an interview on [DATE] at 12:00 p.m., the Certified Dietary Manager (CDM) stated the dietary recommendations were communicated to him by the nursing department through a Diet Requisition Form. He added that once the order was received, he updated the dietary system and printed the meal tickets for the dietary staff. When asked if he had a ticket for Resident #2, he obtained a ticket dated [DATE] at 1:05 p.m., indicating a regular, dysphagia pureed diet with nectar-thickened liquids. On the form there were special instructions indicating Diet Change. (Copy obtained) When asked what the diet was changed from, he stated he had no way to check. When asked what meal was served to Resident #2, he stated he could not tell what was on the ticket. The computer system used by the dietary department did not save the tickets by resident. The system defaulted to the meal for the day. In an interview on [DATE] at 2:12 p.m., Certified Nursing Assistant (CNA) F confirmed that she took care of Resident #2. She stated on [DATE], the resident was served regular-textured food on trays for breakfast and lunch, but she sent the trays back to the kitchen because she was told by the nurse that the resident was NPO (nothing by mouth). CNA F stated during lunchtime, the resident's wife arrived and told her, You can't starve my husband. The resident's wife wanted Resident #2 to have pureed food. She explained to the resident's wife that she was informed that Resident #2 was NPO and therefore, the meal tray was not provided. She stated the resident's wife went to the nurse and speech therapy, and the speech therapist fed Resident #2. She did not remember which nurse told her the resident was NPO. CNA F stated she did not see Resident #2 receiving nutrition through his feeding tube. In an interview on [DATE] at 2:54 p.m., Dietary Staff K was asked how staff ensured each resident received what was specified on their meal ticket. Dietary Staff K stated, I make sure I read the ticket carefully. Whatever diet they are on, I make sure I give them the right diet. The person who calls out the diet order can be any of the dietary staff. Whenever all the trays are done, we push the carts to the floor. She stated when she was by herself, she read the ticket out loud and put the plate on the tray, then covered it and placed it on the cart. When there were two staff, one read the ticket and the other took the plated food, placed it on the tray and ensured it was the correct meal. She stated she received training on how to make sure the trays were correct for about a month or two. In an interview on [DATE] at 10:00 a.m., Registered Nurse (RN) E was asked if he cared for Resident #2. He replied that he had and stated the resident required limited assistance with activities of daily living (ADL) and was mostly in bed. He was asked what diet the resident was on, and he stated Resident #2 was on a regular diet that was later changed to a pureed diet on [DATE]. He confirmed that he completed the diet requisition form for the diet change. When asked how he was notified of the diet change, he stated he could not remember. He confirmed that he did not update the diet consistency in the resident's electronic medical record. In an interview on [DATE] at 10:10 a.m., LPN G was asked to explain the admission process. She stated when a new admission arrived at the facility, the nurse reviewed AHCA form ,d+[DATE] and the discharge orders from the hospital. He/she then conducted an assessment and called the physician with the discharge orders. When asked if the diet was included in the discharge orders, she stated it was normally in the 3008. She added, Most of the time, especially when a resident is on a feeding tube, the feeding tube section of the 3008 is checked, but there is no formula description. Then the nurse should review the hospital package to get the formulation or call the discharging facility for clarification. In a telephone interview on [DATE] at 1:32 p.m., the Medical Director stated he did not recall giving a diet order for Resident #2. He stated typically the diet orders were obtained from the hospital discharge paperwork and the nurse may call for clarification. He added that he did not recall seeing the resident; he obtained most of the information from the hospital History and Physical. When asked if he was notified when Resident #2 was sent emergently to the hospital, he stated he had APRNs (Advanced Practice Registered Nurses) who were on call, and they might have received the call. He confirmed that he was the facility's Medical Director and further stated he did not recall the resident's incident having been discussed in the Quality Assurance meeting. Per the Mayo Foundation of Medical Evaluation and Research ,d+[DATE] (Mayo Clinic) Mayo.org at https://www.mayoclinic.org/first-aid/first-aid-choking/basics/art- 637 (Accessed [DATE] at 5:30 p.m.): Choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In adults, a piece of food often is the culprit. Young children often swallow small objects. Because choking cuts off oxygen to the brain, give first aid as quickly as possible. The universal sign for choking is hands clutched to the throat. If the person doesn't give the signal, look for these indications: · Inability to talk · Difficulty breathing or noisy breathing · Squeaky sounds when trying to breathe · Cough, which may either be weak or forceful · Skin, lips and nails turning blue or dusky · Skin that is flushed, then turns pale or bluish in color · Loss of consciousness If the person is able to cough forcefully, the person should keep coughing. If the person is choking and can't talk, cry, or laugh forcefully, a five-and-five approach to delivering first aid: · Give 5 back blows. Stand to the side and just behind a choking adult. Place one arm across the person's chest for support. Bend the person over at the waist so that the upper body is parallel with the ground. Deliver five separate back blows between the person's shoulder blades with the heel of your hand. · Give 5 abdominal thrusts. Perform five abdominal thrusts (also known as the [MEDICATION(S)] maneuver). · Alternate between 5 blows and 5 thrusts until the blockage is dislodged. To perform abdominal thrusts ([MEDICATION(S)] maneuver) on someone else: · Stand behind the person. Place one foot slightly in front of the other for balance. Wrap your arms around the waist. Tip the person forward slightly. · Make a fist with one hand. Position it slightly above the person's navel. · Grasp the fist with the other hand. Press hard into the abdomen with a quick, upward thrust - as if trying to lift the person up. · Perform between six and 10 abdominal thrusts until the blockage is dislodged A review of the facility's policy and procedure titled Emergency Intervention-[MEDICATION(S)] Maneuver (Document Name: S-120 Effective Date: [DATE]), revealed: The [MEDICATION(S)] Maneuver will be used to expel food, or a foreign body lodged in a person's throat, creating a blockage of the airway. The clinical signs that there is a blockage include one of the following. 1. Victim cannot speak or breathe. 2. Victim turns blue. 3. Victim clutches the neck. 4. Victim collapses. Procedure: Adult: Standing/Sitting 1. If a person is choking on food or a foreign body and exhibits one of the four signs listed above, act immediately. 2. Stand behind the person and wrap your arms around his waist. 3. Place your fist thumb side against the victim's abdomen, slightly above the umbilicus and below the rib cage. 4. Grasp your fist with your other hand and press into the victim's abdomen with a quick upward thrust, Attachment A. 5. Repeat several times, if necessary, until food or foreign body has been removed. 6. If the victim is sitting, stand behind the chair and perform the same maneuver in the same manner. Adult: Lying Down 1. If the victim is lying on his back, face him and kneel astride his hips. 2. With on hand on top of the other, place the heel of the bottom hand on the abdomen slightly above the umbilicus and below the rib cage (see Attachment A). 3. Press into the victim's abdomen with a quick upward thrust. 4. Repeat several times, if necessary, until food or foreign body has been removed.

Based on interviews and record reviews, the facility failed to ensure licensed nurses had specific competencies and skills sets necessary to care for residents' needs and ensure resident safety for one (Resident #2) of two residents reviewed with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 6:00 p.m., Licensed Practical Nurse (LPN) A heard Resident #2, diagnosed with dysphagia, coughing. When she entered his room, he could not speak and struggled to breathe. He had been given a regular-textured dinner meal and was attempting to eat it alone in his private room. He was ordered a pureed/nectar-thick diet and was to have been assisted with his meal. When LPN A saw the resident coughing, holding his throat, and realized that he could not communicate with her, she left his room, called 911 from the nursing station, and waited for Emergency Medical Services (EMS). She did not assess his respirations or lung sounds. She did not do a finger sweep or attempt the [MEDICATION(S)] maneuver. EMS arrived at approximately 6:10 p.m. per interview (no time of arrival was documented) and transported a minimally responsive Resident #2 to the hospital. Upon arrival, he went into respiratory arrest. The facility's failure to provide Resident #2 with the appropriate diet texture and assistance with his meal, as well as its failure to appropriately assess his respiratory status, perform finger sweeps and the [MEDICATION(S)] maneuver following a choking incident, contributed to Resident #2 ' s admission to an acute care hospital ' s intensive care unit due to respiratory arrest following aspiration. On [DATE], the facility census was 82. There were nineteen residents who required assistance with meals. Sixteen of those nineteen residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Vice President of Operations was notified of the Immediate Jeopardy at 6:00 p.m. on [DATE]. The Immediate Jeopardy was ongoing as of the exit on [DATE]. The findings include: Cross reference F684, F805 and F867 A review of Resident #2's medical record revealed he was admitted to the facility on ,d+[DATE]//2022 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Admit to Skilled Nursing Facility, dated [DATE] (Tuesday) Full code, dated [DATE] Dietary liberty for special occasions, dated [DATE] Regular diet, regular texture, regular/thin liquids consistency, ordered [DATE] Percutaneous endoscopic gastrostomy (PEG) tube (feeding tube), change tubing and syringe daily, every night shift, ordered [DATE] Regular diet, dysphagia pureed texture, nectar-thickened fluids consistency, ordered [DATE] (Resident #2 had already been discharged on [DATE].) A review of a Diet Requisition Form for Resident #2 and dated [DATE] at 1:05 p.m. with Diet Change handwritten on the bottom, revealed a regular diet, dysphagia/puree, nectar was checked off. A review of the facility's Admission Completion Check-Off List, outlining the forms required to be completed upon admission of a new resident, revealed the following: - Dietary Communication Form completed and sent to kitchen - Diet orders present/accurate - Telephone orders written for any clarifications not noted on discharge orders and/or 3008 (Florida) A review of the resident's Discharge Minimum Data Set (MDS) assessment, dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) score was not obtained. He was documented as requiring extensive assistance for bed mobility, transfers, eating and toilet use. He had a feeding tube and the section for mechanically altered diet was marked not applicable. A review of the baseline care plan, dated [DATE], revealed that the resident was documented with a regular diet and a feeding tube. His goal was documented as Will maintain stable weight. The intervention checked off was Diet and/or supplements as ordered. Under Self-Care Deficit, Resident #2 was documented as dependent for eating and requiring the assistance of one person. A review of Resident #2's comprehensive care plan, initiated on [DATE], revealed the following: Under the focus area Self-Care Deficit, the intervention related to eating was left blank. EATING: The resident is able to: (SPECIFY), Date Initiated: [DATE] Under the focus area Oral/Dental Health Problems (SPECIFY) related to (blank), the interventions included: Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted, Date initiated: [DATE] Under the focus area Requires Tube Feeding related to Dysphagia (difficulty swallowing), the Goals included: The resident will be free of aspiration through the review date. Target date: [DATE], Date initiated: [DATE]. Interventions included: Head of bed elevated 45 degrees during and thirty minutes after tube feed. Total assistance with tube feeding and water flushes. See MD (doctor's) orders for current feeding orders. Monitor/document/report as needed, any signs or symptoms of aspiration. Resident #2 was care planned on [DATE] with a focus area of Antipsychotic Therapy related to [CONDITION(S)] Resident #2 was care planned on [DATE] with a focus area of Advance Directives, Full Code. A review of the admission nursing assessment dated [DATE], and indicating an admitted [DATE] at 5:51 p.m., revealed that Resident #2 was alert and orientated to himself only. His speech was documented as aphasic (difficulty communicating). He was documented with mild shortness of breath. No cough observed. He was reportedly receiving oxygen at a flow rate of two liters per minute via nasal cannula (tubing delivering oxygen through the nostrils). He was noted with general weakness and under the heading Nutritional Approach, feeding tube was noted. He was documented as cognitively impaired with poor decision-making skills, not independently mobile, and was noted as receiving antipsychotic, antidepressant, antianxiety and hypnotic medications. On the last page of the assessment was documented, Unable to orient resident. A Nursing Progress Note dated [DATE] at 10:38 p.m., read, Resident was eating dinner, suddenly started to cough, appeared to be choking. 911 called and transferred the resident to emergency room (ER) for evaluation, family member notified. A review if the Acute-Care Hospital History and Physical, revealed a Dietary assessment dated [DATE]. It indicated the resident was to receive nothing by mouth (NPO). Recommendations included adjusting the tube feeding to Glucerna 1.5 (a high calorie liquid nutrition tube feeding formula designed to minimize blood sugar spikes) at 55 milliliters per hour (mL/Hour), which gave (1980 Kilo calories (Kcal), 108 grams (g) protein, 176 g carbohydrates (CHO), and 1002 mL of free water. This met 100% of the estimated Kcal and protein fluid, and 59% estimated fluid needs or at least 30 mL every 4 hours to prevent occlusion (blockage of the tube). The resident was anticipated to discharge the hospital with tube feeding (TF) in place. If bolus feed (The delivery of smaller volume feeds at regular intervals) desired, recommend 8 ounces (oz.) of Glucerna 6 times per day to meet protein-Kcal needs. A review of the Acute-Care Hospital's Swallow Evaluation from the Speech Therapist (ST), entitled Modified [MEDICATION(S)] Swallow/Plan of Care (POC), dated [DATE], revealed recommendations for: Pureed and nectar/mildly thick liquid. Swallowing Precautions: Continue PEG as primary source of nutrition for now. Further assess for soft solids. A review of the Acute-Care Hospital intake notes, dated [DATE], the day the resident was discharged emergently from the skilled nursing facility to the hospital emergency room revealed, The patient presented with respiratory distress. The patient presents with difficulty breathing, respiratory problem and respiratory arrest. The onset was just prior to arrival. The course/duration of symptoms is constant. Degree at onset severe. Degree at present severe. Risk factors consist of dysphagia. [AGE] year old male presents to emergency department via EMS (Emergency Medical Services) with dyspnea, respiratory arrest, suspected choking episode. Patient is a resident of a nursing home and has chronic dysphagia of unknown origin. Patient has a tube secondary to his dysphagia. Patient diet recently escalated beyond his G-tube to pureed diet. EMS states that patient was given solid foods just prior to the initiation of his episode. On EMS arrival, patient was minimally responsive and choking. EMS removed multiple pieces of food from patient airway. Patient became unresponsive and EMS team attempted intubation. Unable to intubate secondary to suspected food bolus in airway. EMS team able to remove multiple pieces of the food bolus and placed King tube (airway management device) successfully. On arrival in ED (Emergency Department), patient unresponsive with King tube in place. In an interview with the facility's Speech Therapist/Rehab Director on [DATE] at 9:45 a.m., she stated residents were assessed the first business day following their admission to the facility. When recommendations were made for diet changes, she completed a diet slip (consistency section) and verbally communicated to the nurse, who completed the diet slips and notified the Dietary Department. When asked how long it took for a resident to advance in their diet texture, she stated it was normally a case-by-case basis, dependent upon the individual resident's level of impairment and functional status. She stated diet texture advancement took longer than 24 hours unless there was an error in the diet prescription, and the resident could tolerate the other diet. When asked if she saw Resident #2 after admission, she stated she was out of the facility at the time. She reviewed the chart and stated the resident was seen by a different Speech Therapist (ST) on [DATE]. Per the Admission Diet Sheet, Resident #2 had a PEG tube and was NPO. She added that the note indicated the ST spoke with the resident's wife, who reported that Resident #2 was upgraded to a pureed diet with nectar-thickened liquids at the hospital. The resident's wife also reported that the resident aspirated on thin liquid and regular consistency foods. Recommendation included: puree and nectar-thick liquids. When asked if other food textures were tried, she replied, [Resident #2's] level of impairment with pureed food would not warrant an attempt at a different food texture. She added, According to the notes, the resident had difficulty with pureed. She concluded that the resident was left on a pureed diet. A review of the Speech Therapy Initial Evaluation, dated [DATE], revealed that the clinical impression and recommendation showed the resident demonstrated moderate oropharyngeal dysphagia (Per https://medical-dictionary.thefreedictionary.com/oropharyngeal+dysphagia on [DATE] at 2:18 p.m., Difficulty in propelling food or liquid from the oral cavity into the esophagus). The resident's current diet level was recently upgraded to a pureed texture and nectar-thickened liquids. The resident exhibits decreased lingual (random disorganization of tongue movements), labial (impaired oral sensation or decreased lip strength), and laryngeal (reduced elevation or closure) function with a moderate impairment with ROM (range of motion), strength, coordination, and rate. Upon observation, resident exhibited mild-moderate impairment with bolus (semi-solid mass of food) formation and extended bolus hold and moderate impairment with lingual residue and laryngeal elevation with nectar-thick liquid. (Copy obtained) In an interview on [DATE] at 11:15 a.m., Licensed Practical Nurse (LPN) A stated she had worked at the facility on an as needed (PRN) basis since [DATE]. When asked if she was familiar with Resident #2, she replied yes. She stated on [DATE] at 6:00 p.m. during dinner, she heard Resident #2 coughing, and upon entrance to the resident's room, she noted that the resident could not speak, was holding his throat, and was struggling to breathe. She walked out of the resident's room and called 911. When asked if Resident #2 received any assistance with meals she said no. She stated Resident #2 was capable of feeding himself. She further stated the resident had a PEG tube but was not receiving any nutrition through the tube. When asked what meal texture was provided to the resident, she stated the resident had dysphagia but was on a regular-textured diet. She stated she remembered seeing noodles and salad on he resident's plate. LPN A confirmed that she did not attempt the [MEDICATION(S)] maneuver. When she was asked to explain the process for the [MEDICATION(S)] maneuver, she could not describe the proper steps to take. She stated she received the training outside the facility at the same time she obtained her cardiopulmonary resuscitation (CPR) card. She added that she was the only nurse on the floor at the time, and the fastest thing she thought to do was to contact 911. LPN A could not recall whether she contacted the resident's physician. She stated she contacted the Director of Nursing (DON) and the resident's family. When asked whether she had ever completed any competency checks with nursing management, she replied no. During an interview with the Director of Nursing (DON) on [DATE] at 11:25 a.m., she stated she vaguely remembered the resident. She confirmed that she had added the orders for a regular diet to Resident #2's medical record upon his admission. She added that the resident was admitted with a regular diet order and the order was changed on [DATE] to a pureed diet. She stated the resident also had a PEG tube, but she did not recall whether he was receiving any nourishment or hydration via the PEG tube. When asked whether she was notified of the incident on [DATE], she stated she was told the resident was choking and the staff had to call 911. When asked if staff attempted any type of first aid, she stated she was not sure. She was then asked where the initial admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She obtained form ,d+[DATE] and confirmed that it indicated the resident was to receive PEG tube feedings. When asked if the resident received anything via PEG tube, she stated there were no orders for PEG tube feedings. She further stated the facility followed the discharge orders from the hospital. After she reviewed the hospital discharge orders, she stated they indicated ml per day. When she was asked what that meant, she stated it was not clarified. She was then asked about the Speech Therapy recommendation dated [DATE], and she stated the new recommendation should be followed. When asked why the resident was offered regular-consistency meals, she stated she was not aware that the resident had a regular meal at the time of the incident. She also confirmed that she had not conducted any investigation of the incident. In an interview on [DATE] at 1:42 p.m., Certified Nursing Assistant (CNA) H was asked how he would identify a resident who needed assistance with meals. He stated as he passed out the meal trays, he would ask the residents if they needed help. He was then asked how he identified the type of diet a resident was to receive. He stated he would check the tray slip. When asked how he would obtain that information between meals when the tray slip was not available (For example - providing hydration to residents), he said he did not know. In an interview on [DATE] at 4:09 p.m., LPN I stated she had worked at the facility for a year. She stated she identified resident diets using their meal tickets or by consulting the Dietitian. If a CNA saw that a resident had a g-tube (feeding tube) and also had a meal tray, the CNA should consult the nurse to clarify. She stated she would identify residents who required assistance with meals when they were unable to feed themselves and could not use their arms or hands. She added that residents who required assistance with meals were identified based on how much help they required and through communication with the resident. When asked how to identify whether a resident was choking, she stated, When they cough during feeding. She was then asked what she would do if choking was identified, and she replied, Feeding is stopped, the resident is provided water, and their head will be raised up. LPN I could not identify the appropriate steps to take for a choking resident. She confirmed that she had not received any training or competency check for how to handle a choking resident. In an interview on [DATE] at 10:00 a.m., Registered Nurse (RN) E was asked if he cared for Resident #2. He replied that he had and stated the resident required limited assistance with activities of daily living (ADL) and was mostly in bed. He was asked what diet the resident was on, and he stated Resident #2 was on a regular diet that was later changed to a pureed diet on [DATE]. He confirmed that he completed the diet requisition form for the diet change. When asked how he was notified of the diet change, he stated he could not remember. He confirmed that he did not update the diet consistency in the resident's electronic medical record. In an interview on [DATE] at 10:10 a.m., LPN G was asked to explain the admission process. She stated when a new admission arrived at the facility, the nurse reviewed AHCA form ,d+[DATE] and the discharge orders from the hospital. He/she then conducted an assessment and called the physician with the discharge orders. When asked if the diet was included in the discharge orders, she stated it was normally in the 3008. She added, Most of the time, especially when a resident is on a feeding tube, the feeding tube section of the 3008 is checked, but there is no formula description. Then the nurse should review the hospital package to get the formulation or call the discharging facility for clarification. In an interview on [DATE] at 5:00 p.m., the Assistant Director of Nursing (ADON) stated he had been employed by the facility since [DATE] and was in the process of identifying a better way to conduct staff training and competencies. He stated new hires were provided with training and competency checks during orientation. He further stated established staff received training through an electronic independent training system. He stated he was in the process of developing a training calendar to ensure different topics were discussed each month. When asked if anyone was monitoring staff training completion, he stated no. When asked about First Aid training, he stated nurses were required to have a current CPR (cardiopulmonary resuscitation) card, but there was no training or competency check provided by the facility for First Aid. The ADON was asked how new resident admissions were reviewed, and he stated, All new admissions are reviewed on the next business day during the clinical meeting. The DON, ADON and Unit Managers utilize a checklist to ensure all the components are correct. When asked if a new admission's diet was one of the components for review during the clinical meetings, he stated yes. (Copy of checklist obtained) When asked if Resident #2's chart was reviewed the next business day after admission during the clinical meeting, the ADON stated he did not remember, nor could he remember whether Resident #2's discharge was discussed in the QAPI (Quality Assurance and Performance Improvement) meeting that was scheduled to have been held on the third Friday of the month, [DATE]. A review of a random current employee's (Registered Nurse J) training in the facility's electronic independent training system, revealed that eight courses were documented as due for this employee as of [DATE], but had not been completed. Eight additional courses were documented as due between [DATE] and the date of the survey that had not been completed. A review of LPN A's personnel file revealed she was hired in [DATE]. There was no documentation available for LPN A in the facility's electronic independent training system at the time of the survey, and there was no documentation in her file indicating she received any training from the facility related to the care of a choking resident, a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's clinical new hire orientation documentation revealed no orientation information or competency checks for First Aid, the [MEDICATION(S)] maneuver, emergency response, diet consistencies or care of a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the policy and procedure titled Emergency Intervention-[MEDICATION(S)] Maneuver (Document Name: S-120 - Effective Date: [DATE]), revealed: The [MEDICATION(S)] Maneuver will be used to expel food, or a foreign body lodged in a person's throat, creating a blockage of the airway. The clinical signs that there is a blockage include one of the following. 1. Victim cannot speak or breathe. 2. Victim turns blue. 3. Victim clutches the neck. 4. Victim collapses. Procedure Adult: Standing/Sitting 1. If a person is choking on food or a foreign body and exhibits one of the four signs listed above, act immediately. 2. Stand behind the person and wrap your arms around his waist. 3. Place your fist thumb side against the victim's abdomen, slightly above the umbilicus and below the rib cage. 4. Grasp your fist with your other hand and press into the victim's abdomen with a quick upward thrust, Attachment A. 5. Repeat several times, if necessary, until food or foreign body has been removed. 6. If the victim is sitting, stand behind the chair and perform the same maneuver in the same manner. Adult: Lying Down 1. If the victim is lying on his back, face him and kneel astride his hips. 2. With on hand on top of the other, place the heel of the bottom hand on the abdomen slightly above the umbilicus and below the rib cage (see Attachment A). 3. Press into the victim's abdomen with a quick upward thrust. 4. Repeat several times, if necessary, until food or foreign body has been removed. A review of the facility's policy and procedure titled Tech Information - Kardex (Document Name: N-1018, Effective Dare: [DATE], Revision Date: [DATE]), revealed the following: A Care Kardex or electronic equivalent will be completed for each resident. The Nursing Assistant will utilize the Kardex as a resource to provide care. Each resident will have a completed Care Kardex or electronic equivalent to guide in the direction of care. The Unit Manager or Care Plan Coordinator is responsible to update the Kardex daily and/or as needed. If electronic, the Care Kardex will be updated by the system based on the set triggers or as needed manually. The clinical staff education plan was requested from the DON on [DATE] at 4:30 p.m. It was not received. The plan was requested from the Vice President of Operations on [DATE] at 11:00 a.m., 2:00 p.m., and at the time of survey exit. The clinical staff education plan was never received.

Based on interviews and record reviews, the facility failed to ensure that one (Resident #2) of two residents reviewed for dysphagia, from a total sample of four residents, received a diet texture designed to meet his individual needs. This failure contributed to the resident's emergent transfer to an acute-care hospital where he suffered respiratory arrest upon admission following the aspiration of a regular-textured dinner meal at the nursing home. On [DATE] at 6:00 p.m., Licensed Practical Nurse (LPN) A heard Resident #2, diagnosed with dysphagia, coughing. When she entered his room, he could not speak and struggled to breathe. He had been given a regular-textured dinner meal and was attempting to eat it alone in his private room. He was ordered a pureed/nectar-thick diet and was to have been assisted with his meal. When LPN A saw the resident coughing, holding his throat, and realized that he could not communicate with her, she left his room, called 911 from the nursing station, and waited for Emergency Medical Services (EMS). She did not assess his respirations or lung sounds. She did not do a finger sweep or attempt the [MEDICATION(S)] maneuver. EMS arrived at approximately 6:10 p.m. per interview (no time of arrival was documented) and transported a minimally responsive Resident #2 to the hospital. Upon arrival, he went into respiratory arrest. The facility's failure to provide Resident #2 with the appropriate diet texture and assistance with his meal, as well as its failure to appropriately assess his respiratory status, perform finger sweeps and the [MEDICATION(S)] maneuver following a choking incident, contributed to Resident #2 ' s admission to an acute care hospital ' s intensive care unit due to respiratory arrest following aspiration. On [DATE], the facility census was 82. There were nineteen residents who required assistance with meals. Sixteen of those nineteen residents had a diagnosis of dysphagia and were at risk for serious harm or death. The Regional Vice President of Operations was notified of the Immediate Jeopardy at 6:00 p.m. on [DATE]. The Immediate Jeopardy was ongoing as of the exit on [DATE]. The findings include: Cross reference F684, F726, and F867 A review of Resident #2's medical record revealed he was admitted to the facility on ,d+[DATE]//2022 with a primary diagnosis of [CONDITION(S)] (brain disease). His secondary diagnoses included dysphagia (swallowing problems), acute respiratory failure with [CONDITION(S)] (low oxygen in body tissues), chronic obstructive pulmonary disease ([CONDITION(S)]) (lung disease making breathing difficult), adult failure to thrive (AFTT) (functional decline resulting in poor nutrition and often weight loss), anxiety disorder, [CONDITION(S)] disorder (mental health condition causing extreme mood swings), and hypertension (high blood pressure). A review of Resident #2's Physician's Orders included the following: Admit to Skilled Nursing Facility, dated [DATE] (Tuesday) Full code, dated [DATE] Dietary liberty for special occasions, dated [DATE] Regular diet, regular texture, regular/thin liquids consistency, ordered [DATE] Percutaneous endoscopic gastrostomy (PEG) tube (feeding tube), change tubing and syringe daily, every night shift, ordered [DATE] Regular diet, dysphagia pureed texture, nectar-thickened fluids consistency, ordered [DATE] (Resident #2 had already been discharged on [DATE].) A review of the facility's Admission Completion Check-Off List, outlining the forms required to be completed upon admission of a new resident, revealed the following: - Dietary Communication Form completed and sent to kitchen - Diet orders present/accurate - Telephone orders written for any clarifications not noted on discharge orders and/or 3008 (Florida) A review of a Diet Requisition Form for Resident #2 and dated [DATE] at 1:05 p.m. with Diet Change handwritten on the bottom, revealed a regular diet, dysphagia/puree, nectar was checked off. No other Diet Requisition Form or dietary slip was found for this resident. A review of the resident's Discharge Minimum Data Set (MDS) assessment, dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) score was not obtained. He was documented as requiring extensive assistance for bed mobility, transfers, eating and toilet use. He had a feeding tube and the section for mechanically altered diet was marked not applicable. A review of the baseline care plan, dated [DATE], revealed that the resident was documented with a regular diet and a feeding tube. His goal was documented as Will maintain stable weight. The intervention checked off was Diet and/or supplements as ordered. Under Self-Care Deficit, Resident #2 was documented as dependent for eating and requiring the assistance of one person. A review of Resident #2's comprehensive care plan, initiated on [DATE], revealed the following: Under the focus area Self-Care Deficit, the intervention related to eating was left blank. EATING: The resident is able to: (SPECIFY), Date Initiated: [DATE] Under the focus area Oral/Dental Health Problems (SPECIFY) related to (blank), the interventions included: Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted, Date initiated: [DATE] Under the focus area Requires Tube Feeding related to Dysphagia (difficulty swallowing), the Goals included: The resident will be free of aspiration through the review date. Target date: [DATE], Date initiated: [DATE]. Interventions included: Head of bed elevated 45 degrees during and thirty minutes after tube feed. Total assistance with tube feeding and water flushes. See MD (doctor's) orders for current feeding orders. Monitor/document/report as needed, any signs or symptoms of aspiration. Resident #2 was care planned on [DATE] with a focus area of Antipsychotic Therapy related to [CONDITION(S)] Resident #2 was care planned on [DATE] with a focus area of Advance Directives, Full Code. A review of the admission nursing assessment dated [DATE], and indicating an admitted [DATE] at 5:51 p.m., revealed that Resident #2 was alert and orientated to himself only. His speech was documented as aphasic (difficulty communicating). He was documented with mild shortness of breath. No cough observed. He was reportedly receiving oxygen at a flow rate of two liters per minute via nasal cannula (tubing delivering oxygen through the nostrils). He was noted with general weakness and under the heading Nutritional Approach, feeding tube was noted. He was documented as cognitively impaired with poor decision-making skills, not independently mobile, and was noted as receiving antipsychotic, antidepressant, antianxiety and hypnotic medications. On the last page of the assessment was documented, Unable to orient resident. A Nursing Progress Note dated [DATE] at 10:38 p.m., read, Resident was eating dinner, suddenly started to cough, appeared to be choking. 911 called and transferred the resident to emergency room (ER) for evaluation, family member notified. A review if the Acute-Care Hospital History and Physical, revealed a Dietary assessment dated [DATE]. It indicated the resident was to receive nothing by mouth (NPO). Recommendations included adjusting the tube feeding to Glucerna 1.5 (a high calorie liquid nutrition tube feeding formula designed to minimize blood sugar spikes) at 55 milliliters per hour (mL/Hour), which gave (1980 Kilo calories (Kcal), 108 grams (g) protein, 176 g carbohydrates (CHO), and 1002 mL of free water. This met 100% of the estimated Kcal and protein fluid, and 59% estimated fluid needs or at least 30 mL every 4 hours to prevent occlusion (blockage of the tube). The resident was anticipated to discharge the hospital with tube feeding (TF) in place. If bolus feed (The delivery of smaller volume feeds at regular intervals) desired, recommend 8 ounces (oz.) of Glucerna 6 times per day to meet protein-Kcal needs. A review of the Acute-Care Hospital's Swallow Evaluation from the Speech Therapist (ST), entitled Modified [MEDICATION(S)] Swallow/Plan of Care (POC), dated [DATE], revealed recommendations for: Pureed and nectar/mildly thick liquid. Swallowing Precautions: Continue PEG as primary source of nutrition for now. Further assess for soft solids. A review of the Acute-Care Hospital intake notes, dated [DATE], the day the resident was discharged emergently from the skilled nursing facility to the hospital emergency room revealed, The patient presented with respiratory distress. The patient presents with difficulty breathing, respiratory problem and respiratory arrest. The onset was just prior to arrival. The course/duration of symptoms is constant. Degree at onset severe. Degree at present severe. Risk factors consist of dysphagia. [AGE] year old male presents to emergency department via EMS (Emergency Medical Services) with dyspnea, respiratory arrest, suspected choking episode. Patient is a resident of a nursing home and has chronic dysphagia of unknown origin. Patient has a tube secondary to his dysphagia. Patient diet recently escalated beyond his G-tube to pureed diet. EMS states that patient was given solid foods just prior to the initiation of his episode. On EMS arrival, patient was minimally responsive and choking. EMS removed multiple pieces of food from patient airway. Patient became unresponsive and EMS team attempted intubation. Unable to intubate secondary to suspected food bolus (semi-solid mass of food) in airway. EMS team able to remove multiple pieces of the food bolus and placed King tube (airway management device) successfully. On arrival in ED (Emergency Department), patient unresponsive with King tube in place. In an interview with the facility's Speech Therapist/Rehab Director on [DATE] at 9:45 a.m., she stated residents were assessed the first business day following their admission to the facility. When recommendations were made for diet changes, she completed a diet slip (consistency section) and verbally communicated to the nurse, who completed the diet slips and notified the Dietary Department. When asked how long it took for a resident to advance in their diet texture, she stated it was normally a case-by-case basis, dependent upon the individual resident's level of impairment and functional status. She stated diet texture advancement took longer than 24 hours unless there was an error in the diet prescription, and the resident could tolerate the other diet. When asked if she saw Resident #2 after admission, she stated she was out of the facility at the time. She reviewed the chart and stated the resident was seen by a different Speech Therapist (ST) on [DATE]. Per the Admission Diet Sheet, Resident #2 had a PEG tube and was NPO. She added that the note indicated the ST spoke with the resident's wife, who reported that Resident #2 was upgraded to a pureed diet with nectar-thickened liquids at the hospital. The resident's wife also reported that the resident aspirated on thin liquid and regular consistency foods. Recommendation included: puree and nectar-thick liquids. When asked if other food textures were tried, she replied, [Resident #2's] level of impairment with pureed food would not warrant an attempt at a different food texture. She added, According to the notes, the resident had difficulty with pureed. She concluded that the resident was left on a pureed diet. A review of the Speech Therapy Initial Evaluation, dated [DATE], revealed that the clinical impression and recommendation showed the resident demonstrated moderate oropharyngeal dysphagia (Per https://medical-dictionary.thefreedictionary.com/oropharyngeal+dysphagia on [DATE] at 2:18 p.m., Difficulty in propelling food or liquid from the oral cavity into the esophagus). The resident's current diet level was recently upgraded to a pureed texture and nectar-thickened liquids. The resident exhibits decreased lingual (random disorganization of tongue movements), labial (impaired oral sensation or decreased lip strength), and laryngeal (reduced elevation or closure) function with a moderate impairment with ROM (range of motion), strength, coordination, and rate. Upon observation, resident exhibited mild-moderate impairment with bolus (semi-solid mass of food) formation and extended bolus hold and moderate impairment with lingual residue and laryngeal elevation with nectar-thick liquid. (Copy obtained) A review of the dinner menu for [DATE], revealed the following items: Option one - rancher's chicken thigh, black-eyed peas, corn bread, and country vegetable blend. Option two - smothered steak, buttered noodles, and parsley cauliflower. (consistent with the food suctioned/removed from the resident's mouth/throat) In an interview on [DATE] at 10:00 a.m., Registered Nurse (RN) E was asked if he cared for Resident #2. He stated yes, the resident required limited assistance with activities of daily living (ADL) and was mostly in bed. When he was asked for the diet the resident was ordered, he stated Resident #2 was on a regular-textured diet and was later changed to a pureed diet on [DATE]. RN E acknowledged that he completed the diet requisition form for the diet change. When asked how he was notified of the diet change, he stated he could not remember. He confirmed that he did not update the diet in the resident's electronic medical record. In an interview on [DATE] at 11:15 a.m., Licensed Practical Nurse (LPN) A stated she had worked at the facility on an as needed (PRN) basis since [DATE]. When asked if she was familiar with Resident #2, she replied yes. She stated on [DATE] at 6:00 p.m. during dinner, she heard Resident #2 coughing, and upon entrance to the resident's room, she noted that the resident could not speak, was holding his throat, and was struggling to breathe. She walked out of the resident's room and called 911. When asked if Resident #2 received any assistance with meals she said no. She stated Resident #2 was capable of feeding himself. She further stated the resident had a PEG tube but was not receiving any nutrition through the tube. When asked what meal texture was provided to the resident, she stated the resident had dysphagia but was on a regular-textured diet. She stated she remembered seeing noodles and salad on he resident's plate. LPN A confirmed that she did not attempt the [MEDICATION(S)] maneuver. When she was asked to explain the process for the [MEDICATION(S)] maneuver, she could not describe the proper steps to take. She stated she received the training outside the facility at the same time she obtained her cardiopulmonary resuscitation (CPR) card. She added that she was the only nurse on the floor at the time, and the fastest thing she thought to do was to contact 911. LPN A could not recall whether she contacted the resident's physician. She stated she contacted the Director of Nursing (DON) and the resident's family. When asked whether she had ever completed any competency checks with nursing management, she replied no. During an interview with the Director of Nursing (DON) on [DATE] at 11:25 a.m., she stated she vaguely remembered the resident. She confirmed that she had added the orders for a regular diet to Resident #2's medical record upon his admission. She added that the resident was admitted with a regular diet order and the order was changed on [DATE] to a pureed diet. She stated the resident also had a PEG tube, but she did not recall whether he was receiving any nourishment or hydration via the PEG tube. When asked whether she was notified of the incident on [DATE], she stated she was told the resident was choking and the staff had to call 911. When asked if staff attempted any type of first aid, she stated she was not sure. She was then asked where the initial admission orders for the regular diet were obtained. She stated they were obtained from the Medical Certification for Medicaid Long-Term Services and Patient Transfer form (AHCA (Agency for Health Care Administration) form ,d+[DATE]). She obtained form ,d+[DATE] and confirmed that it indicated the resident was to receive PEG tube feedings. When asked if the resident received anything via PEG tube, she stated there were no orders for PEG tube feedings. She further stated the facility followed the discharge orders from the hospital. After she reviewed the hospital discharge orders, she stated they indicated ml per day. When she was asked what that meant, she stated it was not clarified. She was then asked about the Speech Therapy recommendation dated [DATE], and she stated the new recommendation should be followed. When asked why the resident was offered regular-consistency meals, she stated she was not aware that the resident had a regular meal at the time of the incident. In an interview on [DATE] at 12:00 p.m., the Certified Dietary Manager (CDM) stated the dietary recommendations were communicated to him by the nursing department through a diet requisition form. He added that once the order was received, he updated the dietary system and printed the meal tickets for the dietary staff. When asked if he had a ticket for Resident #2, he obtained a ticket dated [DATE] at 1:05 p.m., indicating a regular, dysphagia pureed diet with nectar-thickened liquids. On the form there were special instructions indicating Diet Change. (Copy obtained) When asked what the diet was changed from, he stated he had no way to check. When asked what meal was served to Resident #2, he stated he could not tell what was on the ticket. The computer system used by the dietary department did not save the tickets by resident. The system defaulted to the meal for the day. In an interview on [DATE] at 2:12 p.m., Certified Nursing Assistant (CNA) F confirmed that she took care of Resident #2. She stated on [DATE], the resident was served regular-textured food on trays for breakfast and lunch, but she sent the trays back to the kitchen because she was told by the nurse that the resident was NPO (nothing by mouth). CNA F stated during lunchtime, the resident's wife arrived and told her, You can't starve my husband. The resident's wife wanted Resident #2 to have pureed food. She explained to the resident's wife that she was informed that Resident #2 was NPO and therefore, the meal tray was not provided. She stated the resident's wife went to the nurse and speech therapy, and the speech therapist fed Resident #2. She did not remember which nurse told her the resident was NPO. CNA F stated she did not see Resident #2 receiving nutrition through his feeding tube. In an interview on [DATE] at 2:54 p.m., Dietary Staff K was asked how staff ensured each resident received what was specified on their meal ticket. Dietary Staff K stated, I make sure I read the ticket carefully. Whatever diet they are on, I make sure I give them the right diet. The person who calls out the diet order can be any of the dietary staff. Whenever all the trays are done, we push the carts to the floor. She stated when she was by herself, she read the ticket out loud and put the plate on the tray, then covered it and placed it on the cart. When there were two staff, one read the ticket and the other took the plated food, placed it on the tray and ensured it was the correct meal. She stated she received training on how to make sure the trays were correct for about a month or two.

Based on interviews, record reviews, and a review of the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to develop and implement appropriate plans of action to correct quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to Resident #2's admission to an acute-care hospital's intensive care unit due to respiratory arrest following aspiration. On [DATE] at 6:00 p.m., Licensed Practical Nurse (LPN) A heard Resident #2, diagnosed with dysphagia, coughing. When she entered his room, he could not speak and struggled to breathe. He had been given a regular-textured dinner meal and was attempting to eat it alone in his private room. He was ordered a pureed/nectar-thick diet and was to have been assisted with his meal. When LPN A saw the resident coughing, holding his throat, and realized that he could not communicate with her, she left his room, called 911 from the nursing station, and waited for Emergency Medical Services (EMS). She did not assess his respirations or lung sounds. She did not do a finger sweep or attempt the [MEDICATION(S)] maneuver. EMS arrived at approximately 6:10 p.m. per interview (no time of arrival was documented) and transported a minimally responsive Resident #2 to the hospital. Upon arrival, he went into respiratory arrest. The facility's failure to provide Resident #2 with the appropriate diet texture and assistance with his meal, as well as its failure to appropriately assess his respiratory status, perform finger sweeps and the [MEDICATION(S)] maneuver following a choking incident, contributed to Resident #2 ' s admission to an acute care hospital ' s intensive care unit due to respiratory arrest following aspiration. On [DATE], the facility census was 82. There were nineteen residents who required assistance with meals. Sixteen of those nineteen residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Vice President of Operations was notified of the Immediate Jeopardy at 6:00 p.m. on [DATE]. The Immediate Jeopardy was ongoing as of the exit on [DATE]. The findings include: Cross reference F684, F726, and F805 A review of Resident #2's medical record revealed he was admitted to the facility on ,d+[DATE]//2022 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He required assistance with activities of daily living. A review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Admit to Skilled Nursing Facility, dated [DATE] (Tuesday) Full code, dated [DATE] Dietary liberty for special occasions, dated [DATE] Regular diet, regular texture, regular/thin liquids consistency, ordered [DATE] Percutaneous endoscopic gastrostomy (PEG) tube (feeding tube), change tubing and syringe daily, every night shift, ordered [DATE] Regular diet, dysphagia pureed texture, nectar-thickened fluids consistency, ordered [DATE] (Resident #2 had already been discharged on [DATE].) A review of the facility's Admission Completion Check-Off List, outlining the forms required to be completed upon admission of a new resident, revealed the following: - Dietary Communication Form completed and sent to kitchen - Diet orders present/accurate - Telephone orders written for any clarifications not noted on discharge orders and/or 3008 (Florida) A review of the resident's Discharge Minimum Data Set (MDS) assessment, dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) score was not obtained. He was documented as requiring extensive assistance for bed mobility, transfers, eating and toilet use. He had a feeding tube and the section for mechanically altered diet was marked not applicable. A review of the admission nursing assessment dated [DATE], and indicating an admitted [DATE] at 5:51 p.m., revealed that Resident #2 was alert and orientated to himself only. His speech was documented as aphasic (difficulty communicating). He was documented with mild shortness of breath. No cough observed. He was reportedly receiving oxygen at a flow rate of two liters per minute via nasal cannula (tubing delivering oxygen through the nostrils). He was noted with general weakness and under the heading Nutritional Approach, feeding tube was noted. He was documented as cognitively impaired with poor decision-making skills, not independently mobile, and was noted as receiving antipsychotic, antidepressant, antianxiety and hypnotic medications. On the last page of the assessment was documented, Unable to orient resident. A nursing progress note dated [DATE] at 10:38 p.m. read, Resident was eating dinner, suddenly started to cough, appeared to be choking. 911 called and transferred the resident to emergency room (ER) for evaluation, family member notified. A review if the Acute-Care Hospital History and Physical, revealed a Dietary assessment dated [DATE]. It indicated the resident was to receive nothing by mouth (NPO). Recommendations included adjusting the tube feeding to Glucerna 1.5 (a high-calorie liquid nutrition tube feeding formula designed to minimize blood sugar spikes) at 55 milliliters per hour (mL/Hour), which gave (1980 Kilo calories (Kcal), 108 grams (g) protein, 176 g carbohydrates (CHO), and 1002 mL of free water. This met 100% of the estimated Kcal and protein fluid, and 59% estimated fluid needs or at least 30 mL every 4 hours to prevent occlusion (blockage of the tube). The resident was anticipated to discharge the hospital with the tube feeding (TF) in place. If bolus feed (the delivery of smaller volume feeds at regular intervals) desired, recommend 8 ounces (oz.) of Glucerna 6 times per day to meet protein-Kcal needs. A review of the Acute-Care Hospital's Swallow Evaluation from the Speech Therapist (ST), entitled Modified [MEDICATION(S)] Swallow/Plan of Care (POC), dated [DATE], revealed recommendations for: Pureed and nectar/mildly thick liquid. Swallowing Precautions: Continue PEG as primary source of nutrition for now. Further assess for soft solids. A review of the Acute-Care Hospital intake notes, dated [DATE], the day the resident was discharged emergently from the skilled nursing facility to the hospital emergency room revealed, The patient presented with respiratory distress. The patient presents with difficulty breathing, respiratory problem and respiratory arrest. The onset was just prior to arrival. The course/duration of symptoms is constant. Degree at onset severe. Degree at present severe. Risk factors consist of dysphagia. [AGE] year old male presents to emergency department via EMS (Emergency Medical Services) with dyspnea, respiratory arrest, suspected choking episode. Patient is a resident of a nursing home and has chronic dysphagia of unknown origin. Patient has a tube secondary to his dysphagia. Patient diet recently escalated beyond his G-tube to pureed diet. EMS states that patient was given solid foods just prior to the initiation of his episode. On EMS arrival, patient was minimally responsive and choking. EMS removed multiple pieces of food from patient airway. Patient became unresponsive and EMS team attempted intubation. Unable to intubate secondary to suspected food bolus (semi-solid mass of food) in airway. EMS team able to remove multiple pieces of the food bolus and placed King tube (airway management device) successfully. On arrival in ED (Emergency Department), patient unresponsive with King tube in place. A review of the Speech Therapy Initial Evaluation, dated [DATE], revealed that the clinical impression and recommendation showed the resident demonstrated moderate oropharyngeal dysphagia (Per https://medical-dictionary.thefreedictionary.com/oropharyngeal+dysphagia on [DATE] at 2:18 p.m., Difficulty in propelling food or liquid from the oral cavity into the esophagus). The resident's current diet level was recently upgraded to a pureed texture and nectar-thickened liquids. The resident exhibits decreased lingual (random disorganization of tongue movements), labial (impaired oral sensation or decreased lip strength), and laryngeal (reduced elevation or closure) function with a moderate impairment with ROM (range of motion), strength, coordination, and rate. Upon observation, resident exhibited mild-moderate impairment with bolus (semi-solid mass of food) formation and extended bolus hold and moderate impairment with lingual residue and laryngeal elevation with nectar-thick liquid. (Copy obtained) In an interview on [DATE] at 11:15 a.m., Licensed Practical Nurse (LPN) A stated she had worked at the facility on an as needed (PRN) basis since [DATE]. When asked if she was familiar with Resident #2, she replied yes. She stated on [DATE] at 6:00 p.m. during dinner, she heard Resident #2 coughing, and upon entrance to the resident's room, she noted that the resident could not speak, was holding his throat, and was struggling to breathe. She walked out of the resident's room and called 911. When asked if Resident #2 received any assistance with meals she said no. She stated Resident #2 was capable of feeding himself. She further stated the resident had a PEG tube but was not receiving any nutrition through the tube. When asked what meal texture was provided to the resident, she stated the resident had dysphagia but was on a regular-textured diet. She stated she remembered seeing noodles and salad on the resident's plate. LPN A confirmed that she did not attempt the [MEDICATION(S)] maneuver. When she was asked to explain the process for the [MEDICATION(S)] maneuver, she could not describe the proper steps to take. She stated she received the training outside the facility at the same time she obtained her cardiopulmonary resuscitation (CPR) card. She added that she was the only nurse on the floor at the time, and the fastest thing she thought to do was to contact 911. LPN A could not recall whether she contacted the resident's physician. She stated she contacted the Director of Nursing (DON) and the resident's family. During an interview with the Director of Nursing (DON) on [DATE] at 11:25 a.m., she stated she vaguely remembered the resident. She confirmed that she had added the orders for a regular diet to Resident #2's medical record upon his admission. She added that the resident was admitted with a regular diet order and the order was changed on [DATE] to a pureed diet. She stated the resident also had a PEG tube, but she did not recall whether he was receiving any nourishment or hydration via the PEG tube. When asked whether she was notified of the incident on [DATE], she stated she was told the resident was choking and the staff had to call 911. When asked if staff attempted any type of first aid, she stated she was not sure. She was then asked where the initial admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She obtained form ,d+[DATE] and confirmed that it indicated the resident was to receive PEG tube feedings. When asked if the resident received anything via PEG tube, she stated there were no orders for PEG tube feedings. She further stated the facility followed the discharge orders from the hospital. After she reviewed the hospital discharge orders, she stated they indicated ml per day. When she was asked what that meant, she stated it was not clarified. She was then asked about the Speech Therapy recommendation dated [DATE], and she stated the new recommendation should be followed. When asked why the resident was offered regular-consistency meals, she stated she was not aware that the resident had a regular meal at the time of the incident. She also confirmed that she did not conduct any investigation of the incident. The DON failed to follow the facility's policy and procedure for reporting an Adverse incident; a condition that required transfer of the resident, within or outside of the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the resident's condition prior to the adverse incident. During an interview with the DON on [DATE] at 3:00 p.m., she stated the QA (Quality Assurance) committee did not identify Resident #2's choking incident as something that required thorough investigation. The facility did not deem the incident as high risk or adverse or possibly adverse. The facility did not initiate an investigation or self-report the incident. The DON stated she felt the incident was isolated and it was one incident. It wasn't house-wide. EMS didn't do the [MEDICATION(S)] on him either. She stated she disciplined the nurse (LPN A). She did not find that the resident received the wrong diet. She stated the kitchen did not print out a regular diet for him. He received a pureed diet. During an interview with the DON and the Regional Vice President of Operations on [DATE] at 4:30 p.m., they where informed about the serious concern regarding Resident #2's choking incident. When asked how facility incidents were investigated, they stated through the clinical meeting. She confirmed that after an interdisciplinary discussion, this incident was not thoroughly investigated, as the resident had not been in the facility. She confirmed that the nurse who conducted the admission failed to follow through on diet clarification and therefore disciplinary action was taken. The administrator added that the facility should follow the hospital orders on admission. When asked how the facility staff were trained, she stated the facility used a computer-based independent training system. New staff recevied training upon hire. She added that she was new to the facility, and she identified a lot gaps in the system which she was trying to fix. She added that the ADON would be monitoring this going forward. When asked if any gaps were identified during the most recent QAPI meeting, she stated no. She added that the incident was just an emergency as resident was just coughing and therefore not identified as an adverse incident. In a telephone interview on [DATE] at 1:32 p.m., the Medical Director stated he did not recall giving a diet order for Resident #2. He stated typically the diet orders were obtained from the hospital discharge paperwork and the nurse may call for clarification. He added that he did not recall seeing the resident; he obtained most of the information from the hospital History and Physical. When asked if he was notified when Resident #2 was sent emergently to the hospital, he stated he had APRNs (Advanced Practice Registered Nurses) who were on call, and they might have received the call. He confirmed that he was the facility's Medical Director and further stated he did not recall the resident's incident having been discussed in the Quality Assurance meeting. In an interview on [DATE] at 5:00 p.m., the Assistant Director of Nursing (ADON) stated he had been employed by the facility since [DATE] and was in the process of identifying a better way to conduct staff training and competencies. He stated new hires were provided with training and competency checks during orientation. He further stated established staff received training through an electronic independent training system. He stated he was in the process of developing a training calendar to ensure different topics were discussed each month. When asked if anyone was monitoring staff training completion, he stated no. When asked about First Aid training, he stated nurses were required to have a current CPR (cardiopulmonary resuscitation) card, but there was no training or competency check provided by the facility for First Aid. The ADON was asked how new resident admissions were reviewed, and he stated, All new admissions are reviewed on the next business day during the clinical meeting. The DON, ADON and Unit Managers utilize a checklist to ensure all the components are correct. When asked if a new admission's diet was one of the components for review during the clinical meetings, he stated yes. (Copy of checklist obtained) When asked if Resident #2's chart was reviewed the next business day after admission during the clinical meeting, the ADON stated he did not remember, nor could he remember whether Resident #2's discharge was discussed in the QAPI (Quality Assurance and Performance Improvement) meeting that was scheduled to have been held on the third Friday of the month, [DATE]. A review of the facility's policy and procedure entitled Performance Improvement Committee (Quality Assurance) (Document Name: PI- 240, Effective Date: [DATE] and Revision Date; [DATE]), revealed: The Performance Improvement Committee will meet to review, recommend, and act upon activities of the facility, performance improvement teams and /or departmental activities. The committee shall direct all activities including approving proposed monitoring, evaluating and review of services. The committee shall assure QAPI activities have indicators and standards/thresholds for evaluation, that appropriate action are implemented, and that such corrections have been evaluated by subsequent monitoring. 3. The Performance Improvement Committee will develop, review, and revise the Performance Improvement Plan annually and as needed to ensure the Performance Improvement Program reviews and addresses key aspects of care and key indicators using data from multiple sources that evaluate a full range of care and services. 4. The completed indicators will be reviewed monthly by the Performance Improvement Committee for meeting threshold. Indicators outside of the threshold will be assigned by the committee to a Performance Improvement for further improvement process. The Committee will monitor and oversee the Performance Improvement Teams. 5. The Committee will assign interdisciplinary performance improvement teams activities and monitor the teams' progress. A Performance Improvement Team will be developed to collect and evaluate data and to plan and implement needed action under the direction of the Performance Improvement Committee. teams may be comprised of representatives of the primary departments involved with the aspect of care or service being evaluated, other affected staff, residents/families, and other appropriate community/customer representatives. 8. The Performance Improvement Committee will utilize the PIP documentation guide to monitor and oversee the Performance Improvement Teams to ensure oversight, guidance, and support is provided. The Committee will review the results of all Performance Improvement Teams through evaluating and monitoring activities and make appropriate recommendations.

Based on observation, interview and record review, the facility failed to ensure medications remained in properly labeled containers until the time of administration for eight (Residents #4, #7, #8, #9, #10, #11, #12 and #13) of 13 residents sampled during medication administration. The facility's nursing staff practice of pre-pouring medications placed residents at risk for medication administration error that could result in adverse reactions. The findings include: A review of Resident #1's medical record, revealed an Admission Minimum Data Set (MDS) assessment, dated 08/05/2021, with a Brief Interview for Mental Status Score (BIMS) of 15 out of a possible 15 points, indicating she was cognitively intact. She had a documented admission on 7/30/2021. Resident #1 also was documented as understanding activity and care provided, could make her needs known and could inform the facility staff of problems and concerns independently. Resident #1 was admitted with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/07/2021 at 8:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) A, and she was asked to open the top drawer of her medication cart. She refused and stated, I don't want to. The survey process was reviewed with her, and it was explained that she was required to open her medication cart upon request. She unlocked the medication cart and eight medication cups were identified with multiple medications including colorful tablets and capsules. (Photographic evidence obtained) On 10/07/2021 at 8:38 AM, LPN A stated she was working at the medication cart and she confirmed the medications were labeled with room numbers 200 A, 200 B, 204 A, 204 B, 205 A, 206 A, 206 B and 214 B. The room numbers were compared with the facility census and Medication Administration Records (MAR), and it was confirmed that the medications were intended to be administered to Resident #4 and Residents #7, #8, #9, #10, #11, #12 and #13. During an interview with LPN A in the conference room on 10/07/2021 at 8:39 AM, she left the eight medication cups with the surveyor unattended by a facility nurse. The Business Office Manager was summoned to sit with the medications until either the Administrator or the Director of Nursing arrived to take over the unattended medications. An interview was conducted with the Administrator on 10/07/2021 at 8:44 AM regarding medications being pulled for eight residents at one time. The Administrator stated she did not think that was appropriate. She relieved the Business Office Manager, took possession of the eight medication cups and left the room with them. On 10/07/2021 at 8:56 AM, a telephone interview was conducted with the Director of Nursing (DON) and the Administrator. The DON confirmed that she spoke with LPN A but did not know all of the details. She stated there was no reason for eight residents' medications to be pulled at the same time. An interview was conducted on 10/07/2021 at 9:46 AM with Resident #4. She stated on 10/06/2021, the RN Regional Director handed her someone else's medications. An interview was conducted with Resident #10 on 10/07/2021 at 2:04 PM. He stated he never refused his medications. An interview was conducted with Resident #12 on 10/07/2021 at 2:22 PM. She stated she never refused her medications. A review of documentation submitted by Resident #1's mother revealed that on September 4, 2021, I received a text at 3:53 PM. [Resident #1] advised me that the RN Regional Director provided [Resident #1] the medication that belonged to her roommate. It was documented that the RN Director came in with the medications while Resident #1 was being changed. The RN Director placed the medications on the table for the resident to take. Resident #1 noticed the cup had the roommate's name on it. Resident #1 told her mother that the roommate took the wrong medications. A review of resident MDS assessments revealed the following: Resident #7-Most recent Annual MDS, dated [DATE], indicated a documented BIMS score of 08, indicating moderate cognitive impairment. Resident #8-Most recent Quarterly MDS, dated [DATE], indicated a documented BIMS score of 12, indicating moderate cognitive impairment. Resident #9-Most Recent Quarterly MDS, dated [DATE], indicated a BIMS score of 12, indicating moderate cognitive impairment. Resident #11-Most recent Admission MDS, dated [DATE], indicated BIMS score of 08, indicating moderate cognitive impairment. A review of the facility's Policy and Procedure for Administering Medications, revealed that it did not address pre-pulling medication for multiple residents at one time. A review of the CEUfast Nursing CE (continuing education) website at https://ceufast.com/course/long-term-care-nursing-medication-pass (accessed on 11/01/21) revealed: Medication errors are serious and can cause resident harm or even death. It is human nature to want to simplify things when there is much to be done. In an attempt to do this, sometimes shortcuts are made. However, this is not good practice. ESPECIALLY when it comes to medications. Do not take shortcuts. More specifically, do NOT, under any circumstances, try to pre-pour medications to save time. Pre-pouring medications are against regulations. In addition, it increases the risk of making mistakes.

Based on interviews and record review, the facility failed to document a grievance for one (Resident #1) of three residents sampled for grievances from a total sample of 13 residents. The findings include: An interview was conducted with Resident #1's mother on 10/06/2021 at 2:31 PM. The mother stated she contacted the facility via multiple methods, including emails to the facility. She checked back on 9/21/2021 and the facility did not respond to her concerns. The mother stated the facility knew she was complaining about her daughter's care (Resident #1). An interview was conducted with Resident #1 on 10/07/2021 at 9:40 AM. She reported that she informed the Registered Nurse (RN)/Regional Director of Nursing (RDON), about a medication error that he provided. She stated her complaints about care not being provided and overall dissatisfaction with call light response times were unresolved. She stated the RN/RDON brushed her off when Resident #1 pointed out that he gave her the medication cup with her roommate's medications one day. An interview was conducted on 10/07/2021 at 12:25 PM with the Physician's Assistant (PA) who cared for Resident #1 and managed her pain. The PA confirmed the facility left the pain medication patch on for four to five days and Resident #1 complained about not getting the patch changed. A review of the facility's Monthly Grievance log was conducted for the dates of July 2021 through September 2021. October 2021 was not provided for review as requested during the entrance conference on 10/07/2021 at 8:56 AM. There was no documented evidence of the complaints described during the telephone interview with the mother of Resident #1 or the interview with Resident #1 herself. The facility was identified as out of compliance for activities of daily living for a dependent resident (Resident #1), and for not providing medication that did not allow for pulling more than one residents' medication at a time. Both of these concerns were documented by Resident #1 and Resident #1's mother as instructed to the facility of their concern. On 10/07/2021 by the 4:30 PM exit, the facility provided no evidence that it documented any grievances for Resident #1.

Based on observation, interviews, and Resident #1's shower schedule, the facility failed to meet the showering needs for one (Resident #1) dependent resident out of three residents sampled for activities of daily living needs. The findings include: An interview was conducted on 10/06/2021 at 2:31 PM with Resident #1's mother, who reported that Resident #1 texted her when she was not being cared for. She stated during the interview that Resident #1 was only provided a shower one time since she was admitted on [DATE]. Resident #1 was interviewed on 10/07/2021 at 9:40 AM, and she stated she never refused showers. She also stated she was only given one shower since she was admitted . A review of Resident #1's medical record, revealed an Admission Minimum Data Set (MDS) assessment, dated 08/05/2021, with a Brief Interview for Mental Status Score (BIMS) of 15 out of a possible 15 points, indicating she was cognitively intact. She had a documented admission on 7/30/2021. Resident #1 also was documented as understanding activity and care provided, could make her needs known and could inform the facility staff of problems and concerns independently. Resident #1 was admitted with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's care plan indicated she had a focus area which included Activities of Daily Living (ADL)/Self-Care Performance Deficit, related to activity intolerance, fatigue, and [CONDITION(S)] from a spinal stroke. The documented intervention under bathing/showering included, Provide sponge bath when a full bath or shower cannot be tolerated and the resident requires extensive to total assist by 2 staff with bathing/showering per schedule and as necessary. A review of the September and October 2021 bath/shower documentation revealed that Resident #1 was provided a shower on 09/06/2021 at 1:38 AM, on 09/08/2021 at 8:24 PM, and on 10/01/2021 at 3:40 PM. Three showers were provided between September 1, 2021 and October 7, 2021. Resident #1 was interviewed and stated she was only provided one shower since her admission on 7/30/2021. The facility could not provide documented evidence of showers having been given more than those three times, skin having been checked, or dates and times that Resident #1 refused showers. During a review of documentation provided on 10/07/2021 at 2:40 PM with the Regional Director (RD), he confirmed there were only three documented showers provided to Resident #1. An S on the obtained Documentation Survey Report was confirmed by the RD to indicate showers. The RD was asked to provide documented resident shower refusals. No documentation of shower refusals was provided by survey exit on 10/07/2021. .

Based on record review and interviews, the facility failed to ensure nursing staff had appropriate competencies and skills in documentation of wound care on the treatment administration record in the electronic medical record for one (Resident #75) of two sampled residents reviewed for wound care and were competent in providing [CONDITION(S)] care for one (Resident #5) of one sampled resident reviewed for [CONDITION(S)] care, from a total of 76 residents in the facility. The finding include: 1. A record review for Resident #75 revealed an admitted [DATE] and readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #75's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. The resident required with two-person extensive assistance for bed mobility, transfer, and toilet use. A review of the resident's care plan, indicated she had an activities of daily living self-care performance deficit related to activity intolerance, fatigue, impaired balance, pain, [CONDITION(S)], and [CONDITION(S)]. Interventions included extensive assistance of two staff members to move between surfaces as necessary. A nursing progress note, dated 6/26/21, revealed the resident had a small skin tear on her left lower leg while transferring from the bed to the wheelchair. Steri-strips were applied with a dry dressing. During an interview with Resident #75 on 9/27/21 at 12:00 PM, she stated that two certified nursing assistants were transferring her from the bed to the wheelchair. They held her under the arm one on each side, her foot got caught under the wheelchair and she sustained a cut that required seven sutures. The resident confirmed that the staff were supposed to use a sit to stand machine but did not use it. On 9/30/21 at 5:05 PM, Employee G, Licensed Practical Nurse (LPN) was asked about skin treatments for Resident #75. She confirmed that Resident #75's wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if she had received any competency check for medication and/or treatment administration, she replied, I have not received any competencies since I have been here. 2. A record review for Resident #5 revealed an admissions date of 6/11/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating cognitively intact. The resident required suctioning and [CONDITION(S)] care. During an interview with Resident #5 on 9/27/21 at 11:00 AM, he stated, he provided his own [CONDITION(S)] suction. He added, he learned to suction himself at another facility. When asked if he was assessed for self-care at the facility, he stated, no, he was not. When asked if staff assisted him with his [CONDITION(S)] care, he stated, No. During an interview with Employee D, Certified Nursing Assistant (CNA) on 9/29/21 at 10:12 AM, she stated, she has been a CNA for a while and knew how to provide care to the residents. When asked if she had completed any competency skills check, she replied, No. On 9/29/21 at 10:15 AM, an interview was conducted with Employee E, CNA. She stated, she received her training by working with another CNA during orientation. When asked if she had completed any competency skills check, she replied, No. On 9/29/21 at 10:26 AM, an interview was conducted with Employee F, Assistant Director of Nursing (ADON)/Registered Nurse (RN). She stated, she was responsible for staff education. When asked if she had conducted any competencies for employees, she stated, the Director of Nursing (DON) and her had talked about having a skill fair, but it had not happened at the time of survey. She confirmed that none of the licensed nursing employees had received competency skills check during the year of 2021. On 9/30/21 at 2:14 PM, an interview was conducted with Employee A, Administrator and Employee B, Regional Administrator regarding employees' competencies. They confirmed competency skills checks were not conducted in 2021. The also confirmed that Resident #5 was not assessed to provide his own [CONDITION(S)] care. They added, the regional nurse consultant would initiate the training as soon as possible. During an interview with Employee G, Patient Care Attendant (PCA) on 9/30/21 at 2:46 PM, she stated, she has been at the facility for about two months. When asked if she received training, she stated that she received online training upon hire and then shadowed another CNA. When asked how to identify resident's requirement with transfer, she stated she would ask the residents or get someone to help. When asked about documentation regarding resident's transfer requirements, she stated that she was not aware of it. On 9/30/21 at 2:05 PM, an interview was conducted with Employee C, LPN, who was the nurse assigned to care for Resident #5. He confirmed, Resident #5 suctioned himself and completed his own [CONDITION(S)] care. When asked about [CONDITION(S)] ties, he stated, they are changed by the nursing staff as needed. He confirmed that he had not had any [CONDITION(S)] care or suctioning competencies since he worked at the facility. He stated his last [CONDITION(S)] care and suctioning training was at his last place of employment two years ago. A review of the staff education calendar for 2021 revealed the facility had a different competency skill set scheduled each month, such as: dressing change in February, use of lifts in June, [CONDITION(S)] care and [CONDITION(S)] suctioning in August, etc. (Copy obtained) A review of the facility assessment updated dated 1/4/2021 revealed the following: III. Facility Resources needed to provide competent support and care for our Resident population every day and during emergencies. Facility resources (staff, equipment, physical plant) are evaluated during annual budget review, monthly during financial operations review or whenever changes in resident population and/or their needs requires resource evaluation. B. Staff training and competencies: Staff training and qualifications are evaluated during the hiring process by reviewing their education and experience. Once hired, staff goes through classroom and floor orientation depending on their discipline. Classroom orientation include the following modules provided to all staff on hire, annual, as needed (PRN) and on Demand: Abuse neglect and exploitation, infection control, cultural change ( that is person- centered and person- directed care), cultural competency, person centered care, disaster planning, medication administration, measurements (vitals, intake and output), caring for people with dementia, Alzheimer's and cognitive impairments, non- pharmacological management of Responsive behaviors and resident assessment. (Copy obtained)

Based on a review of resident and facility records and interviews with staff, the facility failed to: 1) Honor a resident's Do Not Resuscitate Order (DNRO) when he was discovered to be unresponsive and without a pulse or respirations and, 2) Ensure that a resident's DNRO was filed in the resident's medical record. This affected one (Resident #1) of five residents reviewed for advanced directives. Resident #1 executed a DNRO while in the facility, however, facility staff failed to file the order in the resident's clinical record. This resulted in staff initiating cardiopulmonary resuscitation (CPR) after he was found unresponsive 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, provided the potential for a prolonged dying process and presented the likelihood he would experience major physical trauma including fractured ribs, fractured sternum, tracheal and/or [MEDICAL CONDITION] rupture, internal bleeding and/or organ damage. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:30 a.m. on [DATE]. On [DATE] at 6:14 a.m., the Immediate Jeopardy (IJ) began. On [DATE] at 4:00 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed, effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: A closed, electronic clinical record review conducted for Resident #1, found he was admitted to the facility on [DATE] from the hospital. He was [AGE] years old. His [DIAGNOSES REDACTED]. Resident #1 had a baseline care plan dated [DATE], for Advanced Directives related to a full code (desire to be resuscitated following respiratory/coronary arrest) status. The goal was for the resident to have his advanced directives followed. Interventions: Discuss advanced directives with resident and/or resident representative. Responsible: Registered Nurse (RN), Licensed Practical Nurse (LPN), Minimum Data Set (MDS) and Social Worker (SW). The care plan was created by the MDS Coordinator. (Photographic evidence obtained) A review of the resident's hard (paper) chart revealed a State of Florida Do Not Resuscitate Order goldenrod (yellow) form (DH form 1896, revised [DATE]), dated [DATE]. RN A, RN B and Resident #1's physician had signed the form. The paper was loosely placed in the front of the chart. (Photographic evidence obtained) Further review of the chart found there was no Advanced Directives Discussion form completed. In opposition to the care plan, Resident #1 had an electronic physician's orders [REDACTED]. RN B entered the DNR order into the electronic records database on [DATE] at 9:41 a.m. (Photographic evidence obtained) A review of an Admission/Readmission Data Collection form completed by RN A on [DATE], noted that Resident #1 had [MEDICAL CONDITION], was alert to person and place and had okay memory. His pulse was normal, capillary refill was brisk, and respirations were even and unlabored. Resident #1 was noted as weak. (Photographic evidence obtained) A review of the history and physical examination [REDACTED]. (Photographic evidence obtained) A review of the facility's Nursing Home Federal Immediate Report, completed by the Executive Director (ED) on [DATE], revealed an incident involving Resident #1 occurred on [DATE] at 6:55 a.m. The type of incident was noted as neglect. In response, the facility notified the resident representative and law enforcement on [DATE], and the Abuse Registry on [DATE]. The ED reported that on [DATE] at approximately 3:00 a.m., LPN A reviewed Resident #1's vital signs with Certified Nursing Assistant (CNA) A with no concerns. At 5:45 a.m., CNA A checked on Resident #1 and found no concerns. At 6:14 a.m., CNA A entered Resident #1's room and observed the resident did not look right. He immediately alerted LPN A, who responded to the room and evaluated the resident. Resident #1 was unresponsive, warm to the touch and with no pulse or respirations. LPN A exited the room to check the medical record for the resident's code status. She did not locate a DNRO form in the chart. LPN A alerted LPN B to conduct a second check of Resident #1's code status. LPN B verified there was no DNRO in the chart. LPN A instructed LPN B to call a Code Blue and call 911. LPN A and LPN B initiated cardiopulmonary resuscitation (CPR). Within approximately ten minutes, three emergency medical technicians (EMTs) arrived. After evaluating Resident #1, the EMTs ceased CPR. They announced the case was over and pronounced Resident #1's death. The facility notified a family member, the physician and the Director of Clinical Services (DCS) of the event. After the event and upon further review of the records, Resident #1's executed DNRO from [DATE] was found in a different location. It had not been filed in the residents' medical record. A review of the facility's policy and procedure on Advanced Directives, document SS-124, revised [DATE] revealed: Policy: The center will abide by state and federal laws regarding advanced directives. The center will honor all properly executed advanced directives that have been provided by the resident/resident representative. Process: 1. Upon admission, Social Services Director or Business Development Coordinator/designee will: a. Communicate to resident/representative his or her right to make choices concerning health care and treatments, including life sustaining treatments. b. Determine if the resident has an advance directive and, if not, determine whether the resident wishes to establish an advance directive. c. Document in the resident's record via the Advance Discussion Form that the resident/rep has been apprised of his or her right to formulate an advance directive. 2. Social Services Director (SSD) or Business Development Coordinator (BDC)/designee will assist the resident/rep to complete the Advance Directives Discussion Document (ADDD). If an advance directive exists, the SSD/BDC will obtain a copy and place it in the resident's medical record . .4. Upon completion of the ADDD, the SSD or nurse will notify the physician of the resident's wishes and procure a state-approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record . (Photographic evidence obtained) A review of the facility's policy and procedure on Florida Do Not Resuscitate (DNR), document SS-119, effective [DATE] revealed: Policy: The center will follow Florida law regarding obtaining and honoring DNR orders. Procedures: .2. When the resident has executed a DNRO, the form shall be printed on yellow paper and have the words Do Not Resuscitate Order printed in black and displayed across the top of the form . 3. The properly executed DNRO will be placed in the resident's medical record. A review of the facility's policy and procedure on CPR, document N-302, revised [DATE] revealed: Policy: CPR will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a valid Do Not Resuscitate (DNR) Order. Procedures: 1. In the event of [MEDICAL CONDITION], immediately call for assistance. 2. Two licensed nurses are to verify: -Resident Identity -Current physician's orders [REDACTED]. 3. Use the paging system and call Code blue to Room Number ( ), three times (or the location of the event). 4. In the absence of a physician's orders [REDACTED]. 5. Center staff will continue performing CPR until Emergency Medical Technicians arrive . (Photographic evidence obtained) Further review of facility records revealed the facility's written statement given by LPN A on [DATE] (no time noted). In it, she explained that at approximately 6:15 a.m. the CNA called her to Resident #1's room. The resident had no pulse, and no yellow DNRO form was found. She called Code Blue and 911 was called. Emergency Medical Services (EMS) arrived and found no pulse, so they declared him dead. Law enforcement also arrived. The facility's written statement from LPN B on [DATE] (no time noted), revealed she was notified by another nurse at an uncertain time that the resident in room [ROOM NUMBER] (Resident #1) was unresponsive. The chart check revealed no yellow DNRO form, so she got the crash cart and accompanied the second nurse and the aide to the room. The facility's written statement from RN C on [DATE] (no time noted), revealed he responded to the Code Blue in room [ROOM NUMBER]. There was no DNRO for this resident. He helped with CPR and returned to the unit when EMS arrived. The facility's written statement from CNA A on [DATE] (no time noted), revealed that he entered Resident #1's room after 6:00 a.m. and found him unresponsive. He alerted LPN A, who checked the resident's pulse and asked CNA A to stay with the resident while she checked the chart. LPN A then paged Code Blue and two other nurses assisted until EMS arrived. An interview was conducted with the DCS on [DATE] at 12:30 p.m. She explained that Resident #1 was admitted on Sunday ([DATE]) afternoon. He was previously a DNR on hospice in the community. On Monday ([DATE]) mid-morning after discussion with the physician, the resident elected to become a DNR again. RNs A and B served as witnesses and updated the order with the physician, who was present in the building. The order was then updated in the electronic record. RN A put the executed DNRO form into a to be scanned file at the nurses' station before she left the facility. However, the DCS explained, the form should have been placed in the resident's chart as soon as it was executed. The next morning, Resident #1 coded. CNA A had seen him last at around 5:45 a.m. that morning with no concerns. When he returned at 6:14 a.m., he noticed the resident was unresponsive. He notified LPN A, who assessed him and saw he was without vital signs. LPN A called for help and LPN B responded. Both nurses checked Resident #1's chart and there was no DNRO form located. They did not check the electronic chart. The protocol was to check the hard chart for the yellow form. When they couldn't locate the yellow form in the chart, they initiated CPR. EMS arrived and did not continue CPR. When the nurses notified the DCS of the event via telephone, she stated she recalled saying she believed Resident #1 had a DNRO and that the DNRO had been signed the day before. Both nurses said they did not see it. The DCS then instructed the nurses to check the computer. They did and verified the DNR order was there. Then they found the yellow form in the to be scanned file. In response, RN A was educated and a Performance Improvement Plan (PIP) was initiated. The facility conducted 3 or 4 full house audits for advanced directives. Nurse education commenced to include abuse, neglect, the DNR policy, regulations related to the DNR form, Florida guidelines, and where in the chart the form should be. The facility checked the CPR status of all nurses, and nurses without current CPR cards are off the schedule until they renew or show proof of having valid certification. Nurses may not come into work and may not start the shift until re-educated. One hundred percent (100%) of resident records were reviewed to make sure the order matched the computer and the yellow form, and/or that the full code order and Advanced Directive Discussion Document was in the resident's chart. All care plans were reviewed to ensure they were accurately reflecting advanced directives. Code Blue drills were being conducted daily and drills were initially completed across all shifts. Education is continuing and they are ensuring at least one nurse on every shift has CPR certification. The goal is that all nurses get certified. New crash carts are being ordered, (which she admitted was irrelevant), and the facility will educate new nurses. Newly admitted resident's orders are reviewed on admission to ensure the code status is on the dashboard and that all information matches in the chart. The Interdisciplinary Team validates this information the next business day. On weekends, since there is no SSD or MDS Coordinator in the building, the floor nurses are responsible. The admitting nurse is responsible for placing the yellow DNR form in the chart. The Minimum Data Set (MDS) Coordinator was interviewed on [DATE] at 12:50 p.m. She was asked about her process for care planning Resident #1 for a full code status. She explained that on admission, she created a basic care plan for resident medications and COVID-19. Regarding Resident #1, she might not have seen the DNRO form in the chart, or she would not have care planned the resident as full code. If there was a physician's orders [REDACTED]. She would also look for the yellow form in the record. Resident #1's care plan meeting had not been held yet. She stated the facility was now requesting a double-check of the charts for code status, and instructing staff to slow down and have the floor nurse and then the Unit Manager check the resident's status. An Advanced Directives Discussion form was also completed by the nurse on admission. The chart was then taken to the morning meeting for review by the management staff. A telephone interview was conducted with RN A on [DATE] at 2:45 p.m. She stated when Resident #1 was admitted , he did not have a DNRO. She checked with the MDS office and called the hospital, but still found no DNRO. She had seen in his chart that was his wish, and therefore decided to get a new DNRO completed for Resident #1. RN A went to the resident's room and asked if he was able to sign his DNRO. He said no, he was too cold and weak to sign for himself. He allowed RN A and RN B to sign the order along with the physician on his behalf. After the form was signed, RN A placed it in the to be scanned folder at the nurses' station. RN A said she had since been educated and now knew she should have filed the form in Resident #1's clinical record. She was asked if she had Resident #1 complete the required Advanced Directives Discussion form. She stated she believed he already had one. She thought somebody else had completed it with him, so she did not complete one with him. In an interview with the DCS on [DATE] at 1:20 p.m., she was asked if either of the nurses (RN A or RN B) checked the electronic physician's orders [REDACTED].#1's code status per the facility's CPR policy and procedure that instructed after verifying the resident's identity, the physician's orders [REDACTED]. She stated no, and that both nurses had been re-trained. In a follow-up interview on [DATE] at 9:45 a.m., the DCS clarified the intent of the facility CPR policy. She stated the intent, and what she is training her licensed staff to do, was that if the goldenrod DNRO form was not in the chart, then CPR should be initiated. Even if the electronic physician's orders [REDACTED]. The state form was the only order the nurses needed to verify. The DCS stated she didn't understand how RN A would work so hard to clear up the discrepancy about Resident's #1 DNR, then fail to file the form in the chart. RN B was interviewed on [DATE] at 1:38 p.m. She recalled that she came in one morning when RN A, the night nurse, was going off of her shift. RN A approached her about Resident #1 and stated there was an indication that he had a prior DNRO, but there was no executed DNRO form in the record. The physician was in that morning, so they went to Resident #1's room. He was alert and oriented, and together they clarified his wishes. He said he was sick and did not want to be here any longer, so he opted for a DNRO. RNs A and B witnessed and the physician signed the order. RN B said she then left the yellow form with RN A after signing it. RN B explained that if a resident had no yellow DNRO form in their chart, she would start CPR. She checked the electronic medical record database's dashboard for the resident's code status. RN B was asked what she would do if she found a chart that had no yellow DNRO, but the resident also had an electronic physician's DNRO order. She said, There should be a yellow form in the chart. LPN B was interviewed via telephone on [DATE] at 11:30 a.m. She recalled the events with Resident #1, confirming she commenced CPR upon not finding a DNRO form in Resident #1's medical record. She had been a nurse for long time and went by the yellow form. When asked what she would have done if she had checked the electronic orders and discovered the resident had executed a DNRO the day before the event. She hesitated and then stated she might go by the updated physician's orders [REDACTED]. If it was not there, she would commence CPR. The facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the survey team as follows: A Performance Improvement Plan was initiated on [DATE] with a goal of immediate correction and attaining and maintaining regulatory compliance regarding advanced directives center-wide. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Interdisciplinary Team and Medical Director on [DATE]. Action Steps included the SSD and ED conducting DNRO quality reviews with findings reported to QAPI monthly. The ED was notified on [DATE], staff education commenced on [DATE], and the incident report was filed on [DATE]. The plan included 1) Licensed nursing staff education, 2) New nurse education on advanced directives during orientation, 3) CPR certification review for all nurses, 4) Mock code drills every shift until every nurse has attended and competency has been documented, 5) Crash cart audits, 6) Establish a timeline and root cause analysis, 7) Review the code status of all residents, 8) Obtain witness statements, 9) Establish a DNRO list and 10) Complete/validate DNRO quality review. The facility conducted advanced directives audits on [DATE], with 76 residents reviewed for advanced directives and presence of a completed Advanced Directives Discussion form. The resident care plans were also reviewed on [DATE] to ensure accurate reflection of residents' code status. The most recent audit was completed on [DATE] for one newly admitted resident (admitted [DATE]), thus completing a whole-house audit of all 77 current residents. Seventeen (17) residents were identified to have DNROs. A census-wide quality review was performed on [DATE] for the code status of all 77 residents. Inservice training was provided to the DCS on [DATE] by the RN Clinical Quality Specialist. Training topics included a review of the facility policies and procedures on abuse/neglect/exploitation, advanced directives, DNROs and CPR. Training also included ensuring accurate orders and reflection of those orders in the electronic and paper records, ensuring licensed nurses were able to demonstrate two nurses were checking the code status of unresponsive residents prior to initiating or withholding CPR, ensuring medical records were accurate and accessible in order to validate code status, and ensuring the care plans reflected the wishes of each resident. All but six trained nurses had completed the post-test. Any nurse scoring less than 80% on the post-test would received re-education by the DCS and would be re-tested until they demonstrated understanding at 80% or above. All nurses were required to complete the post-test successfully prior to being assigned their next shift. On [DATE], this same in-service education was provided to eighteen (18) of twenty-one (21) nurses by the Director of Clinical Services. Those nurses who were not in-serviced by [DATE] would not be given an assignment until this training was completed. The facility conducted an audit of nurses' CPR certifications. Seventeen (17) of twenty-one (21) nurses employed had valid CPR cards. Copies of the cards were observed on file. Those nurses without a valid CPR certification were required to submit one prior to accepting another shift. Code Blue drills commenced on [DATE] and had been conducted daily through [DATE]. All but six nurses had participated in a drill. Mock code drills will continue to be held twice weekly on all shifts to include weekends. Nurses not participating in a mock drill as of [DATE], would be required to participate in a mock drill prior to being given an assignment.

Based on clinical record review and staff interviews, the facility failed to assess for changes in condition for 1 (Resident #1) of 3 sampled residents at risk for falls. The resident had multiple falls while at the facility and sustained a [MEDICAL CONDITION]. Resident #1 was not assessed for a change in condition until the family called 911 to transport the resident to the hospital. The findings include: Clinical record review revealed that Resident #1 was admitted to the facility on [DATE]. An initial nursing assessment was conducted on 10/18/11 at 5:30 PM and indicated the resident's admitting [DIAGNOSES REDACTED]. The initial nursing assessment performed on 10/18/11 revealed that Resident #1 was forgetful, and alert. Section "G" of the initial admission data revealed that Resident #1 was inconsistent in understanding her limitations, had had two falls within the last month and had a history of [REDACTED]. Section "H" of the initial admission data revealed that this section was the initial plan of care and preferences for Resident #1. This initial care plan goals included to minimize risk of accidents/injuries. Interventions to accomplish the goal included but were not limited to assisting the resident to the toilet every 2 hours while awake and every 2 hours during the the night, keep the call bell within reach, keep the bed in the lowest position while the resident was in bed, and for the resident to wear non-skid socks while in bed. Review of the physician orders [REDACTED]. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/19/11 at 5:30 AM the nursing notes revealed that Resident #1 was found on the floor, and complained of hip pain. The note did not indicate which hip the pain was located in. The clinical record did not revealed that the nurse performed a physical assessment to determine if there were any injuries. The clinical record did not indicate the resident's physician was was notified. Review of the clinical record revealed the facility had developed a fall prevention plan of care on 10/19/11. The problems identified on the fall prevention care plan were cognitive status, unsteady gait, history of falls and recent fall. On 10/19/11 the care plan indicated a fall review on 10/19/11 and included the need for a personal pressure alarm to the resident's bed and chair. On 10/20/11 at 5:30 AM the nursing notes revealed that Resident #1 was found attempting to get out of the bed. The nursing notes indicated that Resident #1 was assisted to the bathroom by the certified nursing assistant (CNA). Per the nursing notes Resident #1 was left in the bathroom unattended and slid down onto the floor. She sustained a small abrasion to the left upper thigh. There were indication further assessment of the resident was done. On 10/20/11 the fall prevention care plan revealed a fall review dated 10/20/11. The fall review indicated the resident would need the Starlight program and for staff to stay with the resident during toileting. (The Starlight program is a structured program for cognitively impaired residents in order to provide a safe environment. Admission criteria to the program include residents that are deemed to be at high risk for falls due to poor safety awareness.) Review of the nursing documentation for 10/21/11 does not indicate that Resident #1 attended the Starlight program as per the plan of care. On 10/22/11 at 12:35 PM the nursing notes revealed that Resident #1 was found on the floor in her room. The note indicated the resident was taken to the Starlight program after she fell . On 10/23/11 at 2:00 PM the nursing notes revealed Resident #1 was resting in bed, no complaints of pain and range of motion was within normal limits. The documentation did not indicate the resident had attended the Starlight program. The nursing notes on 10/23/11 at 5:00 PM revealed the Resident #1's son was in to visit. The son informed the nurse that his mother was in a lot of pain and had called rescue. Another entry to clinical record on 10/23/11 at 7:00 PM revealed the resident had been assessed at 5:00 PM and the resident was unable to lift her left foot. The notes indicated the physician's assistant was contacted a verbal order for an x-ray of the resident's left foot was obtained. The noted indicated that the family had called 911 and the resident was taken to the hospital. On 10/25/11 at 12:40 PM an interview was conducted with the nurse assigned to Resident #1 between 7:00 AM and 3:00 PM on 10/22/11 and 10/23/11. The nurse was asked about the fall that occurred on 10/22/11 regarding Resident #1. He stated that Resident #1 was sitting in the wheelchair in her room and attempted to get out of the wheelchair unassisted and the alarm on the chair sounded. By the time the CNA responded the resident was on the floor. When asked what he did to assess her for injuries he stated he checked for range of motion. Per the nurse the resident did not complain of pain. The nurse stated the staff assisted her back to the wheelchair and took her to the Starlight program in the dayroom. When the nurse was asked asked if Resident #1 had been in the Starlight program in the morning, he stated no she was in her room. The nurse was asked if he was aware of any changes in the resident's condition on 10/23/11, and he indicated the resident was in the Starlight program all day and he had not observed any changes. On 10/25/11 at 12:55 PM an interview was conducted with the CNA assigned to Resident #1 between 7:00 AM and 3:00 PM on 10/22/11 and 10/23/11. When asked if the had attended the Starlight program that day she indicated the resident did not attend the program in the morning, but did attend after she fell . She further stated that Resident #1 had breakfast in bed. After the resident ate breakfast the CNA stated she got the resident up and dressed her after 9:00 AM. The CNA stated she left Resident #1 in her room in the wheelchair with the personal alarm attached. Around 12:35 PM she stated she heard the resident's alarm and found her on the floor in the bathroom. The CNA advised she called for the nurse to come and assess the resident. The CNA was asked if Resident #1 had complained of pain, she stated she had complained of pain in her back. The CNA stated the nurse gave her some pain medication. The CNA stated that after Resident #1 was placed back in her wheelchair she asked the nurse if she could take the resident to the Starlight program and the nurse agreed. The CNA stated that on 10/23/11 she got the resident up for breakfast and took her to the Starlight program where she remained all day. She then said she took her to the bathroom after breakfast and lunch and she asked for pain medicine for back pain. The CNA was asked if she had been made aware that Resident #1 was at high risk for falls. She stated she was aware that Resident #1 had a history of [REDACTED]. The CNA stated she always made sure she had the call light but she was confused and would not remember. .

Based on clinical record review and staff interviews, the facility failed to implement the Fall Prevention care plan for 1 (Resident #1) of 3 sampled residents at risk for falls. Failure to implement to Fall Prevention care plan resulted in actual harm as the resident sustained [REDACTED]. The findings include: Clinical record review revealed that Resident #1 was admitted to the facility on [DATE]. An initial nursing assessment was conducted on 10/18/11 at 5:30 PM and indicated the resident's admitting [DIAGNOSES REDACTED]. The initial nursing assessment performed on 10/18/11 revealed that Resident #1 was forgetful, and alert. Section "G" of the initial admission data revealed that Resident #1 was inconsistent in understanding her limitations, had had two falls within the last month and had a history of [REDACTED]. Section "H" of the initial admission data revealed that this section was the initial plan of care and preferences for Resident #1. This initial care plan goals included to minimize risk of accidents/injuries. Interventions to accomplish the goal included but were not limited to assisting the resident to the toilet every 2 hours while awake and every 2 hours during the the night, keep the call bell within reach, keep the bed in the lowest position while the resident was in bed, and for the resident to wear non-skid socks while in bed. On 10/19/11 at 5:30 AM the nursing notes revealed that Resident #1 was found on the floor, and complained of hip pain. The note did not indicate which hip the pain was located in. The clinical record did not revealed that the nurse performed a physical assessment to determine if there were any injuries. The clinical record did not indicate the resident's physician was was notified. Review of the clinical record revealed the facility had developed a fall prevention plan of care on 10/19/11. The problems identified on the fall prevention care plan were cognitive status, unsteady gait, history of falls and recent fall. On 10/19/11 the care plan indicated a fall review on 10/19/11 and included the need for a personal pressure alarm to the resident's bed and chair. On 10/20/11 at 5:30 AM the nursing notes revealed that Resident #1 was found attempting to get out of the bed. The nursing notes indicated that Resident #1 was assisted to the bathroom by the certified nursing assistant (CNA). Per the nursing notes Resident #1 was left in the bathroom unattended and slid down onto the floor. She sustained a small abrasion to the left upper thigh. There were indication further assessment of the resident was done. On 10/20/11 the fall prevention care plan revealed a fall review dated 10/20/11. The fall review indicated the resident would need the Starlight program and for staff to stay with the resident during toileting. (The Starlight program is a structured program for cognitively impaired residents in order to provide a safe environment. Admission criteria to the program include residents that are deemed to be at high risk for falls due to poor safety awareness.) Review of the nursing documentation for 10/21/11 does not indicate that Resident #1 attended the Starlight program as per the plan of care. On 10/22/11 at 12:35 PM the nursing notes revealed that Resident #1 was found on the floor in her room. The note indicated the resident was taken to the Starlight program after she fell . On 10/23/11 at 2:00 PM the nursing notes revealed Resident #1 was resting in bed, no complaints of pain and range of motion was within normal limits. The documentation did not indicate the resident had attended the Starlight program. The nursing notes on 10/23/11 at 5:00 PM revealed the Resident #1's son was in to visit. The son informed the nurse that his mother was in a lot of pain and had called rescue. Another entry to clinical record on 10/23/11 at 7:00 PM revealed the resident had been assessed at 5:00 PM and the resident was unable to lift her left foot. The notes indicated the physician's assistant was contacted a verbal order for an x-ray of the resident's left foot was obtained. The noted indicated that the family had called 911 and the resident was taken to the hospital. On 10/25/11 at 12:40 PM an interview was conducted with the nurse assigned to Resident #1 between 7:00 AM and 3:00 PM on 10/22/11 and 10/23/11. The nurse was asked about the fall that occurred on 10/22/11 regarding Resident #1. He stated that Resident #1 was sitting in the wheelchair in her room and attempted to get out of the wheelchair unassisted and the alarm on the chair sounded. By the time the CNA responded the resident was on the floor. When asked what he did to assess her for injuries he stated he checked for range of motion. Per the nurse the resident did not complain of pain. The nurse stated the staff assisted her back to the wheelchair and took her to the Starlight program in the dayroom. When the nurse was asked asked if Resident #1 had been in the Starlight program in the morning, he stated no she was in her room. The nurse was asked if he was aware of any changes in the resident's condition on 10/23/11, and he indicated the resident was in the Starlight program all day and he had not observed any changes. On 10/25/11 at 12:55 PM an interview was conducted with the CNA assigned to Resident #1 between 7:00 AM and 3:00 PM on 10/22/11 and 10/23/11. When asked if the had attended the Starlight program that day she indicated the resident did not attend the program in the morning, but did attend after she fell . She further stated that Resident #1 had breakfast in bed. After the resident ate breakfast the CNA stated she got the resident up and dressed her after 9:00 AM. The CNA stated she left Resident #1 in her room in the wheelchair with the personal alarm attached. Around 12:35 PM she stated she heard the resident's alarm and found her on the floor in the bathroom. The CNA advised she called for the nurse to come and assess the resident. The CNA was asked if Resident #1 had complained of pain, she stated she had complained of pain in her back. The CNA stated the nurse gave her some pain medication. The CNA stated that after Resident #1 was placed back in her wheelchair she asked the nurse if she could take the resident to the Starlight program and the nurse agreed. .

Based on staff interviews and record view the facility failed to implement interventions in order to reduce the risk of accidents for 1 (Resident #1) of 3 sampled residents at risk for falls. Resident #1 suffered a fractured hip because the facility failed to implement the interventions identied on the Fall Prevention plan of care. The findings include: Clinical record review revealed that Resident #1 was admitted to the facility on [DATE]. An initial nursing assessment was conducted on 10/18/11 at 5:30 PM and indicated the resident's admitting [DIAGNOSES REDACTED]. The initial nursing assessment performed on 10/18/11 revealed that Resident #1 was forgetful, and alert. Section "G" of the initial admission data revealed that Resident #1 was inconsistent in understanding her limitations, had had two falls within the last month and had a history of [REDACTED]. Section "H" of the initial admission data revealed that this section was the initial plan of care and preferences for Resident #1. This initial care plan goals included to minimize risk of accidents/injuries. Interventions to accomplish the goal included but were not limited to assisting the resident to the toilet every 2 hours while awake and every 2 hours during the the night, keep the call bell within reach, keep the bed in the lowest position while the resident was in bed, and for the resident to wear non-skid socks while in bed. On 10/19/11 at 5:30 AM the nursing notes revealed that Resident #1 was found on the floor, and complained of hip pain. The note did not indicate which hip the pain was located in. The clinical record did not revealed that the nurse performed a physical assessment to determine if there were any injuries. The clinical record did not indicate the resident's physician was was notified. Review of the clinical record revealed the facility had developed a fall prevention plan of care on 10/19/11. The problems identified on the fall prevention care plan were cognitive status, unsteady gait, history of falls and recent fall. On 10/19/11 the care plan indicated a fall review on 10/19/11 and included the need for a personal pressure alarm to the resident's bed and chair. On 10/20/11 at 5:30 AM the nursing notes revealed that Resident #1 was found attempting to get out of the bed. The nursing notes indicated that Resident #1 was assisted to the bathroom by the certified nursing assistant (CNA). Per the nursing notes Resident #1 was left in the bathroom unattended and slid down onto the floor. She sustained a small abrasion to the left upper thigh. There were indication further assessment of the resident was done. On 10/20/11 the fall prevention care plan revealed a fall review dated 10/20/11. The fall review indicated the resident would need the Starlight program and for staff to stay with the resident during toileting. (The Starlight program is a structured program for cognitively impaired residents in order to provide a safe environment. Admission criteria to the program include residents that are deemed to be at high risk for falls due to poor safety awareness.) Review of the nursing documentation for 10/21/11 does not indicate that Resident #1 attended the Starlight program as per the plan of care. On 10/22/11 at 12:35 PM the nursing notes revealed that Resident #1 was found on the floor in her room. The note indicated the resident was taken to the Starlight program after she fell . On 10/23/11 at 2:00 PM the nursing notes revealed Resident #1 was resting in bed, no complaints of pain and range of motion was within normal limits. The documentation did not indicate the resident had attended the Starlight program. The nursing notes on 10/23/11 at 5:00 PM revealed the Resident #1's son was in to visit. The son informed the nurse that his mother was in a lot of pain and had called rescue. Another entry to clinical record on 10/23/11 at 7:00 PM revealed the resident had been assessed at 5:00 PM and the resident was unable to lift her left foot. The notes indicated the physician's assistant was contacted a verbal order for an x-ray of the resident's left foot was obtained. The noted indicated that the family had called 911 and the resident was taken to the hospital. On 10/25/11 at 12:40 PM an interview was conducted with the nurse assigned to Resident #1 between 7:00 AM and 3:00 PM on 10/22/11 and 10/23/11. The nurse was asked about the fall that occurred on 10/22/11 regarding Resident #1. He stated that Resident #1 was sitting in the wheelchair in her room and attempted to get out of the wheelchair unassisted and the alarm on the chair sounded. By the time the CNA responded the resident was on the floor. When asked what he did to assess her for injuries he stated he checked for range of motion. Per the nurse the resident did not complain of pain. The nurse stated the staff assisted her back to the wheelchair and took her to the Starlight program in the dayroom. When the nurse was asked asked if Resident #1 had been in the Starlight program in the morning, he stated no she was in her room. The nurse was asked if he was aware of any changes in the resident's condition on 10/23/11, and he indicated the resident was in the Starlight program all day and he had not observed any changes. On 10/25/11 at 12:55 PM an interview was conducted with the CNA assigned to Resident #1 between 7:00 AM and 3:00 PM on 10/22/11 and 10/23/11. When asked if the had attended the Starlight program that day she indicated the resident did not attend the program in the morning, but did attend after she fell . She further stated that Resident #1 had breakfast in bed. After the resident ate breakfast the CNA stated she got the resident up and dressed her after 9:00 AM. The CNA stated she left Resident #1 in her room in the wheelchair with the personal alarm attached. Around 12:35 PM she stated she heard the resident's alarm and found her on the floor in the bathroom. The CNA advised she called for the nurse to come and assess the resident. The CNA was asked if Resident #1 had complained of pain, she stated she had complained of pain in her back. The CNA stated the nurse gave her some pain medication. The CNA stated that after Resident #1 was placed back in her wheelchair she asked the nurse if she could take the resident to the Starlight program and the nurse agreed. .