Every finding on record at Aviata at Sand Key

Based on record review, interviews, and facility policy review, the facility failed to implement and continue Cardiopulmonary Resuscitation (CPR) for one (#1) of three residents reviewed. Findings included: Record review of the facility's policies and procedures, Advanced Directives, last revised on [DATE], revealed the following:Policy: The Center will abide by stated and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. Record review of the facility's policies and procedures, Florida Cardiopulmonary Resuscitation (CPR), last revised [DATE], documented:Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure:In the event of cardiac arrest, immediately call for assistance.Two licensed nurses are to verify:Resident identificationFully executed Florida Do Not Resuscitate order (DH1896), located in the advanced directive section of the medical recordUse the paging system and call Code Blue to Room Number or location of the event three times.In the absence of a fully executed Florida Do Not Resuscitate order (DH1896) the Licensed Nurse will immediately begin CPR and will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if:The resident responds.Notify the physician and resident representative/legal representativeDocument in the medical record. A review of Resident #1's clinical chart, the face sheet, documented an admission on [DATE]. The diagnosis list included but not limited to acute and chronic respiratory failure with hypoxia; unspecified protein calorie malnutrition; type 2 diabetes mellitus with diabetic neuropath; morbid (server obesity due to excess calories); hemiplegia and hemiparesis following cerebral infarction; chronic obstructive pulmonary disease, unspecified; tracheostomy status. A review of a Brief Interview for Mental Status, dated [DATE], revealed a score of 3, which means severely impaired-never/rarely made decisions. A review of Resident #1's clinical chart revealed a Physician Evaluation of Resident #1 showing Resident #1's capacity to make health care decisions or provide informed consent, signed on [DATE] by the physician which documented the resident was incapacitated (not able to make decisions). An Affidavit of Health Care Proxy, dated [DATE], signed by Resident #1's family member, which indicated he would be responsible for health care decisions for Resident #1. The clinical chart revealed an advanced directives discussion, dated [DATE], signed by the family member. A review of Resident #1's chart revealed an Advanced Practice Registered Nurse (APRN)'s note, dated [DATE], which documented a discussion of code status for Resident #1. (Resident Representative) wishes for patient to remain a Full Code . A review of Resident #1's Care Plan, documented a focus area for Advance Directives: Full Code, initiated [DATE]. The goal: If the resident's heart stops beating, CPR (Cardiopulmonary Resuscitation) will be initiated per the resident's wishes through next review, initiated [DATE]. Interventions included: Full Code. On [DATE] at 1:40 p.m. an interview by phone was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C, CNA confirmed working on [DATE]. Staff C stated the day of the event, recalls two other CNAs completing rounds for Resident #1. Staff C stated overhearing the other two CNAs say Resident #1 did not look good. Staff C said, later around 8:30 a.m., while passing breakfast trays, Resident #1 was not breathing. Staff C, CNA stated I did a sternum rub, then went and got the nurse (Staff A, Registered Nurse (RN). Staff C, CNA said Staff A, RN went to the room and checked Resident #1 for a pulse. Staff A, RN then immediately called the Director of Nursing (DON). Staff C, CNA said, Staff A, RN was on the phone with him for a while. Staff C, CNA, said not seeing Staff A, RN initiate compressions or call a Code Blue. Staff C, CNA, said, I did not know she was a full code. On [DATE] at 11:28 a.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN) Unit Manager (UM). Staff D, LPN/UM stated, if a CNA finds a resident unresponsive, the CNA should immediately alert the nurse. The nurse verifies; if not breathing; verifies code status; and starts to delegate what needs to be completed for a Full Code or steps for DNR. CNAs are only able to assist with the process; no hands on with the CPR. Staff D, LPN, confirmed working on [DATE]. Staff D, LPN, stated arriving at work on [DATE], about 8:30 a.m. Staff D, said, I want to say it happened around 7:45 a.m. from my understanding. The DON notified me via phone, about 8:15 a.m. Staff D, LPN/UM stated the DON was aware first and notified us Resident #1 had passed away. Staff D, LPN/UM stated upon arrival to the unit, speaking with Staff A, RN. Staff A, RN told me she did not call the Code as it was already too late. Staff D, LPN/UM stated informing Staff A, RN it is never too late to call a Code for a resident who wishes to be a Full Code. Staff D, LPN/UM stated Staff A, RN reported Staff B, RN came to verify Resident #1 was not breathing, as well. Staff D, LPN/UM verified Staff B, RN had gone into the room and verified Resident #1 was not breathing. Staff D, LPN/UM stated Staff C, CNA, did the correct thing, notifying the nurse. The nurses should have verified code status, started compressions, verbalized Code Blue, and not stop compressions until EMT (emergency medical transport) arrived. On [DATE] at 11:51 a.m., an interview was conducted with Staff B, RN. Staff B, RN stated recalling the event on [DATE] with Resident #1. Staff B stated, being in the middle of the medication (med) pass when Staff A, RN came and got me to verify Resident #1 was not breathing, this was about 8:30 a.m. or 8:40 a.m. Staff B, RN, said, I went into Resident #1's room, checked for a pulse and respiration, Resident #1's lower extremities were cold to the touch. I told Staff A, RN, yes, Resident #1 passed. Staff B, RN stated leaving the room and returning to work. Staff B, RN said the unit manager was walking up the hallway as I returned to my med cart. Staff B, RN stated, I just assumed that my co-worker had checked the Resident's DNR (Do Not Resuscitate) status. If the resident has a DNR, two people can verify; call the doctor and pronounce. On [DATE] at 1:08 p.m., a phone interview was conducted with Staff A, RN. Staff A, RN stated recalling the event with Resident #1. Staff A, RN stated not feeling well on the day Resident #1 died, if I had it to do over again, I would have called off. Staff A, RN said Staff C, CNA informed me Resident #1 was dead, I immediately went to check Resident #1 for a pulse. I started CPR. Resident #1 was so stiff. I could not get a response. Staff A, RN stated leaving the Resident and went to inform the DON, via text. Staff A, RN stated Resident #1 was extremely stiff and had not experienced someone so stiff in her past. Staff A, RN said upon stopping CPR, exiting Resident #1's room, and called Staff B, RN at about 8:40 a.m. When Staff A, RN was asked if she had verified Resident #1's Code status, she stated, I know she was full code. I did two minutes of CPR. I should have announced a Code Blue. An interview was conducted on [DATE] at 4:38 p.m. with the DON regarding Resident #1. The DON stated, Staff A, RN, called my cell phone, approximately 8:40 a.m. Staff A, RN told me Resident #1 had died. The DON said Staff A, RN told me she started CPR and then stopped. Staff A, RN reported to me being in the room alone when performing CPR on Resident #1. The DON said Staff A, RN could not explain why she stopped CPR or why she did not call a code. The DON said upon arrival to the facility on [DATE] going to speak with Staff A, RN. The DON said he explained to Staff A, RN that she should have called a Code and initiated CPR. The DON said Staff A, RN explained she freaked out as she had a lot going on. The DON stated instructing Staff A, RN to call the doctor and family. The Advanced Practice Registered Nurse (APRN), (Staff E), was here, around 9:30. I told her the situation. I asked the APRN to go lay eyes on the resident, which she did. The DON said he called the Medical Director about 10:00 a.m., and informed him of the event. An interview conducted on [DATE] at 2:46 p.m. with Staff E, APRN. The APRN stated being in the building on [DATE]. The APRN stated being notified of Resident #1's death, although she did not go down and see the resident. On [DATE] at 4:10 p.m. a phone interview was conducted with the facility's Medical Director. He stated, From what I was told it was an unfortunate situation. The patient was found and seemed to be expired, and no CPR was performed despite her being full code. She was found in her room and was seen to be expired when found by nursing. I was told that the nurse did not administer CPR. The expectation for full code status is to at least try. If that's their wishes, that's their wishes. If it was me and she is full code I would have at least tried (if resident is cold). She should stop only when EMS (emergency medical services) arrives, when there is some higher level of care. The facility notified the ON CALL person to tell about the situation. Unfortunate for her, her family, and facility. The nurse's actions were not in line with my expectations, and they were not in line with the expectations of the DON. An interview was conducted on [DATE] at 1:40 p.m. by phone with the former Nursing Home Administrator (fNHA). The fNHA confirmed being in the facility on [DATE]. The fNHA stated the DON informed him someone coded and staff did not initiated CPR. The former NHA stated the nurse should have followed the policy and procedure; the nurse should have followed the Code Blue policy. I would expect the registered nurse to follow that.

Based on observations, interviews, and record review, the facility failed to implement effective pest control and prevention for three resident rooms (207, 407, and 415) located in two out of four nursing units in the facility. Findings included: On 7/11/26 at 9:50 AM an interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN stated there are quite a few pest sightings of roaches in residents' rooms, specifically room [ROOM NUMBER] and room [ROOM NUMBER]. Staff A, LPN stated you see most roach sightings closer to evening time, and if there is a sighting it is documented in the nurses station pest control log.On 7/11/26 at 9:56 AM an interview was conducted with a resident of room [ROOM NUMBER]. This resident stated their room has a couple issues with pests and to go speak with their roommate.On 7/11/26 at 10:02 AM room [ROOM NUMBER] was observed for any pest or roach sightings. In the corner near the bathroom door there was a .25 inch opening with several pest droppings and a roach observed.On 7/11/26 at 10:05 AM an observation of room [ROOM NUMBER] revealed a roach motel in the bathroom. The resident in room [ROOM NUMBER] stated they have observed roaches in the bathroom and around the room.On 7/11/26 at 10:20 AM an interview was conducted with the resident in room [ROOM NUMBER]. This resident indicated there were many roach sightings often in their room, and they come from the corner of their room and see them often in the bathroom. Multiple .5-1 inch holes were found alongside the corner of the resident's room with multiple pest/roach droppings on the floor in the corner area. In room [ROOM NUMBER]'s bathroom, in the bottom corner of the bathroom a .25 inch hole was observed with pest/roach droppings.On 7/11/26 at 11:28 AM an interview was conducted with the Nursing Home Administrator (NHA) and Staff B, Maintenance Assistant (MA). Staff B, MA stated the pest control company comes to the facility about once a month and treats the rooms noted in each nurses station pest log book. Staff B, MA stated they have implemented interventions for having issues with gnats and ants, but are unaware of any current roach issues. The NHA and Staff B, MA stated residents' rooms are not to have roach motels or any kind of pest control as it is a safety hazard for the resident.On 7/11/26 at 12:30 PM a tour to room [ROOM NUMBER] was conducted with the NHA. The NHA observed the .5-1 inch holes in the corner of room [ROOM NUMBER] and stated that is a hazard for potential pests to enter the resident's room. Upon entering room [ROOM NUMBER]'s bathroom, two live pests were observed crawling around the floor of the bathroom and the NHA confirming the pests being roaches.Photographic images obtained.A review of the facility's South Wing nurse's station pest log revealed no entries since 9/2025.A review of provided emails from the facility in communication with a pest control company dated 5/11/26 revealed the following:Pest company to the facility on 5/11/25 at 9:08 AM: After inspection several ant colonies has been found around the facility.Facility to the regional office on 5/11/25 at 11:55 AM: [Facility Name] has had ongoing issues with ants, despite sealing the baseboards and facility, they seem to get into the facility.A review of the facility's Pest Control Policy, dated 11/30/14, revealed the following: The facility will maintain a pest control program, which includes inspection, reporting, and prevention. Treatment will be rendered as required to control insects and vermin. Any unusual occurrence or sighting of insects should be reported immediately to the Supervisor.A review of the facility's Maintenance Policy, dated 11/30/14, revealed the following: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify areas/items in need of repair.

Based on record review and interview, the facility failed to respond to un-timely call bell light grievances voiced by Resident Council for three of three sampled months, June, July and August of 2024. Findings included: A review of Resident Council Monthly meeting notes, dated 06/27/2024, documented, Old Business, Issues from last meeting: Call lights have not been answered in a timely manner. The form continued, How are these issues being resolved?: Staff will rotate shifts to audit call light response times-Administrator and ADON (Assistant Director of Nursing) will do night shifts check-ins call lights. The form continued, New business: Blank A review of Resident Council Monthly meeting notes, dated 07/23/2024, documented, Old Business, Issues from last meeting: Residents have complained that their call lights are not being answered in a timely manner. The form continued, How are these issues being resolved?: Staff will do audits. The form continued, New business: Call lights are still bad . A review of Resident Council Monthly Meeting notes, dated 08/27/2024, documented Old Business, Issues from the last meeting: Call light responses. The form continued, How are these issues being resolved?: Administrator and staff are aware and conducted audits. The form continued, New business: Response time to call lights are horrible-the lights are light (like a) Christmas tree-staff are missing-employees on phones-staff have excuses to not help-3 pm-staff sit and nit (sic). On 09/05/2024 at 1:13 p.m., an interview was conducted with the Resident Council President. She confirmed the resident council meetings were held every month. When asked if the facility had responded to the concern voiced by Resident Counsel about the call bell lights, she stated no. She stated over the last three months, the response to the call lights had gotten worse. She said, because she was the president of the counsel, residents would come to her and complain about the call bell lights. She said, the staff were taking an hour and sometimes more to answer the light. The aid would come in, the resident would ask for something, and an hour later, the resident was still waiting. She said the worst was the 11 pm-7 am shift. An interview was conducted on 09/05/2024 at 1:57 p.m. with the Director of Nursing (DON). She stated she had started her position at the end of July 2024. She stated for call lights, timeliness, or un-timeliness, I have not done audits. I do not know if others have done call bell light issues. On 09/05/2024 at 2:36 p.m., the DON stated, back in June, the ADON (Assistant Director of Nursing) gave an in-service, there has been nothing since.

Based on observation and interview, the facility failed to ensure a safe and sanitary environment for residents as evidenced by discoloration on ceiling tiles in one of two resident day rooms; discoloration on ceiling tile in room [ROOM NUMBER] with evidence of water by the air conditioning wall unit; ceiling damage from rain in room [ROOM NUMBER]; discoloration on ceiling air vents above one of two nursing stations; and a fallen tree limb in one of one resident courtyard. Findings included: During the tour of the facility conducted on 09/05/2024 initiated at 9:30 a.m., the following physical plant observations were conducted. Photographic evidence obtained. At 9:30 a.m., an observation on the 300 hall, the resident day room, revealed three of the ceiling panels next to the fan had brownish, black, pinkish discoloration present. The discoloration was approximately 10 inches by 10 inches in size each, with one of the marks having grayish growth like material on top of the pinkish black. At 9:40 a.m., an observation on the 400 hall, resident room [ROOM NUMBER]. Three ceiling panels had brownish discoloration covering 25-50% of the panels located next to the window which had a room air conditioner (a/c) unit present. Under the a/c unit was a blanket on the floor. At 9:50 a.m., an observation of the south wing (100 and 200 hall) showed the A/C return vent, approximate 18 inches by 18 inches in size in the ceiling outside of the south wing resident day room had an accumulation of dust debris hanging on the slats. Five air vents, approximate 12 inches by 12 inches in size, in the ceiling around the nurses' station and in the halls had noticeable black discolored material present. The ceiling panels and the seams had dust hanging down in the ceiling panels above the nursing station by the ceiling fan. A corner of the ceiling across from the nursing station had ceiling panels with brownish beige discoloration. At 10:10 a.m., an observation was conducted of resident room [ROOM NUMBER]. The ceiling panels above the resident in bed A had been removed. The Maintenance Assistant was present and was interviewed. He stated when the wind blew, and it was raining, the water would come in through the vent in the roof. He was replacing the ceiling tiles above the bed due to water damage. An attempt to interview the resident in 121A was conducted at this time. He was not able to be interviewed. He would talk about other subjects that the questions posed. Observed his bed had a blanket over it to protect it. The ceiling tiles above his bed had been removed. The resident was sitting at bedside, dressed in seasonally appropriate clothing. On 09/05/2024 at 11:40 a.m., an interview was conducted with the Maintenance Director. He stated the facility had been cited before for unclean air vents. It was corrected back in March 2024. When asked how often the vents were cleaned, he stated probably not since March. He stated the building had no insulation, there was condensation, the panels were discolored continuously. He stated a vendor for roof repairs had been out to the facility approximately one month ago. He stated, this company used one vendor for the repairs, and he had not heard any updates since the vendor had come out. He stated for room [ROOM NUMBER], the discoloration in the ceiling tiles was from the roof leaking. He stated the blanket on the floor was because the water would pool outside the building, and it would come in through the frame of the wall a/c (air conditioning) unit. He stated, that was not the only room with that issue. He stated he had gone around the building and raked the leaves away in order to facilitate better drainage. He stated, really, there should be rocks out there and the trees cut back. He stated, there were downed branches from Tropical Storm [NAME], August 4-5, 2024, there was a big one in the courtyard. He stated, I had three tree trimmers come out within the last two weeks. The Administrator just sent the bids up to corporate yesterday. He stated, for the roof repair there was a process. He provided the process, roof repair procedure. He said, from the e-mail date, the request was sent up on 08/15/2024, because they asked for a facility map. An observation was conducted on 09/05/2024 at approximately 12:05 p.m. of the middle courtyard of the building with the Maintenance Director. An observation of the resident smoker's gazebo revealed the sidewalk, leading away from the gazebo to a fence with a gate, had a large portion of a tree laying across it. The tree limb was observed to be approximately 30 feet in length, the main branch approximately 12-14 inches diameter. The branches smothered the sidewalk. The Maintenance director stated at this time, the tree limb had come down during the tropical storm. He stated he had gotten two bids for the tree issue; the bids must go through corporate for approval. He stated one guy wanted to remove the trees because they look like they are dying; and he pointed to the tree that had lost the large section, which was hollow in the center. The Maintenance Director subsequently provided two documents which he stated were proposals. Review of one Proposal, invoice 1198 by (name of company, for $5400. Dated 10/03/24, which the Maintenance director stated, at approximately 12:15 p.m., the date was wrong, he thought the estimate was given approximately 1 month ago. Review of the proposal documented the labor description: Trim trees over roof throughout complex & remove 1 large limb laying on ground. Review of the second Proposal, quote 08/13/2024, from (name of company), dated 08/13/2024, for $6,200.00, documented the labor description: 4 Laurel Oak Trees (courtyard) Remove all large limbs over units & remove large deadwood 360 degrees. Remove all hanging limbs. Strongly suggested for removal all four trees are in decline. 2 Laurel Oak Trees (right rear) elevate & reduce, remove all large deadwood over structure. 2-3 large limbs. Remove. 2 Laurel Oak trees (left rear) elevate & reduce, remove all large deadwood over structure. 4 large limbs remove. 1 dead queen Palm (front) remove. All the Laurel Oaks on this property are approaching the end of their life cycle and are in decline. No further documentation of a commitment to remove the tree downed in the courtyard was provided. Subsequently, the Maintenance Director provided an e-mail document: Review of the e-mail dated 08/15/2024, to [Email address of tree company], documented a facility map with tree pictures had been provided to the e-mail address. No further documentation of a commitment to repair the roof was provided to the survey team. On 09/05/2024 at 12:25 p.m. an interview was conducted with the Activities Director. When asked if he conducted activities out in the courtyard with the residents, he stated yes. He stated, mainly at this time it was supervised smoking. But we have done tea parties, corn hole games, or other games. Yes, the branch had been laying there since the tropical storm, it had been a while.

Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services to residents on four (100, 200, 300 and 400) of four halls observed Findings Include: 1. On 1/29/2024 at 7:00 AM an observation occurred of Staff O, Registered Nurse (RN) stating to another employee, I refuse to take over two medications carts that are across the building, that is too much. On 1/29/2024 at 7:30 AM an observation of Staff O, RN was in the Nurse Manager office stating, only taking the cart accepted on the 300 hallway and to accept the cart for 100 hallway is too much for one nurse. On 1/29/2024 at 7:45 AM an observation of Staff O, RN speaking to Staff C, RN. Staff O, RN explained that Staff O, RN would not be taking over the care of the residents on the 100 cart. An interview was conducted with Staff C, RN on 1/29/2024 at 10:45 AM. Staff C, RN stated I am the only nurse on this unit, the other nurse scheduled did not show up. I am currently responsible for 47 residents. An interview was conducted with the Staffing Coordinator (SC) on 1/29/2024 at 11:10 AM. The SC stated we usually staff 4 nurses on day (7a-3p) shift, although we are trying to split the assignment down to 3 nurses. Today, we had a nurse, no call no show and another nurse who called off. We are not utilizing any agency for staff, management decided we could work with 3 nurses today. We have a total of 90 residents on the 4 hallways. Continuing, she said I am not aware [Staff O, RN] refused to assist with the 100 hall residents, I will have to go find out. An interview was conducted with the SC on 1/29/2024 at 11:45 AM. The SC stated the Licensed Practical Nurse (LPN) Unit Manager (UM) would be taking over the cart on the 100 hallway. An interview was conducted with Resident #66 on 1/29/2024 at 7:20 AM. Resident #66 stated it takes forever for the staff to answer the call light, stating It does not matter time of day or day of week, takes a long time. This makes me nervous, if I were to really need help. An interview was conducted with Resident #47's responsible party on 1/29/2024 at 1:29 PM. Resident #47's responsible party stated, I see some care areas lacking. The responsible party continued to state, I have to wipe him up when I come and massage his hands the staff don't seem to have time for any extras. An interview was conducted with Staff J, Certified Nursing Assistant (CNA) on 1/30/2024 at 4:20 PM. Staff J, CNA stated, I don't have time to finish all my work. The entire assignment of residents need total care (they are all dependent for all activities of daily living). When I mention this to the Director of Nursing (DON), I am told to just find someone to help you. I try to find someone to assist me although everyone is busy. No one has time to assist anyone else, plus I would need someone all day since the entire assignment is total care and requires two people for most everything. I can get the basics completed with the residents, change them, meals, etc. but any extra Passive Range of Motion, some documentation just doesn't happen. An interview was conducted with the SC on 1/31/2024 at 12:50 PM. The SC stated the facility only staff by the census. She continued saying We do not take any acuity into the equation. We usually try to schedule 5 CNAs for the first shift (11p-7a), 9 CNAs for second (7a-3p) and third (3p-11p) shift. Nurses work 12-hour shifts, and we schedule the nurses by numbers required, as well. Sometimes, 4 but we are trying to go to 3 for all shifts. An interview was conducted with Staff E, CNA on 1/31/2024 at 1:10 PM. Staff E, CNA stated staffing is terrible. I can barely finish my work, cannot usually finish my documentation or any little extra for my residents. I refuse to work two of the assignments as I don't know how the CNAs accomplish what they need to for the residents. An interview was conducted with Staff B, CNA on 1/31/2024 at 1:15 PM. Staff B, CNA stated the assignments are ridiculous, especially the front hall of 300. All the residents are total care, require 2-person assistance. The facility just staff by the number. I can get the very basic completed, ensure they are clean and dry, repositioned etc. but extras are not possible. Documentation is just barely completed. An interview was conducted with the DON and the Nursing Home Administrator (NHA) on 2/1/2024 at 8:55 AM. The DON stated the facility staffed by the minimum requirements. The floor nurses complete the assignments for the CNAs prior to the beginning of the shift. This usually happens by the number of residents they care for. The DON stated The CNAs don't like it if the numbers are not the same. I educate them to assist each other out if an assignment is more challenging than another. Continuing, the DON stated For example, if one CNA has 4 showers on that shift and another CNA only has one shower assigned. The CNA with only one should assist the CNA with 4. The NHA stated we discussed earlier in the week at looking how the resident's acuity is taken into account for the assignments. 37999 2. An interview was conducted with 1/29/24 at 8:35 a.m. with Staff N, Certified Nursing Assistant (CNA), who stated sometimes the unit (400) will go down to 2-3 aides if the facility pulls a floor aide to go on transport. She stated she is able to get work done if there were 4 (aides) sometimes 3 depending on the residents. An interview was conducted with Staff P (CNA) on 2/1/24 at 11:19 a.m. The staff member reported not being able to get everything done, and when the unit went down to 3 aides, assignment was going to be 15, 15, and 14 residents for the remaining aides. Staff P stated it can't be about the family and residents. A review of the schedule board showed 4 aides were assigned to the unit at the time. Staff P, Staff L (CNA) and Staff T (RN) reported one aide had left at 11:00 a.m. 39438

Based on interviews and record review, the facility failed to ensure screening and eligibility to offer the COVID -19 vaccine and vaccine education regarding the benefits and potential side effects was documented according with national recommendations for five (# 12, #77, #15, #55 and #20) out of five resident immunization records reviewed. Findings Included: A review of the facility's admission forms, provided to all new admissions did not reveal COVID-19 immunization education, refusal or consents related to vaccines. On 1/30/24 at 2:25 p.m. during an interview the Director of Nursing (DON), said vaccine administration is documented in the Medication Administration Record (MAR). When vaccine education is provided the Vaccine Information Sheet (VIS) is scanned to the resident's Electronic Health Record (EHR). Documentation can also be found in the immunization section of the EHR. A request was made for the facility's immunization policies. On 1/31/24 at 10:15 a.m. an interview was conducted with the DON said this is what I found. Documentation of screening, and eligibility to offer the COVID -19 vaccine, and education regarding the benefits and potential side effects of the vaccine was not provided for Residents # 12, #77, #15, #55 and #2. The DON failed to provide a Covid-19 immunization policy throughout the survey. Review of facility's policy and procedure subject, Admission Assessment, effective 11/30/2014 and revised on 8/22/2017. -Procedure: at the time of admission or readmission, the nurse shall initiate the admission data collection form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with the resident and a family and review of the resident's available medical records. The data collection form or its electronic equivalent will be completed within 24 hours.

Based on interviews and record reviews, the facility failed to ensure the resident's medical record included documentation indicating the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations; and the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal for five (#12, #77, #15, #55 and #20) out of five resident immunization records reviewed. Findings Included: A review of the facility's admission forms, provided to all new admissions did not include influenza and pneumococcal immunization education and vaccine consents. A review of the immunization and miscellaneous sections of the resident's Electronic Health Record (EHR) where vaccine administration and related education are documented was conducted. Residents #12, #77, #15, #55 and #20 EHR was silent for documentation indicating the resident or the resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations; and the resident either received the immunization or did not receive the immunizations due to medical contraindications or refusal. A review of residents #77, #15, #55 and #20 did not reveal documentation the influenza vaccine was offered and/or administered between 10/1/23 and 2/1/24 per facility policy. On 1/30/24 at 2:25 p.m. during an interview the Director of Nursing (DON) said, vaccine administration is documented in the Medication Administration Record (MAR) of the EHR. Evidence regarding vaccine education was the Vaccine Information Sheet (VIS) is scanned to the Electronic Health Record (EHR). Immunization administration documentation can also be found in the immunization section of the EHR. A review of EHR did not reveal influenza and pneumonia vaccines were offered to residents #77, #15, #55, #30 and immunization education was provided. The DON said she would provide immunization records residents # 12, #77, #15, #55 and #20. (Photographic Evidence Obtained) On 1/31/24 at 10:15 a.m. during an interview the DON said this is what I found and provided several sheets of paper. The DON said documentation regarding resident influenza and pneumonia immunization status is missing and the facility will have to start over verifying resident's immunization status and providing vaccine education. Review of facility's policy titled, Pneumococcal Vaccine, version 2.1. -Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/ pneumococcal infections. Policy and interpretation and implementation 1. Prior or upon admission, residents will be as for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Before receiving the pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. Review of facility's policy and procedure subject, Influenza Vaccine- Resident, revised on 8/17/2020, showed. -Policy residents will be offered the influenza vaccine annually (between October 1st and March 31st unless otherwise directed by the CDC) to encourage and promote the benefits associated with vaccinations against immunization, in accordance with the local health department and Centers for Disease control guidelines. 1. Provide resident and resident /. representative education on potential side effects and risk and benefits of the vaccine -Provide a copy of the Vaccine Information Sheet (VIS) from the Centers for Disease Control (CDC) 2. Obtain informed consent from them. resident / resident representative if indicated. 3. Obtain a physician's order. 4. Administer the vaccine and document on the Medication Administration Record 5. File the informed consent in the medical record. 6. Document in the medical record included. -Education including potential side effects of the vaccine. -Resident received the vaccine. -The resident did not receive the vaccine due to medical contraindication, has received the vaccine outside of the center, or refused. Review of facility's policy and procedure subject, Admission Assessment, effective 11/30/2014 and revised on 8/22/2017. -Procedure: at the time of admission or readmission, the nurse shall initiate the admission data collection form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with the resident and a family and review of the resident's available medical records. The data collection form or its electronic equivalent will be completed within 24 hours.

Based on observations, interviews, and policy review, the facility failed to ensure infection control practices were followed related to 1.) cleanliness and prevention of biogrowth on two (north and south) ice machines; 2.) use of Personal Protective Equipment (PPE) as required by door signage for two (#342, #20) of two residents; 3.) hand hygiene on three of four halls (100, 200 and 400) halls; and 4.) cleanliness of resident equipment/supplies in resident rooms for residents #47 and #66 Findings included: On 1/13/24 at 8:20 a.m. during observation of the North and South Clean utility rooms. The Ice machines (bins) had what appeared to be yellow mineral deposits and grayish black bio growth. (Photographic Evidence Obtained). On 1/31/24 at 8:45 a.m. the Nursing Home Administrator (NHA) was accompanied to observe the ice machines. The NHA said she was not sure if the housekeeping or maintenance staff was responsible for cleaning the ice machines. The NHA took photographs of the ice machine. Copies of the ice machines cleaning logs and maintenance service invoices were requested. On 1/31/24 at 08:50 a.m. the Environmental Services Director (EVS) said it was the maintenance department's responsibility to clean the ice machines. On 1/31/24 at 9:30 a.m. the NHA said the ice machine bins in the North and South clean utility rooms have been placed out of commission. She said she will provide ice machine cleaning logs and service invoices. On 2/1/24 the NHA provided a [brand name], Instruction Manual, issued 4/18/2016, revised 10/14/2022, cleaning and sanitizing instructions revealed -The ice dispenser must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions. Throughout the remainder of the survey the facility failed to provide copies of the ice machines cleaning logs or maintenance invoices. On 1/31/24 at 10:34 a.m. during interview and observation of the facility's laundry area was conducted with the Environmental Services Director. In the clean side of the laundry area, mechanical lift slings were hanging from wall hooks and resting directly on the floor. On 1/31/24 at 1:09 p.m. during an interview Staff H, Certified Nursing Assistant (CNA), said it is easy to know when residents require PPE because isolation precautions signs are posted on the room doors. A tour of 100 and 200 halls was conducted with Staff H. Two separate isolation rooms were observed (100 and 200 halls) with residents in Special Droplet/ Contact Precautions signs. The sign on 100 hall contained x beside the precaution's instructions while the same sign on 200 halls did not. Staff H, CNA, said she did not know what the sign with the x meant. (Photographic Evidence Obtained) A review of Resident 342's admission record revealed admission to the facility on [DATE]. Resident 342 diagnoses include cellulitis (inflammation), and methicillin resistant staphylococcus aureus (MRSA) infection. A review of Resident # 342's Medical Certification for Medicaid Long-term Care Services and Patient Transfer form (3008), signed 1/22/24 revealed MRSA infection in the wound. A review of physician order for Resident # 342 written on 1/25/24 revealed evaluate for possible scabies. A review of physician order for Resident # 342 dated 1/29/ 24 at 10:39 a.m. revealed an order for Contact precautions- MRSA in wound. A review of Resident #342's admission orders revealed both ankle wounds should be cleansed, and dressing applied every night shift. On 1/29/24 at 7:30 a.m. Staff N, CNA, was observed entering and exiting Resident #342's room without wearing PPE. An interview was conducted and Staff N, CNA, said I do not have any residents on isolation. During an interview on 01/29/24 at 7:32 a.m. Resident # 342 said she was admitted to the facility on [DATE]. She was told at the hospital she had scabies and needs a pill to treat the condition. Resident #342 said her wound dressings had not been changed since Friday night 1/26/24. A scattered rash was observed on Resident #342's right forearm. During an interview one 01/29/24 10:37 a.m. the Director of Nursing (DON) said Resident #342 was on Contact isolation for MRSA in wound. The DON was notified of staff observations entering and interacting with the resident without the use of PPE. The DON confirmed if it was noted on admission Resident #342 was in contact isolation for MRSA in wound, the admission staff should have initiated the appropriate isolation precautions. Review of the admission records for Resident #20's admission record revealed Resident #20 was admitted on [DATE] with diagnoses including diabetes, renal disease, right below the knee amputation. Review of Resident #20's order listing report revealed the following: -Enhanced contact precautions for C. Auris. Must wear gown and gloves when providing intimate care dated 9/7/23. Isolation-Contact: Enhanced Barrier dated 11/21/23. Observation of Resident #20's room door revealed a sign titled Contact Precautions posted Resident #20's room door revealed the following instructions: -Perform hand hygiene -Wear gown before entering and remove upon exiting -Wear gloves before entering and remove upon exiting On 1/29/24 at 9:30 a.m. observation and interview conducted with Resident #20 who in reference to the isolation sign stated Don't know what it means, people come in and out don't know what the sign is for. Resident #20 said he has lived at the facility a little over a year. Review of Resident # 45's admission record revealed admission to the facility on [DATE] with diagnoses to include chronic respiratory failure, dependence on supplemental oxygen, and diabetes. Review of Resident #45's Order Listing Report revealed on 1/23/24 Isolation droplet precautions due to COVID-19. An observation on 01/29/24 at 7:23 a.m. revealed Resident # 45's room door had signage special droplet/ contact precautions sign posted. The sign revealed the following. -Everyone must clean hands when entering and leaving the room -Wear facemask at all ties (N-95 or higher-level respirator for aerosol generating procedures) -Wear eye protection -Gown and glove at door -Keep door closed -Use patiently dedicated or disposable equipment. Clean and disinfect shared equipment. On 01/29/24 at 8:29 a.m. an unidentified facility staff member was observed entering resident #45's room. The Staff member did not wear eye protection; a second staff member was observed entering the room to provide assistance and did not wear eye protection. 01/31/24 at 9:32 a.m. during observation of the south shower room shower chairs, mechanical lifts and wheelchairs are all commingled with no indication if the equipment is clean or dirty. An interview was conducted with Staff B, Certified Nursing Assistance (CNA) at the time of the observation who said I always clean the shower chair before I use it, it is common Sense. Review of facility's policy titled, Infection Control, undated, version 1.3 revealed. - Policy statement This facility's infection control policies and practices are intended Review of facility's policy titled, Cleaning and Disinfection of Resident-Care, undated, version 2.0 revealed. Items and equipment. to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. - Policy Interpretation and Implementation 1. This facility's infection control policies and apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers and the public alike, regardless, of race, color, national origin, religion, age, sex, handicap, marital or veteran status or payor source. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate and control infections in the facility. b. Maintain a safe sanitary, and comfortable environment for personnel, residents, visitors, and the general public. c .Establish guidelines for implementing isolation precautions, including stand and transmission-based precautions; d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission-based precautions. e. Maintain records of incidents and corrective actions related to infections and f. Provide guidelines for the safes cleaning and reprocessing of reusable resident-care equipment. 3.The Quality Assurance and Performance Improvement Committee (QAPI), through the Infection Control Committee, shall establish, review, and revise infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. 5.The administration and governing board, through the QAPI and infection control committees, has adopted infection control policies and practices. Inquiries concerning our infection control policies and facility practices should be referred to the infection preventionist or director of nursing services. Review of facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, undated, version 2.0 revealed. -Policy statement: resident- care equipment including reusable items and durable medical equipment will be clean and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard. -Policy Interpretation and Implementation 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) 5 a. Single resident use items are cleaned/ disinfected between uses by a single resident and disposed of afterwards (e.g. bedpans and urinals) 6. Reusable resident care equipment is decontaminated and/ or sterilized between residents according to manufacturer's instructions. 7. Only equipment that is designated reusable is used by more than one resident. 9. DME is cleaned and disinfected before reuse by another resident. Review of facility's policy titled, Isolation - Categories of Transmission Based Precautions (TBP), undated, version 2.1 revealed. Items and equipment. -Policy Statement: transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.\ -Policy Interpretation and Implementation 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 2. Transmission based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it spreads from person to person. The three types of transmission-based precautions our contact, droplet and airborne. 3. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions. 4. The facility makes every effort to use the least restrictive approach to manage an individual's potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by a less restrictive method. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and type of precaution. a. The signage informs the staff of the type of CDC precautions, instructions for use of PPE, and/ or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. Contact Precautions 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganism that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. 2. The decision on whether contact precautions are necessary will be evaluated on a case-by-case basis. 3. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g. cohorting, placing with a row risk roommate). 4. Staff and visitors will wear gloves (clean, or non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage) b. Gloves will be removed, and hand hygiene performed before leaving the room. c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after a gown is removed. 6. When transporting individuals with skin lesions, excretions, secretions, or drainage that is difficult to contain, contact precautions will be taken join resident transport to minimize the risk of transmission. Droplet Precautions 1. Droplet precautions may be implemented for an individual documented or suspected to be infected with transmitted by droplets (large particle droplets [ larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 2. Residence on droplet precautions will be placed in a private room if possible. a. When a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors. b. When a private room is not available and cohorting is not achievable, a curtain will be used and a distance of at least three feet in space will be maintained between the infected resident and his or her roommate. c. Special air handling and ventilation are unnecessary and the door to the room may remain open. 3. Mask must be worn when entering the room. 4. Gloves, gowns and goggles should be worn if there is risk of spraying respiratory secretions. 48223 2. On 1/29/2024 at 8:20 AM, Staff D, Certified Nursing Assistant (CNA) was observed with procedure mask on. Staff D, CNA started to assist with the morning breakfast tray service to the residents of the 100 hallway. Staff D, CNA removed a breakfast tray from the meal cart outside the door of room [ROOM NUMBER]. room [ROOM NUMBER] had a droplet isolation sign posted on the door and a Personal Protective Equipment (PPE) supply cart outside the door. Staff D, CNA opened the meal cart, removed a tray, and proceeded into room [ROOM NUMBER], bed A. Placed the tray down and set up the meal, exited the room. No hand hygiene was observed. Walked to the coffee cart, which was located behind the nurse's station. Prepared a cup of coffee. Carried the cup back to room [ROOM NUMBER]. Entered and gave the coffee to the resident in bed A. Exited the room at 8:23 AM. No hand hygiene was observed. At 8:25 AM Staff D, CNA touched her procedure mask with her ungloved hands and requested Staff H, CNA assist her. Staff D, CNA walked directly back into room [ROOM NUMBER]. Staff H, CNA called to Staff D, CNA to come back and put on your PPE. Staff H, CNA, and Staff D, CNA donned gown and gloves. Staff D, CNA had a procedure mask on and Staff H, CNA had a KN95. Staff H, CNA went to two PPE carts looking for eye protection. Gave up and entered the room without eye protection. At 8:28 AM both CNAs were observed doffing the gowns and gloves inside the resident door, placed the gowns in the trash receptacle. Both removed gloves. Staff H, CNA donned a new pair of gloves and gathered up the overflowing trash bag. Proceeded to exit the room. While walking to exit the room, Staff H, CNA removed one glove and placed this glove in the hand of her other gloved hand, which was holding the trash bag. Exited the room. Proceeded to the soiled utility room. No hand hygiene was observed. Staff D, CNA doffed PPE inside resident room [ROOM NUMBER]. Exited room, walked to the nurses' station, attempted to open the bathroom door, was unsuccessful. Proceeded to the recreation/dining room, located in front of the nurses' station and washed her hands with soap and water. An interview was conducted with Staff H, CNA on 1/29/2024 at 2:05 PM. Staff H, CNA stated room [ROOM NUMBER]B has Covid and is on droplet isolation. Staff H, CNA noted a droplet sign on the door indicates the PPE needed to enter, gown, gloves, N95 or equivalent, and eye protection. Staff H, CNA stated proper PPE must be worn any time entering the room. Staff H, CNA confirmed no shield was available for eye protection and earlier in the morning no eye protection was available and had to enter the room without. Staff H, CNA confirmed no hand hygiene was completed at the time they exited the room. An interview was conducted with Staff D, CNA on 1/29/2024 at 2:35 PM. Staff D, CNA stated she only needed to wear PPE in room [ROOM NUMBER] when caring for bed B. Staff D, CNA was not able to differentiate between what PPE to wear in a contact isolation room and droplet. Staff D, CNA stated only if I am providing care do you need to wear PPE and this is when hand hygiene would be performed. Staff D, CNA confirmed no hand hygiene occurred earlier in the day. An interview was conducted with the Licensed Practical Nurse, Unit Manager (LPN, UM) on 1/29/2024 at 3:05 PM. The LPN, UM stated the staff know what PPE to wear by reading sign on the outside of the resident room door. The staff should utilize whatever PPE is on the sign. Proper hand hygiene should always be utilized regardless of isolation. Hand hygiene should be done when entering/exiting a room, don/doff PPE etc. On 1/29/2024 at 7:20 AM and 1/30/2024 at 2:30 PM, Resident #66's bathroom was observed with a bowl and eating utensil, sitting in the resident's sink, the dish was full of cloudy water. On the top of the toilet tank was a stack of dishes and utensils. (Photographic Evidence Obtained). An interview was conducted with Resident #66 on 1/29/2024 at 7:20 AM. Resident #66 stated the CNAs wash them for me if they have time. I utilize the dishes to make some of the food I have here in my room. The CNAs assist me with preparing and serving when I ask. He stated the CNAs must've forgotten to wash them. After they wash the dishes in my sink, they place them on the back of the toilet. On 1/29/2024 at 7:15 AM and 1/30/2024 at 10:30 AM, Resident #47's oxygen concentrator was observed with small particles of debris, crusted brownish particles and a light brownish liquid sticky in appearance dripping, all over the front of the machine. An interview was conducted with Director of Nursing (DON) on 1/31/2024 at 1:20 PM. The DON confirmed the dish in the sink appeared dirty and the dishes on the back of the toilet. The DON continued to state the dishes should not be stored in the bathroom. The dishes should be taken to the kitchen for proper sanitation. The DON continued to state the oxygen concentrator for Resident #47 was soiled and needed to be cleaned. A review of the facilities policy and practices titled, Infection Control, revealed: Policy: this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy interpretation and implementation: 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payer source. 2.d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission based precautions; . f. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities

Based on observations, record reviews, and interviews, the facility failed to store medications appropriately and safely as evidenced by improper temperature in one (north) of two medication room refrigerators, failed to ensure medications were stored when administering medications on one (100) out of four hallways, and failed to ensure medications were not left at the resident's bedside unattended in five (104a, 302, 303b, 304b, and 308b) of five resident rooms. Findings included: 1. On 1/31/24 at 7:56 a.m., an observation was conducted with Staff S, Licensed Practical Nurse (LPN) of medication administration. The staff member dispensed medications which were refused by the resident. Staff S walked to the medication room on the north unit to destroy the medications and the observation of the med room revealed the refrigerator door was open. The thermometer hanging inside the refrigerator read 68 degrees Fahrenheit. The staff member stated it was warm, and she had not noticed the door being open but did confirm the temperature could not have risen from the posted temperature taken by night shift of 36 degrees to the 68 in the seconds this writer brought the refrigerator to her attention. The refrigerator door was unable to shut, the staff member left it as is and left the room returning to the medication cart. The observation revealed several insulin pens and 2 pre-filled immunization-type syringes were left in 2 gray basins inside the warm refrigerator. The observation revealed staff members had recorded a refrigerator temperature of 36 Fahrenheit at 5:30 a.m. During the task of medication administration, on 1/31/24 at 8:07 a.m., Staff S was observed dispensing medication at the cart parked at the side of Resident #29's room. The resident was sitting in the doorway. The staff member left 3 pharmacy blister cards containing medications and 2 bottles of over-the-counter medications on the opposite end of the cart, while administering the medications to the resident. The staff member confirmed the medications were left on the cart, unsecured. An interview was conducted on 1/31/24 at 8:30 a.m. with Staff A, Licensed Practical Nurse/Unit Manager. The staff member observed the refrigerator in the medication room on the North unit. The door of the refrigerator continued to be open. The staff member became upset stating all the insulins, 9 pens, were not any good, would have to be reordered. Staff A examined the refrigerator and removed a slim yellow plastic bin from the door and reported it was the reason the door had not been able to shut. The Regional Nurse Consultant (RNC) arrived and stated the insulin would need to be reordered. and asked Staff A to ensure nurses had not removed any medications from the refrigerator. The policy - Storage of Medications, effective April 2018, revealed: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The procedure showed Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medications supplies are locked when not attended by persons with authorized access. All medications are maintained within the temperature ranges noted in the United States Pharmacopoeia and by the Centers for Disease Control: 1.Room temperature 59 to 77 Fahrenheit (F) 2. Controlled room temperature (the temperature maintained thermostatically) 68 to 77 F. 3. Refrigerated 36 to 46 F with a thermometer to allow temperature monitoring. 4. Frozen in the fridge freezer at 14 to 20 F. Review of the manufacturer information, unused Novolog should be stored in a refrigerator between 36 to 46 degrees F. (Information located at https://www.novo-pi.com/novolog.pdf) 39438 2. On 01/29/24 at 8:18 a.m., a medication cart was observed unlocked (photographic evidence obtained), with no staff in direct sight of the cart on the 100 hall. The nurse who was assigned to the cart was observed going into room [ROOM NUMBER] with medications and the cart was outside of room [ROOM NUMBER]. Two staff members walked by the cart and did not lock the cart. At 8:23 am., Staff C, Registered Nurse (RN), confirmed the cart was left unlocked. 48223 3. On 1/29/2024 at 6:35 AM and 1/30/2024 at 9:11 AM, two skin prep packets were observed on the top of the nightstand next to the bed of room [ROOM NUMBER] A. (Photographic Evidence Obtained). On 1/29/2024 at 6:50 AM and 1/30/2024 at 11:47 AM, Psyllium fiber supplement, Dulcolax laxative, and multiple packets of skin prep were observed on the top of the dresser of room [ROOM NUMBER]. (Photographic Evidence Obtained). On 1/29/2024 at 7:10 AM and 1/30/2024 at 9:15 AM, Dermal wound cleanser was observed in a basin on the top of the nightstand next to the bed of 303 B. (Photographic Evidence Obtained). On 1/29/2024 at 7:15 AM and 1/30/2024 at 9:05 AM, Hydrogen Peroxide bottle was sitting on the over the bed table, next to bed 304 B and dermal wound cleanser was in the bathroom, on top of the back of the toilet tank. (Photographic Evidence Obtained). On 1/29/2024 at 9:22 AM and 1/30/2024 at 9:40 AM, Dermal wound cleanser was observed on the nightstand next to the bed of 308 B. (Photographic Evidence Obtained). An interview was conducted with Staff T, RN on 1/31/2024 at 10:30 AM. Staff T, RN stated skin prep and dermal wound cleanser are considered medicine and require an order from a physician. Staff T, RN is not aware of any of the residents having self-administration orders. An interview was conducted with Staff A, LPN who confirmed Hydrogen Peroxide should not be left at the bedside of the resident. During an interview) on 1/31/2024 at 1:22 PM the Director of Nursing (DON) stated medications should not be left out in the open. Review of the facility policy and procedures titled: Medication Storage In The Facility, ID1: Storage of Medications, by Polaris Pharmacy dated April 2018. Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: . B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. D. Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately per facility policy. F. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart. I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. J. Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified. K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. L. All medications are maintained within temperature ranges noted in the United States Pharmacopoeia (USP) and by the Centers for Disease Control (CDC). 1) Room Temperatures 59 F to 77 F (15 C to 25 C). 2) Controlled Room Temperature (the temperature maintained thermostatically) 68 F to 77 F (20 C to 25 C) 3) Refrigerated 36 F to 46 F (2 to 8 C) with a thermometer to allow temperature monitoring. 4) Frozen in the freezer at 14 F to 20 F (-10 C to -7 C). Temperature: A. Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopoeia (USP) guidelines for temperature ranges. C. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F (2 C) and 46 F (8 C) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. D. Medications that should be frozen should be stored in the freezer at 14 F (-10 C) to -20 F(-7 C). E. The facility should maintain a temperature log in the storage area to record temperatures at least once day. F. The facility should check the refrigerator or freezer in which vaccines are stored at least two times a day, per CDC guidelines.

Based on record review and interview, the facility failed to ensure the arbitration agreements presented to two residents of of three residents reviewed provided for the selection of a venue convenient to both parties and selection a neutral arbitrator agreed upon by both parties. Findings included: Review of the Admission Agreement with a revised date of 8/19, page 13 and 14. Page 13, showed a heading of OPTIONAL ARBITRATION AGREEMENT. the fifth paragraph on page 13 shows: The parties agree that only one (1) arbitrator is required to resolve any Dispute(s) and the arbitrator shall be selected from a panel to be provided by the Facility. The panel shall consist of at least three (3) individuals who are qualified by the state to serve as an arbitrator, who have experience and knowledge of the health care industry or have served as mediators in health care malpractice claims, and who can certify they are neutral and impartial. If the parties agree to a single arbiter, the arbitrator's compensation and administrative fees related to the arbitration shall initially be paid by Facility. If the Facility prevails, then the arbitrator may order that the Resident/Representative reimburse it for any or part of any compensation or administrative fees paid. In the event the parties are unable to agree on a single (1) arbitrator, then a panel of three (3) is to be used (each party will select one (1) arbitrator and then the two (2) selected arbitrators shall select the third (neutral). If the parties cannot agree to a single arbitrator, then each party shall bear the cost of their selected arbitrators compensation and administrative fees and will pay half of the neutral's costs and fees. The panel may order the non-prevailing party to reimburse the prevailing party for any or part of any compensation or administrative fees paid. An interview was conducted with the Admission Director (AD) on 1/31/2024 at 8:59 AM. The AD confirmed responsibility of Admission Agreement, which includes the Arbitration Agreement. The AD stated that the wording of a panel to be provided by the Facility does not indicate a neutral arbitrator agreed upon by both parties. Appears the Facility chooses the panel for the Resident/Representative to choose from. An interview was conducted with the Nursing Home Administrator (NHA) on 1/31/2024 at 9:30 AM. The NHA reviewed the Arbitration Agreement and stated, a panel to be provided by the Facility. The NHA stated this does not sound like a neutral arbitrator agreed upon by both parties. An interview was conducted with the Nursing Home Administrator (NHA) on 1/31/2024 at 11:15 AM. The NHA returned and stated the legal department had been consulted and that a a panel to be provided by the Facility, not one chosen by the parties.

Based on observations and interviews, the facility failed to ensure one (north) of two nourishment refrigerator/freezer was maintained to prevent the potential for foodborne illness and to ensure that food items were dated and labeled. Findings Included: On 01/31/ 2024 at 9:00 AM an observation was made in North and South Nourishment Rooms with the dietary manager and Nursing Home Administrator. The North nourishment room was observed dirty with food items stored in the refrigerator and freezer not dated or labeled. On 01/31/2024 at 9: 20 AM an interview was conducted with the Certified Dietary Manager. He said the nourishment room refrigerator and freezer were maintained by the dietary staff daily. The refrigerators and freezers in the nourishment rooms should be kept clean. If food items are stored in the nourishment rooms staff must ensure those items are labeled and dated before they store food in the refrigerator or freezers. Staff are not allowed to store their own food in the refrigerator because it's only for the residents. If food is stored in the refrigerator of freezers the policy is that it must be discarded within three days. He stated In the North side nourishment room food should have never been stored in the refrigerator and freezer without being labeled or dated. I will give an in service to the nursing and dietary staff regarding food storage. On 1/31/2024 at 9:35 AM an interview was conducted with the Nursing Home Administrator. She said food should be labeled and dated before staff store any food items in the nourishment rooms refrigerator or freezers. We will have to provide further education for our staff regarding the usage of the nourishment rooms and food storage. Review of the facility policy titled Food and Supply Storage Effective date 11/30/2014, Policy: Food and supplies will be stored under sanitary and secure conditions and according to approved State and Federal standards, to retain the quality of products. The facility did not provide a completed food storage policy to reflect the facility storage guidelines as referred to in their food and supply storage policy. (Photographic evidence obtained)

Based on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and ten errors were identified for three (#86, #29, and #63) of six residents observed. These errors constituted a 28.57% medication error rate. Findings included: On 1/30/24 at 4:18 p.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #86. The staff member dispensed the following medications: - Lubiprostone 8 microgram (mcg) capsule - medroyprogesterone acetate 2.5 milligram (mg) - 2 tablets - Metformin Extended Release 850 mg tablet The staff member confirmed dispensing 2 tablets of medroyprogesterone and with a plastic spoon removed one of the tablets, taking it to the medication room where it was destroyed. Staff A stated I wouldn't normally. Review of Resident #86's Medication Administration Record (MAR) revealed the following medication was scheduled to be administered at the time of the observation: - medroxyprogesterone acetate 2.5 mg tablet - Give 1 tablet by mouth in the evening. During an interview on 1/31/24 at 3:27 p.m., the Director of Nursing (DON) said the expectation was for nurses to triple check, look at card (medication), the order, match the two. On 1/31/24 at 8:07 a.m., an observation of medication administration with Staff S, Licensed Practical Nurse (LPN), was conducted with Resident #29. The staff member dispensed the following medications: - Docusate sodium 100 mg tablet over-the-counter (otc) - Eliquis 5 mg tablet - Gabapentin 300 mg capsule - Metoprolol Tartrate 50 mg tablet - Amlodipine 10 mg tablet - 0.5 tab - Vitamin C 500 mg otc tablet Review of Resident #29's Medication Administration Record (MAR) showed the following medications were scheduled to be administered at time of the observation: - Aldactone 25 mg tablet (documented as administered),, scheduled at 9:00 a.m. - Sennosides 8.6 mg - 2 tablets (documented as administered), scheduled at 9:00 a.m. - Hiprex (Methenamine Hippurate) 1 gram (gm) (documented as administered), scheduled at 9:00 a.m. - Miralax 17 gm (documented as administered), scheduled at 9:00 a.m. - Ascorbic Acid 500 mg - 2 tablets, scheduled at 9:00 a.m. - Oxybutynin ER 5 mg (documented as administered), scheduled at 9:00 a.m. - Paroxetine 30 mg (documented as administered), scheduled at 9:00 a.m. On 1/31/24 at 8:38 a.m., an observation of medication administration with Staff T, Registered Nurse (RN), was conducted with Resident #63. The staff member dispensed the following medications: - Vitamin D 25 mcg over-the-counter (otc) tablet - Calcium + Vitamin D 500 mg otc tablet - Ferric X 150 mg otc capsule - Aripiprazole 15 mg tablet - Triamterene - HCTZ 37.5-25 mg tablet - Oxybutynin 100 mg ER tablet - Prazosin 1 mg capsule - Metformin 1000 mg tablet - Duloxetine 60 mg capsule - Losartan potassium 25 mg tablet - Gemfibrozil 600 mg tablet - Eye drops (Tetrahydrozoline) 0.05% otc Staff F confirmed dispensing 11 oral tablets. The staff member administered one drop of Tetrahydrozoline into right eye then one drop into the left eye. Review of Resident #63's Medication Administration Record (MAR) revealed the following errors were observed: - Cholecalciferol - Give 1000 mg by mouth one time a day. - Artificial Tears Ophthalmic 1% solution (carboxymethlcullulose sodium) During an interview on 1/31/24 at 3:40 p.m. the DON stated the eye drops administered were not what was ordered, and voiced no comment regarding the milligram dosage of Vitamin D. Review of the policy - Administration Procedures For All Medications (April 2018) revealed To administer medications in a safe and effective manner. The procedure instructed staff to Review 5 Rights (3) times, which included: - Prior to removing the medication package/container from the cart/drawer staff were to check MAR for order, check for vital signs and other tests, and prepare resident for medication administration. - Prior to removing the medication from the container staff were to check the label against the order on the MAR and note any supplemental labeling (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication). - After the dose has been prepared and before returning the medication to storage.

Based on observations, policy review and interview, the facility failed to provide a clean, clutter free, comfortable, and homelike environment in three (100 Hall, 200 Hall, 400 Hall) of four halls, and in one (#47) of one resident rooms. Findings included: 1. On 2/1/2024 the following observations were made: -In the clean utility rooms (North and South) multiple pieces of trash on the floor, flowerpot, walls without baseboards, baseboards with gunk, dirty floor tiles, air vents with hanging dust particles and dust on adjacent ceiling. (Photographic Evidence Obtained) -In the North and South shower rooms, the external toilet surface was dirty. The shower chair was noted with feces on the seat stored next to clean patient items. (Photographic Evidence Obtained). Staff M, Certified Nursing Assistant, who was present during the observation agreed there was feces on the shower chair seat and said, I will clean it now. During the survey between 1/29/24 to 2/1/24 the following was observed in multiple resident rooms: -peeling paint, scuffed and dirty walls, buckling baseboards, holes in the walls, furniture with groves, bedside table and dresser drawers that cannot close, missing dresser drawers, and dirty floors. (Photographic Evidence Obtained) Review of facility's policy titled, Infection Control, undated, version 1.3 revealed the following - Policy statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. - Policy Interpretation and Implementation 1.This facility's infection control policies and apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers and the public alike, regardless, of race, color, national origin, religion, age, sex, handicap, marital or veteran status or payor source. 2.The objectives of our infection control policies and practices are to: -Maintain a safe sanitary, and comfortable environment for personnel, residents, visitors, and the general public. -Provide guidelines for the safes cleaning and reprocessing of reusable resident-care equipment. Review of facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, undated, version 2.0 revealed the following: -Policy statement: resident- care equipment including reusable items and durable medical equipment will be clean and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard. -Policy Interpretation and Implementation 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) 9. DME is cleaned and disinfected before reuse by another resident. 48223 2. On 1/29/2024 at 7:15 AM, 1/30/2024 at 9:05 AM and 3:15 PM, and on 1/31/2024 at 10:30 AM, Resident #47's room floor had large spills of a brownish liquid on the floor between the A bed and B bed. The substance had a stickiness when touched with a gloved hand. (Photographic Evidence Obtained). During an interview on 1/31/2024 at 1:30 PM, the Director of Housekeeping confirmed there was a substance on the floor of Resident #47's room. The Director of Housekeeping stated the substance should have been mopped and cleaned up. Review of facility policy and procedure titled Healthcare Cleaning Policy, Policy Section: Environmental Services. Policy: To clean a facility to a measure of cleanliness routinely maintained in care areas of the health care setting as they are periodically monitored and audited with feedback and education. Procedure: 1. Floors and baseboards are free of stains, visible dust, spills and streaks. 2. Walls, ceilings and doors are free of visible dust, gross soil, streaks, spider webs and handprints. 3. All horizontal surfaces are free of visible dust or streaks (includes furniture, window ledges, overhead lights, phones, picture frames, carpets, etc.) 4. Bathroom fixtures including toilets, sinks, tubs and showers are free of streaks, soil, stains and soap scum. 5. Mirrors and windows are free of dust and streaks. 6. Dispensers are free of dust, soiling and residue and replaced/replenished when empty. 7. Appliances are free of dust, soiling and stains. 8. Waste is disposed of appropriately daily by housekeeping team as well as at shift change by nursing department. 9. Items that are broken, torn, cracked or malfunctioning are replaced. 10. High touch surfaces and client/patient/resident care areas are cleaned and disinfected with a hospital-grade disinfectant. 11. Non-critical medical equipment is cleaned and disinfected between clients/patients/residents.

Based on observation, interviews, and record reviews, the facility failed to ensure two residents (#20 and #78) out of two residents the at will right to access persons and services outside the facility. Findings included: On 1/30/23 at 02:50 p.m. Resident #20 was observed in his wheelchair in the lobby. On return to his room during an interview he said he enjoys going to [retail store] (close to the facility) to get snacks. Resident #20 said the Social Services Director (SSD) told him, Unsupervised leave of absence (LOA) was rescinded because the facility was told I [Resident #20] was observed behind a retail store smoking and drinking alcohol. Resident #20 said facility staff refused to identify who made the accusation. Review of admission records for Resident #20's admission record revealed [last] admitted [DATE] with diagnoses including diabetes, renal disease, right below the knee amputation. Review of Resident #20's order listing report revealed the following: -May go LOA per Nurse Practitioner (NP) last order date 5/4/23. -May go on LOA with staff supervision, last order date 10/05/23. Review of Resident #20's Annual Minimum Data Set (MDS) assessment, dated 11/16/23, Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Review of Resident #20's communication with Resident note, dated 10/18/23 at 12:58 p.m. by Social Services (SS) revealed; Note Text: Resident asking to have LOA reinstated. Informed him that the [doctor] has discontinued his LOA privileges due to suspicious behavior and he can only go out on an LOA with staff supervision. Informed him that if he needs anything such as snacks, lottery tickets, etc. he will need to call his brother and sister-in-law to provide it [for] him. Resident did voice understanding. During an interview on 1/30/24 at 3:13 p.m. the Director of Nursing (DON) referred discussions regarding Resident #20's LOA to the SSD. During an interview on 01/30/24 at 3:20 p.m. the Social Services Director (SSD) said Resident #20's LOA was rescinded because someone told the facility the resident doing unsavory things behind a retail store. The SSD said the facility's interdisciplinary team (IDT) makes decisions regarding LOA supervised or unsupervised status. The SSD said a second resident, Resident #78 unsupervised LOA status was rescinded by the facility. Review of admission record revealed Resident #78 was admitted on [DATE] with diagnoses including chronic ulcer (sores) of the lower leg and atherosclerosis (buildup of substances in the arteries) of right leg. Review of Resident #78's order listing report revealed the following: -May go [out on] LOA independently, ordered on 05/18/23. -May go out on leave of absence with supervision when arrangements recommend and found safe per care plan team, ordered 12/28/2023. Review of Resident #78's quarterly MDS assessment, dated 11/16/23, Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Review of Resident 78's communication with Resident note, dated, 11/24/2023 at 3: 00 p.m. by SS revealed; Note Text: Resident spoke to writer to discuss LOA, informed her that the Doctor and Advanced Registered Nurse Practitioner (ARNP) have talked to her that she can only have an LOA with supervision. During an interview and observation on 1/31/24 at 1:29 p.m. Resident #78 was dressed and sitting in a wheelchair. Resident #78 said the facility did not let the residents know that when on unsupervised LOA, the facility requires return before midnight. On two occasions, the resident returned to the facility after midnight and the facility rescinded unsupervised LOA orders. Review of facility's policy and procedure subject, Resident Rights, effective on 11/30/2014 revealed: Policy: Make residents and their legal representatives aware of residents' rights. Procedure: Residents and /or their representatives, will be made aware of their rights upon admission to the nursing home. Review of facility's policy and procedure subject, leave of absence, effective on 11/30/2014 and revised on 6/14/2021 revealed: Process: A patient/ resident is allowed a leave of absence (LOA) from the center in accordance with safe medical practice and state and federal regulations. During admission process/ residents receive information regarding the Leave of Absence procedure.

Based on observations, record reviews, and interviews, the facility failed to recognize, document, and educate staff regarding triggers for two (#74 and #14) out of two residents sampled for Post-Traumatic Stress Disorder (PTSD). Findings included: 1. On [DATE] at 9:34 a.m., Resident #74 was observed lying in bed with no lights, and the door and blinds closed. The resident reported falling during the night and the aide had been rude to her. The resident showed writer an approximate 6 inch abrasion to the right forearm. The resident said she does see psychiatry and has had suicidal ideations in the past. Review of Resident #74's Admission Record showed the resident was admitted on [DATE] and the diagnoses of unspecified Post-Traumatic Stress Disorder (PTSD) was added on [DATE]. Review of Resident #74's Level II Preadmission Screening and Resident Review, dated [DATE], showed the resident had a medical history included suicide attempt and opioid abuse with intoxication. The screening revealed the resident had prior psychiatry admissions, history of substance abuse, was noted to be homeless, and hospitalized after being found unresponsive. The review did not show the resident had been diagnosed with PTSD at the time of its completion. Review of Resident #74's Minimum Data Set (MDS), dated [DATE], revealed the resident had a diagnosis of PTSD, anxiety, and depression. The assessment showed the resident's Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating a moderate impairment of cognition. Review of Resident #74's Trauma Informed Care Evaluation, dated [DATE], showed the resident had answered yes to the following questions: - Any serious car accident, or a serious accident at work or somewhere else? --- If the event happened, did you think your life was in danger or you might be seriously injured? --- If the event happened, were you seriously injured? - Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill? --- If the event happened did you think your life was in danger or you might be seriously injured? --- If the event happened, were you seriously injured? - Have you ever had a life threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etcetera? - Before age 18 were you ever physically punished or beaten by parent, caretaker, or teacher so that: you were very frightened; Or you thought you might be injured; or you received bruises, cuts, welts, lumps, or other injuries? --- If the event happened did you think your life was in danger or you might be seriously injured? - Has anyone ever made or pressured you into some type of unwanted sexual contact? - Has a close family member or friend died violently, force example in a serious car crash, mugging attack, suicide or homicide? The evaluation did not include any triggers that may cause the resident retraumatization or comments. Review of Resident #74's Trauma Informed Care Evaluation, dated [DATE], showed the resident had answered yes to the following questions: - Any serious car accident, or a serious accident at work or somewhere else? --- If the event happened, did you think your life was in danger or you might be seriously injured? --- If the event happened, were you seriously injured? - Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill? --- If the event happened did you think your life was in danger or you might be seriously injured? --- If the event happened, were you seriously injured? - Have you ever had a life threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etcetera? - Before age 18 were you ever physically punished or beaten by parent, caretaker, or teacher so that: you were very frightened; Or you thought you might be injured; or you received bruises, cuts, welts, lumps, or other injuries? --- If the event happened did you think your life was in danger or you might be seriously injured? - Has anyone ever made or pressured you into some type of unwanted sexual contact? - Has a close family member or friend died violently, force example in a serious car crash, mugging attack, suicide or homicide? The evaluation did not include any triggers that may cause the resident retraumatization or comments. Review of Resident #74's Trauma Informed Care Evaluation, dated [DATE], showed the resident had answered yes to the following questions: - Any serious car accident, or a serious accident at work or somewhere else? --- If the event happened, did you think your life was in danger or you might be seriously injured? --- If the event happened, were you seriously injured? - Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill? --- If the event happened did you think your life was in danger or you might be seriously injured? --- If the event happened, were you seriously injured? - Have you ever had a life threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etcetera? - Before age 18 were you ever physically punished or beaten by parent, caretaker, or teacher so that: you were very frightened; Or you thought you might be injured; or you received bruises, cuts, welts, lumps, or other injuries? --- If the event happened did you think your life was in danger or you might be seriously injured? - Has anyone ever made or pressured you into some type of unwanted sexual contact? - Has a close family member or friend died violently, force example in a serious car crash, mugging attack, suicide or homicide? The evaluation did not include any triggers that may cause the resident retraumatization or comments. Review of Resident #74's care plan listed special instructions Only female caregivers for all tasks. Must be two staff member present at all times due to history of false allegations. The care plan did not reveal foci or interventions related to resident's history or diagnosis of PTSD and did not show the resident had any triggers related PTSD. During an interview on [DATE] at 1:07 p.m, Staff O, Registered Nurse (RN) stated Resident #74 had reported a diagnosis of PTSD and had listed on it the resident's list of diagnosis. The staff member stated the resident's triggers were not getting medications timely, wanting showers when the resident wanted showers, and stated I don't know what really is the trigger, maybe it's males going in the room. During an interview on [DATE] at 1:20 p.m. Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM), reviewed Resident #74's diagnoses and confirmed the diagnosis of PTSD. The staff member reported the resident would be smooth and mellow and every so often would walk out (into the hallway) naked. Staff A stated the resident's triggers were getting pain medication, tries to get everything (medications) at one time, no male aides, and suppose to have 2-persons for care. During an interview on [DATE] at 2:49 p.m., the Social Service Director (SSD) stated there were no (PTSD) triggers for Resident #74. The staff member reported the resident had quite a few behaviors, episodes of yelling out related to pain medications, making accusations regarding medications, come out of the room naked looking for medications, and has made allegations against staff regarding care, the reason for no males was the resident had made accusations against male caregivers. The SSD stated the resident had a care plan for mood and behaviors and confirmed PTSD should have been added. 39438 2. A review of the Admission Record showed Resident #14 was originally admitted on [DATE] with diagnoses of Alzheimer's disease, unspecified, schizoaffective disorder, unspecified, vascular dementia, unspecified severity, with agitation, unspecified dementia, unspecified severity, with other behavioral disturbance, brief psychotic disorder, major depressive disorder, recurrent, mild, other specified persistent mood disorders, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and personal history of other mental and behavioral disorders. Section C Cognitive Patters of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. Section E Behavior of the MDS showed Resident #14 had behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Section I Active Diagnoses of the quarterly MDS dated [DATE] revealed Resident #14 had the following psychiatric/mood disorders: anxiety disorder, depression, schizophrenia, and post-traumatic stress disorder. A review of the Progress Notes revealed the following notes: -[DATE] at 15:11- Resident had been agitated today. He was refusing to allow the nurse aide to give him a shower. Refused bed bath offered. Agitated at staff for changing soiled brief. -[DATE] at 11:11- Met with resident in room to ask about events over this weekend. Resident in bed with old western on TV, smiling, and appearing calm. He said, Oh, I just went over on the floor, I do that sometimes, I'm ok. When asked if he went to the floor on purpose, he responded, Yeah, when I get upset with them over something that is what I do. Encouraged resident in future to speak to staff and/or management as soon as he starts to feel upset so that we can help him and decrease risks for injuries. The Trauma Informed Care Evaluation dated [DATE] showed the only question marked yes was: 1. Have you ever served in a war zone, or have you ever served in a noncombatant job that exposed you to war related casualties? The evaluation revealed Resident #14 could not identify triggers that may cause re-traumatization and no triggers were listed on the evaluation. The Social Services assessment dated [DATE] revealed Resident #14 had a history of being verbally aggressive with staff, being physically aggressive, yelling at staff, and saying inappropriate things to staff at times. The care plans included a focus area related to behavior problems such as verbally aggressive, yelling out, calling staff inappropriate names, and throwing things. He had diagnoses of PTSD, depression, and anxiety. He was physically aggressive, will place himself on the floor, agitation, ran into med cart injured toes, pulls trim off handrails, and peels paint off walls/doors initiated on [DATE]. Interventions included administer medications as ordered, approach/speak in a calm manner, assist him with developing appropriate methods of coping and interacting, encourage him to express his feelings appropriately, explain all procedures to him before starting and allow him enough time to adjust to changes, explain/reinforce why behavior is inappropriate and/or unacceptable, if reasonable, discuss his behavior, psychiatry services as needed, redirect him as necessary, and social services will visitor to monitor behaviors as needed. The care plans included a focus area related to being at risk for distressed/fluctuating mood symptoms related to PTSD and depression initiated on [DATE]. Interventions included administer medications as ordered, attend PTSD groups at the VA, behavioral health consult as needed, encourage/assist him to maintain as much independence and control as possible, if he needs time to talk, encourage him to express feelings, provide empathy, reassurance and supportive listening, monitor/document and report increased anger, labile mood or agitation, monitor/document and report mood patterns to doctor as needed, and social services visits to provide support and monitor mood as needed. There was no care plan in place related to triggers for Resident #14's diagnosis of PTSD. On [DATE] at 12:34 p.m., Staff W, Licensed Practical Nurse (LPN), stated Resident #14 had PTSD bad. It can be really bad, stated Staff W, LPN. Continuing, Staff W stated He gets antsy towards the end of the day. He will throw himself out of the wheelchair and throw himself out the bed when he gets mad. He was in the war so he's had it for a while. She reported she was not sure what triggered him, stating He goes out for peer group meeting at a local hospital for PTSD. Once in the while he will lose it. He throws medications and throws things out the door while in his room. On [DATE] at 1:04 p.m., Staff H, Certified Nursing Assistant (CNA), stated his mood depends on the day. She was his assigned CNA and stated she took care of him often. She stated He throws himself out the bed. He was very demanding, but not aggressive. He goes to meetings at a local hospital every Thursday but every time he goes to the meetings, he comes back very upset. Staff H, CNA, stated she was not sure if he had PTSD, and she was not sure about what triggered him. She reported staff took his wheelchair from him once because he threw himself out of it. Staff H, CNA, stated she did not remember being educated on whether Resident #14 had PTSD and his triggers. On [DATE] at 2:39 p.m., the Social Services Director (SSD) stated Resident #14 gets upset, yells at staff, he's verbally aggressive, gets angry, and will say he wants to get out of the facility. She said they would call his wife if they couldn't calm him down. Continuing, The behaviors usually happen around an important date in his life like the day his mother died , the day his twin died , and the 4th of July was always a trigger which we all know because that's when he came back from Vietnam. When the wife calls, she speaks to the staff and that's how they are aware of the dates that may trigger him. His wife had not been coming in often due to her own health issues, but she normally calls. His wife would call and say if it was an anniversary of a death. There was no specific thing that triggered Resident #14 stated the SSD. The State Surveyor asked, What happens if she forgets to call or if she calls later that evening to tell staff about the important date in his life? She stated his wife would normally call ahead of time to keep an eye on him on certain dates. He goes out weekly every Thursday to a local hospital for PTSD group meetings and was followed by psychiatry at that hospital. A few weeks ago, she worked with him, and it was determined that he was just hungry as the reason he was acting out. He would throw a remote and coffee at staff, but it was not an everyday thing. The SSD stated she did not know his triggers. I don't know if any of us know, stated the SSD. The SSD stated they do a trauma assessment to see if there can be retraumatization. Resident #14 did not report any triggers when she completed the assessment with him. If a patient say, there are triggers then they would identify that on the care plan. She answered the questions on the assessment according to the answers he provided. The State Surveyor asked, Would the important dates or anniversaries of deaths provided by his wife be triggers? The SSD stated yes. She stated she would try to get exact dates from his wife to get them put on the care plan. She stated staff should look at care plans for triggers related to PTSD. She confirmed that triggers for PTSD were not listed on the care plan. The polices and procedures Trauma Informed Care effective [DATE] revealed the following: Policy: Residents will be evaluated to identify a history of trauma, triggers, and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization. Procedure: 1. Residents are evaluated for trauma, triggers and cultural preference on admission/ readmission, quarterly and annually. 2. Develop resident-center interventions based on trauma triggers and resident cultural preferences. 3. Develop a care plan and add interventions to the nurse aide Kardex. 4. Review and update care plan and interventions quarterly and as needed.

Based on observations, record reviews, and interviews, the facility failed to document a fall, assess the resident, and notify the physician of an injury for one (#74) out of four residents sampled for accidents. Findings included: During an initial observation and interview with Resident #74 on 1/29/24 at 9:34 a.m., the resident reported falling last night (1/28/24). The resident stated the Certified Nursing Assistant (CNA) and the nurse were aware of the fall. Resident #74 revealed a right forearm abrasion approximately 6 inches long that was reported as occurring during the fall the night before. Review of Resident #74's progress notes did not show the resident had a fall on the night of 1/28 or prior to the interview conducted on 1/29/24. During an interview with the Director of Nursing (DON) on 1/29/24, she stated she was unaware Resident #74 had fallen. Review of a late entry progress note, effective 1/29/24 at 1:27 p.m., showed Resident #74 had reported to the DON of a fall in the resident room while walking to the bathroom and scraping arm on the footboard of bed causing an abrasion to arm. An interview was conducted on 1/31/24 at 1:07 p.m., with Staff O, Registered Nurse (RN). The staff member reported the first thing to do when a resident fell was to ask them if they had pain, what happened, get vital signs, and if having pain call the physician, then stated the physician should be called regardless, call family if not own emergency contact, and start neurological checks. Staff O stated a fall assessment should be completed in the electronic record, a change in condition (form), a post-fall evaluation, and a fall risk scale. The staff member reported Resident #74 had scraped the right arm last week either Tuesday or Wednesday. During an interview on 1/31/24 at 1:20 p.m., Staff A, Licensed Practical Nurse /Unit Manager (LPN/UM) reported not knowing about Resident #74's fall. A review of the risk manager report revealed a fall had occurred on 1/29/23 at 12:22 a.m. but could not tell when the date or time the report had been completed. The staff member reported the fall should be documented in the clinical record and the physician should have been notified. On 1/31/24 at 3:01 p.m., the DON stated the nurse on Sunday night should have documented Resident #74's fall and assessment. She said the expectation was a risk management/incident report be completed as well as a fall risk assessment, pain assessment, skin assessment, post-fall assessment, and a change in condition (assessment). The DON reported the risk management information transfers into a progress note, the physician should have been notified of the fall and treatment orders received as needed. The policy - Fall Management, revised 7/29/19, showed Residents are evaluated for fall risk. A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as the result of an overwhelming external force (e.g. resident pushes another resident). The policy revealed Post-fall Strategies included: 1. Resident will be evaluated and post-fall care provided. 2. Initiate neurological tracts as per policy or directed by physician order. 3. Notify the physician in resident representative. 4. Re-evaluate fall risk utilizing the post fall evaluation. 5. Update care plan and nurse aid Kardex with interventions. 6. Initiate post fall documentation every shift for 72 hours. 7. Interdisciplinary team to review fall documentation and complete root cause analysis. 8. Update plan of care with new interventions as appropriate. 9. Review resident weekly times (x) four.

Based on observations, record review, and interviews, the facility failed to ensure splints were applied and oxygen flow rate was accurate and completed per physicians' orders for one (Resident #47) of one sampled resident. Findings included: Multiple observations were conducted of Resident #47, from 1/29/2024 at 6:50 AM to 2/1/2024 at 10:00 AM. Resident #47 was observed in his bed, with the head of his bed slightly raised without any splints, braces, abduction pillow, or palm guards. Resident #47 was observed during this time frame with a washcloth rolled up in the palm of his right hand. Resident #47's right and left hands were closed, fingers bent and touching the palms. The oxygen concentrator flow rate was set to 4.5 liters/minute (L/M). (Photographic Evidence Obtained). Review of the medical record for Resident #47 was conducted. The Admission Record revealed diagnoses that included persistent vegetative state, Traumatic Brain Injury with loss of consciousness of unspecified duration, person injured in a motor-vehicle accident, tracheostomy, gastrostomy, and other co-morbidities. The Minimum Data Set (MDS) assessment, dated 12/21/2023, revealed a Brief Interview for Mental Status (BIMS) score of 0/15 which meant the resident was severely cognitively impaired. The MDS revealed Resident #47 required total assistance with all activities of daily living (ADL) performance and had functional limitations in range of motion on both sides for upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle foot). The Order Summary Report with active orders as of 11/01/2023 reflected the following orders: Abduction pillow to be utilized at all times may remove for care and assessment of skin condition; resident to wear bilateral palm guards on in AM and Off in PM *Check skin for breakdown pre/post application*. Place rolled clean washcloth in hands over night and compressed, humidified Oxygen at 2 L/Min via trach collar. The Treatment Administration Record revealed documentation that the bilateral palm guards and abduction pillow were in place during the time from of 1/29/2024 to 2/1/2024. The Medication Administration Record revealed staff administered the Oxygen at 2 L/Min for the time frame of 1/29/2024 to 2/1/2024. An interview was conducted on 1/30/2024 at 3:15 PM with Staff F, Certified Nursing Assistant (CNA) assigned to resident #47. Staff F, CNA stated Resident #47 does not have any splints or other devices, we only put pillows under the heels, that is all. Staff F, CNA continued to state if the Resident were to have splints, they would be in the resident room. Staff F, CNA could not locate any splints or abduction pillows in the resident room. An interview was conducted on 1/30/2024 at 3:30 PM with Staff A, Licensed Practical Nurse (LPN) assigned to resident #47. Staff A, LPN stated the Resident should have a foam cushion between his legs to keep his knees apart and hand splints on. Staff A, LPN confirmed, Resident #47 has a washcloth in the palm of the right hand. Staff A, LPN confirmed no splints or abduction pillow was in the resident room. Staff A, LPN confirmed no splints or pillows in place and the treatment administration record had been marked as if they were available. Staff A, LPN confirmed the oxygen flow rate was set at 4.5 to 5 L/M. Staff A, LPN stated the physician orders for the oxygen flow rate was 2 L/M. An interview was conducted on 1/31/2024 at 10:45 AM with Staff B, CNA assigned to resident #47. Staff B, CNA stated caring for Resident #47 on a regular basis and is not aware of any splints or other devices. Staff B, CNA continued to state if the Resident were to have splints, they would be in resident room. Staff B, CNA could not locate any splints or abduction pillows in the resident room. An interview was conducted with the Director of Rehabilitation (DOR) on 1/31/2024 at 11:00 AM. The DOR stated familiarity with Resident #47 and therapy has recommended splints for the resident's contractures. The DOR continued to state the past medical records are not available at this time due to the company ownership change. The DOR stated the resident was currently placed on Occupational Therapy caseload for evaluation of range of motion, started 1/30/2024. An interview was conducted with the Director of Nursing (DON) on 1/31/2024 at 1:22 PM. The DON confirmed the Oxygen flow setting was set to 4.5 to 5 L/M. The DON continued to state the expectation is to follow all physician orders. Review of the facility policy and procedures on the subject of : Contractures, Prevention with a revision date of 8/22/2017 showed: Policy: To prevent contracture of extremities for those residents who no longer have full use of their extremities. All contracture prevention devices should be removed at least daily for hygiene and observation of skin conditions. Each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Procedure: . Positioning: Some residents may have braces or splints to prevent or help release contractures - be sure to follow the physician's order regarding the schedule of when to put these on and when to remove them. Review of the facility policy and procedures on the subject of: Oxygen Therapy with a revision date of 8/28/2017 showed. Policy: Oxygen therapy is the administration of a FiO2 [fraction of inspired oxygen] greater than 21% by means of various administration devices to: Equipment: the selection of an appropriate oxygen delivery device is based on the FiO2 necessary to reduce or correct the hypoxemia, provide resident comfort and is practical to use for that individual. The type must be sized properly to avoid skin irritation and nasal obstruction. Procedure: *Physician's order for oxygen therapy shall include: *Administration modality *FiO2 or liter flow .

Based on observations, interview, and record review, the facility failed to develop and implement a care plan related to a urinary catheter for one resident (# 62) out of three residents sampled. Findings included: On 01//30//24 at 9:00 AM., Resident was observed laying in bed with his call light within reach. On 02/01/2024 at 10:00 AM., Resident was observed laying in bed with his call light within reach. Resident was observed with a urine catheter, with sluggish sediment inside the tubing. Review of a Resident Information Record dated 02/01/2024 showed Resident # 62 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Sepsis, Unspecified Organism, Urinary Tact Infection Site Not Specified, Retention of Urine, Difficulty Walking Major Depressive Disorder. Review of a Minimum Data Set (MDS) dated [DATE] showed Resident # 62 had a Brief Interview Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Further review of the MDS showed Section H for bladder and bowel that Resident # 62 was coded for having an indwelling catheter. Review of an order summary report dated 02/01/2024 showed an active order for a urine catheter to straight bag drainage (16fr [french] 10 cc [cubic centimeters]) for diagnosis of: Urinary retention due to (d/t) obstructive uropathy. Further review of the clinical record showed no evidence a care plan was developed for Resident # 62's urine catheter. On 02/01/2024 at 10:00 AM., an interview was conducted with Staff R, Certified Nursing Assistant (CNA). She said she is familiar with Resident # 62 and his care needs. She assistant him with most of his activities of daily living (ADL's) and she assists him with emptying his urine catheter bag. She said she had not been provided with catheter care training at the facility. She said honestly, I learned how to do catheter care by looking at YouTube videos. She said if there was a problem with Resident # 62's catheter she would report it to the nurse. She said she seen the sluggish sediment in his catheter, but she did not report it to the nurse because she did not think anything was wrong with him. On 02/01/2024 at 10:30 AM., an interview was conducted with Staff L, Registered Nurse (RN). She said she was the nurse responsible for Resident # 62 today and she was familiar with all his care needs. He has had a catheter for a long time for urinary retention, stating I take care of his catheter, but I haven't looked at it today. When I reviewed the resident care plan, I did not see a care plan for his catheter. Continuing, she stated I did not go over any interventions with the cna's because the nurses are the ones responsible for cleaning and changing out the resident's catheter if there are any problems. I was not aware of the resident having any sluggish sediment in his tubing. On 02/01/2024 at 10:45 AM., an interview was conducted with Staff R, Minimum Data Set /License Practical Nurse (MDS/ LPN). She said she is responsible for developing the residents' care plans in the facility. After reviewing Resident # 62's care plan she confirmed she did not develop a care plan for his catheter. On 02/01/2024 at 10: 50 AM., an interview was conducted with the Director of Nursing (DON) inside Resident # 62's room. She said her expectation is that staff should notify their nurse if they see a resident with sluggish sediment in their catheter tubing. The tubing should be either changed out or flushed out. She confirmed if a resident has Catheter they should also have a care plan in place with intervention for her staff to follow. Review of facility policy titled, Plans of Care, Revision Date 09/25/2017 showed: Policy: An individualized person - centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representative (s) to the extent practicable and updated in accordance with state and federal regulatory requirement. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a com plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. Review updated and/ or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.

Based on record review, and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four (#74, #81, #14, and #45) of thirty-eight initially sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and/or later identified. Findings included: 1. Review of Resident #74's Admission Record revealed the resident was admitted on [DATE]. The record showed diagnoses present on admission included primary insomnia and generalized anxiety. The record revealed secondary diagnoses with an onset date of 4/12/23 of unspecified post-traumatic stress disorder (PTSD), uncomplicated cocaine, and opioid abuse, a diagnosis of moderate recurrent major depressive disorder with an onset date of 4/26/23, and a diagnosis of dysthymic disorder with an onset date of 9/21/23. Review of Resident #74's Level 1 PASRR, completed at an acute care facility on 11/2/22, showed the resident had diagnoses of substance abuse, anxiety disorder, and depressive disorder. The screening showed the resident had recent partial hospitalization or inpatient psychiatric treatment and had experienced an episode of significant disruption to the normal living situation. The level 1 screening did not include the resident's diagnosis of PTSD. Review of Resident #74's Level II determination summary, completed on 11/4/22, showed the resident had a medical history of moderate depressive episode, suicide attempt, opioid abuse with intoxication with a history of psychiatric hospitalization s/Baker Acts. The Level II included the Level I diagnoses of anxiety disorder, depressive disorder, and substance abuse. The review did not reveal the resident's diagnosis of PTSD was included in the determination. Review of Section I: Active Diagnoses, of Resident #74's annual Minimum Data Set (MDS), dated [DATE] revealed diagnoses of anxiety disorder, depression (other than bipolar), and Post-Traumatic Stress Disorder (PTSD). An interview was conducted with the Social Services Director (SSD) on 1/31/24 at 2:41 p.m. The SSD reviewed Resident #74's medical diagnoses and Level 1 PASRR. She stated the PASRR came from the hospital. The SSD confirmed the diagnosis of PTSD which should have been added to the Level 1 under other in the Mental Illness (MI) section and resubmitted. 2. Review of Resident #81's Admission Record revealed the resident had been admitted on [DATE]. The record showed the resident had admission diagnoses of neurocognitive disorder with Lewy Bodies, unspecified severity dementia in other disease classified elsewhere with other behavioral disturbance, recurrent moderate major depressive disorder, and brief psychotic disorder. Review of Resident #81's PASRR, dated 12/12/23, revealed completion by Staff O, Registered Nurse (RN) at the facility. The mental illness section of the evaluation revealed a diagnosis of visual hallucinations and section II showed the resident had primary diagnoses of dementia and a related neurocognitive disorder. The screening revealed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. The evaluation showed Resident #81 did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated and a Level II evaluation was not required. Review of Resident #81's Minimum Data Set (MDS), dated [DATE], showed the resident was currently not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS assessment of section I revealed diagnoses of dementia and psychotic disorder. An interview was conducted with the Social Service Director (SSD) on 1/31/24 at 2:39 p.m. The SSD reviewed Resident #81's PASRR, stating the resident came from home and the facility went off what had been presented at that time. She reviewed the medical diagnoses and PASRR, confirming the PASRR should have been resubmitted with the additional diagnoses of major depressive disorder and psychotic disorder. The SSD stated depending on the resubmission with the diagnoses a Level II could be possibly be required. 39438 3. A review of the Admission Record showed Resident #45 was originally admitted on [DATE] with diagnoses of schizoaffective disorder, bipolar type, and major depressive disorder, recurrent, mild. Review of Resident #45's PASRR Level I Assessment, dated 06/27/18 revealed no qualifying mental health diagnosis and that no PASARR Level II was required. Review of Resident #45's medical record revealed new diagnoses of generalized anxiety disorder on 12/16/19, other bipolar disorder on 11/30/22, major depressive disorder, recurrent, moderate on 04/26/23, and the resident was not assessed for PASRR Level II Section I Active Diagnoses of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had the following psychiatric/mood disorders: anxiety disorder, depression, bipolar disorder, and schizophrenia. On 01/31/24 at 2:25 p.m., the Social Services Director (SSD) reported she reviews PASRR's for accuracy with nursing upon admission. She also looks to see if there was anything checked in section II of the PASRR. If a PASRR was incorrect, she would do a corrected PASRR with the assistance of the Director of Nursing (DON). A Level II PASRR was submitted if the resident had a change in behavior or had to be [NAME] Acted during their stay if the hospital did not initiate one. The SSD confirmed a new PASRR should have been submitted due to the new diagnoses during Resident #45's stay. 4. A review of the Admission Record showed Resident #14 was originally admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance, brief psychotic disorder, major depressive disorder, recurrent, mild, generalized anxiety disorder, and post-traumatic stress disorder, unspecified. Review of Resident #14's PASRR Level I Assessment, dated 06/01/16 revealed no qualifying mental health diagnosis and that no PASRR Level II was required. Review of Resident #14's medical record revealed new diagnoses of schizoaffective disorder on 10/28/21, vascular dementia, unspecified severity, with agitation on 10/21/22, and the resident was not assessed for PASRR Level II Section I Active Diagnoses of the quarterly MDS dated [DATE] revealed Resident #14 had the following psychiatric/mood disorders: anxiety disorder, depression, schizophrenia, and post traumatic stress disorder. On 01/31/24 at 2:34 p.m., the SSD confirmed a new PASRR should have been submitted due to the new diagnoses during Resident #14's stay. The policies and procedures Preadmission Screening and Resident Review (PASRR) dated 11/08/21 provided by the facility revealed the following: Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disable (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and ensure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of the Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records.

Based on observations, record reviews, and interviews, the facility failed to ensure one (#81) out of four residents utilizing a Geri-chair was assessed for its use, a physician order had been obtained for its use, and it did not restrict the residents movement. Findings included: On 1/29/24 at 6:48 a.m. Resident #81 was observed lying in a Geri-chair, asleep and dressed appropriately in the doorway of the resident's room. On 1/29/24 at approximately 2:19 p.m., Resident #81 was observed lying in a Geri-chair next to the nursing station and the 400 hall medication cart. The chair back was laid back and resident was observed attempting to sit upright. On 1/30/24 at 2:18 p.m. Resident #81 was observed sitting upright in a high-back wheelchair in the North unit Dining Room alone, while facing out toward the hallway. On 1/31/24 at 8:50 a.m., Resident #81 was observed sitting in a highback wheelchair with the back layed back to approximately 30 degrees near the nursing station. Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) who was present during the observation stated the brown substance around the resident's mouth was probably breakfast and the reason the chair was laid back was for the resident to rest due to being awake all night and trying to walk. On 2/1/24 at 7:18 a.m., Resident #81 was observed lying in a Geri-chair in the corner across from the North unit nursing station, next to the Dining Room door. The resident was wearing a hospital gown with one bare leg showing, both legs were bent at the knees, and the chair was laid down to approximate 45 degrees. Staff U, Registered Nurse (RN) who was present during the observation stated the resident was put in Geri-chair because the resident kept trying to get out of wheelchair and stand up, so for safety the resident was placed in the Geri-chair. On 2/1/24 at 10:59 a.m., Resident #81 was observed in therapy sitting in a highback wheelchair with eyes closed and unattended. Review of Resident #81's Admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to Parkinson's Disease without dyskinesia without mention of fluctuations, Neurocognitive disorder with Lewy Bodies, other abnormalities of gait and mobility, legal blindness as defined in the USA, and unspecified severity unspecified dementia with other behavioral disturbance. Review of the comprehensive Minimum Data Set (MDS) dated [DATE], showed Resident #81 had functional limitation in range of motion in bilateral lower extremities, utilized both walker and wheelchair for mobility, required partial/moderate assist with bed mobility, and supervision/touching assistance with transferring between bed-to-chair. Review of Resident #81's physician orders, active as of 2/1/24, showed the resident had an electronic monitoring device (observed on ankle of resident) due to exit-seeking and staff were to check functioning every night shift and placement every shift. The physician orders did not include an order for the use of a Geri-chair. Review Resident #81's care plan included the following focuses and interventions: - Has episodes of sleeplessness, Health. The interventions showed staff were to administer medication as ordered, offer food and drink, and to provide (a) quiet environment. - At risk for elopement/exit seeking, Actively exit-seeking. The interventions showed staff were to use diversional activities when exit-seeking behavior is occurring (i.e.: offer food, activities, one-on-one company). - At risk for decline in behaviors, can be resistive to care, going to bed, taking showers, has had periods of agitation and restlessness. Grabs onto residents walking by while trying to stand. Does have diagnosis (dx) of dementia, Lewy body disease, (and) resistant with wearing clothing. The interventions showed staff were to provide quiet environment, redirect (resident) as necessary, and explain all procedures to (resident) before starting and allow (pronoun) enough time to adjust to changes. - At risk for falls and fall-related injury related to cognitive loss/decline, difficulty in walking, impaired mobility, Parkinson's, hard of hearing, legally blind-glaucoma, (and) Lewy body disease. The interventions showed staff were to encourage (resident) to be in common areas when out of bed (OOB). - At risk for decreased ability to perform Activities of Daily Living (ADLs) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to activity intolerance, chronic disease process, impaired mobility, Parkinson's, gait and mobility abnormality, (and) Lewy body disease. The interventions showed staff with to assist x1 with ambulation and may use high back wheelchair as tolerated. Continued review of Resident #81's care plan did not include any interventions related to the use of a Geri-chair. Review of Resident #81's progress notes showed the following: - 12/21/23 at 7:57 p.m., Writer observed Residents family putting Resident in regular chair in TV/dining room by nurses station. Writer asked family to transfer resident back to w/c (wheelchair) to deter Resident getting out of chair and falling. - 1/14/24 at 4:00 a.m., Has been up in wc most of the shift after attempting to get out of bed several times without assistance. Taking oral fluids when offered. - 1/22/24 at 10:00 p.m., a Change in Condition evaluation was written in response to Resident #81 falling. - 1/26/24 at 12:10 a.m., a Change in Condition evaluation was completed due to Resident #81 suffering a fall. - 1/26/24 at 7:54 p.m., a note showed the resident had attempted to self transfer twice and staff reminded resident to wait for assistance (asst). - 1/27/24 at 6:38 p.m., a note revealed the resident was very agitated. He tried to stand up numerous times. The note showed during one of the times the resident attempted to stand, grabbed another resident arm, and caused skin tears. The note revealed despite redirection (resident) continues to try to stand and grab other residents who walk by. - 1/28/24 at 10:17 p.m., Resident continues to attempt to rise without assistance. Requires constant direct monitoring to decrease the likelihood of falls and possible injury. - 1/29/24 at 3:12 a.m., Will sleep for approximately 15 to 20 minutes when laid down in bed, but awakens and attempts to rise unassisted. Seems to calm some when wheeled around facility in w/c, but becomes agitated soon after. Several attempts to redirect behavior unsuccessful. During an interview on 1/31/24 at 1:32 p.m. Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) stated therapy assesses residents for the use of Geri-chairs. An interview was conducted with Resident #81's family member on 1/31/24 at 2:20 p.m. The family member reported being notified of three of the believed four falls. The family member stated they feel it was not fair for long-term care facilities were unable to use methods (restraints) to keep people from falling and was happy with the highback wheelchair and reported when resident was sitting upright the family member will lean it (the wheelchair) back so the resident was less likely to lean out of chair. An interview was conducted with the Director of Nursing (DON) on 1/31/24 at 3:09 p.m. The DON said Resident #81 was a frequent faller and Risk Management was only showing one fall however confirmed the resident has had 4 fall assessments since December. The DON reported the resident sees things that are not there, doesn't normally try to walk but will lean forward to reach for something not there, staff were to encourage resident to be in common areas when out of bed and keep frequently used items within reach. She reported the facility has not added any interventions related to the resident falling for the past 30 days. The DON stated a resident required a (physician) order and an assessment for the use of a Geri-chair and the resident has been in a Geri-chair since her arrival to the facility (30 days prior to 1/29/24). She said a Geri-chair was used for positioning needs and would be inappropriate for someone who attempts to get up to ambulate. The observations were discussed with the DON, she confirmed a Geri-chair lying back for the resident, I know then confirmed it looked like a restraint. The DON continued the interview on 1/31/24 at 3:19 p.m. with the Director of Rehabilitation (DoR). The DoR reported Resident #81 could ambulate with moderate/maximum assist from 1-person with 1- person following behind the wheelchair depending on the day and the resident had not been assessed for the use of a Geri-chair, the resident went from a standard wheelchair to a reclining highback wheelchair. Review of the policy titled Physical Restraints, revised 11/6/2020, showed Residents have the right to considerate and respectful care at all times and under all circumstances, with recognition of their personal dignity and safety in the least restrictive manner. As needed, the interdisciplinary team will evaluate the resident for the potential need for physical restraint. The restraint must be the least restrictive means available. If a resident is identified by the interdisciplinary team and/or a discipline as requiring further intervention due to safety concerns, alternative methods will be attempted before restraint application will be considered. Monitoring and release of restraints will be done according to any state specific regulation. This policy and procedure does not apply to protective/adaptive/mechanical services. These devices are used for postural support, to assist the resident to obtain/maintain normative body functioning, or to compensate for a specific physical deficit. For example, bed rail used to enable movement. The policy revealed the following procedures related to the use of physical restraints: - A restraint evaluation will be performed by nursing to assess physical, mental and other contributing factors which include indicate the need for a restraint/enabler. - The interdisciplinary team may use restraint decision making tools as needed to assist in determining restraint versus enabler versus restraint/enabler. - The resident/responsible party will sign consent for the use of a safety device after review of risk /benefits. - The risk and benefits shall be explained to the resident or representative prior to initiating the restraint. - The nurse will obtain the physicians order for the restraint. This order will include the medical reason for the restraint. - Restraint use is documented in the resident care plan and in the nurses note. - Documentation to include: -- Events leading to the initiation of restraint; -- Resident behavior; -- Least restrictive measures attempted; -- Medical rationale for application; -- Date, time, type of restraint; -- Resident response to restraint Each resident will be reassessed and reviewed as per state regulation but at a minimum of quarterly and as needed to determine whether or not the resident is a candidate for restraint reduction, least restrictive measures are being utilized or total restraint elimination is warranted. According to PhysicalTherapy.com, The definition of a physical restraint is any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Review of the information, (located at https://www.physicaltherapy.com/ask-the-experts/definition-of-restraint-2423), revealed an example of a physical restraint would be a reclining geri-chair. An upright geri-chair with a lap tray, any standard wheelchair or any other seating that prevents the resident from rising from the seat due to physical functioning deficits; basically what we mean by that is if you have a person who can stand up, but if you change the angle at the hip such that it is a very acute angle, they are not able to stand up. You make your seating system or your wheelchair such that you really recline the patient and you wedge them in there, that could be considered a restraint, even though they do not have a lap belt, a lap tray, or anything else. Review of the website, verywellhealth.com/the-dangers-of-restraints-for-people-with-dementia-, updated August 29, 2021, showed the definition of a restraint was anything that hinders movement or restricts freedom. Years ago, restraint use was much more common and included extremely restrictive restraints such as straight jackets and vests. While these restraints aren't used today in a nursing home, it's important to recognize that other equipment can act as a restraint even it the goal in its use is to keep someone safe. The listed examples of restraints included recliner chairs and explained While a recliner chair can be used for comfort and positioning, it also can be a restraint for some people if they can't get out of it independently. The information presented revealed Restraints as a Last Resort and In order for a nursing home to use restraint, the staff must have tried and been unsuccessful in using less restrictive alternatives first, and these attempts must be clearly documented. (Less restrictive measures include attempts to more safely and comfortably position the person in a chair, providing increased supervision, offering meaningful activities or attempting to improve functioning through physical or occupational therapy.) Facilities must also have a time-limited order from a physician in order to use any type of restraint, and the person, his guardian or his power of attorney for health care must have been educated on the risks vs. the benefits of using restraint and have given permission to do so.

Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to protect the resident's right to be free from neglect for one Resident (#1) of three residents reviewed for change in condition. On [DATE] during a 12 hour shift when Resident #1 exhibited shortness of breath and not feeling well, was unable to perform her normal daily activities, unusual behaviors and was begging to go to the hospital the nurses on duty neglected to respond with in a way that could have helped the resident. There were no PRN (as needed) medications provided to the resident except pain medication, no documented assessments or vital signs (VS), no call to the resident's provider, and no call to the resident's family. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) started. EMS (Emergency Medical Services) transported the resident to a hospital where she was admitted to intensive care and died 2 days later. This failure created a situation that resulted in a worsened condition, serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: An interview was conducted on [DATE] at 11:20 a.m. with Staff A, Personal Care Attendant. (Personal Care Attendant or PCA means a person who meets the training requirement in this rule and Section 400.141(1)(w), F.S., and provides care to and assists residents with tasks related to the activities of daily living. According to Florida Administrative Code 59A-4.1081 Personal Care Attendant Training Program Requirements). Staff A, PCA said the day Resident #1 went to the hospital, [DATE], she looked really bloated and hadn't been able to go to the bathroom. Staff A, PCA said the resident was really out of it. He said Resident #1 didn't go out of her room, didn't eat all day and she took her clothes on and off. He said he had never seen the resident act that way before. He said Resident #1 said she wasn't feeling good and was begging to go to the hospital. Staff A, PCA said he told Staff B, Licensed Practical Nurse (LPN) what the resident said and Staff B, LPN told him [Resident #1] tends to exaggerate. Staff A, PCA said when the LPN made that comment he reminded her the resident wanted to go to the hospital. He said another time he went to Staff B, LPN and told her the resident was bloated and not feeling good, Staff B, LPN said she would give Resident #1 a suppository. He said he went to Staff B, LPN three to four times during his shift and told her the resident wasn't feeling good and wanted to go to the hospital. Review of admission records showed Resident #1 was admitted on [DATE] with diagnoses including Acute and Chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), atrial fibrillation, speech and language deficits following cerebral infarction (CI,) hemiplegia and hemiparesis following CI, focal symptomatic epilepsy and epileptic syndromes. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], Section C, Cognition, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section E, Behaviors, did not indicate the resident had any behaviors. Section G, Functional Status, showed the resident needed one-person physical assist with bed mobility, transfers, and toileting. Review of Resident #1's Order Summary Report, printed on [DATE] showed the following orders: Full Code. (Meaning all resuscitation efforts should be made to keep the resident alive) Date [DATE] Record pain level every shift using numerical scale or pain scale for cognitively impaired. Every shift. Date [DATE]. Atorvastatin Calcium Oral Tablet 20 milligram (mg). Give 20 Mg by mouth at bedtime for cholesterol. Date. [DATE]. Allopurinol Oral Tablet 100 mg. Give 100 mg by mouth two times a day for gout. Date [DATE]. Clonazepam Oral Tablet 0.5 mg. Give 1.5 tablets by mouth two times a day for anxiety. Date [DATE]. Cholecalciferol Oral Tablet. Give 25 microgram (mcg) by mouth one time a day for supplement. Date [DATE]. Debrox Otic Solution. Instill 5 drops in both ears at bedtime for ears. Date [DATE]. Diltiazem HCL (hydrocholoride) ER (extended release) Oral Tablet. Give 120 mg by mouth in the morning for hbp (high blood pressure). Date [DATE]. Advair Diskus Inhalation Aerosol Power Breath Activated ,d+[DATE] mcg/act (actuation.) 1 puff orally two times a day for SOB (shortness of breath). Date [DATE]. Ferrous Sulfate Tablet 325 mg. Give 1 tablet by mouth two times a day for low hgb (hemoglobin). Date [DATE]. Guaifenesin Oral Tablet. Give 600 mg by mouth two times a day for mucus. Date [DATE]. Furosemide Oral Tablet 20 mg. Give 20 mg by mouth one time a day for edema. Date [DATE]. Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. Date [DATE]. Magnesium Oxide Oral Tablet 400 mg. Give 400 mg by mouth one time a day for antacid. Date [DATE]. Nicotine Patch 24 hour 14 mg/24 hour. Apply to arm topically in the morning for Nicotine for 14 days for less than 10 cigarettes a daily. Date [DATE]. Olanzapine Oral Tablet 5 mg. Give 5 mg by mouth in the morning for bipolar. Date [DATE]. Omeprazole Oral Capsule Delayed Release 30 mg. Give 20 mg by mouth in the morning for GERD (Gastroesophageal reflux disease). Date [DATE]. Potassium Chloride ER (extended release) Tablet 20 milliequivalents (meq). Give two tablets by mouth one time a day for hypoxia. Date [DATE]. Pregabalin Oral Capsule 75 mg. Give 75 mg by mouth at bedtime for muscle pain. Date [DATE]. Levetiracetam oral tablet 1000 mg. Give 1000 mg by mouth two times a day for seizure. Date [DATE]. Albuterol Sulfate HFA 108 mcg/act Aerosol, solution 2 puff inhale orally every 6 hours as needed for SOB. Date [DATE]. Ipratropium-Albuterol solution 0XXX,d+[DATE].5 mg/3 ml [milliliter] inhale orally via nebulizer every 6 hours as needed for SOB. Date [DATE]. Norco Oral tablet ,d+[DATE] mg. Give 1 tablet by mouth every 4 hours as needed for Moderate to severe pain ,d+[DATE]. Date [DATE]. Ondansetron HCL Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. Date [DATE]. Complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night for 10 days. Date [DATE]. Isolation Droplet Precautions due to COVID-19 and/or possible exposure. Every shift for 10 days. Date [DATE]. Review of Resident #1's Treatment Administration Record (TAR) dated [DATE] - [DATE] revealed: Oxygen at 2 liters/ min [minute] via Nasal Cannula, Humidification: [specify] No. every shift, Start date [DATE] 1500, D/C [discontinue] date [DATE] 0829. The oxygen was signed off as provided for 2 shifts on [DATE] and one shift for [DATE]. Review of Resident #1's Order Summary Report, printed on [DATE], and Resident #1's Medication Administration Record (MAR) and TAR dated [DATE] - [DATE] revealed no active order for oxygen administration. Review of Resident #1's MAR showed the resident was administered Cholecalciferol, Diltiazem HCL, Furosemide, Magnesium oxide, a nicotine patch, Olanzapine, Omeprazole, Potassium Chloride, Advair Diskus, Allopurinol, Clonazepam, Ferrous Sulfate, Guaifenesin, Levetiracetam on the morning of [DATE]. These were all scheduled medications. Review of Resident #1's medical records showed a care plan in place for Risk for respiratory complications related to dx [diagnosis] of COPD, Acute and Chronic hypoxia, respiratory failure, tobacco dependance, Asthma, CHF [Congestive heart failure], initiated [DATE]. The Interventions included: Administer oxygen as ordered (Refer to MAR for current order), Check and report O2 Sat (oxygen saturation) levels via pulse oximetry as ordered and report prn, Encourage to express feelings of fear and anxiety and provide verbal and non-verbal support, Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects, Report to MD (Medical doctor) as indicated, Observe for increased wheezing and or lower activity tolerance and report to MD as indicated. Review of an article titled Pulse Oximetry, accessed on [DATE], showed the following: Oxygen saturation is a crucial measure of how well the lungs are working A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person.Note that for people with known lung disorders such as COPD, resting oxygen saturation levels below the normal range are usually considered acceptable. (https://www.yalemedicine.org/conditions/pulse-oximetry) Review of Resident #1's medical records showed a care plan in place for Risk for cardiovascular complications related to: A-fib, H/O [history of] Arrhythmias, HTN [hypertension,] Pacemaker, CHF, HLD [Hyperlipidemia], initiated [DATE]. The interventions included administer medication as ordered, administer oxygen as ordered, diet as ordered and meal consumption monitored, monitor for SOB, chest pains, bradycardia, hypotension, dizziness, tachycardia, HTN, increased edema, weight gain-report abnormalities to nurse, and monitor for vitals. Review of a progress note dated [DATE] at 6:12 a.m. showed the following: LATE ENTRY Resident c/o (complained of) SOB. Full assessment of resident showed decreased O2 SATs 88%. Call placed to MD. Orders to send out to (hospital name) for observation. Review of progress notes showed the following: [DATE] at 7:12 a.m. Change in Condition: Shortness of Breath. The VS documented in the progress note were dated [DATE] 6:29 a.m.: Blood pressure (BP) ,d+[DATE] Pulse (P) 80, Respiratory rate (RR) 18, Temperature (T) 98.0, Pulse Oximetry (O2 Sat) 93% Method: Oxygen via Nasal Cannula. Primary care provider responded to send resident out to the hospital. Review of Resident #1's Medical Certification for Medicaid Long-Term Care [NAME] and Patient Transfer From (AHCA Form ,d+[DATE],) dated [DATE], showed the resident returned to the facility from the hospital. At the time of transfer Resident #1 was on 2 Liters of continuous oxygen, could ambulate independently with assistance, could feed herself, was continent of bowel and bladder, was alert and oriented, followed instructions, and was capable of making healthcare decisions. Review of a progress note dated [DATE] at 4:00 a.m. showed the following: Awake in bed complaining she was incontinent of urine and she could not breathe to go to the bathroom. SATS 90% with O2 @2L/m via nasal cannula. Inhale provided without good effect. Nebulizer treatment provided with good relief and O2 SAT up to 96% with O2 @2L/m via nasal cannula. Requested and provided pain medication for back pain. Peri care provided. Had another episode of urinary incontinence and peri care provided with new brief. Will continue to monitor. Review of a progress note dated [DATE] at 6:30 a.m. showed the following: Resting quietly in bed at present. SATs 96% with O2 @3L/M via nasal cannula. Requested to be given smoke patches to help her stop smoking as she was very upset with her SOB. Will pass on to oncoming nurse to obtain orders for same. Review of a Progress Note written by an APRN (Advanced Practice Registered Nurse) dated [DATE] revealed the following: History of Present Illness: This is a complicated patient who was recently discharged from the hospital under the care of multiple subspecialists. Medically the patient requires continued close monitoring and follow up in the skilled nursing arena on a proactive basis to have an impact on reduction of rehospitalization /morbidity/and mortality. The patient's respiratory status is slowly improving at this time. We will continue to monitor closely due to the patient's multiple comorbidities and high risk for decompensation. In the review of systems the resident was negative for reduced appetite, negative for dyspnea (feeling short of breath) on exertion. Review of a progress note dated [DATE] at 6:59 p.m. showed the following: Pt (patient) reported to NP(Nurse practitioner name) she was having severe pain in her abdomen. NP (name) gave orders to write to order a KUB (kidney, ureter, and bladder x-ray). Review of a Radiology Results Report, dated [DATE], showed the KUB conclusion was: Unremarkable abdomen exam. Consider more sensitive imaging evaluation with CT (computerized Tomography Scan, sometimes called a CAT scan) as clinically directed. This result was reviewed by Staff G, LPN/UM on [DATE] at 9:40 a.m. Review of a progress note dated [DATE] at 11:21 a.m. showed the following: During care plan meeting resident verbalized that she would like to stay at facility for long term care as she feels this is the level of care she needs. Explained that she will need to speak to the BOM (Business office manager) regarding the Medicaid process and she did state she has spoken to her about this as well as the owner of the previous home she was in. A Nutrition/Dietary Note, dated [DATE] at 11:50 a.m. showed the following: Resident came in dining room today and spoke to this clinician regarding her teeth. Resident c/o tooth pain d/t (due to) cracked/broken upper teeth. Resident states that she thinks that all of her upper teeth need to be pulled. Resident states that she has lower dentures but that they may to be readjusted. Resident on regular textures and agreed to downgrade to mech (mechanical) soft at this time for easier chewing. Resident had concerns regarding her hearing and needing glasses. Notified unit manager as social services was not available. Will continue to monitor and f/u (follow-up) prn. The resident had an active order for Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 mg/3ml. 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Start date: [DATE]. The MAR shows this medication was last administered on [DATE] and was not administered on [DATE]. The MAR showed Resident #1 was administered PRN Norco ,d+[DATE] mg at 8:18 a.m. on [DATE] with a pain level documented as 0 out of 10 and again at 3:02 p.m. with a pain level documented as 0 out of 10. The resident received Norco 2 to 3 times daily from [DATE] to [DATE]. Resident #1 had an order to complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night shift for 10 days. Start date [DATE]. This was signed off on the Treatment Administration Record (TAR) as being completed ,d+[DATE] and [DATE]. There was no documentation related to the assessments in the medical record. Review of Resident #1's electronic medical record weights and vitals summary pages and progress notes showed the VS documented for her stay of [DATE] to [DATE] and [DATE] to [DATE] were the following: [DATE] admitted , no VS documented [DATE] 6:29 a.m. BP ,d+[DATE], P 80, RR 18, T 98.0, O2 Sat 93% Method: Oxygen via Nasal Cannula. [DATE] 6:12 a.m. O2 Sat 88%, no other VS documented [DATE] Resident in the hospital [DATE] Resident in the hospital [DATE] readmitted , no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] 4:00 a.m. O2 Sat 90% with oxygen at 2L/m, no other VS documented [DATE] 4:00 a.m. O2 Sat 96% with oxygen at 2L/m after breathing treatment [DATE] 6:30 a.m. O2 Sat 96% with oxygen at 2L/m, no other VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] 8:00 p.m. BP ,d+[DATE], P 0, RR 0, T 98 , O2 Sat 90% [DATE] 8:30 p.m. BP ,d+[DATE] [DATE] 8:39 p.m. BP ,d+[DATE] An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN/UM said the documentation of blood pressure (of ,d+[DATE]) on [DATE] at 8:30 p.m. and O2 Saturation (at 90%) on [DATE] at 8:00 p.m. were an error. Staff G, LPN/UM said Staff D, RN had called her that evening to let her know she had problems with documenting VS at the time. During an interview on [DATE] at 9:35 a.m. Staff F, RN said the VS were documented in the weights and vitals tab of the electronic medical record. During an interview on [DATE] at 10:05 a.m. Staff C, RN said VS were documented on the MAR/TAR if it asks for them and if vital signs are being taken because of a concern they are documented directly under the VS tab or sometimes in the progress notes (in the electronic record). During an interview on [DATE] at 11:51 a.m. Staff B, LPN/UM said VS are documented in the electronic record in the progress notes and she does not know the Policy and Procedure for monitoring VS. She said there was usually an O2 sat order along with the oxygen order. She agreed there was no evidence in the medical record of the resident being stable because assessments and VS were not documented. She said that she did not notify the physician about the resident wanting to go to the hospital and she said I know, I didn't document . An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN said regarding vitals for Resident #1 being documented throughout her stay at the facility she said, that would have been nice, especially her. Staff G, LPN said for a resident with a distended abdomen she would listen for bowel sounds, call the doctor, and see if they wanted to order an x-ray or anything else. Staff G, LPN/UM reviewed Resident #1's KUB results from [DATE] and confirmed there had been no follow-up. An interview was conducted on [DATE] at 1:05 p.m. with Resident #1's primary care physician. He said he would not have expected Resident #1's oxygen orders to have stopped. He said he would expect a patient that came to the facility with a history of respiratory failure to have oxygen saturation monitoring and I would be surprised if they were not. He said for the chest x-ray results on [DATE], the results would not have been overly concerning assuming the resident did not have a fever, but the facility should have notified the provider of all abnormal labs. An interview was conducted on [DATE] at 2:18 p.m. with Staff H, RN. Staff H, RN said Resident #1 was pleasant, alert, and oriented. He said she would sometimes take her oxygen off when she was in the hall and staff would tell her to put it back on due to her having shortness of breath. He said she was out of her room [ROOM NUMBER]% of the time. Staff H, RN said the resident didn't ever complain, say she wanted to go to the hospital and didn't have any behaviors besides occasionally refusing something. An interview was conducted on [DATE] at 2:22 p.m. with Staff J, CNA. Staff J, CNA said Resident #1 mostly took care of herself. Staff J, CNA said the resident would ask for ice or help with little things. She said the resident did get short of breath getting out of bed or doing simple tasks. Staff J, CNA said the resident never gave anybody a hard time and didn't complain unless it was something small. She said Resident #1 would normally eat and if she didn't like the meal, she would ask for snacks or order something to be delivered. Staff J, CNA said the resident never complained of stomach pain or said she wanted to go to the hospital. She said the resident would often have conversations with other residents. An interview was conducted on [DATE] at 2:48 p.m. with Staff I, CNA. Staff I, CNA said Resident #1 was a sweet lady and a good eater. Staff I, CNA said she doesn't remember the resident complaining or having any behaviors. An interview was conducted on [DATE] at 10:34 a.m. with Staff B, LPN. Staff B, LPN said the day Resident #1 went to the hospital ([DATE]) she had cared for the resident on the day shift, from 7:00 a.m. to 7:00 p.m. Staff B, LPN said Resident #1 was not feeling well that day. She confirmed Staff A, PCA came to her three to four times during her shift and told her the resident wasn't feeling good and wanted to go to the hospital. Staff B, LPN said while she was at lunch, Staff A, PCA came and said he didn't feel like Resident #1 was acting right. Staff C, RN went down and was getting a set of VS when Staff B, LPN said she joined him. Staff B, LPN said Resident #1 was saying she was having a hard time breathing. She said the resident was scooted down in the bed and Staff B, LPN told the resident she could breathe better if staff pulled her up in bed and got her lungs straight. Staff B, LPN said she thinks that was around 3:,d+[DATE]:00p.m. She said when Staff A, PCA told her what the resident said, she did an assessment of what the resident needed and she basically just wanted her pain medication. Staff B, LPN said she gave Resident #1 a pain pill when she went down there and she was much more pleasant. A follow-up interview was conducted on [DATE] at 11:51 a.m. with Staff B, LPN. Staff B, LPN said for Resident #1 she noticed her abdomen was distended earlier in the day on [DATE]. She said when she went back around 3:00 p.m. the resident had just had a bowel movement. She said she thinks the resident's abdomen was down some compared to what it was. Staff B, LPN said she thinks the bowel movement could have possibly been the cause of her distended abdomen. Staff B, LPN confirmed the resident was complaining of breathing issues on [DATE]. She said she did not administer the resident's PRN breathing treatment because her oxygen saturation was ok. She said we just sat her up in bed. Staff B, LPN said at that time no she did not ask the resident if she wanted her breathing treatment. Staff B, LPN confirmed she did not document any assessments or VS she did during the day of [DATE]. Staff B, LPN said on [DATE] she did not consider the resident was having a change in condition. She said the resident had taken her oxygen off before and was short of breath. She said that day the resident was slumped in bed, so we straightened her up and put her oxygen back on. Staff B, LPN was asked if a resident is alert and oriented and requested to go to the hospital does she have the right to go. Staff B, LPN responded, yes ma'am! She said, I wasn't trying to rebuke her rights, I checked on her and like I said, she was stable. Staff B, LPN confirmed she did not notify the physician about the resident's condition or request to go to the hospital. She said at the time I assessed her. I didn't feel at the time she needed to go to the hospital. An interview was conducted on [DATE] at 11:43 a.m. with Staff C, Registered Nurse (RN.) Staff C, RN said on [DATE] from 7:00 a.m. to 7:00 p.m. he worked on the unit with Staff B, LPN. Staff C, RN said Staff A, PCA said Resident #1 was feeling bad and needed assistance. He said he and Staff B, LPN went to the room and Resident #1 said she wasn't feeling ok and wanted to go to the hospital. Staff C, RN said the resident's stomach was distended and he believes her oxygen saturation was normal for her. He said Staff B, LPN was the nurse assigned to the resident and the one that would have assessed her. A follow-up interview was conducted on [DATE] at 10:05 a.m. with Staff C, RN. He said the PCA came to him because Staff B, LPN was on her lunch break. He said as he walked to the resident's room, Staff B, LPN came in. He said vitals were done and the resident's abdomen was distended. Staff C, RN said the resident was saying she was in a lot of pain and wanted to go to the hospital. Since Staff B, LPN was the assigned nurse, she took over and he went back to his residents. An interview was conducted on [DATE] at 4:03 p.m. with Staff D, RN. Staff D, RN said she worked [DATE] from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #1. She said she got report at 7:00 p.m. from Staff B, LPN and does not recall anything being said about Resident #1 not feeling well, having a distended abdomen, or wanting to go to the hospital. She said she was only told about the room being on precautions due to Resident #1's roommate having COVID. Staff D, RN said she had not seen Resident #1 yet that shift until the Certified Nursing Assistant (CNA) came down the hall around 8:00 p.m. and said the resident needed help. Staff D, RN said she went to assess the resident and the resident did not have a pulse and was not breathing. She said she started CPR on the resident and attached the AED (Automated External Defibrillator) and allowed it to analyze. Staff D, RN said she continued compressions until EMS arrived. An interview was conducted on [DATE] at 4:32 p.m. with Staff E, CNA. Staff E, CNA said she took over care for Resident #1 at 7:00 p.m. on [DATE]. She said in report she was told Resident #1 had been different that day and not her usual self. She said it was not like the resident to soil her bed, but when she went to check on her the resident had her brief off and had urinated all over the bed. Staff E, CNA said she thought Resident #1 was asleep. She said she grabbed supplies and asked another CNA to assist her. She said when she went to the resident to wake her up and roll her to her side, she noticed the resident was limp. She said the other CNA ran and got the nurse, the nurse came right away and started CPR. An interview was conducted on [DATE] at 11:46 a.m. with the facility's Medical Director. The Medical Director said he doesn't know the specifics of Resident #1, but it sounded like she had a pretty sudden change in condition. He said usually with COPD you see a slow decline in oxygen saturation. The Medical Director said if a patient with that history said she isn't feeling well and needs to go to the hospital, the nurse should call the provider. He said if a resident had a change in condition the process should be for the nurse to first assess the resident, hopefully properly and completely, then contact the provider for orders. He said that could be medication or going to the hospital. The Medical Director said, no matter how self-inflicted things may be a change in condition warrants an assessment. An interview was conducted on [DATE] at 1:20 p.m. with the interim DON and Registered Nurse Consultant (RNC). The RNC said if Resident #1 came from the hospital with oxygen orders, they should have been put in the computer. The interim DON said staff should have been monitoring Resident #1's O2 saturation and documenting. He said they have identified the facility is lacking in the area of documentation and have started education. Regarding the stat x-ray for Resident #1 on [DATE], the RNC said she could not attest to what happened or why there was no documented response. She said, Regardless, the nurse who received the results should have notified the physician and documented. The RNC stated regarding Resident #1 complaining she did not feel well on [DATE], she spoke with the nurse (Staff B) who said once the resident had a bowel movement, she was okay and did not have further complaints. She stated the nurse reported the resident had a bowel movement sometime after 3 p.m. She said, I would expect if a resident was requesting to go to the hospital, that their right to seek medical care was honored. The RNC stated she would have expected the nurse (Staff B) to document vitals and all assessments completed on Resident #1 when she verbalized not feeling well. Review of hospital records showed the patient presented in cardiac arrest. Allegedly had been in cardiac arrest for 30 minutes prior to arrival. She was immediately intubated in the prehospital airway was swapped out for an endotracheal tube. After initial dose of epinephrine in the emergency department she did have return of spontaneous circulation. Pulses were palpable. The record added the prognosis is extremely guarded considering she was allegedly in cardiac arrest for approximately 30 to 45 minutes prior to the return of spontaneous circulation. Of note, EMS reported her bloog [sic] glucose was 26 on arrival. They administered d10 and her glucose went up to 126 prior to arrival. A normal blood glucose level is between ,d+[DATE] milligrams(mg)/deciliter(dL.) The Emergency Department history of present illness showed Patient is a [AGE] year old Female presenting in cardiac arrest. Patient allegedly was found around 8 PM this evening approximately an hour prior to arrival unresponsive and allegedly in cardiac arrest. Unknown when she was last normal per the rehab facility. EMS reports that she was in PEA (Pulseless Electrical Activity) cardiac arrest through the entire transport. She underwent multiple rounds of ACLS (Advanced Cardiac Life Support) guidelines and epinephrine prior to arrival. However other than this the history is extremely limited from what was provided to me via EMS from the rehab facility. Hospital records showed the resident was admitted to the ICU (Intensive Care Unit) and died on [DATE] at 10:35 a.m. The hospital record Death Summary showed Resident #1's individual problem list as follows: Cardiac arrest, Patient found down at facility for unknown amount of time. Underwent CPR for more than 30 minutes prior to return of circulation. Patient placed on Arctic sun protocol [A non-invasive temperature management system used to induce hypothermia in comatose patients that have suffered from sudden cardiac arrest.] admitted to ICU, intubated and sedated, Critical care, cardiology consulted, Reviewed very poor prognosis with patient's husband, patient eventually made CMO [comfort measures only] . Review of the Florida Death Record for Resident #1, signed [DATE], listed the cause of death as Pulseless electrical activity (PEA) cardiac arrest, acute hypoxic respiratory failure, and aspiration pneumonia. COPD was listed as a significant contributing condition. Review of the facility's policy titled, Abuse, Neglect and Exploitation revised [DATE] showed the following: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The components of the facility abuse prohibition plan are discussed herein: I. Screening B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. 1. An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. 2. The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. D. The

Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure nursing staff were competent to recognize and respond to a change in condition for one resident (#1) out of three residents reviewed for change in condition. On [DATE] Resident #1 complained of shortness of breath and not feeling well, was unable to perform her normal daily activities, exhibited unusual behaviors and was begging to go to the hospital. The aide assigned to the resident notified the nurses on duty of the resident's condition and complaints multiple times during a 12-hour shift. There were no documented assessments, vital signs (VS) or notifications to a physician or family member. There were no PRN (as needed) medications provided to the resident except pain medication. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) was begun by facility staff. EMS (Emergency Medical Services) transported the resident to a hospital where she was admitted to intensive care and died 2 days later. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: An interview was conducted on [DATE] at 11:20 a.m. with Staff A, Personal Care Attendant. (Personal Care Attendant or PCA means a person who meets the training requirement in this rule and Section 400.141(1)(w), F.S., and provides care to and assists residents with tasks related to the activities of daily living. According to Florida Administrative Code 59A-4.1081 Personal Care Attendant Training Program Requirements). Staff A, PCA said the day Resident #1 went to the hospital, [DATE], she looked really bloated and hadn't been able to go to the bathroom. Staff A, PCA said the resident was really out of it. He said Resident #1 didn't go out of her room, didn't eat all day and she took her clothes on and off. He said he had never seen the resident act that way before. He said Resident #1 said she wasn't feeling good and was begging to go to the hospital. Staff A, PCA said he told Staff B, Licensed Practical Nurse (LPN) what the resident said and Staff B, LPN told him [Resident #1] tends to exaggerate. Staff A, PCA said when the LPN made that comment he reminded her the resident wanted to go to the hospital. He said another time he went to Staff B, LPN and told her the resident was bloated and not feeling good, Staff B, LPN said she would give Resident #1 a suppository. He said he went to Staff B, LPN three to four times during his shift and told her the resident wasn't feeling good and wanted to go to the hospital. An interview was conducted on [DATE] at 10:34 a.m. with Staff B, LPN. Staff B, LPN said the day Resident #1 went to the hospital ([DATE]) she had cared for the resident on the day shift, from 7:00 a.m. to 7:00 p.m. Staff B, LPN said Resident #1 was not feeling well that day. She confirmed Staff A, PCA came to her three to four times during her shift and told her the resident wasn't feeling good and wanted to go to the hospital. Staff B, LPN said while she was at lunch, Staff A, PCA came and said he didn't feel like Resident #1 was acting right. Staff C, RN went down and was getting a set of VS when Staff B, LPN said she joined him. Staff B, LPN said Resident #1 was saying she was having a hard time breathing. She said the resident was scooted down in the bed and Staff B, LPN told the resident she could breathe better if staff pulled her up in bed and got her lungs straight. Staff B, LPN said she thinks that was around 3:,d+[DATE]:00p.m. She said when Staff A, PCA told her what the resident said, she did an assessment of what the resident needed and she basically just wanted her pain medication. Staff B, LPN said she gave Resident #1 a pain pill when she went down there and she was much more pleasant. A follow-up interview was conducted on [DATE] at 11:51 a.m. with Staff B, LPN. Staff B, LPN said for Resident #1 she noticed her abdomen was distended earlier in the day on [DATE]. She said when she went back around 3:00 p.m. the resident had just had a bowel movement. She said she thinks the resident's abdomen was down some compared to what it was. Staff B, LPN said she thinks the bowel movement could have possibly been the cause of her distended abdomen. Staff B, LPN confirmed the resident was complaining of breathing issues on [DATE]. She said she did not administer the resident's PRN breathing treatment because her oxygen saturation was ok. She said we just sat her up in bed. Staff B, LPN said at that time no she did not ask the resident if she wanted her breathing treatment. Staff B, LPN confirmed she did not document any assessments or VS she did during the day of [DATE]. Staff B, LPN said on [DATE] she did not consider the resident was having a change in condition. She said the resident had taken her oxygen off before and was short of breath. She said that day the resident was slumped in bed, so we straightened her up and put her oxygen back on. Staff B, LPN was asked if a resident is alert and oriented and requested to go to the hospital does she have the right to go. Staff B, LPN responded, yes ma'am! She said, I wasn't trying to rebuke her rights, I checked on her and like I said, she was stable. Staff B, LPN confirmed she did not notify the physician about the resident's condition or request to go to the hospital. She said at the time I assessed her. I didn't feel at the time she needed to go to the hospital. An interview was conducted on [DATE] at 11:43 a.m. with Staff C, Registered Nurse (RN.) Staff C, RN said on [DATE] from 7:00 a.m. to 7:00 p.m. he worked on the unit with Staff B, LPN. Staff C, RN said Staff A, PCA said Resident #1 was feeling bad and needed assistance. He said he and Staff B, LPN went to the room and Resident #1 said she wasn't feeling ok and wanted to go to the hospital. Staff C, RN said the resident's stomach was distended and he believes her oxygen saturation was normal for her. He said Staff B, LPN was the nurse assigned to the resident and the one that would have assessed her. A follow-up interview was conducted on [DATE] at 10:05 a.m. with Staff C, RN. He said the PCA came to him because Staff B, LPN was on her lunch break. He said as he walked to the resident's room, Staff B, LPN came in. He said vitals were done and the resident's abdomen was distended. Staff C, RN said the resident was saying she was in a lot of pain and wanted to go to the hospital. Since Staff B, LPN was the assigned nurse, she took over and he went back to his residents. An interview was conducted on [DATE] at 4:03 p.m. with Staff D, RN. Staff D, RN said she worked [DATE] from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #1. She said she got report at 7:00 p.m. from Staff B, LPN and does not recall anything being said about Resident #1 not feeling well, having a distended abdomen, or wanting to go to the hospital. She said she was only told about the room being on precautions due to Resident #1's roommate having COVID. Staff D, RN said she had not seen Resident #1 yet that shift until the Certified Nursing Assistant (CNA) came down the hall around 8:00 p.m. and said the resident needed help. Staff D, RN said she went to assess the resident and the resident did not have a pulse and was not breathing. She said she started CPR on the resident and attached the AED (Automated External Defibrillator) and allowed it to analyze. Staff D, RN said she continued compressions until EMS arrived. An interview was conducted on [DATE] at 4:32 p.m. with Staff E, CNA. Staff E, CNA said she took over care for Resident #1 at 7:00 p.m. on [DATE]. She said in report she was told Resident #1 had been different that day and not her usual self. She said it was not like the resident to soil her bed, but when she went to check on her the resident had her brief off and had urinated all over the bed. Staff E, CNA said she thought Resident #1 was asleep. She said she grabbed supplies and asked another CNA to assist her. She said when she went to the resident to wake her up and roll her to her side, she noticed the resident was limp. She said the other CNA ran and got the nurse, the nurse came right away and started CPR. Review of admission records showed Resident #1 was admitted on [DATE] with diagnoses including Acute and Chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), atrial fibrillation, speech and language deficits following cerebral infarction (CI,) hemiplegia and hemiparesis following CI, focal symptomatic epilepsy and epileptic syndromes. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], Section C, Cognition, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section E, Behaviors, did not indicate the resident had any behaviors. Section G, Functional Status, showed the resident needed one-person physical assist with bed mobility, transfers, and toileting. Review of Resident #1's Order Summary Report, printed on and dated [DATE] showed the following orders: Full Code. (Meaning all resuscitation efforts should be made to keep the resident alive) Date [DATE] Record pain level every shift using numerical scale or pain scale for cognitively impaired. Every shift. Date [DATE]. Atorvastatin Calcium Oral Tablet 20 milligram (mg). Give 20 Mg by mouth at bedtime for cholesterol. Date. [DATE]. Allopurinol Oral Tablet 100 mg. Give 100 mg by mouth two times a day for gout. Date [DATE]. Clonazepam Oral Tablet 0.5 mg. Give 1.5 tablets by mouth two times a day for anxiety. Date [DATE]. Cholecalciferol Oral Tablet. Give 25 microgram (mcg) by mouth one time a day for supplement. Date [DATE]. Debrox Otic Solution. Instill 5 drops in both ears at bedtime for ears. Date [DATE]. Diltiazem HCL (hydrocholoride) ER (extended release) Oral Tablet. Give 120 mg by mouth in the morning for hbp (high blood pressure). Date [DATE]. Advair Diskus Inhalation Aerosol Power Breath Activated ,d+[DATE] mcg/act (actuation.) 1 puff orally two times a day for SOB (shortness of breath). Date [DATE]. Ferrous Sulfate Tablet 325 mg. Give 1 tablet by mouth two times a day for low hgb (hemoglobin). Date [DATE]. Guaifenesin Oral Tablet. Give 600 mg by mouth two times a day for mucus. Date [DATE]. Furosemide Oral Tablet 20 mg. Give 20 mg by mouth one time a day for edema. Date [DATE]. Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. Date [DATE]. Magnesium Oxide Oral Tablet 400 mg. Give 400 mg by mouth one time a day for antacid. Date [DATE]. Nicotine Patch 24 hour 14 mg/24 hour. Apply to arm topically in the morning for Nicotine for 14 days for less than 10 cigarettes a daily. Date [DATE]. Olanzapine Oral Tablet 5 mg. Give 5 mg by mouth in the morning for bipolar. Date [DATE]. Omeprazole Oral Capsule Delayed Release 30 mg. Give 20 mg by mouth in the morning for GERD (Gastroesophageal reflux disease). Date [DATE]. Potassium Chloride ER (extended release) Tablet 20 milliequivalents (meq). Give two tablets by mouth one time a day for hypoxia. Date [DATE]. Pregabalin Oral Capsule 75 mg. Give 75 mg by mouth at bedtime for muscle pain. Date [DATE]. Levetiracetam oral tablet 1000 mg. Give 1000 mg by mouth two times a day for seizure. Date [DATE]. Albuterol Sulfate HFA 108 mcg/act Aerosol, solution 2 puff inhale orally every 6 hours as needed for SOB. Date [DATE]. Ipratropium-Albuterol solution 0XXX,d+[DATE].5 mg/3 ml [milliliter] inhale orally via nebulizer every 6 hours as needed for SOB. Date [DATE]. Norco Oral tablet ,d+[DATE] mg. Give 1 tablet by mouth every 4 hours as needed for Moderate to severe pain ,d+[DATE]. Date [DATE]. Ondansetron HCL Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. Date [DATE]. Complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night for 10 days. Date [DATE]. Isolation Droplet Precautions due to COVID-19 and/or possible exposure. Every shift for 10 days. Date [DATE]. Review of Resident #1's Treatment Administration Record (TAR) dated [DATE] - [DATE] revealed: Oxygen at 2 liters/ min [minute] via Nasal Cannula, Humidification: [specify] No. every shift, Start date [DATE] 1500, D/C [discontinue] date [DATE] 0829. The oxygen was signed off as provided for 2 shifts on [DATE] and one shift for [DATE]. Review of Resident #1's Order Summary Report, printed on and dated [DATE], and Resident #1's Medication Administration Record (MAR) and TAR dated [DATE] - [DATE] revealed no active order for oxygen administration. Review of Resident #1's MAR showed the resident was administered Cholecalciferol, Diltiazem HCL, Furosemide, Magnesium oxide, a nicotine patch, Olanzapine, Omeprazole, Potassium Chloride, Advair Diskus, Allopurinol, Clonazepam, Ferrous Sulfate, Guaifenesin, Levetiracetam on the morning of [DATE]. These were all scheduled medications. Review of Resident #1's medical records showed a care plan in place for Risk for respiratory complications related to dx [diagnosis] of COPD, Acute and Chronic hypoxia, respiratory failure, tobacco dependance, Asthma, CHF [Congestive heart failure], initiated [DATE]. The Interventions included: Administer oxygen as ordered (Refer to MAR for current order), Check and report O2 Sat (oxygen saturation) levels via pulse oximetry as ordered and report prn, Encourage to express feelings of fear and anxiety and provide verbal and non-verbal support, Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects, Report to MD (Medical doctor) as indicated, Observe for increased wheezing and or lower activity tolerance and report to MD as indicated. Review of an article titled Pulse Oximetry, accessed on [DATE], showed the following: Oxygen saturation is a crucial measure of how well the lungs are working A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person.Note that for people with known lung disorders such as COPD, resting oxygen saturation levels below the normal range are usually considered acceptable. (https://www.yalemedicine.org/conditions/pulse-oximetry) Review of Resident #1's medical records showed a care plan in place for Risk for cardiovascular complications related to: A-fib, H/O [history of] Arrhythmias, HTN [hypertension,] Pacemaker, CHF, HLD [Hyperlipidemia], initiated [DATE]. The interventions included administer medication as ordered, administer oxygen as ordered, diet as ordered and meal consumption monitored, monitor for SOB, chest pains, bradycardia, hypotension, dizziness, tachycardia, HTN, increased edema, weight gain-report abnormalities to nurse, and monitor for vitals. Review of a progress note dated [DATE] at 6:12 a.m. showed the following: LATE ENTRY Resident c/o (complained of) SOB. Full assessment of resident showed decreased O2 SATs 88%. Call placed to MD. Orders to send out to (hospital name) for observation. Review of progress notes showed the following: [DATE] at 7:12 a.m. Change in Condition: Shortness of Breath. The VS documented in the progress note were dated [DATE] 6:29 a.m.: Blood pressure (BP) ,d+[DATE] Pulse (P) 80, Respiratory rate (RR) 18, Temperature (T) 98.0, Pulse Oximetry (O2 Sat) 93% Method: Oxygen via Nasal Cannula. Primary care provider responded to send resident out to the hospital. Review of Resident #1's Medical Certification for Medicaid Long-Term Care [NAME] and Patient Transfer From (AHCA Form ,d+[DATE],) dated [DATE], showed the resident returned to the facility from the hospital. At the time of transfer Resident #1 was on 2 Liters of continuous oxygen, could ambulate independently with assistance, could feed herself, was continent of bowel and bladder, was alert and oriented, followed instructions, and was capable of making healthcare decisions. Review of a progress note dated [DATE] at 4:00 a.m. showed the following: Awake in bed complaining she was incontinent of urine and she could not breathe to go to the bathroom. SATS 90% with O2 @2L/m via nasal cannula. Inhale provided without good effect. Nebulizer treatment provided with good relief and O2 SAT up to 96% with O2 @2L/m via nasal cannula. Requested and provided pain medication for back pain. Peri care provided. Had another episode of urinary incontinence and peri care provided with new brief. Will continue to monitor. Review of a progress note dated [DATE] at 6:30 a.m. showed the following: Resting quietly in bed at present. SATs 96% with O2 @3L/M via nasal cannula. Requested to be given smoke patches to help her stop smoking as she was very upset with her SOB. Will pass on to oncoming nurse to obtain orders for same. Review of a Progress Note written by an APRN (Advanced Practice Registered Nurse) dated [DATE] revealed the following: History of Present Illness: This is a complicated patient who was recently discharged from the hospital under the care of multiple subspecialists. Medically the patient requires continued close monitoring and follow up in the skilled nursing arena on a proactive basis to have an impact on reduction of rehospitalization /morbidity/and mortality. The patient's respiratory status is slowly improving at this time. We will continue to monitor closely due to the patient's multiple comorbidities and high risk for decompensation. In the review of systems the resident was negative for reduced appetite, negative for dyspnea (feeling short of breath) on exertion. Review of a progress note dated [DATE] at 6:59 p.m. showed the following: Pt (patient) reported to NP([Nurse practitioner name) she was having severe pain in her abdomen. NP (name) gave orders to write to order a KUB (kidney, ureter, and bladder x-ray). Review of a Radiology Results Report, dated [DATE], showed the KUB conclusion was: Unremarkable abdomen exam. Consider more sensitive imaging evaluation with CT (Computerized Tomography Scan, sometimes called a CAT scan) as clinically directed. This result was reviewed by Staff G, LPN/UM on [DATE] at 9:40 a.m. Review of a progress note dated [DATE] at 11:21 a.m. showed the following: During care plan meeting resident verbalized that she would like to stay at facility for long term care as she feels this is the level of care she needs. Explained that she will need to speak to the BOM (Business office manager) regarding the Medicaid process and she did state she has spoken to her about this as well as the owner of the previous home she was in. A Nutrition/Dietary Note, dated [DATE] at 11:50 a.m. showed the following: Resident came in dining room today and spoke to this clinician regarding her teeth. Resident c/o tooth pain d/t (due to) cracked/broken upper teeth. Resident states that she thinks that all of her upper teeth need to be pulled. Resident states that she has lower dentures but that they may to be readjusted. Resident on regular textures and agreed to downgrade to mech (mechanical) soft at this time for easier chewing. Resident also had concerns regarding her hearing and needing glasses. Notified unit manager as social services was not available. Will continue to monitor and f/u (follow-up) prn. Resident #1 had an order for a stat chest x-ray PA/Lateral one time only for hypoxia on [DATE]. The results, reported on [DATE] at 6:36 p.m. showed the following: Findings: The heart is modestly enlarged. Mediastinum is normal. There is a right lower lobe atelectasis. Pulmonary vascularity is normal. There is a pacemaker in position. Conclusion: Right lower lobe atelectasis and modest cardiomegaly, no infiltrate or congestion. There was no progress note, VS, or assessment to show why the Stat Chest x-ray was ordered. The results, however, do not show they were reviewed until [DATE] by Staff G, LPN/Unit Manager (UM,) after the resident left the facility. There is no note indicating a provider had been notified of the results. The resident had an active order for Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 mg/3ml. 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Start date: [DATE]. The MAR shows this medication was last administered on [DATE] and was not administered on [DATE]. The MAR showed Resident #1 was administered PRN Norco ,d+[DATE] mg at 8:18 a.m. on [DATE] with a pain level documented as 0 out of 10 and again at 3:02 p.m. with a pain level documented as 0 out of 10. The resident received Norco 2 to 3 times daily from [DATE] to [DATE]. Resident #1 had an order to complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night shift for 10 days. Start date [DATE]. This was signed off on the Treatment Administration Record (TAR) as being completed ,d+[DATE] and [DATE]. There was no documentation related to the assessments in the medical record. Review of Resident #1's electronic medical record weights and vitals summary pages and progress notes showed the VS documented for her stay of [DATE] to [DATE] and [DATE] to [DATE] were the following: [DATE] admitted , no VS documented [DATE] 6:29 a.m. BP ,d+[DATE], P 80, RR 18, T 98.0, O2 Sat 93% Method: Oxygen via Nasal Cannula. [DATE] 6:12 a.m. O2 Sat 88%, no other VS documented [DATE] Resident in the hospital [DATE] Resident in the hospital [DATE] readmitted , no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] 4:00 a.m. O2 Sat 90% with oxygen at 2L/m, no other VS documented [DATE] 4:00 a.m. O2 Sat 96% with oxygen at 2L/m after breathing treatment [DATE] 6:30 a.m. O2 Sat 96% with oxygen at 2L/m, no other VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] no VS documented [DATE] 8:00 p.m. BP ,d+[DATE], P 0, RR 0, T 98 , O2 Sat 90% [DATE] 8:30 p.m. BP ,d+[DATE] [DATE] 8:39 p.m. BP ,d+[DATE] An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN/UM said the documentation of blood pressure (of ,d+[DATE]) on [DATE] at 8:30 p.m. and O2 Saturation (at 90%) on [DATE] at 8:00 p.m. were an error. Staff G, LPN/UM said Staff D, RN had called her that evening to let her know she had problems with documenting VS at the time. During an interview on [DATE] at 9:35 a.m. Staff F, RN said the VS were documented in the weights and vitals tab of the electronic medical record. During an interview on [DATE] at 10:05 a.m. Staff C, RN said VS were documented on the MAR/TAR if it asks for them and if vital signs are being taken because of a concern they are documented directly under the VS tab or sometimes in the progress notes (in the electronic record). During an interview on [DATE] at 11:51 a.m. Staff B, LPN/UM said VS are documented in the electronic record in the progress notes and she does not know the Policy and Procedure for monitoring VS. She said there was usually an O2 sat order along with the oxygen order. She agreed there was no evidence in the medical record of the resident being stable because assessments and VS were not documented. She said that she did not notify the physician about the resident wanting to go to the hospital and she said I know, I didn't document . An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN said lab and x-ray results go into a portal and have to be reviewed. The nurses, Director of Nursing (DON,) UM, and Advanced Practice Registered Nurse (APRN) had access to view. The reviewed by on the report is the first person to review the results. Staff G, LPN said nurses can view the results without clicking reviewed. She confirmed the results for the stat chest x-ray for Resident #1 on [DATE] were not reviewed until [DATE]. Staff G, LPN also confirmed there is no documentation showing a provider was notified of the results. Regarding vitals for Resident #1 being documented throughout her stay at the facility she said, that would have been nice, especially her. Staff G, LPN said for a resident with a distended abdomen she would listen for bowel sounds, call the doctor, and see if they wanted to order an x-ray or anything else. Staff G, LPN/UM reviewed Resident #1's KUB results from [DATE] and confirmed there had been no follow-up. An interview was conducted on [DATE] at 1:05 p.m. with Resident #1's primary care physician. He said he would not have expected Resident #1's oxygen orders to have stopped. He said he would expect a patient that came to the facility with a history of respiratory failure to have oxygen saturation monitoring and I would be surprised if they were not. He said for the chest x-ray results on [DATE], the results would not have been overly concerning assuming the resident did not have a fever, but the facility should have notified the provider of all abnormal labs. An interview was conducted on [DATE] at 1:57 p.m. with the Social Services Director (SSD.) The SSD said Resident #1 was alert and was trying to decide if she was going to stay long term care or move back home with her husband. The SSD said Resident #1 was a smoker and understood the issues with smoking. She said the week prior to going to the hospital, the resident said she was going to try to stop smoking. The SSD said Resident #1 was active with therapy, would eat normally and was out of her room often interacting with people. She said the resident got close with the group of smokers. The SSD said Resident #1 wasn't difficult to work with and if the resident had concerns, she would go to social services. An interview was conducted on [DATE] at 2:05 p.m. with the Activities Director. The Activities Director said Resident #1 was alert, oriented, and aware. She said the resident was boisterous and would get into discussions with other residents. The Activities Director said Resident #1 would come out to smoke and got along with most of the people out there. She said Resident #1 had started a smoking patch and wanted to stop smoking. The Activities Director said she never heard Resident #1 complain about being sick or wanting to go to the hospital. An interview was conducted on [DATE] at 2:18 p.m. with Staff H, RN. Staff H, RN said Resident #1 was pleasant, alert, and oriented. He said she would sometimes take her oxygen off when she was in the hall and staff would tell her to put it back on due to her having shortness of breath. He said she was out of her room [ROOM NUMBER]% of the time. Staff H, RN said the resident didn't ever complain, say she wanted to go to the hospital and didn't have any behaviors besides occasionally refusing something. An interview was conducted on [DATE] at 2:22 p.m. with Staff J, CNA. Staff J, CNA said Resident #1 mostly took care of herself. Staff J, CNA said the resident would ask for ice or help with little things. She said the resident did get short of breath getting out of bed or doing simple tasks. Staff J, CNA said the resident never gave anybody a hard time and didn't complain unless it was something small. She said Resident #1 would normally eat and if she didn't like the meal, she would ask for snacks or order something to be delivered. Staff J, CNA said the resident never complained of stomach pain or said she wanted to go to the hospital. She said the resident would often have conversations with other residents. An interview was conducted on [DATE] at 2:48 p.m. with Staff I, CNA. Staff I, CNA said Resident #1 was a sweet lady and a good eater. Staff I, CNA said she doesn't remember the resident complaining or having any behaviors. An interview was conducted on [DATE] at 11:46 a.m. with the facility's Medical Director. The Medical Director said he doesn't know the specifics of Resident #1, but it sounded like she had a pretty sudden change in condition. He said usually with COPD you see a slow decline in oxygen saturation. The Medical Director said if a patient with that history said she isn't feeling well and needs to go to the hospital, the nurse should call the provider. He said if a resident had a change in condition the process should be for the nurse to first assess the resident, hopefully properly and completely, then contact the provider for orders. He said that could be medication or going to the hospital. The Medical Director said, no matter how self-inflicted things may be a change in condition warrants an assessment. An interview was conducted on [DATE] at 1:20 p.m. with the interim DON and Registered Nurse Consultant (RNC.) The RNC said if Resident #1 came from the hospital with oxygen orders, they should have been put in the computer. The interim DON said staff should have been monitoring Resident #1's O2 saturation and documenting. He said they have identified the facility is lacking in the area of documentation and have started education. Regarding the stat x-ray for Resident #1 on [DATE], the RNC said she could not attest to what happened or why there was no documented response. She said, Regardless, the nurse who received the results should have notified the physician and documented. The RNC stated regarding Resident #1 complaining she did not feel well on [DATE], she spoke with the nurse (Staff B) who said once the resident had a bowel movement, she was okay and did not have further complaints. She stated the nurse reported the resident had a bowel movement sometime after 3 p.m. She said, I would expect if a resident was requesting to go to the hospital, that their right to seek medical care was honored. The RNC stated she would have expected the nurse (Staff B) to document vitals and all assessments completed on Resident #1 when she verbalized not feeling well. Review of hospital records showed the patient presented in cardiac arrest. Allegedly had been in cardiac arrest for 30 minutes prior to arrival. She was immediately intubated in the prehospital airway was swapped out for an endotracheal tube. After initial dose of epinephrine in the emergency department she did have return of spontaneous circulation. Pulses were palpable. The record added the prognosis is extremely guarded considering she was allegedly in cardiac arrest for approximately 30 to 45 minutes prior to the return of spontaneous circulation. Of note, EMS reported her bloog [sic] glucose was 26 on arrival. They administered d10 and her glucose went up to 126 prior to arrival. A normal blood glucose level is between ,d+[DATE] milligrams(mg)/deciliter(dL.) The Emergency Department history of present illness showed Patient is a [AGE] year old Female presenting in cardiac arrest. Patient allegedly was found around 8 PM this evening approximately an hour prior to arrival unresponsive and allegedly in cardiac arrest. Unknown when she was last normal per the rehab facility. EMS reports that she was in PEA (Pulseless Electrical Activity) cardiac arrest through the entire transport. She underwent multiple rounds of ACLS (Advanced Cardiac Life Support) guidelines and epinephrine prior to arrival. However other than this the history is extremely limited from what was provided to me via EMS from the rehab facility. Hospital records showed the resident was admitted to the ICU (Intensive Care Unit) and died on [DATE] at 10:35 a.m. The hospital record Death Summary showed Resident #1's [TRUNCATED]